Evolution and application of the competencies and educational milestones in physician graduate education in the United States

More than 15 years ago, the organization that accredits physician education in the United States introduced 6 competencies relevant to medical practice. The next phase of this effort resulted in the development of educational milestones based on the competencies to focus the assessment of physicians in training on dimensions of performance critical to good medical practice. This article summarizes the competency-based approach to the education and assessment of US physicians in training, and the shift in the accreditation of physician training programs from a focus on structure and process to an emphasis on educational outcomes.The milestones were developed through expert consensus in each specialty that established a set of competencies, and a 5-level developmental framework that described the developmental steps in their acquisition from novice to expert/master. The work was informed by the literature, specialty curricula, stakeholder review, and initial testing.By basing learner assessment on dimensions of performance relevant in the practice of medicine, the milestones produce feedback that is more meaningful to learners, and concurrently base the accreditation of programs on real educational outcomes, contrasted with other attributes that are less directly related to the performance capabilities of graduates.The development of the milestones and initial testing by communities of practice in internal medicine, pediatrics, surgery, emergency medicine, neurological surgery and urology establishes the initial validity argument for the milestones. Further validity evidence will require study of the value of the milestones in assessment and accreditation, and linking educational outcomes to the performance and clinical outcomes of physicians in practice.