The story of simulation-based training in medicine cannot be told without foundational chapters on the role of simulation training in graduate medical education in anesthesiology, the test kitchen for many simulation training pioneers. The ACGME Anesthesiology RRC formalized this role in 2011 by creating a mandate for simulation-based training in anesthesiology residency training. This mandate comes at the same time that the ACGME has charged anesthesiology residency training programs with developing methods to ensure that trainees are achieving attainment of specific competency-based milestones prior to completion of their training. For educators in graduate medical education in anesthesiology, this dual mandate provides an opportunity for curricular evolution as each mandate can mutually facilitate the other. The benefits of simulation-based medical education, particularly to the adult learner, can facilitate the goals of training for and formative and summative assessment of competency-based milestones. Furthermore, the milestone project provides educators with a practical outline in the development of content for a prospective simulation-based education program. The goals of a simulation-based curriculum can utilize these milestones to create a progressive curriculum modeled on Miller’s taxonomy of competency attainment, coupling targeted milestones and skills with appropriate simulation-based tools for graduate medical education and assessment. While each institution will face unique challenges in the integration of simulation-based training into their overall curriculum, multiple strategies can be employed leveraging the variety of simulation modalities (partial task trainers, high-fidelity simulation, OSCEs) and a variety of curricular formats. In developing the components of a simulation-based curriculum, educators must maintain focus on the purpose of each component, introductory training, formative assessment, or summative assessment, and tailor a curriculum that meets these goals taking into account the considerations and challenges unique to each of these goals.