Realizing the promise of competency-based medical education.

Competency-based medical education (CBME) places a premium on both educational and clinical outcomes. The Milestones component of the Next Accreditation System represents a fundamental change in medical education in the United States and is part of the drive to realize the full promise of CBME. The Milestones framework provides a descriptive blueprint in each specialty to guide curriculum development and assessment practices. From the beginning of the Outcomes project in 1999, the Accreditation Council for Graduate Medical Education and the larger medical education community recognized the importance of improving their approach to assessment. Work-based assessments, which rely heavily on the observations and judgments of clinical faculty, are central to a competency-based approach. The direct observation of learners and the provision of robust feedback have always been recognized as critical components of medical education, but CBME systems further elevate their importance. Without effective and frequent direct observation, coaching, and feedback, the full potential of CBME and the Milestones cannot be achieved. Furthermore, simply using the Milestones as end-of-rotation evaluations to "check the box" to meet requirements undermines the intent of an outcomes-based accreditation system. In this Commentary, the author explores these challenges, addressing the concerns raised by Williams and colleagues in their Commentary. Meeting the assessment challenges of the Milestones will require a renewed commitment from institutions to meet the profession's "special obligations" to patients and learners. All stakeholders in graduate medical education must commit to a professional system of self-regulation to prepare highly competent physicians to fulfill this social contract.