Milestones: Not Millstones but Stepping Stones

In a recent Perspective entitled “Competency-Based Education: Milestones or Millstones?” Norman et al1 listed conceptual, psychometric, and logistic problems with competency-based medical education (CBME). Their conclusion—that learning and assessment based on the Milestones offer real benefit—may be lost on readers of this provocative piece. We take this opportunity to expand their description of 4 benefits of CBME over a traditional approach. We also suggest 2 additional benefits: (1) Milestones are critical to assessment based on direct observation in the context of real clinical practice; and (2) by targeting essential attributes of a high-performing physician, Milestones will advance the quality of care across specialties.There are 2 additional benefits to those described by Norman et al.1All these benefits contribute to making Milestones the stepping stones to competence and, ultimately, expertise. Although the concept of CBME may be revolutionary, its implementation is evolutionary. The medical education community must accept this paradox and be willing to engage in the rigorous study of Milestones and EPAs to deliver the demanded “proof” that this framework improves educational outcomes. We embrace a “realist” approach for the study of this evolutionary process, focusing on what works and why, facilitating adoption and adaptation of the principles of CBME in graduate medical education and the assessment of performance in practice.6 We look forward to vigorous dialog and rigorous study that will advance competency-based assessment. As a self-regulating profession, we owe our colleagues and the public nothing less.