Research in Medical Education

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Mahdavifard H. Milestones and Competency-Based Medical Education. Res Med Edu 2026; 17 (4) :1-5
URL: http://rme.gums.ac.ir/article-1-1456-en.html

Competency-Based Medical Education (CBME) in medical education is defined as “an outcomes-based approach to the design, implementation, assessment, and evaluation of medical education programs using a competency-based organizational framework” (1). The result of competency-based education is training of physicians who are able to provide safe, effective, and unsupervised medical care that meets the needs of today’s complex and evolving healthcare system (2). Competency is defined as “the observable ability of an individual, integrating multiple components, such as knowledge, skills, values, and attitudes” (1). This definition focuses on the specific abilities expected of each physician (3). Competency requires more than the discrete performance of competent behavior at a particular time and place. It requires that the individual apply those abilities appropriately in routine clinical work(s) to achieve desired outcomes (4).
A distinctive feature of CBME is that learners can progress through the educational process at different rates. Talented learners can transition into their professional roles sooner, while others need more time to develop the knowledge, attitudes, and skills to enter the field of unsupervised practice. It is essential to note that experience and time are still important in the CBME program; nonetheless, time is not viewed as an intrusive factor. Rather, it is deemed a resource that must be used wisely and effectively. No medical education expert denies that a certain amount of experience is important for performing procedures. In this regard, various frameworks have been proposed for achieving the necessary experience and competencies; however, the number of competencies required in each framework varies. For instance, the number of competencies in the CanMEDS framework is eight, the number of competencies in the ACGME framework is six, and the number in the Scottish Doctor framework is seven (5).
In a competency-based system, program managers must be confident that trainees have the necessary competencies to progress in their training or continue to the next stages of their training in their profession. Educational milestones, in simple terms, are important points in the overall educational progression. Milestones enable learners and program managers to define individual paths of professional development (6). Milestones, as their name suggests, are used to help trainees and the program, much like developmental milestones on a child’s growth chart. milestones describe the learning path in terms of a competency that transforms a novice student from basic and clinical specialization courses in medical sciences into a proficient student. Milestones differ from many other assessments in that they provide a golden opportunity for the learner to demonstrate achievement of the ultimate levels of sub-competencies, while also allowing for a shared understanding of expectations for the learner and faculty members. Milestones can provide a framework for all programs that allows for assurance that graduates and students have achieved a high level of competency (3).
Milestones provide a roadmap for programs and learners, defining their competencies at specific stages during the course of their education (3). Milestones were originally designed for residency and fellowship education to produce physicians who are capable of meeting the needs of patients and healthcare providers in the 21st century. Milestones, along with the related concept of entrustable professional activities (EPAs), were developed to provide a descriptive language that can facilitate a deeper and shared understanding of the competencies required in various disciplines across programs. Milestones also allow for a shift away from the overreliance on medical knowledge and the use of numerical rating scales in assessment forms, which have made assessment tools difficult for faculty to use. Milestones can also serve as a guide to creating more meaningful assessments. In addition, by identifying learner differences, milestones develop the ability to provide individualized coaching to help them move to the next level (6). Sometimes milestones are described as simple tasks: the ability to take blood pressure, take a relevant history, and perform an abdominal examination. Nevertheless, there is a broader range of higher-order competencies that are complex and have a deeper context. Milestones are a meaningful narrative of a checklist for describing a student’s progress in a specific competency and are a powerful way to justify one’s judgments about a student’s progress toward the competency (8). Simply put, milestones describe levels of performance at which learners are expected to demonstrate their skills, knowledge, and behaviors in core competency areas. They provide a framework of observable behaviors and other characteristics associated with a trainee’s or resident’s progress as a physician. In general, a milestone is a significant point in the overall progression of development. Milestones provide specific descriptors for competencies and sub-competencies along a developmental continuum with varying degrees of detail (6). The implementation of milestones requires faculty empowerment, as most assessments rely on observation. Therefore, faculty members are responsible for measurement and should receive the necessary education in observational assessment skills. However, milestones have been criticized for a number of conceptual problems. Some experts believe that milestones have a reductionist perspective (8).
It is noteworthy that competency-based education has a number of prerequisites and requirements, and meeting these prerequisites and requirements plays a significant role in facilitating competency-based education. Among the prerequisites for competency-based education is the development of a competency-based curriculum. When a competency-based curriculum is developed, learners' education will be shaped based on competency. One of the requirements of competency-based education is competency-based assessment. In competency-based assessment, process owners must develop entrustable professional activities and milestones for assessment.
In general, according to the literature review on competency-based education in different countries, competency-based education is an approach that all developed countries are moving towards, and have changed their approach in medical curricula from time-based education to competency-based education. The medical sciences educational system in Iran is bound to change its direction towards competency-based education to fulfill its primary objective of enhancing health services for its key recipients, the general public.