EPAs, Core Outcomes, Competencies, Subcompetencies, and Milestones

Core Outcomes of Family Medicine Education

The ACGME Family Medicine Review Committee (FM-RC) and the ABFM established the “core outcomes” of family medicine residency education, building on the family medicine EPAs. The core outcomes represent observable behaviors that can be improved with deliberate practice.

"The ACGME Family Medicine Review Committee, the American Board of Family Medicine, and family medicine residency programs and faculty across the country commit to the patients and communities they serve that residents who complete ACGME-accredited training in family medicine will be able to:

1. Develop effective communication and constructive relationships with patients, clinical teams, and consultants
2. Practice as personal physicians, providing first-contact access, comprehensive, and continuity medical care for people of all ages in multiple settings and coordinate care by helping patients navigate a complex health care system
3. Provide preventive care that improves wellness, modifies risk factors for illness and injury, and detects illness in early, treatable stages for people of all ages while supporting patients’ values and preferences
4. Evaluate, diagnose, and manage patients with undifferentiated symptoms, chronic medical conditions, and multiple comorbidities
5. Diagnose and manage common mental health conditions in people of all ages
6. Diagnose and manage acute illness and injury for people of all ages in the emergency room or hospital
7. Perform the procedures most frequently needed by patients in continuity and hospital practices
8. Care for low-risk patients in prenatal care, labor and delivery, and post-partum settings
9. Effectively lead, manage, and participate in teams that provide care and improve outcomes for the diverse populations and communities they serve
10. Model lifelong learning and engage in self-reflection
11. Assess priorities of care for individual patients across the continuum of care—in-office visits, emergency, hospital, and other settings, balancing the preferences of patients, medical priorities, and the setting of care
12. Model professionalism and be trustworthy for patients, peers, and communities" ¹

Beginning in June 2024, the American Board of Family Medicine will require program directors to attest "both that each resident has finished their residency and is competent in all the core outcomes, "with an additional focus on robust continuity of care, the care of children and more specific aspects of the care of pregnant women." The  attestation requirement will be rolled out over 3 years, with the following schedule.² 

June 2024 program directors will attest that each graduating resident is competent to:

• "Practice as personal physicians, providing first contact, comprehensive and continuity care, to include excellent doctor-patient relationships, excellent care of chronic disease and routine preventive care and effective practice management.
• Diagnose and manage acute illness and injury for people of all ages in the emergency room or hospital.
• Provide comprehensive care of children, including diagnosis and management of the acutely ill child and routine preventive care.
• Develop effective communication and constructive relationships with patients, clinical teams, and consultants
• Model Professionalism and be trustworthy for patients, peers, and communities."

June 2025, program directors will attest that each graduating resident is competent in the above and to:

• "Practice as personal physicians, to include care of women, the elderly, and patients at the end of life, with excellent rate of continuity and appropriate referrals.
• Provide care for low-risk patients who are pregnant, to include management of early pregnancy, medical problems during pregnancy, prenatal care, postpartum care and breastfeeding, with or without competence in labor and delivery.
• Diagnose and manage of common mental health problems in people of all ages.
• Perform the procedures most frequently needed by patients in continuity and hospital practices.
• Model lifelong learning and engage in self-reflection."

In June 2026, program directors will attest that each graduating resident is competent in the above and to:

• "Practice as personal physicians, to include musculoskeletal health, appropriate medication use and coordination of care by helping patients navigate a complex health system.
• Provide preventive care that improves wellness, modifies risk factors for illness and injury, and detects illness in early, treatable, stages for people of all ages while supporting patients’ values and preferences.
• Assess priorities of care for individual patients across the continuum of care—in-office visits, emergency, hospital, and other settings, balancing the preferences of patients and medical priorities.
• Evaluate, diagnose, and manage patients with undifferentiated symptoms, chronic medical conditions, and multiple comorbidities.
• Effectively lead, manage, and participate in teams that provide care and improve outcomes for the diverse populations and communities they serve."²

^{1. Newton W, Cagno CK, Hoekzema GS, Edje L. Core Outcomes of Residency Training 2022 (Provisional). Ann Fam Med. 2023 Mar-Apr;21(2):191-194. doi: 10.1370/afm.2977. Epub 2023 Mar 2. PMID: 36863777; PMCID: PMC10042560.}

^{2. Newton W, Magill M, Barr W, Hoekzema GS, Karuppiah S, Stutzman K. Implementing Competency Based ABFM Board Eligibility. The Journal of the American Board of Family Medicine Aug 2023, 36 (4) 703-707; DOI: 10.3122/jabfm.2023.230201R0}

ACGME Competencies

"The Accreditation Council for Graduate Medical Education US’ graduate medical education programs foster resident physicians’ development of competencies in six domains and collect performance data that reliably and accurately depicts residents’ ability to care for patients and to work effectively in healthcare delivery systems."¹

Patient Care
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Medical Knowledge
Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care.

Practice-Based Learning and Improvement
Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.

Interpersonal and Communication Skills
Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.

Professionalism
Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.

Systems-Based Practice
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

1. Swing SR. 2007. The ACGME outcomes project: Retrospective and prospective. Med Teach 29(7):648–654.

ACGME Family Medicine Subcompetencies

Patient Care
Patient Care 1: Care of the Acutely Ill Patient
Patient Care 2: Care of Patients with Chronic Illness
Patient Care 3: Health Promotion and Wellness
Patient Care 4: Ongoing Care of Patients with Undifferentiated Signs, Symptoms, or Health Concerns
Patient Care 5: Management of Procedural Care

Medical Knowledge
Medical Knowledge 1: Demonstrates Medical Knowledge of Sufficient Breadth and Depth to Practice Family Medicine
Medical Knowledge 2: Critical Thinking and Decision Making

Systems-Based Practice
Systems-Based Practice 1: Patient Safety and Quality Improvement
Systems-Based Practice 2: System Navigation for Patient-Centered Care
Systems-Based Practice 3: Physician Role in Health Care Systems
Systems-Based Practice 4: Advocacy

Practice-Based Learning and Improvement
Practice-Based Learning and Improvement 1: Evidence-Based and Informed Practice
Practice-Based Learning and Improvement 2: Reflective Practice and Commitment to Personal Growth

Professionalism
Professionalism 1: Professional Behavior and Ethical Principles
Professionalism 2: Accountability/Conscientiousness
Professionalism 3: Self-Awareness and Help-Seeking Behaviors

Interpersonal and Communication Skills
Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication
Interpersonal and Communication Skills 2: Interprofessional and Team Communication
Interpersonal and Communication Skills 3: Communication within Health Care Systems

ACGME Milestones

Each subcompetency has five Milestone levels, which represent the resident education process and graduation into independent practice. According to the ACGME, the definition of each level is as follows:

• Level 1: The resident demonstrates some of the behaviors or skills that would be expected of someone with some education in family medicine
• Level 2: The resident demonstrates increased achievement of expected behaviors or skills.
• Level 3: The resident continues to advance with further achievement of behaviors or skills, and has achieved most of the milestones expected for residency graduation.
• Level 4: The resident has achieved all of the milestones expected for residency graduation.
• Level 5: Describes an "expert resident" who has performed at a level beyond expectations.

Core Outcomes of Family Medicine Education Mapped to ACGME Family Medicine Subcompetencies

This mapping project, completed by the STFM CBME Task Force, is intended to facilitate growth in both the resident and the curriculum. It is intended to be a guidepost, not a final destination, on the journey from learning to competency. True assessment requires frequent, multimodal assessment including direct observation.

• Mapping of Core Outcomes to ACGME Family Medicine Subcomptencies (pdf)
• Best Practice Recommendations for Utilizing the Core Outcome Mapping Project (pdf)

Recommended Ways to Use this Mapping:

• Competency-Based Assessment and Individual Learning Plans (ILPs)
  1. When a resident is found to have a growth area in a particular Core Outcome (CO), the Clinical Competency Committee (CCC) can use this mapping to identify specific measurable behaviors within the sub-competencies with which to recommend learning activities that residents can include in their ILP.
  2. Residents who are not progressing toward competency in the required COs can use the language from the corresponding mapped sub-competencies to help develop remediation plans beyond the resident-driven ILP when necessary.
  3. Example: if a resident is found to need/want more growth in communication skills (CO #1), the advisor might look at the milestones mapped to that CO, see the Level 4 descriptors for ICS 2, and design a SMART goal around coordinating recommendations from different members of the healthcare team.
• Program Curricular Gaps
  1. As the Program Evaluation Committee (PEC) evaluates the overall residency curriculum, they can use this mapping to identify areas in need of further development.
  2. Example: if the program sees they are having trouble assessing residents in care of patients across the continuum (CO #13), the PEC might look at milestones mapped to that CO, see the Level 4 descriptors for SBP 2, and find a way to add education and/or assessment of transitions of care hand-offs to their curriculum.
• Updating Existing Curriculum
  1. As the CCC is looking for better ways to assess resident performance across the various Core Outcomes, they can work with the PEC to better link existing rotations and other educational experiences to Core Outcomes without creating new curriculum.
  2. Example: if the CCC lacks adequate assessments for residents practicing as personal physicians (CO #2), the PEC could use the mapping to note that existing evaluation of resident ability to facilitate patient engagement in managing their own chronic disease and preventative health links to that CO through milestones in sub-competencies PC-2 and PC-3.

What this mapping is NOT:

• A graduation benchmark or other requirement
• A substitute for ACGME milestones

An all-inclusive linkage of sub-competencies to Core Outcomes