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As part of medical education’s shift toward competencybased education (CBE), the Accreditation Council for Graduate Medical Education (ACGME) announced the Milestones Project in 2008 to create an outcomes-based model of competency development. The goal was to characterize specific accomplishments or behaviors demonstrated by physician trainees as they progressed toward independent practice. Since then, multiple specialties, with emergency medicine (EM) at the forefront, have developed and incorporated competency-based assessment of residents using specialty-specific Milestones. The development of EM Milestones by the Emergency Medicine Milestone Working Group (EMMWG) has been well-described.1 The EMMWG identified 23 subcompetencies within the six core competencies, and within each subcompetency, five different levels of proficiency. Each level has one or more Milestones of competency to mark the level of proficiency. As part of the Next Accreditation System (NAS) implemented by the ACGME in July 2013, each Milestone subcompetency has to be reported for every resident at six-month intervals by individual residency clinical competency committees (CCC).1 While well-intended, methodically planned and developed, these standards have been met with various levels of exasperation and confusion by medical educators seeking to implement the new requirements.2 It is not my goal to push back against the Milestones approach, as it represents an iterative, dynamic process to continually advance medical education to provide safer and higher quality patient care. However, I aim to describe some frontline challenges for clinician educators attempting to implement these recommendations. Ankel et al. predicted that “the future of CBE will require significant changes in the learning environment, resident assessment frequency, and faculty development.”3 Such changes have not happened in many programs, including my own. As a result, the sources of the trials and tribulations in the implementation of EM Milestones can Boston University School of Medicine, Boston Medical Center, Department of Emergency Medicine, Boston, Massachusetts

Trials and Tribulations in Implementation of the Emergency Medicine Milestones from the Frontlines