As a pediatric cardiologist, I have spent my career watching children grow. During clinic visits, we track their height, weight, and milestones. We also sit with families and ask what makes their children smile. We might send a toddler to physical therapy for gross motor delay while we also encourage her love of art or music. Years of listening to parents share what their child enjoys has taught me that focusing on strengths builds confidence and resilience. Somewhere along the long treadmill of medical education, we forget this lesson. We reduce adults to numerical scores, class ranks, and lists of accomplishments. It is time to re-imagine how we train physicians and to design a system that honors development while ensuring the rigor patients deserve.

The problem with merit-based selection

Undergraduate pre-medical programs and medical schools have long rewarded performance. Students compete for the highest grade point averages, research publications, volunteer hours, and exam scores. Even after the United States Medical Licensing Examination (USMLE) Step 1 became pass/fail, Step 2 Clinical Knowledge quickly replaced it as a screening tool, and clerkship grades, honors society membership, and research output still dominate residency applications. Ironically, the evidence underpinning these metrics is thin. A narrative review of residency selection factors found that while program directors frequently cite USMLE scores, letters of recommendation, and honors grades when ranking applicants, studies rarely show that high Step 1 or Step 2 scores predict resident performance; only failure on these exams consistently predicts problems in training. A systematic review concluded that Step 1 and Step 2 scores should be used as only one component of a holistic review because correlations between these scores and residency performance vary widely across specialties and often disappear when other factors are considered.

Clerkship grades are no better. An analysis of 86 U.S. medical schools found that the percentage of students receiving “honors” in surgery clerkships ranged from 5 percent to 67 percent; there is no standardized method for awarding honors, making grades unreliable for comparing applicants. A scoping review of assessments in undergraduate medical education concluded that no single assessment could meaningfully differentiate medical students; many studies narrowly defined validity or failed to report validity evidence at all. Only 33 studies in the review examined content validity, and a minority explored response processes or consequences. The literature therefore suggests that our reliance on numerical metrics reflects convenience rather than evidence.

Evaluators themselves struggle to use competency frameworks as intended. In a study examining the Accreditation Council for Graduate Medical Education (ACGME) international competency measures, confirmatory factor analysis demonstrated severe multicollinearity among the six core competencies; physicians’ ratings of patient care, medical knowledge, professionalism, and other domains were so highly correlated that they essentially measured the same underlying construct. The authors cautioned that simply adding more sub-competencies, such as those found in the Milestones, without addressing flawed tools would amplify an already flawed strategy. In practice, faculty often judge learners using holistic impressions or “gut feelings.” If we acknowledge this subjectivity, we can design assessments that capture a trainee’s strengths and areas for growth rather than distilling them into a single number.

Why Milestones have helped, but not enough

Recognizing the limitations of grades and test scores, the ACGME and American Board of Medical Specialties launched the Milestones Project to describe progressive levels of competence across the six core competencies. The ACGME Milestones Guidebook explains that milestones provide descriptive language to articulate expectations and were meant to reduce reliance on high-stakes tests. Milestone levels are criterion-based, not tied to postgraduate year, and are used for individualized coaching and structured clinical competency committee deliberations. Programs report milestone ratings twice a year, and early experiences suggest that milestones encourage more specific feedback and a shared mental model of competence.

However, research on the validity of milestones is still developing. Furthermore, training in how to coach learners is almost nonexistent. A systematic review of studies in surgical specialties found that evidence for the internal structure of milestones and their predictive validity for future patient outcomes is limited; further investigation is needed to examine measurement error and to confirm the factor structure across specialties. An editorial argued that the pressure to meet accreditation requirements may lead programs to add milestone items to existing global end-of-rotation forms without increasing direct observation; in such circumstances, milestone ratings become another checkbox rather than a developmental tool. A 2024 JAMA study underscores these concerns: Among nearly 7,000 newly trained hospitalists, high vs. low milestone ratings were not associated with lower seven-day or 30-day patient mortality or readmission rates, whereas physicians in the top quartile of certification exam scores had significantly lower seven-day mortality and readmission rates. In other words, milestone ratings may not yet capture the competencies that matter most for patient outcomes.

Entrustable professional activities: Towards authentic assessment

To bridge the gap between competency frameworks and workplace readiness, medical educators have introduced entrustable professional activities (EPAs). An EPA is a unit of professional practice, such as performing an initial patient assessment or handing over care, that can be fully entrusted to a trainee once sufficient competence is demonstrated. EPAs provide a structure for increasing autonomy and emphasize the progression from novice to independent practitioner. They recognize that competence is not demonstrated in isolation but through integration of multiple skills in authentic contexts.

