Pediatrics – Psychiatry – Child and Adolescent Psychiatry (Combined) programs must annually report on each set of milestones.
Pediatrics – Psychiatry – Child and Adolescent Psychiatry (Combined) programs must annually report on each set of milestones.
The Pediatrics Milestone Project
A Joint Initiative of The Accreditation Council for Graduate Medical Education
and The American Board of Pediatrics
July 2017
i
The Pediatrics Milestone Project
The Milestones are designed only for use in evaluation of resident physicians in the context of their participation in ACGME accredited residency or fellowship programs. The Milestones provide a framework for the assessment of the development of the resident physician in key dimensions of the elements of physician competency in a specialty or subspecialty. They neither represent the entirety of the dimensions of the six domains of physician competency, nor are they designed to be relevant in any other context.
ii
Pediatrics Milestones
Working Group Advisory Group Chair: Carol Carraccio, MD, MA Carol Aschenbrener, MD
Bradley Benson, MD Richard Behrman, MD
Ann Burke, MD Timothy Brigham, MDiv, PhD
Robert Englander, MD, MPH Stephen Clyman, MD
Susan Guralnick, MD Eric Holmboe, MD
Patricia Hicks, MD, MHPE M. Douglas Jones Jr., MD
Stephen Ludwig, MD Gail McGuinness, MD
Daniel Schumacher, MD Victoria Norwood, MD
Jerry Vasilias, PhD Robert Perelman, MD
William Raszka, MD
Theodore Sectish, MD Susan Swing, PhD
iii
Milestone Reporting
This document presents milestones designed for programs to use in semi-annual review of resident performance and reporting to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced. The pediatrics milestones are designed to describe changes in observable attributes of the learner across the continuum of medical education from medical school through residency into practice. In the initial years of implementation, the Review Committee will examine milestone performance data for each program’s residents as one element in the Next Accreditation System (NAS) to determine whether residents overall are progressing. For each reporting period, review and reporting will involve selecting the level of milestones that best describes each resident’s current performance level in relation to milestones. Milestones are arranged into levels (See the figure on page iv). Progressing from Level 1 to Level 5 is synonymous with moving from novice to expert. Selection of a level implies that the resident substantially demonstrates the milestones in that level, as well as those in lower levels. Additional Notes Level 3 is designed as the graduation target but does not represent a graduation requirement. Making decisions about readiness for graduation is the purview of the residency program director (See the Milestones FAQ for further discussion of this issue: “Can a resident/fellow graduate if he or she does not reach every milestone?”). Study of Milestone performance data will be required before the ACGME and its partners will be able to determine whether Level 3 milestones and milestones in lower levels are in the appropriate level within the developmental framework, and whether Milestone data are of sufficient quality to be used for high stakes decisions.
Answers to Frequently Asked Questions about the Milestones are available on the Milestones web page: http://www.acgme.org/acgmeweb/Portals/0/MilestonesFAQ.pdf. A full report on the Pediatrics Milestone Project, including background information on each set of Milestones, is located at http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/320_PedsMilestonesProject.pdf.
iv
The figure below presents an example set of milestones for one sub-competency in the same format as the milestone report worksheet. For each reporting period, a resident’s performance on the milestones for each sub-competency will be indicated by:
• selecting the level of milestones that best describes that resident’s performance in relation to the milestones or
• selecting the “Not yet Assessable” response option. This option should be used only when a resident has not yet had a learning experience in the sub-competency.
Selecting a response box in the middle of a level implies that milestones in that level and in lower levels have been substantially demonstrated.
Selecting a response box on the line in between levels indicates that milestones in lower levels have been substantially demonstrated as well as some milestones in the higher level(s).
