The Family Medicine Milestone Project
The Milestones provide a framework for the assessment of the development of the resident physician in key dimensions of the elements of physician competency in a specialty or subspecialty. The Milestones are designed only for use in evaluation of resident physicians in the context of their participation in Accreditation Council for Graduate Medical Education (ACGME)–accredited residency or fellowship programs. They neither represent the entirety of the dimensions of the 6 domains of physician competency, nor are they designed to be relevant in any other context.
Family Medicine Milestone Prologue
Family medicine contributes to the care of patients at all levels, throughout all stages of life, and is more than a primary care specialty. It is a discipline characterized by its breadth and integrative functions.
Family physicians are personal physicians who focus on each individual in his or her given situation, integrating mental and physical health within each individual's own social context. These physicians possess a unique skill set to take primary responsibility for and manage any problems with which patients present for attention and care. They provide a reliable point of first contact with the health care system for patients regardless of the type or nature of their problems, providing a comprehensive set of services that resolve most of the problems the majority of people have most of the time. They remain with their patients across time and health care settings and work with dynamic teams to integrate proper care of individuals. Family physicians interface with all medical specialties and public health. When necessary, they rely on community resources, helping individuals, families, and communities meet their health-related goals. The specialized focuses of family physicians are the individual in the context of his or her family and community and all the complexities this entails. It is essential for family physicians to have in-depth knowledge of a patient as an individual and broad knowledge of medical science to act in the best interest of that patient. The effectiveness of family physicians depends on their abilities to earn the trust of their patients and sustain relationships over time. Because of the breadth of involvement of family medicine in the health care system, family physicians are in a special position to critique, positively influence, and lead the health care delivery system.
Family medicine residency programs aim to graduate physicians with the necessary attitudes, knowledge, and skills to serve any and all of the nation's communities. The Family Medicine Milestones document is a living document that provides guidance for how family physicians are developed from the start of residency as undifferentiated medical students to becoming competent family physicians ready to enter independent practice.
The Milestones are developmentally-based, family medicine–specific attributes that family medicine residents can be expected to demonstrate as they progress through their programs. Organized around the 6 ACGME core competencies, each group of related Milestones includes an introductory statement that describes the specific emphasis of family medicine within that competency.
Milestone Reporting
This document presents Milestones designed for programs to use in semiannual review of resident performance and reporting to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies, organized in a developmental framework from less to more advanced. They are descriptors and targets for resident performance as a resident moves from entry into residency through graduation. In the initial years of implementation, the Review Committee will examine Milestone performance data for each program's residents as 1 element in the Next Accreditation System (NAS) to determine whether residents overall are progressing.
For each reporting period, review and reporting will involve selecting the level of Milestones that best describes each resident's current performance level in relation to Milestones. Milestones are arranged into levels. Selection of a level implies that the resident substantially demonstrates the Milestones in that level, as well as those in lower levels (figure). A general interpretation of Milestone levels for family medicine is as follows:
Citation: Journal of Graduate Medical Education 6, 1s1; 10.4300/JGME-06-01s1-05
Level 1: The resident demonstrates Milestones expected of a resident who has had some education in family medicine.
Level 2: The resident is advancing and demonstrating additional Milestones.
Level 3: The resident continues to advance and demonstrate additional Milestones; the resident consistently demonstrates the majority of Milestones targeted for residency.
Level 4: The resident has advanced so that he or she now substantially demonstrates the Milestones targeted for residency. This level is designed as the graduation target.
Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating aspirational goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level.
Additional Notes
Level 4 is designed as the graduation target but does not represent a graduation requirement. Making decisions about readiness for graduation is the purview of the residency program director (see the NAS Frequently Asked Questions for educational Milestones on the ACGME's website for further discussion of this issue: “Can a resident graduate if he or she does not reach every Milestone?”). Study of Milestone performance data will be required before the ACGME and its partners will be able to determine whether graduating resident Milestones and Milestones in lower levels are in the appropriate level within the developmental framework, as well as whether Milestone data are of sufficient quality to be used for high-stakes decisions.
Some Milestone descriptions include statements about performing independently. These activities must follow the ACGME supervision guidelines. For example, a resident who performs a procedure or takes independent call must, at a minimum, be supervised through oversight.
ACGME Milestone Report Form
The figure presents an example of a set of Milestones for 1 subcompetency in the same format as the ACGME Milestone Report Form. For each reporting period, a resident's performance on the Milestones for each subcompetency will be indicated by selecting:
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the level of Milestones that best describes the resident's performance in relation to the Milestones, or
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the “Has Not Achieved Level 1” option.
FAMILY MEDICINE MILESTONES
Patient Care
Family physicians provide accessible, quality, comprehensive, compassionate, continuous, and coordinated care to patients in the context of family and community, not limited by age, gender, disease process, or clinical setting, and use the biopsychosocial perspective and patient-centered model of care.
Medical Knowledge
The practice of family medicine demands a broad and deep fund of medical knowledge to proficiently care for a diverse patient population with undifferentiated health care needs.
Systems-Based Practice
The stewardship of the family physician helps to ensure high value, high quality, and accessibility in the health care system. The family physician uses his or her role to anticipate and engage in advocacy for improvements to health care systems to maximize patient health.
Practice-Based Learning and Improvement
The family physician must demonstrate the ability to investigate and evaluate the care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning.
Professionalism
Family physicians share the belief that health care is best organized and delivered in a patient-centered model emphasizing patient autonomy, shared responsibility, and responsiveness to the needs of diverse populations. Family physicians place the interests of patients first while setting and maintaining high standards of competence and integrity for themselves and their professional colleagues. Professionalization is the developmental process that requires individuals to accept responsibility for learning and maintaining the standards of the discipline, including self-regulating lapses in ethical standards. Family physicians maintain trust by identifying and ethically managing the potential conflicting interests of individual patients, patients' families, society, the medical industry, and their own self-interests.
Interpersonal and Communication Skills
The family physician demonstrates interpersonal and communication skills that foster trust and result in effective exchange of information and collaboration with patients, their families, health professionals, and the public.
Patient Care (PC)
Medical Knowledge (MK)
Systems-Based Practice (SBP)
Practice-Based Learning and Improvement (PBLI)
Professionalism (PROF)
Interpersonal and Communication Skills (C)
Example Set of Milestones for 1 Subcompetency in the ACGME Milestone Report Form