Implementation of EPAs has been uneven. Developing specialty-specific EPAs requires consensus among stakeholders, faculty development, robust monitoring systems, and administrative support. In emergency medicine, program directors felt that generalist EPAs were too broad, lacked granular observable practice activities, and failed to account for limited opportunities for students to practice complex tasks. They advocated for a framework that maps EPAs to specific observable practice activities and milestones, and for better data transfer from medical school to residency to inform intern readiness. These challenges illustrate that EPAs cannot simply be grafted onto existing curricula; they require cultural change and collaboration across the education continuum.

The American Board of Pediatrics (ABP) has committed to incorporating EPAs into certification decisions by 2028. Beginning in the 2025-2026 academic year, training programs are expected to incorporate EPA-based assessment tools and discuss supervision requirements for EPAs in clinical competency committee meetings. By 2028, programs will report levels of supervision for each trainee annually, and final evaluation forms will require program directors to attest that each graduate is ready to practice unsupervised for every EPA relevant to their field. The ABP emphasizes that readiness to practice means safe and effective care without supervision, not mastery, and that continued growth and lifelong learning are expected. This approach aims to align assessment with the ultimate goal of physician training: producing clinicians who can deliver safe care independently while continuing to evolve.

Balancing growth mindset and academic rigor

Moving away from grades and standardized tests cannot mean abandoning rigor. Patient safety depends on physicians who possess deep medical knowledge, sound clinical judgment, and professionalism. The JAMA study demonstrating that higher certification exam scores correlate with lower patient mortality and readmission rates reminds us that knowledge matters. Likewise, board pass rates are used as markers of program quality and are publicly reported; because passing board exams is tied to earlier standardized test performance rather than to specific residency program features, programs may feel pressure to recruit high test scorers. Campbell’s law warns that when high-stakes metrics drive behavior, they can distort the process (e.g., “recruit for the ability to pass the test”). In our desire to de-emphasize test scores, we must ensure that new assessment tools are valid, reliable, and aligned with patient outcomes.

This balance between developmental focus and academic rigor parallels what we teach parents in clinic. We can reassure a family that a child will learn to read at her own pace while still ensuring she receives excellent instruction. Similarly, we must provide physicians with structured curricula, deliberate practice, and feedback to master the knowledge and skills required for safe practice. The Milestones, EPAs, and certification exams each contribute different pieces: Milestones offer descriptive feedback and developmental trajectories; EPAs link competence to clinical tasks and entrustment decisions; exams ensure foundational knowledge. None should function in isolation. As educators, we must build systems that integrate these tools into coherent, longitudinal learning plans.

A call for a longitudinal, learner-centered continuum

One reason change has been slow is the fragmentation of the education continuum. Pre-medical advisors, medical school faculty, and residency programs often operate in silos. The information collected during the residency application process seldom flows forward to inform individualized learning plans. Fellowships and continuing medical education are often treated as separate chapters rather than continuations of professional growth. Even within institutions, internal coaching programs are frequently perceived as punitive remediation rather than opportunities for development.

To support physicians across the lifespan, we need to begin investment early. Pre-medical advisors should work with students to cultivate reflective practice, resilience, and curiosity rather than simply chasing shadowing hours. Medical schools should design assessments that capture a range of competencies, provide meaningful feedback, and demonstrate validity evidence. Residency programs must adopt programmatic assessment that includes multiple direct observations, narrative feedback, and learner self-assessment. Faculty need training to deliver coaching that focuses on strengths while addressing deficiencies. Finally, board-certifying organizations should ensure that their metrics promote both rigor and growth: EPAs must be defined clearly, milestone ratings should be improved with better assessment tools, and board exams should continue to evolve to test clinically relevant knowledge.

Academic medicine has made progress. Competency-based education anchored in EPAs and qualitative milestones shifts success metrics from hours logged to skills demonstrated; scholars have called for rigorous, longitudinal evaluation of these reforms to ensure they enhance competence and learner well-being. If we succeed, we may build training environments that are psychologically safe, data-driven, and invested in their learners’ strengths, thereby reducing burnout and improving patient care.

