Good intentions do not necessarily lead to good results. A case in point is the milestones initiative of the Accreditation Council of Graduate Medical Education and its various medical specialty boards, which are working together in an attempt to improve the quality of graduate medical education. In practice, however, the milestones are often not proving to be a valuable indicator of learner progress and are in fact acting like millstones around the necks of trainees and program directors.
The goals behind the milestones initiative are laudable. Introduced as part of the Next Accreditation System (NAS), they were intended to shift attention of learners and educators from processes to outcomes. They would foster self-directed learning and assessment and provide more helpful feedback. In theory, programs that were doing well would face less burdensome oversight and under-performing ones would receive more prompt and helpful guidance.
In practice, however, the milestones initiative has reminded many program directors and trainees of the onerous impact of maintenance of certification programs enacted by the American Board of Medical Specialties. Simply put, when the lofty rhetoric of initial assurances is set aside, the risks and costs of such initiatives appear to many to exceed the benefits by an unacceptably high margin. In many cases, this can be traced to a failure to assess outcomes before implementing system-wide change.
