Introduction
The Psychiatry Milestones describe key steps in the acquisition of foundational knowledge, skills, and attributes, culminating in competence for unsupervised practice at the completion of formal training. The Psychiatry Milestones also will assure continued lifelong learning after completion of residency. Aggregated to the program level, the Milestones will be used by the Residency Review Committee (RRC) for Psychiatry as a measure of program training efficacy in the Next Accreditation System (NAS).
Milestone Development History
Leaders from the American Psychiatric Association (APA), the American Board of Psychiatry and Neurology (ABPN), the American Association of Directors of Psychiatric Residency Training (AADPRT), and the RRC for Psychiatry selected the members of the Psychiatry Milestone Working Group and the Advisory Group (2a1box 1).
Box 1 Members of the Psychiatry Milestone Working Group and Advisory Group
Psychiatry Milestone Working Group
Christopher R. Thomas, MD, University of Texas Medical Branch at Galveston, Chair
Sheldon Benjamin, MD, University of Massachusetts Medical School
Adrienne L. Bentman, MD, University of Connecticut School of Medicine
Robert Boland, MD, Brown University
Deborah S. Cowley, MD, University of Washington Medical Center
Jeffrey Hunt, MD, MS, Alpert Medical School of Brown University
George A. Keepers, MD, Oregon Health and Sciences University
Louise King, MS, Accreditation Council for Graduate Medical Education (ACGME)
Gail H. Manos, MD, Naval Medical Center Portsmouth
Donald E. Rosen, MD, Austin Riggs Center
Kathy M. Sanders, MD, Massachusetts General Hospital
Mark E. Servis, MD, University of California, Davis Health System
Kallie Shaw, MD, University of South Florida
Susan R. Swing, PhD, ACGME
Alik Widge, MD, PhD, University of Washington
Psychiatry Milestone Advisory Group
Christopher R. Thomas, MD, University of Texas Medical Branch at Galveston, Chair
Timothy Brigham, MDiv, PhD, ACGME
Carol A. Bernstein, MD, New York University School of Medicine
Beth Ann Brooks, MD, University Psychiatric Center
Larry R. Faulkner, MD, American Board of Psychiatry & Neurology
Deborah Hales, MD, American Psychiatric Association
Victor I. Reus, MD, University of California, San Francisco
Richard F. Summers, MD, University of Pennsylvania
The working group began its work in December 2011 and held 5 face-to-face meetings and numerous conference calls to develop the Psychiatry Milestones. The working group reviewed the Core Competencies for Psychiatric Practice (2003),1 the Core Competencies for Psychiatric Education (2004),2 and the Psychiatry RRC Program Requirements and content outlines for the ABPN Certification Examination in Psychiatry and the American College of Psychiatrists (ACP) Psychiatry Residents In-Training Examination. Levels for Milestone attainment were established by consensus on expected competencies of entering and graduating residents, with subsequent elaboration of the progression of skills, knowledge, and attributes for the remainder of the Milestones. One of the central challenges was recognition that programs differ in when certain clinical rotations occur and how this influences the opportunity for residents to demonstrate proficiency on the various Milestones. The advisory group reviewed the drafts following each face-to-face meeting of the working group, and their comments and questions clarified the focus and intent of the Psychiatry Milestones. The working group also sought review and input from a variety of professional groups in the specialty, including the Association for Academic Psychiatry (AAP), the Association of Directors of Medical Student Education in Psychiatry, and the Group for Advancement of Psychiatry.
The working group and the AADPRT conducted separate surveys of the program directors of psychiatry residencies, which guided the revision of the Psychiatry Milestones. Members of the working group facilitated presentations, workshops, and discussions at the annual meetings of the AADPRT, APA, and ACP.
General Features of the Specialty Milestones
The Psychiatry Milestones comprise 22 subcompetencies (3a1box 2), covering all 6 Accreditation Council for Graduate Medical Education (ACGME)/American Board of Medical Specialties competencies. The working group organized the individual Milestones into 66 developmentally or conceptually related groups, labeled threads, to provide a better conceptual organization to assist in developing training modules and assessments. The specialty-specific competencies of medical knowledge (MK) and patient care (PC) have the largest number of subcompetencies. The subcompetencies of the psychotherapies and somatic therapies are reflected in both MK and PC, with the Milestones in the former reflecting an understanding of treatment principles and those in the latter encompassing the skills to carry out treatment. In creating the Milestones for systems-based practice, practice-based learning and improvement, interpersonal and communication skills, and professionalism, the working group studied sample Milestones developed by other specialties and generic, cross-specialty Milestones developed by an ACGME expert panel. The subcompetencies for interpersonal and communication skills proved to be challenging, as there is a great deal of conceptual overlap with PC for psychotherapy.
