Mind the Gap: The Bumpy Transition From Medical School to Residency.

I n 2008, the Accreditation Council for Graduate Medical Education began development of the Next Accreditation System, an assessment strategy based on residents’ achievement of specific milestones within defined competencies as they progress through training. Medical specialties were tasked with creating milestones specific to their training programs. Although similar competency frameworks were used across specialties, these milestones were largely developed in isolation. Not surprisingly, the resulting milestones were ‘‘richly diverse.’’ In several specialties, Level 1 is considered the novice level, and is assumed to have been reached in medical school. In this issue of the Journal of Graduate Medical Education, 2 articles report on the use of milestones to assess learners at the transition from undergraduate medical education (UME) to graduate medical education (GME). Clay et al described the assessment of fourth-year medical students with Transitional Year Milestones during a 4-week mandatory capstone course at the conclusion of their undergraduate training, while Weizberg and colleagues measured whether emergency medicine residents had achieved Level 1 Emergency Medicine Milestones at the end of their first month of residency. Although these were neither the same subjects, nor the same set of milestones, one would expect comparable performance on the overall construct of milestone evaluation, given the difference of only 1 month of residency. However, the results of these 2 studies suggest very different levels of performance. For students in the study by Clay et al, with a range of possible milestone levels from 1 to 5, the mean milestone levels on self-, peer, and faculty evaluations ranged between 2.2 and 3.6; in fact, no mention was made of anyone failing to achieve at least Level 2. In contrast, only 20% to 73% of the cohort of residents studied by Weizberg et al achieved Level 1 milestones on faculty evaluations, and on 2 competencies, a majority of interns rated themselves as not achieving Level 1. Considering the difficulties with self-assessment, it is remarkable that interns admitted they did not achieve entry-level milestones. Depending on the subcompetency, 34% to 92% of interns reported achieving Level 1 on self-evaluations. Can we explain how senior medical school students achieved levels 2 to 3 milestones in one group, while a second group of interns in their first month of residency are, for the most part, not achieving Level 1?