The evolution of medical education, from a time-based to a competency-based platform, began nearly 30 years ago and continues to slowly take shape. The development of valid and reproducible assessment tools is the first step. Medical educators across specialties acknowledge the challenges and remain motivated to develop a relevant, generalizable, and measurable system. The Accreditation Council for Graduate Medical Education (ACGME) remains committed to its responsibility to the public by assuring that the process and outcome of graduate medical education in the nation’s residency programs produce competent, safe, and compassionate doctors. The Milestones Project is the ACGME’s current strategy in the evolution to a competency-based system, which allows each specialty to develop its own set of subcompetencies and 5-level progression, or milestones, along a continuum of novice to expert. The education community has now had nearly 5 years of experience with these rubrics. While not perfect, Milestones 1.0 provided important foundational information and insights. The first iteration of the Anesthesiology Milestones highlighted some mismatch between subcompetencies and current and future clinical practices. They have also highlighted challenges with assessment and evaluation of learners, and the need for faculty development tools. Committed to an iterative process, the ACGME assembled representatives from stakeholder groups within the Anesthesiology community to develop the second generation of Milestones. This special article describes the foundational data from Milestones 1.0 that was useful in the development process of Milestones 2.0, the rationale behind the important changes, and the additional tools made available with this iteration.

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