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PEDIATRICS MILESTONES
ACGME Report Worksheet
PC1. Gather essential and accurate information about the patient
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Either gathers too little
information or exhaustively gathers information following a template regardless of the patient’s chief complaint, with each piece of information gathered seeming as important as the next. Recalls clinical information in the order elicited, with the ability to gather, filter, prioritize, and connect pieces of information being limited by and dependent upon analytic reasoning through basic pathophysiology alone
Clinical experience allows linkage of signs and symptoms of a current patient to those encountered in previous patients. Still relies primarily on analytic reasoning through basic pathophysiology to gather information, but has the ability to link current findings to prior clinical encounters allows information to be filtered, prioritized, and synthesized into pertinent positives and negatives, as well as broad diagnostic categories
Demonstrates an advanced development of pattern recognition that leads to the creation of illness scripts, which allow information to be gathered while simultaneously filtered, prioritized, and synthesized into specific diagnostic considerations. Data gathering is driven by real-time development of a differential diagnosis early in the information-gathering process
Creates well-developed illness scripts that allow essential and accurate information to be gathered and precise diagnoses to be reached with ease and efficiency when presented with most pediatric problems, but still relies on analytic reasoning through basic pathophysiology to gather information when presented with complex or uncommon problems
Creates robust illness scripts and instance scripts (where the specific features of individual patients are remembered and used in future clinical reasoning) that lead to unconscious gathering of essential and accurate information in a targeted and efficient manner when presented with all but the most complex or rare clinical problems. These illness and instance scripts are robust enough to enable discrimination among diagnoses with subtle distinguishing features
Comments:
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PC2. Organize and prioritize responsibilities to provide patient care that is safe, effective, and efficient
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Struggles to organize patient
care responsibilities, leading to focusing care on individual patients rather than multiple patients; responsibilities are prioritized as a reaction to unanticipated needs that arise (those responsibilities presenting the most significant crisis at the time are given the highest priority); even small interruptions in task often lead to a prolonged or permanent break in that task to attend to the interruption, making return to initial task difficult or unlikely
Organizes the simultaneous care of a few patients with efficiency; occasionally prioritizes patient care responsibilities to anticipate future needs; each additional patient or interruption in work leads to notable decreases in efficiency and ability to effectively prioritize; permanent breaks in task with interruptions are less common, but prolonged breaks in task are still common
Organizes the simultaneous care of many patients with efficiency; routinely prioritizes patient care responsibilities to proactively anticipate future needs; additional care responsibilities lead to decreases in efficiency and ability to effectively prioritize only when patient volume is quite large or there is a perception of competing priorities; interruptions in task are prioritized and only lead to prolonged breaks in task when workload or cognitive load is high
Organizes patient care responsibilities to optimize efficiency; provides care to a large volume of patients with marked efficiency; patient care responsibilities are prioritized to proactively prevent those urgent and emergent issues in patient care that can be anticipated; interruptions in task lead to only brief breaks in task in most situations
Serves as a role model of efficiency; patient care responsibilities are prioritized to proactively prevent interruption by routine aspects of patient care that can be anticipated; unavoidable interruptions are prioritized to maximize safe and effective multitasking of responsibilities in essentially all situations
Comments:
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PC3. Provide transfer of care that ensures seamless transitions
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Demonstrates variability in
transfer of information (content, accuracy, efficiency, and synthesis) from one patient to the next; makes frequent errors of both omission and commission in the hand-off
Uses a standard template for the information provided during the hand-off; is unable to deviate from that template to adapt to more complex situations; may have errors of omission or commission, particularly when clinical information is not synthesized; neither anticipates nor attends to the needs of the receiver of information
Adapts and applies a standardized template, relevant to individual contexts, reliably and reproducibly, with minimal errors of omission or commission; allows ample opportunity for clarification and questions; is beginning to anticipate potential issues for the transferee
Adapts and applies a standard template to increasingly complex situations in a broad variety of settings and disciplines; ensures open communication, whether in the receiver- or the provider-of-information role, through deliberative inquiry, including read-backs, repeat-backs (provider), and clarifying questions (receivers)
