title: Ways to Write a Milestone: Approaches to Operationalizing the Development of Competence in Graduate Medical Education.
abstract: To identify approaches to operationalizing the development of competence in Accreditation Council for Graduate Medical Education (ACGME) milestones.
  
  
  
  The authors reviewed all 25 "Milestone Project" documents available on the ACGME Web site on September 11, 2013, using an iterative process to identify approaches to operationalizing the development of competence in the milestones associated with each of 601 subcompetencies.
  
  
  
  Fifteen approaches were identified. Ten focused on attributes and activities of the learner, such as their ability to perform different, increasingly difficult tasks (304/601; 51%), perform a task better and faster (171/601; 45%), or perform a task more consistently (123/601; 20%). Two approaches focused on context, inferring competence from performing a task in increasingly difficult situations (236/601; 29%) or an expanding scope of engagement (169/601; 28%). Two used socially defined indicators of competence such as progression from "learning" to "teaching," "leading," or "role modeling" (271/601; 45%). One approach focused on the supervisor's role, inferring competence from a decreasing need for supervision or assistance (151/601; 25%). Multiple approaches were often combined within a single set of milestones (mean 3.9, SD 1.6).
  
  
  
  Initial ACGME milestones operationalize the development of competence in many ways. These findings offer insights into how physicians understand and assess the developmental progression of competence and an opportunity to consider how different approaches may affect the validity of milestone-based assessments. The results of this analysis can inform the work of educators developing or revising milestones, interpreting milestone data, or creating assessment tools to inform milestone-based performance measures.
authors.affiliation: A.N. Leep Hunderfund is assistant professor of neurology, Mayo Clinic, Rochester, Minnesota. D.A. Reed is associate professor of medical education and medicine and senior associate dean of academic affairs, Mayo Medical School, Mayo Clinic, Rochester, Minnesota. S.R. Starr is assistant professor of pediatric and adolescent medicine and director of science of health care delivery education, Mayo Medical School, Mayo Clinic, Rochester, Minnesota. R.D. Havyer is assistant professor of medicine, Mayo Clinic, Rochester, Minnesota. T.R. Lang is assistant professor of pediatric and adolescent medicine, Mayo Clinic, Rochester, Minnesota (now at Gundersen Health System, LaCrosse, Wisconsin). S.M. Norby is associate professor of medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Andrea N
authors.initials: AN
authors.lastname: Leep Hunderfund
authors.forename: Darcy A
authors.initials: DA
authors.lastname: Reed
authors.forename: Stephanie R
authors.initials: SR
authors.lastname: Starr
authors.forename: Rachel D
authors.initials: RD
authors.lastname: Havyer
authors.forename: Tara R
authors.initials: TR
authors.lastname: Lang
authors.forename: Suzanne M
authors.initials: SM
authors.lastname: Norby
mesh_terms: D000068:Accreditation / Q000592:standards*; D002983:Clinical Competence / Q000592:standards*; D004503:Education, Medical, Graduate / Q000592:standards*; D006801:Humans; D007388:Internal Medicine / Q000193:education*; D020407:Internet; D007396:Internship and Residency / Q000592:standards*; D014481:United States