How Changes to ACGME’s Accreditation Standards Are Affecting Fellowship Training

A Conversation With Jill Gilbert, MD

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Jill Gilbert, MD

Leora Horn, MD, MSc

On a global level, we hope these changes will have an impact on the kind of physician these fellows become, which ultimately will improve patient care.

—Jill Gilbert, MD

Two years ago, the Accreditation Council for Graduate Medical Education (ACGME), the nonprofit organization that evaluates and accredits more than 9,000 medical residency programs in the United States, began phasing in implementation of its Next Accreditation System for graduate medical education, developed in conjunction with the American Board of Internal Medicine (ABIM). The new system requires all medical training programs to use milestones-based assessment and reporting through descriptive and observable behaviors for the evaluation of resident skills within these competencies as they progress through training.1 The internal medicine subspecialties use general “subspecialty reporting milestones,” which are not specific to any one area of internal medicine.

Fellow progress in attainment of the subspecialty milestones is now reported every 6 months to the ACGME (and ultimately ABIM). The key is demonstrating that the fellow is “trusted” to perform the activities safely and independently prior to graduation.

Hematology and clinical oncology work groups, sponsored by the American Society of Hematology (ASH) and ASCO, took this one step further and created Curricular Milestones to establish a real-life, relevant hematology-oncology framework, which can help inform subspecialty milestone reporting. The hope is that faculty will feel comfortable and confident evaluating fellow performance on core activities within the field and that valuable feedback will be provided to the trainee.

The ASCO Post talked with Jill Gilbert, MD, Associate Professor of Medicine and Director of the Hematology/Oncology Fellowship Program at Vanderbilt University Medical Center in Nashville, about the ACGME requirements and how the more targeted evaluations of performance are resulting in better-trained physicians.

New Requirements

Please tell us about the changes in ACGME requirements for oncology fellows and residents and how they will improve clinical training.

Our first Hematology/Oncology Subspecialty Milestones reporting for fellows and residents under the new requirements was due in January 2015. Prior to the Next Accreditation System, we judged fellows’ ability to graduate from the residency program based on the six core clinical competencies: patient care, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice.

The problem was that these competency requirements were very esoteric, broad concepts and were not grounded in actual activities that could be measured. In fact, we are not really sure that they were accurately measuring the ability of fellows to finish training and be ready for independent practice.

Now, we have moved to the Next Accreditation System, which includes outcomes-based milestones for resident performance within these six domains of clinical competence. The idea behind the change was that for every clinical rotation, there is a specific list of clinical activities called “entrustable professional activities” that can be observed and are considered essential for the fellow to demonstrate mastery over prior to graduation.

Each entrustable professional activity can usually “map” or inform several of the subspecialty milestones. For example, if a fellow has a rotation in leukemia, one entrustable professional activity the fellow must show proficiency in prior to graduation is the ability to perform a bone marrow biopsy. The activity is something that faculty can actually observe and judge. However, this one activity includes multiple components (which fall within the aforementioned competencies and thus map to the subspecialty milestones). These milestones include knowing what to order on the biopsy/aspirate (medical knowledge and patient care), obtaining informed consent (interpersonal and communication skills), and having professional and successful interactions with the bone marrow technologist (system-based practice, professionalism). Thus, this one activity allows the faculty to evaluate multiple milestones (see box below).

Projected Benefits

What are some projected benefits of the Next Accreditation System?

Fellows and residents can be assured that all the programs are standardized and teach and evaluate the same desired outcomes in terms of milestones. For faculty, the new milestones allow a more concrete activity-based way of evaluating fellows and providing feedback.

Ideally, this system will help alleviate “grade inflation,” which often occurred in the previous competency-based system when faculty did not understand what they were actually evaluating. Now, evaluations are graded in observable activities that faculty can grasp. Moreover, the Next Accreditation System emphasizes that trainees are on a trajectory of competence and should demonstrate progress, not perfection, as they progress in the fellowship.

Early Results

What have been the results of the Next Accreditation System so far?

Although the new requirements only recently went into effect, we have already gotten positive feedback from the fellows and faculty members. The fellows say that the Next Accreditation System provides specific tools to assess rotations, and faculty like the program because it allows them to evaluate performance based on actual observable skill.

On a global level, we hope these changes will have an impact on the kind of physician these fellows become, which ultimately will improve patient care. ■

Disclosure: Dr. Gilbert reported no potential conflicts of interest.


1. The Internal Medicine Subspecialty Milestones Project. Available at Accessed January 15, 2015.

Guest Editor

Education in Oncology focuses on faculty development, medical education curricula, fellowship training, and communication skills. The column is guest edited by Leora Horn, MD, MSc, Associate Professor of Medicine, Assistant Director of the Educator Development Program, and Clinical Director of the Thoracic Oncology Program at Vanderbilt University School of Medicine, Nashville.


More on Accreditation and Subspecialty Milestones

For more information on ACGME, the Next Accreditation System, and Milestones Resources for Training Programs, visit: