The milestone OSCE:
eight stations, mapped to the competency domains

Why this OSCE

Since licensing-exam scoring went pass/fail and pandemic-era clerkships left uneven clinical exposure, programs know less about their incoming interns than they used to — and the honest response, argued in the introduction’s assessment spine, is to measure the floor before teaching to it. The Milestones give the blueprint its vocabulary: the ACGME’s framework for describing “the development of the resident in key dimensions of the elements of physician competency,” organized as twenty-one sub-competencies across the six domains.¹ An OSCE blueprinted against those domains on day zero gives each intern a concrete, personal starting map instead of a generic curriculum — and gives the program a set of early behavioral observations its own assessment system can use as one input among many.

Design rules

1. Every case is fictional and every behavior observable. Stations are scored on what the intern demonstrably does — asked the perception question, traced the medication interaction, stopped talking after the headline — never on inferred attitude.
2. Efficiency by braiding. Each station is blueprinted against three to six sub-competency domains at once, the way real clinical moments braid them; that is how eight stations give every domain at least one observed moment, most of them two.
3. One shipped scoring layer, one local slot. What this page ships is the ten-item binary behavioral checklist per station (did/did not, no partial credit) — observable behaviors are what a single encounter can honestly record. What it deliberately does not ship is any instrument that turns a station into a Milestone rating: that translation is each program’s own, and the note below explains why.
4. Formative, stated out loud. The brief to interns before station one: this is a map-making exercise, not an exam; nobody passes or fails; the output goes to you and your advisor. Assessment anxiety corrupts baseline data — honesty is a psychometric intervention.
5. Localized props, national skeleton. Chart packets, order tasks, and the digital-health station run in your program’s training environment with your forms; the station designs and rubric logic are the portable part.

The eight stations

1. The cross-cover call

   A nurse phones about a post-operative patient with new tachycardia and hypotension; the intern triages by phone, evaluates at a simulated bedside, selects initial tests, and makes an SBAR call to a senior.

   Domains observed: PC-3 clinical reasoning · PC-4 inpatient management · MK-3 diagnostic testing · ICS-2 team communication · PROF-3 accountability

2. The new-patient history

   A standardized patient with limited English proficiency and an accompanying adult child presents to establish care; the intern must take a focused history, arrange interpretation correctly, and handle a confidentiality moment when the patient asks the child to leave.

   Domains observed: PC-1 history · ICS-1 patient- and family-centered communication · SBP-2 system navigation · PROF-2 ethical principles

3. The focused exam and presentation

   A standardized patient with findable cardiopulmonary findings; the intern examines, then presents the case to a faculty examiner with an assessment that commits to a leading diagnosis and links the findings to mechanism.

   Domains observed: PC-2 physical examination · PC-3 clinical reasoning · MK-1 applied foundational sciences · ICS-2 team communication

4. The handoff

   The intern receives a deliberately flawed sign-out on four patients — vague plans, a missing contingency — must interrogate it as the receiver, then give a corrected structured handoff on the same patients to a second examiner.

   Domains observed: ICS-3 communication within health care systems · PC-4 inpatient management · SBP-1 patient safety · PROF-3 accountability

5. The serious conversation

   A standardized patient asks directly about a concerning imaging result; the intern must assess perception, deliver a warning shot and a plain-language headline, respond to emotion, and close with concrete next steps.

   Domains observed: ICS-1 patient- and family-centered communication · PROF-1 professional behavior · PROF-2 ethical principles

6. The discharge

   From a short chart packet, the intern reconciles discharge medications (one interaction and one renal-dosing decision embedded), completes an electronic discharge task and a patient-portal message in the training environment, adjusts one prescription for a formulary/coverage constraint, and counsels the standardized patient with teach-back.

   Domains observed: PC-5 outpatient management · PC-6 digital health · MK-2 therapeutic knowledge · SBP-2 system navigation · SBP-3 physician role in health care systems · ICS-1 communication

7. The error conversation

   A medication error has reached a patient without lasting harm; the intern must disclose honestly to the standardized patient, avoid blame and speculation, and then complete a brief structured event-report exercise and a one-question written reflection.

   Domains observed: PROF-1 professional behavior · PROF-2 ethical principles · SBP-1 patient safety and QI · ICS-1 communication · PBLI-2 reflective practice

8. The evidence and self-assessment station

   Given a focused clinical question arising from Station 1’s case, the intern locates and appraises an answer using permitted resources, interprets a diagnostic-test scenario in pretest-probability terms, then completes a structured self-assessment naming two strengths, two growth areas, and one well-being resource they would actually use — the seed of their individualized learning plan.

   Domains observed: PBLI-1 evidence-based practice · PBLI-2 reflective practice · MK-3 diagnostic testing · MK-1 foundational sciences · PROF-4 well-being knowledge

Each station runs twelve minutes plus three minutes of rotation; stations 1, 4, and 6 tolerate fifteen. The checklist for each is written from its domain line: for every mapped domain, two or three observable behaviors, phrased as items a trained examiner can score in real time.

The blueprint — a mapping exercise, not a scorecard

This table is curriculum mapping — the use of Milestone language the ACGME’s own guidebook endorses, “to determine which Competencies are best covered in specific rotations and curricular experiences.”² It shows which domains each station gives the program an observed look at. It is not a claim that any station measures a sub-competency.

Every domain gets at least one observed moment, thirteen get two or more — and an observed moment is a starting sketch that seeds each intern’s ILP, never a verdict or a ranking. The single-station domains — outpatient management, digital health, therapeutic knowledge, systems role, evidence practice, well-being knowledge — are exactly the ones the curriculum then teaches longitudinally, which is the point of a diagnostic: it only has to see each once, honestly.

Scoring, and what comes out

Examiners score the binary checklist live, while the performance is fresh. The output per intern is a one-page profile: checklist results by station and the examiners’ free-text pearls — read as hypotheses for coaching, never Milestone levels — delivered to the intern and their advisor, and folded directly into the individualized learning plan alongside the intern’s own self-assessment from station 8 (the assessment-machinery session explains where the ILP sits in the program’s machinery). Aggregate, de-identified results serve one more purpose: they tell the bootcamp faculty where this cohort’s floor actually sags, which tunes the three days that follow and the refresher series after them.

Running it

Eight rooms, eight standardized patients (stations 4 and 8 can run with an examiner alone), one trained examiner per station, groups of eight interns rotating — roughly two hours per group, two groups per half-day. Examiners calibrate together for thirty minutes beforehand on the rubric’s edge cases. Standardized patients receive scripts with graduated prompts — the same escalation beats for every intern. And the debrief matters as much as the circuit: each intern gets ten minutes with a faculty member the same week, profile in hand, drafting the first version of their learning plan while the experience is vivid.

Notes — a design limitation, stated deliberately

For the program running this: why this OSCE ships behavioral checklists and a domain map, and nothing more. The ACGME’s Milestones Guidebook is explicit that the Milestones “were never intended to serve as regular assessment tools such as end-of-rotation evaluations”: the sub-competencies “do not contain sufficient detail or levels of performance on a developmental trajectory to facilitate an accurate determination of the knowledge, skills, or abilities of an individual learner over a short period of time,” and are instead “designed to guide a synthetic judgment of progress at least twice a year” — the judgment your Clinical Competency Committee makes from many observations accumulated over months.² A short-term evaluation should record observable behaviors; translating those observations into Milestone terms is the work of each program’s own evaluation criteria — its local translation of the Milestones into observable activities — which no generic curriculum can write for it. So the stations here are scored on what an examiner can watch an intern do, the matrix above is a curriculum map, and the Milestone connection runs the only direction the framework intends: your instruments record behaviors now; your committee synthesizes them into Milestones over time. Feed this OSCE’s output to that system as one early, formative data point among many — and let no decision about any intern rest on this OSCE alone.

The Milestones are used under the ACGME’s grant of non-exclusive educational use.¹

Sources

1. Accreditation Council for Graduate Medical Education. (2020). Internal medicine Milestones (2nd rev.; implementation July 1, 2021). https://www.acgme.org/globalassets/pdfs/milestones/internalmedicinemilestones.pdf ↩₁ ↩₂
2. Edgar, L., Hatlak, K., Haynes, I. L., Holmboe, E. S., Hogan, S. O., & McLean, S. (2025). The Milestones guidebook. Accreditation Council for Graduate Medical Education. https://prep.acgme.org/globalassets/milestonesguidebook.pdf ↩₁ ↩₂

This page is an assessment framework for program-run education. Station stems are fictional scaffolds; programs supply their own standardized-patient scripts, chart packets, and training-environment tasks, and validate rubrics with their own faculty. The Milestones are ©ACGME, used for educational purposes under the ACGME’s published grant. Last reviewed July 2026.