The Use of Milestones in Clinical Training of Veterinary Students   

By: Jessica Meekins (https://www.r

The American Association of Veterinary Medical College’s (AAVMC) Council on Outcomes-based Veterinary Education COVE has been working towards widespread adoption of competency-based clinical training for almost a decade. Each competency in the Framework represents an expected outcome for a veterinary graduate after completion of the clinical training portion of a program, while milestones define the stages of learner development during training, and EPAs allow assessment of multiple competencies during an authentic workplace-based activity representative of entry-level veterinary work. The adoption of this outcomes-based approach has numerous benefits to the learner, faculty, profession, patients, employers, and society.

Milestones provide a mechanism for implementing competency-based education by providing sequenced developmental learning outcomes for each competency. They allow learners to visualize the expected course of development for each competency across the program. Educators may use milestones to document learner progression along the learning continuum, to assess learner performance, and to provide feedback for their continued growth and learning.

In medical education, milestones include the following levels:  Novice, Advanced Beginner, Competent, Proficient, and Expert. Milestones have also been used with increasing frequency to support medical students transitioning through internship and into residency training.  Like medical school, in the U.S. most veterinary students are typically admitted after a pre-health science undergraduate degree and the veterinary degree program is a four-year program. However, in contrast to physician training, most veterinarians will go on to practice after the professional degree without completing an internship and/or residency. The typical DVM program in the U.S. is structured to include two to three years of pre-clinical didactic/laboratory coursework with a final one to two years of clinical training. Given the organizational differences between veterinary and physician-based medical training, the four milestones within the CBVE Model were initially published to support learner development in the final clinical phase of training prior to graduation.

  • Novice (Beginner) milestone: expected level of achievement prior to entering in training in the clinical workplace.
  • Advanced Beginner milestone: achieved across the clinical training program.
  • Competent milestone: expected level of achievement by the time of graduation.
  • Proficient milestone: this milestone is aspirational and meant to be achieved at some point during clinical practice.

Though significant focus has been placed on the development and use of EPAs in medical education, the importance of milestones as ‘signposts’ for both learners and educators along the learning pathway should not be overlooked. Milestones can be particularly helpful when using EPAs, with EPAs providing the clinical context for assessment of competencies using a wide-angle lens (e.g., the big picture) where learners must integrate multiple competencies to deliver effective patient care. Not only can milestones help inform decisions about progression towards competence, but they can also serve as aids in determining when a learner is struggling and may benefit from remediation. With that in mind, those of us involved with the CBVE Model are making a concerted effort to focus on the important role milestones play in both learner development and in educator assessment.

We can use a bike-riding example, an activity with which most individuals have experience, to help define how milestones relate towards the acquisition of competencies. In this example, several domains of competence and their associated competencies have been created to demonstrate the complex EPA of riding a bike. Each of these competencies must be mastered to successfully ride a bike.

Next, we encourage veterinary educators to apply this principle to veterinary education. Here is an example of an activity (EPA) that all graduates must be able to perform at the time of graduation: “Perform a common surgical procedure.” This example demonstrates how milestones are used to evaluate a learner’s achievement or progression in learning for an individual competency.  In this case, for an individual student performing a common surgical procedure, an educator/assessor should be able to assign the student’s performance at a point upon the learning pathway according to the milestones for the Competency – Performs veterinary procedures and post-procedural care.

Recognizing that the CBVE Competency Framework is applicable to all aspects of a veterinary training program, the AAVMC COVE and its associated CBVE Working Groups are currently drafting preclinical milestones to help veterinary educators understand how to implement CBVE across all phases of the training program. This is somewhat analogous to implementing CBME in undergraduate medical education. Since learners are expected to reach the Novice milestone level prior to entering the clinical portion of a veterinary training program, it only makes sense that preclinical milestones should be established to help guide learners to that point; they are essentially the building blocks of competency acquisition in the preclinical phase of training. After all, you don’t expect to be handed a half-drawn map in order to successfully navigate your way on a complicated journey! By combining both clinical and preclinical milestones, learners and educators can visualize the course along the pathway of learning that is expected for each competency, from entry into the program and through the point of graduation. Students may find value in preclinical milestones as signposts or a roadmap for their learning pathway. Likewise, preclinical milestones allow educators to visualize how foundational sciences contribute to the educational experiences of veterinary students. Preclinical milestones provide another opportunity for programs to operationalize competency-based education across the veterinary program.  Bringing together preclinical and clinical milestones allows students and educators a more holistic view of the approach to outcomes-based training.

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Jessica Meekins, DVM, MS, DACVO is an assistant professor in veterinary Ophthalmology at Kansas State University. Her clinical interests include management of viral surface ocular diseases in cats and investigating comparative ophthalmology in exotic/non-domestic species. She is also interested in clinical teaching and the integration of competency-based veterinary education into instruction and assessment of students participating in clinical rotations.

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