Adapts and applies the template without error and regardless of setting or complexity; internalizes the professional responsibility aspect of hand-off communication, as evidenced by formal and explicit sharing of the conditions of transfer (e.g., time and place) and communication of those conditions to patients, families, and other members of the health care team
Comments:
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PC4. Make informed diagnostic and therapeutic decisions that result in optimal clinical judgment
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Recalls and presents clinical
facts in the history and physical in the order they were elicited without filtering, reorganization, or synthesis; demonstrates analytic reasoning through basic pathophysiology results in a list of all diagnoses considered rather than the development of working diagnostic considerations, making it difficult to develop a therapeutic plan
Focuses on features of the clinical presentation, making a unifying diagnosis elusive and leading to a continual search for new diagnostic possibilities; largely uses analytic reasoning through basic pathophysiology in diagnostic and therapeutic reasoning; often reorganizes clinical facts in the history and physical examination to help decide on clarifying tests to order rather than to develop and prioritize a differential diagnosis, often resulting in a myriad of tests and therapies and unclear management plans, since there is no unifying diagnosis
Abstracts and reorganizes elicited clinical findings in memory, using semantic qualifiers (such as paired opposites that are used to describe clinical information [e.g., acute and chronic]) to compare and contrast the diagnoses being considered when presenting or discussing a case; shows the emergence of pattern recognition in diagnostic and therapeutic reasoning that often results in a well-synthesized and organized assessment of the focused differential diagnosis and management plan
Reorganizes and stores clinical information (illness and instance scripts) that lead to early directed diagnostic hypothesis testing with subsequent history, physical examination, and tests used to confirm this initial schema; demonstrates well-established pattern recognition that leads to the ability to identify discriminating features between similar patients and to avoid premature closure; Selects therapies that are focused and based on a unifying diagnosis, resulting in an effective and efficient diagnostic work-up and management plan tailored to address the individual patient
Current literature does not distinguish between behaviors of proficient and expert practitioners. Expertise is not an expectation of GME training, as it requires deliberate practice over time
Comments:
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PC5. Develop and carry out management plans
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Develops and carries out
management plans based on directives from others, either from the health care organization or the supervising physician; is unable to adjust plans based on individual patient differences or preferences; communication about the plan is unidirectional from the practitioner to the patient and family
Develops and carries out management plans based on one’s theoretical knowledge and/or directives from others; can adapt plans to the individual patient, but only within the framework of one’s own theoretical knowledge; is unable to focus on key information, so conclusions are often from arbitrary, poorly prioritized, and time-limited information gathering; develops management plans based on the framework of one’s own assumptions and values
Develops and carries out management plans based on both theoretical knowledge and some experience, especially in managing common problems; follows health care institution directives as a matter of habit and good practice rather than as an externally imposed sanction; is able to more effectively and efficiently focus on key information, but still may be limited by time and convenience; begins to incorporate patients’ assumptions and values into plans through more bidirectional communication
Develops and carries out management plans based most often on experience; effectively and efficiently focuses on key information to arrive at a plan; incorporates patients’ assumptions and values through bidirectional communication with little interference from personal biases
Develops and carries out management plans, even for complicated or rare situations, based primarily on experience that puts theoretical knowledge into context; rapidly focuses on key information to arrive at the plan and augments that with available information or seeks new information as needed; has insight into one’s own assumptions and values that allow one to filter them out and focus on the patient/family values in a bidirectional conversation about the management plan
Comments:
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MK1. Critically evaluate and apply current medical information and scientific evidence for patient care
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Explains basic principles of
Evidence-based Medicine (EBM), but relevance is limited by lack of clinical exposure
Recognizes the importance of using current information to care for patients and responds to external prompts to do so; is able to formulate questions with significant effort and time; online search efficiency is minimal; (e.g., may require multiple search strategies); knows how to read and interpret the literature but requires guidance for application
Identifies knowledge gaps as learning opportunities; makes an effort to ask answerable questions on a regular basis and is becoming increasingly able to do so; understands varying levels of evidence and can utilize advanced search methods; is able to critically appraise a topic by analyzing the major outcomes, however, may need guidance in understanding the subtleties of the evidence; begins to seek and apply evidence when needed, not just when assigned to do so
Formulates answerable clinical questions regularly; incorporates use of clinical evidence in rounds and teaches fellow learners; is quite capable with advanced searching; is able to critically appraise topics and does so regularly; shares findings with others to try to improve their abilities; practices EBM because of the benefit to the patient and the desire to learn more rather than in response to external prompts
Teaches critical appraisal of topics to others; strives for change at the organizational level as dictated by best current information; is able to easily formulate answerable clinical questions and does so with majority of patients as a habit; is able to effectively and efficiently search and access the literature; is seen by others as a role model for practicing EBM
Comments:
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SBP1. Coordinate patient care within the health care system relevant to their clinical specialty
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Performs the role of medical
decision-maker, developing care plans and setting goals of care independently; informs patient/family of the plan, but no written care plan is provided; makes referrals, and requests consultations and testing with little or no communication with team members or consultants; is not involved in the transition of care between settings (e.g., outpatient and inpatient, pediatric and adult); shows little or no recognition of social/educational/cultural issues affecting the patient/family
Begins to involve the patient/family in setting care goals and some of the decisions involved in the care plan; a written care plan is occasionally made available to the patient/family; care plan does not address key issues; has variable communication with team members and consultants regarding referrals, consultations, and testing; answers patient/family questions regarding results and recommendations; may inconsistently be involved in the transition of care between settings (e.g., outpatient and inpatient, pediatric and adult); makes some assessment of social/educational/cultural issues affecting the patient/family and applies this in interactions
Recognizes the responsibility to assist families in navigation of the complex health care system; frequently involves patient/family in decisions at all levels of care, setting goals, and defining care plans; frequently makes a written care plan available to the patient/family and to appropriately authorized members of the care team; care plan omits few key issues; has good communication with team members and consultants; consistently discusses results and recommendations with patient/family; is routinely involved in the transition of care between settings (e.g., outpatient and inpatient, pediatric and adult); considers social, educational and cultural issues in most care interactions
Actively assists families in navigating the complex health care system; has open communication, facilitating trust in the patient-physician interaction; develops goals and makes decisions jointly with the patient/family (shared-decision-making); routinely makes a written care plan available to the patient/family and to appropriately authorized members of the care team; makes a thorough care plan, addressing all key issues; facilitates care through consultation, referral, testing, monitoring, and follow-up, helping the family to interpret and act on results/recommendations; coordinates seamless transitions of care between settings (e.g., outpatient and inpatient, pediatric and adult; mental and dental health; education; housing; food security; family-to-family
Current literature does not distinguish between behaviors of proficient and expert practitioners. Expertise is not an expectation of GME training, as it requires deliberate practice over time
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support); builds partnerships that foster family-centered, culturally-effective care, ensuring communication and collaboration along the continuum of care
Comments:
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SBP2. Advocate for quality patient care and optimal patient care systems
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Attends to medical needs of
individual patient(s); wants to take good care of patients and takes action for individual patients’ health care needs Example: Sees a child with a firearm injury and provides good care.
Demonstrates recognition that an individual patient’s issues are shared by other patients, that there are systems at play, and that there is a need for quality improvement of those systems; acts on the observed need to assess and improve quality of care Example: A physician notes on rounds, “We have sent home four-to-five firearm-injury patients and one has come back with repeated injury. We need to do something about that.”
Acts within the defined medical role to address an issue or problem that is confronting a cohort of patients; may enlist colleagues to help with this problem Example: The physician works with colleagues to develop an approach, protocol, or procedure for improving care for penetrating trauma injury in children and measures the outcomes of system changes.
Actively participates in hospital-initiated quality improvement and safety actions; demonstrates a desire to have an impact beyond the hospital walls Example: The physician attends a hospital symposium on gun-related trauma and what can be done about it and then arranges to speak on gun safety at the local meeting of the parent-teachers association.