Coaching, the physician development ladder, and operating system

Even the most carefully designed assessment system cannot replace the human element of growth. Physicians continuously navigate changes in medical knowledge, technology, work-life integration, and personal priorities. Coaching has emerged as a mechanism to help individuals clarify goals, recognize barriers, and translate feedback into meaningful action. A review of physician coaching programs demonstrates that coaching reduces burnout, improves resilience, and enhances performance. Across diverse models, coaching is defined as a process that equips individuals with tools and opportunities to develop themselves, grounded in relationship-building, problem definition, goal setting, and transformation. Effective programs attend to the fit between coach and coachee, the balance of internal versus external coaching, and the structure that underpins the process.

To operationalize these principles, we pair coaching with two complementary frameworks: the Physician Development Ladder and the Developing Doctor Operating System (Identify, Align, Develop, Sustain). Together, they provide both a longitudinal map of professional identity formation and a practical method for day-to-day growth.

The Physician Development Ladder emphasizes progression across stages of identity and impact, from Developing Professional and Emerging Healer, through Adaptive Clinician and Intentional Physician, to Evolving Leader. Each stage is anchored by reflective questions (e.g., Do I belong? How do I stay whole? What impact do I want to leave?), helping physicians contextualize their experiences within a broader developmental journey. This ladder reframes growth as an evolving process rather than a fixed endpoint.

Complementing the ladder is the Operating System, which provides the mechanism for movement along it:

• Identify. The first step is self-awareness. Physicians examine stress patterns, emotional triggers, strengths, and core values. They explore the root causes of dissatisfaction, whether excessive workload, lack of meaning, or misalignment with personal priorities, and begin to define what fulfillment and success truly mean. This aligns with reflective practices emphasized in competency-based education and anchors development in insight rather than external metrics.
• Align. With greater clarity, physicians begin to intentionally choose their path. They align their actions with their values, set boundaries, and make decisions that reflect long-term goals rather than immediate pressures. This stage represents a critical shift from reactive functioning to intentional career design.
• Develop. Physicians then build the skills required to execute on that alignment. This includes both clinical excellence and the nonclinical capabilities often underemphasized in training, emotional intelligence, communication, leadership, resilience, and boundary setting. A structured curriculum supports this phase, including modules on distinguishing burnout from job dissatisfaction, working to one’s strengths, clarifying values, improving communication (e.g., DISC frameworks), building community, and exploring nonclinical opportunities.
• Sustain. The final phase focuses on durability. Physicians create systems that support long-term well-being, purpose, and performance. They reconnect with the motivations that drew them to medicine while building a career that remains adaptable as life circumstances evolve. Rather than episodic fixes, the goal is sustainable fulfillment.

Importantly, both the ladder and operating system are cyclical rather than linear. Physicians move fluidly between stages and phases as new challenges, roles, and opportunities emerge. This mirrors the reality of medical careers, where growth is iterative and context-dependent.

Integrating coaching with these frameworks alongside traditional assessment such as milestones, EPAs, and board examinations creates a more complete model of physician development. It reframes feedback as a collaborative, strengths-based process and shifts the focus from performance alone to identity, alignment, and sustainability. Critically, coaching should not be reserved for those labeled as “problem learners.” When embedded routinely and positioned as a pathway to excellence, it becomes an expected and valued part of professional growth.

By incorporating the Development Ladder and Operating System into the continuum of medical education from pre-medical advising through independent practice, we create a bridge between competency and fulfillment. Coaching supports the growth mindset central to competency-based education, while these frameworks help physicians make sense of who they are becoming. Together, they ensure that physicians not only meet the standards required for safe patient care but also cultivate the resilience, leadership, and sense of purpose necessary for a meaningful and sustainable career.

Conclusion

Development never stops. As physicians, we ask our patients to embrace growth and to use their strengths. We owe ourselves the same opportunity. Yet we must pair a growth mindset with evidence-based assessment and unwavering commitment to academic rigor. By rethinking physician training, de-emphasizing unreliable performance metrics, harnessing the descriptive power of milestones, entrusting learners with authentic clinical activities, and ensuring that knowledge standards correlate with patient outcomes, we can cultivate clinicians who are not only competent but continually evolving. The health of our patients, and the joy of those called to medicine, depend on it.

Ben Reinking is a board-certified pediatric cardiologist, medical educator, and certified physician development coach, as well as the owner of The Developing Doctor. He can also be reached on Instagram.

He’s not just any coach—he’s a practicing physician who truly understands the realities of modern medicine. He knows firsthand the internal battles you’re facing, from short-staffing and limited resources to production metrics, constant billing pressures, and the ways your altruism can be taken advantage of. Ben is here to help you reignite the passion that first led you to medicine and provide you with the strategies needed to regain control.