The Milestone Project: Leading The Way Further On in Medical Education?

The other day, one of the residents rotating through the psychiatry consultation service asked me how to document psychiatric formulations. I have a blog post about it, What’s the Best Way to Teach Psychiatric Residents How to Make Case Formulations? – The Practical Psychosomaticist, so I summarized that for him. On the other hand, we’re pretty busy on the consult service and we have two customers–the patient and the consulting physician–neither of whom is interested in reading a formulation of the type I wrote about in that post.

To the Tops of TreesAnd then I read the article about the Milestone Project in residency education in the September 6, 2013 print edition of Psychiatric News, PsychiatryOnline | Psychiatric News | News Article Milestone Project. The Milestones Project is the “…latest stage of what educational leaders say is a dramatic sea change in American medical education.” It will set specific goals for assessing progress toward moving further on in their residency education toward competency. The milestones are supposedly measurable anchors for skills that might operationalize evaluation of the six basic competencies including patient care, medical knowledge, professionalism, systems-based practice, practice-based learning and improvement, and communication and interpersonal skills. See this link for more about it,

Psychiatry Milestone Project

One of the examples of a milestone outlined in the article relates to psychiatric formulation. The first year resident who has attained Level 1 of this skill should be able to demonstrate that he or she can accurately summarize, report, and present to colleagues information obtained from the patient evaluation and develop a working diagnosis based on that evaluation. In Level 4, the resident should “efficiently synthesize all information into a concise but comprehensive formulation…,” which “…incorporates subtle, unusual, or conflicting findings into alternative hypotheses and formulations.”

I think we’d better make sure our faculty can still do things like this before we expect trainees to learn these skills from us. Few practitioners ever do enough formulations after graduation (if they do them at all) in academics or in private practice to make this milestone a practical measure of educational progression.

I think the Milestone Project is an extension of the Maintenance of Certification (MOC) madness rearward into residency training. I’ve written about this previously:

Save Time for Patients – The Practical Psychosomaticist.

Ten Minutes Enough for the MOC Complexities? – The Practical Psychosomaticist

Leaders in the Accreditation Council for Graduate Medical Education (ACGME) are very enthusiastic about the Milestone Project and talk it up as though every residency program director is fully on board with it. I doubt it. Although the ACGME chair of the Psychiatry Milestone Project, Dr. Christopher Thomas, MD, says it’s not a “cookbook” for grading residents, I’m pretty sure that’s how it will come to be regarded. And program directors supposedly will not be required to use it to gauge readiness for promotion.

That makes me wonder why they’re promoting it in the first place. It’s enormously complicated, labor intensive, impractical to incorporate into the training schedule–and not required? If it’s not required and program directors will still be able to graduate trainees at their discretion, what kind of “sea change” can this innovation be expected to make?

It sounds like more MOC nonsense to me.


1. Moran, M. (2013). Milestone Project Called Paradigm Shift In Residency Education. Psychiatric News, American Psychiatric Association. 48.

Draft milestones for psychiatry in six domains of physician competency are expected to be finalized this year and implemented for residency training programs in July 2014.



  1. Jim – I read the same article and was trying to get fired up to write a commentary. Agree with you completely about the MOC aspects of this and do not like to see the same organizations (ABPN and ACGME) fronting it. The conflict of interest is obvious to me and I have never gotten an adequate response about why cradle to grave MOC/MOL by the same organizations based on their purely political theories is not a problem.

    Like I have said before the actual experiment is easy to run – MOC examinees versus people taking the same FOCUS course for one year and see who has a better knowledge base on an exam. Nobody seems willing to run the experiment. It is always interesting to see how the evidence based crowd really prefers anecdotes.


    • George, you’re right. It’s patently obvious that the Milestone Project, just like MOC and MOL, has no high level research supporting the imposition of this empty checklist tyranny of wasteful busy work on either trainees or licensed, experienced practitioners.



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