Alejandra Maiz

The aim of graduate medical education (GME) is to train competent physicians with the necessary abilities to care for patients.1,2 However, the design of early medical training programs was highly variable and lacked educational standards. Therefore, in the early 1900s, Abraham Flexner was tasked with assessing the state of medical education in the United States.3 The resulting Flexner Report highlighted the importance of standards in medical training.3Nearly a century after the Flexner Report, a resurgence in awareness of medical education shortcomings arose in conjunction with reports from the National Academy of Medicine (formerly the Institute of Medicine) that highlighted safety and quality problems in US health care.4,5 As a result, the Accreditation Council for Graduate Medical Education (ACGME) launched the Outcome Project in 2001 to better support the professional development of residents and fellows while reconfiguring standards for GME training programs.6,7 This project shifted the focus of GME accreditation requirements and policies to measurable educational outcomes of programs and learners.6 The 6 general core competencies (CCs) were developed to support the transition to an outcomes-based GME system by focusing on learning experiences and assessments for the following educational outcomes: patient care and procedural skills, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice.2 In 2013, the ACGME introduced Milestones 1.0 as a tool to describe an individual’s learning progression within the CCs.7 Milestones 2.0 were more recently implemented as a planned improvement based on research, feedback, and comments from multiple medical education stakeholders seeking simplification and harmonization of most of the competencies, except for patient care and procedural skills and medical knowledge.8 There was also increased support for GME community engagement and resource sharing.8 Some specialties have developed entrustable professional activities (EPAs) to complement the CCs and Milestones for better assessment of observable and measurable tasks or responsibilities in the clinical learning environment.9 Although there are currently various levels of EPA integration in residency, the American Board of Surgery is the first specialty board to require the use of EPAs for resident assessment and determining eligibility for certification.10Despite the availability of outcomes-based assessment tools, a structure and process-based medical education model (often referred to as fixed-time medical education) remains the predominant model for GME.11 This traditional model emphasizes exposure to specific educational experiences (eg, rotations on particular units such as the intensive care unit or emergency department) and hypothesizes that specific clinical experiences will enable acquisition of needed abilities. Competency-based medical education (CBME) is an outcomes-based model where the CCs and Milestones define the educational outcomes, and trainees are individually assessed and advanced for competency achievements in required medical practices. However, transitioning to a CBME model, even without changing the fixed-time structure still present in GME, will take substantial effort and time.11 At present, nearly all ACGME-approved programs in the United States adhere to a fixed-time format, but there are pilot CBME programs underway to trial this new paradigm.11 As this movement takes hold, trainee engagement in development and implementation of CBME is likely to be invaluable for a successful transition. Therefore, the purpose of the current article is to describe trainee engagement and future participation in CBME discussions and to provide their insights about the transition to CBME.Over the past year, residents and fellows participated in discussions about the development and understanding of a CBME model for GME. Specifically, the ACGME provided 2 meeting opportunities for trainees to engage in CBME discussions.In August 2022 the ACGME and American Board of Medical Specialties (ABMS) hosted the inaugural CBME Symposium as a 2-day event.12 The symposium was designed to accelerate the transition to CBME in the United States, and representatives from all major medical specialties participated.12The symposium had several key objectives. A primary objective was to recognize the essential role of the 5 core components of the framework of CBME: outcome competencies, sequenced progression, tailored learning experiences, competency-focused instruction, and programmatic assessment.12 This framework explicitly highlights the intensely developmental process of becoming a physician specialist. Subsequent objectives involved identification of the policy, financial and administrative facilitators for spreading and innovating CBME, and the barriers that could inhibit its growth.12 Desired outcomes were to encourage collaboration within and across specialties, to create actionable plans that supported innovation and implementation, and to promote recommended changes to ACGME and ABMS procedures for CBME.12Attendees of the symposium included leaders from the ACGME and ABMS, ACGME review committee chairs, designated institutional officials, department chairs, program directors, faculty members, and learners. The symposium was the most recent large-scale engagement of medical education stakeholders in the CBME conversation and the first to include residents and fellows from several different specialties. During roundtable discussions, trainees shared their current experiences with fixed-time medical education and their thoughts about the impact of CBME on future training. This symposium and its follow-up in June 2023 highlighted the importance of trainee perspectives and involvement for successful implementation of CBME.The Council of Review Committee Residents (CRCR) is 1 of 3 advisory councils at the...

