Background? Residents in Accreditation Council for Graduate Medical Education accredited emergency medicine (EM) residencies were assessed on 23 educational milestones to capture their progression from medical student level (Level 1) to that of an EM attending physician (Level 5). Level 1 was conceptualized to be at the level of an incoming postgraduate year (PGY)-1 resident; however, this has not been confirmed.;Objectives? Our primary objective in this study was to assess incoming PGY-1 residents to determine what percentage achieved Level 1 for the 8 emergency department (ED) patient care–based milestones (PC 1–8), as assessed by faculty. Secondary objectives involved assessing what percentage of residents had achieved Level 1 as assessed by themselves, and finally, we calculated the absolute differences between self- and faculty assessments.;Methods? Incoming PGY-1 residents at 4 EM residencies were assessed by faculty and themselves during their first month of residency. Performance anchors were adapted from ACGME milestones.;Results? Forty-one residents from 4 programs were included. The percentage of residents who achieved Level 1 for each subcompetency on faculty assessment ranged from 20% to 73%, and on self-assessment from 34% to 92%. The majority did not achieve Level 1 on faculty assessment of milestones PC-2, PC-3, PC-5a, and PC-6, and on self-assessment of PC-3 and PC-5a. Self-assessment was higher than faculty assessment for PC-2, PC-5b, and PC-6.;Conclusions? Less than 75% of PGY-1 residents achieved Level 1 for ED care-based milestones. The majority did not achieve Level 1 on 4 milestones. Self-assessments were higher than faculty assessments for several milestones.;What was known and gap While emergency medicine has conceptualized Level 1 performance to be at the level of an incoming resident, research to date has not assessed this aspect of the milestone framework.;What is new A study using faculty and residents' self-ratings on the Emergency Medicine Milestones.;Limitations Single specialty, small sample, and lack of standardization of faculty assessments all limit generalizability.;Bottom line Less than 75% of entering residents achieved Level 1 for emergency department care-based milestones, and the majority did not achieve Level 1 on 4 of these milestones.;Introduction Medical education has moved to a competency-based education and assessment model. This is a distinct deviation from previous time-based models and has been driven by the Accreditation Council for Graduate Medical Education (ACGME), first through the Outcome Project and, more recently, the Milestones Project.1,2 The core element of the new approach is to use real-time, competency-based assessments. These frequent low-stakes, competency-based assessments would replace many of the traditional, less frequent, high-stakes global assessments, which are often done long after the actual behavior or skill being evaluated was performed.2,3 Presently, all emergency medicine (EM) residents must be rated on a continuum describing the trainee's level of function across 23 milestones.3 These milestone assessments capture EM residents' progression across a continuum of maturation, ranging from medical student level up to that of an attending physician, via a 5-level hierarchical progression score.4 Subcompetencies measure discrete and observable skills in interpersonal and communication skills (ICS), professionalism (Prof), patient care (PC), medical knowledge (MK), practice-based learning and improvement (PBLI), and systems-based practice (SBP).4 For convenience, the milestones have been subdivided by EM program directors into 3 categories: emergency department (ED) care-based milestones (PC 1–8), procedural-based milestones (PC 9–14), and systems-based milestones (MK, SBP 1–3, PBLI, Prof 1–2, and ICS 1–2). The ACGME describes Level 1 as “The resident demonstrates milestones expected of an incoming resident.”4 Level 1 milestones were initially conceptual
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