In 2021, the Accreditation Council for Graduate Medical Education (ACGME) updated its Milestones tool for assessing geriatrics fellows, now called Milestones 2.0. Programs were required to use Milestones 2.0 in July 2021, but the implementation process is meant to be iterative over multiple assessment cycles.

Shoshana Streiter, MD, a geriatrician in the Division of Aging at Brigham and Women’s Hospital, Laura Edgar, EdD, vice-president of Milestones Development at ACGME, and colleagues have outlined a four-step process for geriatric fellowship programs to use in transitioning from the original Milestones to Milestones 2.0. They offer their recommendations in the Journal of the American Geriatrics Society.

Step 1: Train Faculty

Faculty should become thoroughly familiar with the three significant changes to the original Milestones:

• Content updates to emphasize geriatric knowledge and skills (e.g., performing a comprehensive geriatric assessment, assessing and optimizing cognition); interdisciplinary team engagement; framing care within the context of patient prognosis, goals, and values; and family and caregiver needs. In addition, “Physician Well-being” is a new milestone.

• Revision of the rating system to refocus assessment on skills acquisition rather than deficiencies of the learner. Level 1 indicates a beginning fellow; level 2, an advanced beginner; level 3, an advancing and improving learner; level 4, a proficient learner (the goal for a graduating fellow); and level 5, an aspirational expert who serves as a coach and/or role model for others.

• Creation of a supplemental guide available in Microsoft Word so fellowship faculty can tailor it to their program. Leaders should begin by writing a brief introduction to Milestones 2.0 with an outline of the overall plan and timeline for training faculty and fellows and implementing changes.

Opportunities to train faculty are the annual program evaluation meeting, division or department meetings, program evaluation committee meetings, faculty retreats, and dedicated shorter training sessions.

Step 2: Map to Current Tools

To integrate Milestones 2.0 into existing assessments, teaching faculty should first review the components of the current fellowship curriculum, including clinical rotations, continuity experiences, didactics, other formal teaching sessions, and fellows’ scholarly projects. They can then cross-check to verify that Milestones 2.0 is included in the curriculum and develop strategies to incorporate missing milestones.

Special attention is warranted for the patient care and medical knowledge milestones, the content of which has been substantially changed.

The Milestones 2.0 document incorporates the 76 Geriatric Curricular Milestones and the 12 End-of-Training Entrustable Professional Activities for Geriatric Medicine published by the American Geriatrics Society and Association of Directors of Geriatric Academic Programs in 2014. Programs already assessing their fellows based on those tools can remap their assessments to Milestones 2.0.

A written plan for aligning learner assessment to Milestones 2.0 should be reviewed by program directors, clerkship directors, administrators, fellows, and the Clinical Competency Committee (CCC). Scheduled, iterative review of all assessment tools by the CCC is also recommended.

Step 3: Train Learners

Milestones 2.0 should be presented to fellows as a tool for their self-assessments as well as a tool for faculty. Fellows can use the document to track their progress and develop their own action plans for improvement.

Fellows may have a variable understanding of the original milestones from their residencies, so a review of the six core competencies and an introduction to Milestones 2.0 can create a shared mental model between teachers and learners. This could be undertaken during fellow orientation using a sample self-assessment approach with one or more milestones and the Supplemental Guide.

It’s important for fellows to understand a score of 1 early in the year has no pejorative connotation; it reflects the expected level of performance at the beginning of the fellowship. Similarly, level 4 is the graduation target; most graduating fellows will not achieve level 5.

Step 4: Integrate Milestones 2.0 Into CCC Meetings

Milestones 2.0 should be regularly reviewed at CCC meetings to ensure each committee member is thoroughly trained in its application. One strategy is to:

1. Create a mock portfolio describing a hypothetical fellow’s performance across different sites of care and including key quality improvement metrics based on simulated chart review.
2. Ask faculty to say how they would rate the fellow by identifying certain milestones where the learner either excelled or had room for growth.
3. Have the group discuss differences of opinion until they achieve a shared understanding.

Another strategy is to have each faculty member complete a self-assessment by choosing one of the milestones and applying it to themselves. These strategies may also be useful for orienting other faculty, and fellows themselves, to Milestones 2.0.