Medical Educator Minute: What’s the Difference between Milestones and EPAs?

Last month, we discussed methods of assessment in medical education. Milestones and EPAs are both methods of assessing trainees in a system of competency-based medical education (CBME). If you recall, competency-based medical education starts with the final outcome in mind (i.e., providing excellent patient care as a competent physician) and includes levels to capture progression towards that end goal. Training programs can then design educational opportunities and/or provide coaching to help trainees gain knowledge and skills needed to move from their current level to a higher level of competence.

Milestones, as published by the ACGME, focus on the individual components (i.e., knowledge and skills) needed to become a competent physician. These components vary slightly among specialties but are generally grouped under common categories, including medical knowledge, patient care, system-based practice, professionalism, interpersonal and communication skills, and practice-based learning and improvement. Within each milestone, different levels are articulated, and generally, a medical trainee should progress from level 1 as a medical student to level 5 as an attending or independent practitioner. A trainee can be at different levels within different categories at the same time (such as level 2 in medical knowledge while level 4 in communication skills), as trainees are all on their own individual path towards competence. You can read more about milestones here.

Entrustable Professional Activities (EPAs) are measures of competence from a more global perspective grounded in patient care. They are often determined by each specialty (with input from the specialty board) to capture the physician activities needed to practice competently within that specialty. As these are more global measures of competence, they often include components from several milestone categories. For example, “Care of the Newborn” (an EPA within general pediatrics) requires medical knowledge, skills of patient care, communication skills, and experience in systems-based practice to competently care for a newborn independently. EPAs are measured by levels of “entrustment,” as in ‘is the trainee trusted to perform this type of patient care only with direct supervision, or with indirect supervision, or independently’, etc.

Both EPAs and milestones can be useful tools for assessing trainees, as well as for guiding feedback conversations: EPAs can give us a snapshot of where a trainee is in the progression towards competence needed for independent practice, and milestones can give us more specific information about which additional knowledge and skills are needed to reach competence. You can read more about using EPAs to shape your curriculum, as well as how EPAs and milestones are related here: AMEE Guide No. 99:.