Opportunities and Challenges: Residents' Perspectives on the Next Accreditation System in Psychiatry

The unfolding of the Accreditation Council on Graduate Medical Education (ACGME)’s Next Accreditation System (NAS) and its corresponding Milestones introduce new data elements into resident evaluation. In theory, these new regulations should be welcomed and freeing for programs and trainees alike. The switch to a self-study model will reduce site visits and may relieve the associated cycles of panic. Standardized evaluations across programs should allow us to more directly compare graduates of different residencies. The grand vision is that these comparative data will act in a virtuous cycle, encouraging programs and individual trainees to try harder and innovate more [1]. NAS is intended as a step towards the utopia of “value-based health care” that was taught to us in medical school, but of which we have seen far too little on the wards [2]. That perspective has much to recommend it. First, although the Milestones were developed by committee and contain much that is subjective, they are grounded in both evidence and the collective experience of multiple respected educators. Residents can take comfort that we will be measured by a yardstick that is fair, rigorous, and well-aligned to the needed skill-set of a 21st century psychiatrist. This is doubly true given that the Psychiatry Milestones come with suggested assessment tools and anchors. No longer will an entire year be summarized by a stack of Likert scales filled with average scores and empty comment boxes. Second, a key value of the Milestones is identification of our individual areas of distinction and deficit. We and our faculty preceptors will know where we need help, and we can seek out mentors to remedy our weaknesses. Where we are exceptional, we will have standardized data to prove it. Those data could be the door to greater autonomy at an earlier stage, opportunities for teaching and scholarship, and leadership roles earlier than the chief year. All those things happen now, as strengths are organically recognized by faculty, but the Milestones could easily expedite the process. They will also galvanize new teaching, as neuroscience, system-based practice, and formal self-improvement take on the same stature in education that they are rapidly gaining in psychiatric practice. As noted elsewhere in this issue, the Milestones codify expectations in competencies that have long been neglected, but that will be critical in coming decades. Beyond the immediate horizon, Milestones might be the bridge to a portfolio-model residency. The ongoing crisis in Federal Graduate Medical Education (GME) funding, has fueled a growing call for shorter and more flexible training [3]. Although the current framework is not explicitly designed to support this, it is easy to imagine a future in which rapid progression through Milestones qualifies a resident for early graduation, perhaps even earlier than is achievable under the current “fast tracking” system. Although there would be much to resolve in terms of funding, such a scenario could benefit both trainees (by bringing us more quickly to attending salaries) and payors (by maximally leveraging GME dollars). NAS’ designers hope that all programs are (or want to be) above average, and thus, their residents also will be. Unfortunately, all of us, from the newest intern to the most senior faculty, know this to be untrue. Problem residents have existed as long as there have been residencies, and the objectivity of the Milestones will make their deficiencies blatant and unA. S. Widge (*) Massachusetts General Hospital, Charlestown, MA, USA e-mail: awidge@partners.org