Identifies and acts to begin the process of improvement projects both inside the hospital and within one’s practice community Example: Upon completion of quality improvement project, the physician works on new proposed legislation and testifies in City Council.
Comments:
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SBP3. Work in inter-professional teams to enhance patient safety and improve patient care quality
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Seeks answers and responds to
authority from only intra-professional colleagues; does not recognize other members of the interdisciplinary team as being important or making significant contributions to the team; tends to dismiss input from other professionals aside from other physicians
Is beginning to have an understanding of the other professionals on the team, especially their unique knowledge base, and is open to their input, however, still acquiesces to physician authorities to resolve conflict and provide answers in the face of ambiguity; is not dismissive of other health care professionals, but is unlikely to seek out those individuals when confronted with ambiguous situations
Aware of the unique contributions (knowledge, skills, and attitudes) of other health care professionals, and seeks their input for appropriate issues, and as a result, is an excellent team player
Same as Level 3, but an individual at this stage understands the broader connectivity of the professions and their complementary nature; recognizes that quality patient care only occurs in the context of the inter-professional team; serves as a role model for others in interdisciplinary work and is an excellent team leader
Current literature does not distinguish between behaviors of proficient and expert practitioners. Expertise is not an expectation of GME training, as it requires deliberate practice over time
Comments:
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PBLI1. Identify strengths, deficiencies, and limits in one’s knowledge and expertise
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
The learner acknowledges
external assessments, but understanding of his performance is superficial and limited to the overall grade or bottom line; has little understanding of how the performance measure relates in a meaningful way to his specific level of Knowledge, Skills and Attitudes (KSA)
Assessment of performance is seen as being able to do or not do the task at hand without appreciation for how well it is done and whether there is a need to improve the outcome
Prompts for understanding specifics of level of performance are internal and may be identified in response to uncertainty, discomfort, or tension in completing clinical duties; evidence of this stage is demonstrated by active questioning and application of knowledge in developing a rationale for care plans or in teaching activities
Prompted by anticipation or contemplation of potential clinical problems, the learner self-identifies gaps in KSA through reflection that assesses current KSA versus understanding of underlying basic science or pathophysiologic principles to generate new questions about limitations or mastery of KSA; evidence of this stage can be determined by the advanced nature and level of questioning or resource seeking
Prompted by a self-directed goal of improving the professional self, the practitioner anticipates hypothetical clinical scenarios that build on current experience and systematically addresses identified gaps to enhance the level of KSA; elaborate questioning occurs to further explore gaps and strengths
Example: During a semiannual review, a learner is unable to describe in any specific terms how he has performed when asked to do so by his mentor. In response, the mentor reviews and interprets the learner’s evaluations and then asks the learner to reflect on the discussion. The learner repeats the language used and recites the overall score/grade
Example: The learner seeks external assessment of performance as ability “to do” or “not able to do” with little understanding of what the assessment means. “Are these orders written correctly?” “Did I do that correctly?” Seeks feedback approval on whether KSA were “right” or “wrong.”
Example: Learner requests elaboration, clarification, or expansion on patient-care related task. “Why would we use this antibiotic for this condition?” or “The patient has underlying condition x. Does that alter therapy y for this patient?” or “I think we should order study w
Example: In caring for a patient with an illness not previously encountered, this practitioner says, “I have experience taking care of patients with this acute illness but have never had a patient with this acute illness who also had this particular underlying condition and wonder if
Example: In caring for a patient, a practitioner becomes aware of a gap in KSA, and in response (with or without consultation from a mentor) seeks to understand more about the identified KSA gap. A PICO-formatted question (P = Patient, I = Intervention, C = Comparison, O =
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without interpretation of further meaning or inference regarding the reported performance assessment
Does not seek “How?” or “Why?” as part of request for feedback to assist identification of KSA.
for this patient, since sometimes this disease presents with underlying condition z.”
the chronic condition might alter his clinical course?”
Outcome) is constructed, followed by a process of identification of learning needed.