Box 2 Psychiatry Milestone Subcompetencies
Patient Care
Psychiatric Evaluation
Psychiatric Formulation and Differential Diagnosis
Treatment Planning and Management
Psychotherapies
Somatic Therapies
Medical Knowledge
Development Through the Life Cycle
Psychopathology
Clinical Neuroscience
Psychotherapies
Somatic Therapies
Practice of Psychiatry
Systems-Based Practice
Patient Safety and Health Care Team
Resource Management
Community-Based Care
Consultation to Non-Psychiatric Medical Providers and Non-Medical Systems
Practice-Based Learning and Improvement
Development and Execution of Lifelong Learning
Formal Practice-Based Quality Improvement
Teaching
Professionalism
Compassion, Integrity, Respect, and Sensitivity for Others, Adherence to Ethical Principles
Accountability to Self, Patients, Colleagues, and the Profession
Interpersonal and Communication Skills
Relationship Development and Conflict Management
Information Sharing and Record Keeping
Establishing Milestone Validity, Utility, and Practicality
The working group organized pilot testing of the Psychiatry Milestones, with 19 programs completing assessments on a sample of their residents, and 16 programs repeating the assessments 6 months later. The pilot results provided valuable information on the time needed to complete resident reviews, on the composition of and procedures for the Clinical Competency Committee (CCC), and also generated early support for the validity for the Milestones, reflected by the observation in pilot programs that performance results across levels conformed to expected patterns.
The ACGME and AADPRT conducted separate surveys of program directors on the Psychiatry Milestones that were useful in guiding revisions. The surveys asked program directors' opinion on whether the Milestones were clearly written, specific enough, described a realistic progression, and were achievable. Milestones that were vague or confusing were reworded to clarify their intent. In addition to specific Milestones, subcompetencies that received comments and questions were carefully reviewed and rewritten. The subcompetencies for “Development Through the Life Cycle” and “Teaching” were extensively reorganized and revised based on comments from program directors.
Envisioned Practical Use in Evaluating Residents
The Psychiatry Milestones will provide information regarding programs' performance in training competent practitioners that will be useful to the assessment of educational outcomes in the NAS. At the level of the individual resident, the Milestones will provide new important data for resident assessment and feedback that will be highly relevant to practice in psychiatry. The Milestones provide objective criteria for describing resident knowledge and abilities that will assist in identifying possible deficiencies and assist in guiding correction. Supervisors will be able to point out what the resident has mastered and what needs further work. The progression of Milestones also can assist in the semiannual meeting between program directors with individual residents in discussing progress over the prior 6 months and setting goals for the coming 6 months. At the program aggregate level, data on overall resident performance on the Milestones will assist in internal program assessment and improvement.
Recommendations for Competency Committee Composition and Functioning
The ACGME Common Program Requirements set the basic expectations for the CCC composition and functions. Unlike some specialties, the Psychiatry RRC and Psychiatry Milestone Working Group do not prohibit the program director from being the chair or a member of the CCC. It is useful to have at least several members of the CCC who have direct supervisory contact with residents so that at least 1 member of the committee will have worked directly with the resident being reviewed within the past year. It also is helpful to have reviews of specific residents assigned to members of the committee along with the assessments on those residents prior to the meeting to facilitate continuity in the assessments. On occasion, there will not have been opportunity to assess all Milestones in the previous 6 months. In those instances, when there is no new assessment information, the CCC must assume that the resident has remained at prior levels of demonstrated competence for the specific subcompetency or subcompetencies.
Conclusion
The Psychiatry Milestones represent a major change not only in the process of program accreditation, but also in resident assessment and program review and improvement. The Milestones provide clearly described objectives for programs to guide curriculum development and identify program deficiencies. They also inform conversations between residents and their supervisors and mentors, and improve resident supervision by basing the degree of supervision on documented progress in training. Over time, use of the Milestones in assessments and accreditation will offer new information on their utility for these purposes. It will be important to review the implementation of the Psychiatry Milestones to assure these goals are met and to facilitate an ongoing improvement in the Milestones and the value of the information they generate.