Medical training is siloed into distinct stages, namely undergraduate medical education (UME), graduate medical education (GME), and continuing medical education (CME).1 Despite the shared purpose of developing competent and humanistic physicians, cross collaboration among leaders and educators of each stage is less common than expected. Medical education is beginning to move toward competency-based assessment at all levels. Over 2 decades ago, the Accreditation Council for Graduate Medical Education (ACGME) introduced competency-based education,2 which is now most prominently demonstrated by the incorporation of Milestones 2.0 and Clinical Competency Committees.3 Thus, the notion of medical education as a continuum, rather than individual stages, has risen in popularity but has not met complete implementation.4The COVID-19 pandemic resulted in disruptions to all stages of medical education and highlighted shortcomings in transition support, which is particularly notable for learners who have or will have spent their entire training under pandemic conditions or gone through multiple career transitions during the pandemic. For example, in the beginning months of the pandemic, some trainees were reassigned to services where more clinicians were necessary, while some fellows were called on to practice in their core specialties.5 Medical students' rotations were significantly impacted, and many in-person clinical rotations were replaced with distance learning.6To address these widespread and rapid changes in the clinical learning environment, the ACGME, in collaboration with other GME organizations, developed a series of toolkits to ease transitions between the stages of training. In collaboration with the American Association of Colleges of Osteopathic Medicine, Association of American Medical Colleges, and Educational Commission for Foreign Medical Graduates, the ACGME released its first transition guide in 2021 to address major disruptions to the clinical learning environment caused by the COVID-19 pandemic.7 It was followed by 2 additional guides in April 2022 that addressed the transition from residency to fellowship8 and from GME training to practice.9The Council of Review Committee Residents (CRCR) consists of approximately 30 GME trainees who serve as resident or fellow representatives on the ACGME's specialty Review Committees and 2 resident representatives who serve on the ACGME's Board of Directors. This diverse group consisting of trainees from every core specialty program fosters interspecialty collaboration and dialogue. Twice a year, the council meets to discuss topics relevant to the GME community.At the May 2022 CRCR meeting, council members joined the ongoing conversation of optimizing learners' needs through the transitions in medical education by participating in small group discussions. These discussions were facilitated by CRCR members who volunteered for this group role. A total of 30 CRCR members participated in the topic-focused discussions and were randomly grouped into Zoom breakout rooms. There were a total of 5 groups with 6 members each. Participation in the discussions was voluntary, and participants were informed that the ideas collected during discussions may be included in a future publication.To start, Dr. Eric Holmboe, Chief Research, Milestone Development, and Evaluation Officer at the ACGME, presented on the effects of COVID-19 on GME. This was followed by a theory of inventive problem solving (TRIZ) exercise,10 wherein discussion participants were challenged to design a transition approach that ensures every graduate of a program is completely unprepared for the next stage of their career.The next segment of the topic-focused discussion began with Dr. Holmboe presenting theory burst 1, a mini-lecture on competency-based medical education to provide information to support the subsequent discussion. Small group participants were then tasked with discussing how a developmental mindset, grounded in the core components of competency-based medical education,11 can facilitate successful transitions across a career. Results from theory burst 1 have been intentionally excluded due to the presented focused intent on the UME-GME-CME continuum.Information for theory burst 2 was dedicated to the transition from medical school to residency. Participants returned to their small groups to discuss 2 questions related to this transition: (1) How can residency programs support this transition? and (2) How can peers and near peers support this transition?Information for theory burst 3 involved the transition from residency to fellowship or independent practice. Participants again returned to their groups to discuss 2 questions related to this transition: (1) How can residency/fellowship programs support this transition? and (2) How can peers and near peers support this transition?Each small group assigned a scribe who collated participants' discussion responses. The authors of this article then reviewed the responses, identified common themes, and summarized recommendations to address these themes (Tables 1-4).During theory burst 2 small group discussions, participants brainstormed ways for residency programs and peers to facilitate the transition from medical school to residency. Recommendations were broken down by theme, and by residency program led (Table 1) and peer led or near peer led (Table 2).Although all incoming residents are required to have passed standardized medical licensing examinations (USMLE Step 1 and Step 2 or COMLEX-USA Levels 1 and 2), the depth and breadth of UME varies by school. In order to create a more equitable starting point for residency, the discussion groups recommended creation of bootcamps and skill labs to address deficiencies or gaps in UME. The purpose of these bootcamps is to provide basic education and skills, thereby promoting an equal opportunity for intern success via adequate and uniform preparedness. Additionally, peers can...