Comments:
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PBLI2. Identify and perform appropriate learning activities to guide personal and professional development
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Sets learning activities based
on readily available curricular materials, irrespective of learning style, preferences, appropriateness of activity, or any outcome measures Example: After realizing a need to better understand what medications should be used in the management of a clinic patient with moderate asthma, the learner asks a peer who is working with him in clinic rather than pursuing the references suggested by his clinic preceptor.
Well-defined goals are mapped to appropriate learning activities and resources based on assigned curriculum; assignment may be part of a teacher-constructed curriculum, or part of a prescribed curriculum offered by others, or sought by the learner in response to a performance gap Example: A learner reads cases assigned for primary care in advance of coming to a scheduled clinic session where a discussion of the cases is to take place. Others have not read the case, and after the session the resident is left wondering about the case and its relevance to overall
Learning resources are sought based on analysis of learning needs assessment and constructed goals, and with consideration of the nature of the learning content and method Example: Having failed at intubation in the delivery room, the learner goes back to the simulation lab to receive further training on intubation with the manikin (and does not simply reread the Neonatal Resuscitation Protocol10).
Consideration of choice of activities is based on instructional methods that are known to be effective in the development of the relevant knowledge content, application of that knowledge, and development of skills or behaviors; learning takes place through collaborative interface with experts in which learning activities sought are ones that allow for constant course correction and interactive sharing of alternative perspectives and differing lenses Example: A learner is planning an advocacy workshop for parents of children with complex medical needs to improve their skills with managing medical devices. In the process of preparing for this workshop, he discovers that there is an in-service for parents of hospitalized patients in
Seeking resources to learn is undertaken with high efficiency and effectiveness, with open and flexible inclusion of the influences from outside sources (including regulatory and oversight groups); fruitful pathways and resources for learning are readily shared with peers and self-assessment of learning drives further resource seeking Example: The learner seeks to expand the types of devices discussed in the workshop and looks to the work published by the Institute of Medicine Committee on Safe Medical Devices for Children.11 He decides to pursue resources (experts in the field) to see if it would be possible to learn how to provide the
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learning. The case is part of a core curriculum with learning goals and objectives. Later, in clinic a patient presents with a problem similar to last week’s case discussion, and the learner is able to go back to that case to glean further information on how to manage the patient.
how to care for devices and participates in this learning activity. Through this in-service, he identifies written resources, models useful for demonstrations, and video-recorded illustrations of anticipated complications with device use. He chooses to conduct a practice rehearsal with some families in the inpatient setting, with course correction from the hospital’s nurse-educator.
instructional materials, plans, and workshops to parents throughout the state.
Comments:
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PBLI3. Systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Unable to gain insight from
encounters due to a lack of reflection on practice; does not understand the principles of quality improvement methodology or change management; is defensive when faced with data on performance improvement opportunities within one’s practice
Able to gain insight from reflection on individual patient encounters, but potential improvements are limited by a lack of systematic improvement strategies and team approach; is dependent upon external prompts to define improvement opportunities at the population level
Able to gain insight for improvement opportunities from reflection on both individual patients and populations; grasps improvement methodologies enough to apply to populations; is still reliant on external prompts to inform and prioritize improvement opportunities at the population level
Able to use both individual encounters and population data to drive improvement using improvement methodology; analyzes one’s own data on a continuous basis, without reliance on external forces, to prioritize improvement efforts, and uses that analysis in an iterative process for improvement; is able to lead a team in improvement
In addition to demonstrating continuous improvement activities and appropriately utilizing quality improvement methodologies, thinks and acts systemically to try to use one’s own successes to benefit other practices, systems, or populations; is open to analysis that at times requires course correction to optimize improvement
Comments:
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PBLI4. Incorporate formative evaluation feedback into daily practice
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Has difficulty in considering
