Curricular milestones in rheumatology: Is granular better?

December 19, 2016|Rheumatology News

FROM ARTHRITIS CARE & RESEARCH

A new curricular “road map” attempts to lay out precisely what rheumatology fellows are expected to be able to know and do at different time points in their training.

The 80 “curricular milestones” for rheumatology, developed under the direction of the Accreditation Council for Graduate Medical Education, are meant to complement the 23 internal medicine subspecialty reporting milestones already mandated by the ACGME for use in trainee evaluation.

Unlike the reporting milestones, which came into use in 2014, the curricular milestones are not compulsory. Instead they “offer a guide so that trainees and the people teaching them know what’s expected of them,” said Lisa Criscione-Schreiber, MD, of Duke University, Durham, N.C., the lead author of a recent article in Arthritis Care & Research describing the new milestones (Arthritis Care Res. 2016 Nov 11. doi: 10.1002/acr.23151).

Dr. Lisa Criscione-Schreiber oversees rheumatology fellow Dr. Stephanie Giattino conducting a physical exam on a patient.

“The curricular milestones point to knowledge, skills, and attitudes that we think, and that the American College of Rheumatology’s board of directors agrees, are core to what it means to be a rheumatologist,” and which correspond with the Entrustable Professional Activities approved by the ACR, Dr. Criscione-Schreiber said in an interview.

While the reporting milestones are designed to target broader competencies, the curricular milestones are highly granular. For example, a rheumatology fellow at 12 months is expected to be able to “perform compensated polarized microscopy to examine and interpret synovial fluid,” according to one milestone; before 24 months of training, he or she is expected to be able to teach others to do the same.

Authors of an accompanying editorial (Arthritis Care Res. 2016 Nov 11. doi: 10.1002/acr.23150) by Richard Panush, MD, of the University of Southern California in Los Angeles, Eric Hsieh, MD, also of USC, and Nortin Hadler, MD, of the University of North Carolina at Chapel Hill, praised the curricular milestones as meticulous and well conceived, but questioned their complexity and the broader push toward rubric-based training, particularly in the absence of evidence showing it to be superior to established methods.

Further, they wrote, the milestones’ granularity could prove a problem: “We fear that the investment in metrics designed to parse someone’s notion of the components of competence as a trainee will have far less relevance to professional performance ... than the global assessments.”

Ultimately, Dr. Panush acknowledged in an interview, the move to milestones – including the curricular milestones – may prove worthwhile. But it simply “isn’t as sufficiently grounded in science as we would have liked for such a major departure from everything we have done, and with all that implementing the change would imply: the time, the manpower, the cost,” he said.

A leap of faith?

Dr. Criscione-Schreiber, who is Duke’s rheumatology program director, acknowledged that the milestones’ value and utility remain to be determined. “We’re not sure it’s the best way, but it’s a try,” she said. “We’re all in an era of continuous quality improvement in which you change something then test whether it works. The ACGME is collecting data about all this – if they find out it’s burdensome, they have assured program directors that they will change it.”

Calvin Brown, MD, rheumatology program director at Northwestern University in Chicago and a coauthor of the milestones, pointed out that the approach isn’t entirely novel: Canadian educators have been moving forward with an increasingly granular milestones-based approach for some time, and that much of the ACGME’s work parallels that of Canada’s Royal College of Physicians and Surgeons.

But Dr. Brown conceded that the editorialists’ concerns were valid. “The ACGME has been the main organization describing parameters by which we train doctors, and it is relatively unopposed. We’ve seen a proliferation of the rubric-based approach, and we are adopting these [curricular milestones] without scientific evidence. I commend the editorial authors in saying we need to find ways to measure this to see if it does improve, but if we wait for that evidence before we move forward, we’ll never get past square one.”

Observation and feedback

A key goal of the milestones is to encourage direct observation of trainees. Dr. Panush and his colleagues, in their editorial, argue that “a wise and astute clinician educator ... can judge when trainees are ready to function independently and have learned how to keep learning and changing without needing menus of evaluations or detailed instruments.”