Milestones and EPAs

In the past decade, pediatric educators and researchers, with support and leadership from the American Board of Pediatrics (ABP), have developed and evaluated the integration of frameworks for assessing trainee readiness to practice medicine without supervision. These frameworks — core competencies along with their milestones and entrustable professional activities (EPAs) — complement each other and fill the assessment gaps that result when either is used alone.

To implement assessment in a competency-based medical education (CBME) system, health care teams directly observe trainees’ behavior when the trainees are providing care. The goal is to gather evidence of individual physician competence and give meaningful feedback to trainees that is specific, immediate, and behaviorally based. Other goals include measuring and improving training program effectiveness and, ultimately, linking educational and patient care outcomes.

Core Competencies

The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) developed the six core competency domains used to assess physicians during medical training and throughout their careers, are:

  • Patient care;
  • Medical knowledge;
  • Practice-based learning and improvement;
  • Interpersonal and communication skills;
  • Professionalism; and
  • Systems-based practice.

Within each domain, there are a number of specific competencies such as, “Gather essential and accurate information about a patient.”


Milestones are narrative descriptions of behaviors for each of the competencies, along a continuum of development ranging from a novice or early medical student to an advanced beginner, competent practitioner, proficient practitioner, and then to an expert clinician who is committed to ongoing practice improvement.

They also can be used as a learning roadmap at each phase of pediatric training to help reinforce and set learning goals and to assess the developmental progress along the novice to expert trajectory.

The pediatrics milestones were developed as a joint initiative of the ACGME, the ABMS, and the ABP, with thoughtful feedback from the Association of Pediatric Program Directors (APPD). The working group for the Pediatrics Milestone Project conducted a thorough literature review to inform their process of piecing together the developmental progression of knowledge, skills, and attitudes for each competency and then translating that information into milestones.



Entrustable Professional Activities (EPAs)

EPAs describe the essential activities that physicians are entrusted to perform safely and effectively without supervision. They provide the context in which the competencies and milestones come to life. An example of an EPA is “provide care to a well newborn.” This EPA maps to competencies that are most critical to making an entrustment decision for the EPA. In this example, competencies such as performing a thorough physical examination, being able to communicate with the family of a newborn, and transferring care to a community pediatrician are important to assess.

Seventeen EPAs describe the scope of practice as well as the knowledge, skills, and attitudes needed for general pediatricians. Four of those also apply to subspecialists (e.g., leading an interprofessional health care team). While two more EPAs are common to all subspecialties, each subspecialty has its own list of between three and six unique EPAs.

The ABP, along with both the general pediatrics and subspecialty pediatrics communities, identified the EPAs and developed their descriptions, functions, and curricular components.