others’ points of view when these differ from his or her own, leading to defensiveness and inability to receive feedback and/or avoidance of feedback; demonstrates a limited incorporation of formative feedback into daily practice
Is dependent on external sources of feedback for improvement; is beginning to acknowledge other points of view, but reinterprets feedback in a way that serves his or her own need for praise or consequence avoidance, rather than informing a personal quest for improvement; little to no behavioral change occurs in response to feedback (e.g., listens to feedback but takes away only those messages he or she wants to hear)
Understands others’ points of view and changes behavior to improve specific deficiencies that are noted by others (e.g., understands that the perceptions of others are important even when those perceptions are different from his or her own, (such as when a nurse interprets a response as abrupt when it was not intended to be) causing the learner to examine what prompted this perception)
Internal sources of feedback allow for insight into limitations and engagement in self-regulation; improves daily practice based on both external formative feedback and internal insights (e.g., is able to point out what went well and what did not go well in a given encounter, and makes positive changes in behavior as a result)
Demonstrates professional maturity and deep emotional commitment that lead to deliberate practice and result in the habits of continuous reflection, self-regulation, and internal feedback and that lead to continuous improvement beyond a focus solely on deficiencies
Comments:
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PROF1. Demonstrate humanism, compassion, integrity, and respect for others; based on the characteristics of an empathetic practitioner
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Interacts with patients and
families in a way that is detached and not sensitive to the human needs of the patient and family
Demonstrates compassion for patients in selected situations (e.g., tragic circumstances, such as unexpected death), but has a pattern of conduct that demonstrates a lack of sensitivity to many of the needs of others
Demonstrates consistent understanding of patient and family expressed needs and a desire to meet those needs on a regular basis; is responsive in demonstrating kindness and compassion
Goes beyond responding to expressed needs of patients and families; is altruistic and anticipates the human needs of patients and families and works to meet those needs as part of her skills in daily practice
Proactively advocates on behalf of individual patients, families, and groups of children in need
Comments:
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PROF2. Professionalization: A sense of duty and accountability to patients, society, and the profession
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Appears to be interested in
learning pediatrics but not fully engaged and involved as a professional, which results in an observational or passive role
Appreciates the role in providing care and being a professional, at times has difficulty in seeing self as a professional, which may result in not taking appropriate primary responsibility
Demonstrates understanding and appreciation of the professional role and the gravity of being the “doctor” by becoming fully engaged in patient care activities; has a sense of duty; has rare lapses into behaviors that do not reflect a professional self-view
Internalizes and accepts full responsibility of the professional role and develops fluency with patient care and professional relationships in caring for a broad range of patients and team members
Extends professional role beyond the care of patients and sees self as a professional who is contributing to something larger (e.g., a community, a specialty, or the medical profession)
Comments:
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PROF3. Professional Conduct: High standards of ethical behavior which includes maintaining appropriate professional boundaries
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Demonstrates repeated lapses
in professional conduct wherein responsibility to patients, peers, and/or the program are not met. These lapses may be due to an apparent lack of insight about the professional role and expected behaviors or other conditions or causes (e.g., depression, substance use, poor health)
Demonstrates lapses in professional conduct under conditions of stress or fatigue, that lead others to engage in reminding about and, enforcing professional behaviors as well as resolving conflicts; there may be some insight into behavior, but an inability to modify behavior when placed in stressful situations
Conducts interactions In nearly all circumstances with a professional mindset, sense of duty, and accountability; demonstrates conduct that illustrates insight into her own behavior, as well as likely triggers for professionalism lapses, and is able to use this information to remain professional
Demonstrates an in-depth understanding of professionalism that allows her to help other team members and colleagues with issues of professionalism; demonstrates self-reflection to identify and voice insights to prevent lapses in conduct as part of her duty to help others
Role models professional conduct; interactions with patients, families, and peers demonstrates high ethical standards across settings and circumstances; utilizes excellent emotional intelligence about human behavior and insight into self, to promote and engage in professional behavior as well as to prevent lapses in others and self
