Feb 25, 2021 • By Jenny Kessler

Today the conference opened up with the President’s Plenary address, where Dr. Nasca gave us all a look at the big picture of the state of graduate medical education in the world. We got to hear the history of the New Accreditation System, which began 20 years ago, with the four phases of the ACGME Outcomes Project.

There were many challenges at the outset starting with the reforms to duty hours in 2003, Medicare caps for residency positions in 1997 and the medical liability crisis. The focus on outcomes for GME started with identifying core competencies and the struggle with translating them into specialty specific evaluation tools. However, this was a problem that needed to be solved as external pressures mounted on the ACGME to lead on defining the competency of graduates.

When Dr. Nasca joined the ACGME in 2007, he set out to make competencies real and discipline specific. While this effort was ongoing, the ACGME formed a task force to address medical errors due to resident schedules. This brought about the duty hours rules that sought to maintain an educational environment that assures patient safety and quality of care in the hands of residents and graduates of residency programs in their practice. There was also a focus on teaching professionalism and effacement of self interest in order to best serve their patients.

In 2014, as the ACGME prepared to reform residency education, they took part in “alternative futures planning,” where they envisioned the world in 2035 to plan for a wide range of challenges. Dr. Nasca also pointed to research about how the graduate learns becomes how they practice for many years afterwards. Their objective was to increase the effectiveness of graduates in practice.

As they look forward, the ACGME strives to meet four aims: to improve patient experience of care, population health, and health-care provider work life, while lowering per capita cost. This includes a focus on competency-based medical education, inspirational faculty role models, evidence-based, data driven clinical learning and care environments, housed in institutions that equitably meet local and regional community needs, and that graduates residents and fellows who strive for continuous mastery and altruistic professionalism.

Dr. Nasca also addressed the impacts of COVID-19 on graduate medical education. He noted that the pandemic was anticipated by their strategic plan and this helped react in an effective way. However, he did note that the US Medical Education System is a single point of failure system. While there have been efforts locally to optimize systems, there hasn’t been consideration on the system as a whole. Because the system is so complex and fragmented, it is easily disrupted.

We then looked at Dr. Nasca’s next realization: that we have three pandemics: COVID-19, the impact of COVID-19 on clinician well-being, and the pandemic of intolerance and the moral vacuum of our society. He spoke to the hearts of all of us when he wondered whether any child should have their lifespan shortened due to their economic status. He outlined the “Five I’s Pandemic” as inequity, intolerance, incivility, incoherence, and inhumanity.

“Only by learning the lessons we have learned fighting this virus, and employing an approach based on a solid ethical and moral framework, can we hope to cure the virus of intolerance, hatred, and incivility and end the disease that threatens to destroy our nation. It can be done, and given our experience, we can help lead the way.” - T. Nasca. Letter to the Community. January 13, 2021.

Dr. Nasca’s heartfelt plea to us all to use this moment where public favor and trust for healthcare providers is high, to “rise to this challenge…achieve the quadruple aim, end racism and intolerance in our society, and achieve the equity we all seek for all the children and grandchildren.

The next I attended session was “Lessons from the Pandemic: Moving Urgently Toward Competency Based Assessment in GME,” with Dr. Eric Holmboe, Chief Research, Milestone Development, and Evaluation Officer at the ACGME and Dr. Richard Wakins, President and CEO of ABMS. We took a look at the GME Assessment System that serves that quadruple aim of better outcomes, improved clinician experience, improved patient experience, and lower costs.

The American Board of Medical Specialties is responsible for certifying physicians. The requirements for certification are to meet licensure requirements, complete an ACGME accredited training program, pass knowledge and skills assessments, and meet requirements designated by their chosen specialty.

Both the ABMS and the ACGME’s missions have been greatly disrupted by the COVID-19 pandemic. Most training programs experienced at least a 30-day disruption and over 7,000 programs were disrupted for 60 or more days. Both clinical care and training activities were affected and the impact on faculty and residents was huge: thousands quarantined and hundreds were hospitalized.

By April of 2020, the ACGME and the ABMS issued joint principles to address these disruptions. They formed a task force that began meeting in May, and had recommendations available by September. The joint principles included an attitude of support and flexibility as well as a trust in the judgements of CCCs and Program Directors to determine “readiness for unsupervised practice and to inform specialty board decisions regarding eligibility for initial board certification.” The Joint Task Force was there to provide guidance on assessment and formulate a hybrid implementation strategy for competency based assessment, time modification, and volume based requirements that are supported by the principles of entrustment.

As we look towards the future of Competency Based Medical Education (CBME), we see a model that “de-emphasizes time-based training and promises greater accountability, flexibility, and learner-centeredness.” CBME is made up of an outcomes-based competency framework that starts with the end in mind and provides social accountability. There also must be a demonstration of progression, by means of the milestones, entrustment, and supervision. Learning and teaching needs to be tailored to the competencies and there should be robust programmatic assessment in place.

Going forward, Review Committees will focus on the quality of educational programs. There are many tools in place for programs to use to assess their learners and programs. This includes Predictive Probability Values (which you can find in your Milestones Reviews in the Portfolio section). There are also many resources available on the ACGME website in their Milestones section and on ACGME Learn.

The ACGME has also offered two free assessment tools to any program who’d like to try them out: Direct Observation of Clinical Care and a Teamwork Effectiveness Assessment Module. We also support Direct Observation assessment via on demand evaluations or in our new Direct Observation feature located in Logger.

In conclusion, the COVID-19 pandemic has pressed on the need for a more flexible and stable competency-based assessment model, that relies less on time and volume metrics and more on entrustment judgments, “based on ongoing observations and robust assessments.”

The final session of the day was: Milestones 2.0: Preparing for the Next Academic Year with Dr. Eric Holmboe, Laura Edgar, Sydney McLean. In this session we received an update on which specialties will begin using Milestones 2.0 for the upcoming academic year. Please see their Milestones by Specialty page for the complete list and effective dates.

The main updates to Milestones 2.0 included reducing the number of subcompetenies, making sure the narratives were threaded through each level of progression, and harmonizing the milestones that address non Patient Care and Medical Knowledge related subcompencies (Professionalism, Practice-based Learning and Improvement, Systems based Practice, and Interpersonal Communication).

Each Patient Care and Medical Knowledge subcompetency have two extra indicators, if no level is appropriate. These include “Not yet completed Level 1” and “Not yet assessable.” The former indicates that the learner is performing below the Novice level while the latter indicates that the learner hasn’t had a chance to demonstrate competency in this area.

Once we were updated on the changes, we got a full tour of the many resources available for all participants in ACGME accredited programs. There are supplemental guides to help demonstrate how milestones work and how to apply them in your program, guidebooks for learners and faculty, CCC guidebooks, and implementation guides. Please check the ACGME website for all of these very helpful resources!

As usual, the Presidential Plenary set a high bar for all of us to strive for excellence in medical education in order to make the world a better place for everyone. The COVID-19 pandemic has brought many things into sharp focus that we cannot ignore, from physician well-being, to equity in care, to the importance of civility. The sessions I attended followed this thread and integrated the quadruple aims into their content, emphasizing not only the urgent and need for competency based medical education but also the ACGME’s undying and overwhelming support for everyone involved in Graduate Medical Education.