Comments:
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PROF4. Self-awareness of one’s own knowledge, skill, and emotional limitations that leads to appropriate help-seeking behaviors
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Demonstrates limited insight
into limitations in knowledge, skills or attitudes which results in the learner not seeking help when needed, sometimes resulting in unintended consequences
Expresses concern that limitations may be seen as weaknesses that will negatively impact evaluations; this results in help-seeking behaviors, typically only in response to external prompts rather than internal drive
Recognizes limitations, but has the perception that autonomy is a key element of one’s identity as a physician, and the need to emulate this behavior to belong to the profession may interfere with internal drive to engage in appropriate help-seeking behavior
Recognizes limitations and has matured to the stage where a personal value system of help-seeking for the sake of the patient supersedes any perceived value of physician autonomy, resulting in appropriate requests for help when needed
Demonstrates the personal drive to learn and improve results in the habit of engaging in help-seeking behaviors and explicitly role modeling and encouraging these behaviors in others
Comments:
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PROF5. Trustworthiness that makes colleagues feel secure when one is responsible for the care of patients
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Demonstrates gaps or is
unaware of significant knowledge, skills or attitudes (KSA) gaps; demonstrates lapses in data-gathering or in follow-through of assigned tasks; may misrepresent data (for a number of reasons) or omit important data, leaving others uncertain as to the nature of the learner’s truthfulness or awareness of the importance of attention to detail and accuracy (overt lack of truth-telling is assessed in another professionalism competency) Example: * A learner calls his supervisor at home to present a patient that he admitted. Key laboratory results are missing in the presentation and the supervisor requests that the learner seek this critical information and report back. Several hours later
Demonstrates gaps in KSA, but does not always voice awareness of or seek help when confronted with limitations; demonstrates lapses in follow-up or follow-through with tasks, despite awareness of the importance of these tasks; follow-through may be limited due to inconsistency or yielding to barriers; when such barriers are experienced, no escalation occurs (such as notifying others or pursuing alternative solutions) Example: On hand-over of patients from the day team to the night team, several tasks are identified as needing follow-up or completion during the next shift. The following day, when the service is handed back over
Demonstrates inadequate level of KSA for the level of clinical responsibility, with realistic insight into limits with responsive help seeking; data-gathering is complete with consideration of anticipated patient care needs, and careful consideration of high-risk conditions first and foremost; little prompting is required for follow-up Example: Presentation of a patient consultation is done in a comprehensive manner, without the need for prompting. Questions posed by the learner allow the consultant to appreciate the learner’s
Demonstrates competent level of KSA for the level of clinical responsibility and assumes full responsibility for all aspects of patient care, anticipating problems and demonstrating vigilance in all aspects of management; pursues answers to questions, and communications include open, transparent expression of uncertainty and limits of knowledge Example: An individual possesses the KSA to lead the team on rounds, asking for pertinent data not presented by other team members (assertive inquiry). Constant review and vigilance of patient
Demonstrates competent level of KSA for the level of clinical responsibility and assumes full responsibility for all aspects of patient care, anticipating problems and demonstrating vigilance in all aspects of management; pursues answers to questions, and communications include open, transparent expression of uncertainty and limits of knowledge; uncertainty brings about rigorous search for answers and conscientious and ongoing review of information; may seek the help of a consultant in addition to primary source literature Example: This is the practitioner who leaves no stone unturned. Colleagues are confident when handing-off a patient that the patient will receive exemplary care. In fact, when there is a complex patient, colleagues are
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on rounds, the learner is again questioned about the laboratory values, and reports that the results are normal, but is unable to locate those results in his paperwork. D-2, C-1, T-2 KSA= Knowledge, skills &
attitudes D= Discernment C= Conscientiousness T= Truth telling Number refers to
performance level (1-5)
to the original learner, several of these tasks were either incomplete or not completed as specified in the sign-out. When questioned about these tasks, the night-float individual indicated that things were busy, he forgot, or gives another excuse indicating an awareness of the expectation but failure to complete the tasks. KSA-3, D-2, C-3
understanding of the disease process and the learners’ awareness of gaps in his knowledge. Careful attention to detail and accuracy are evident in the history and physical examination that is presented. The next day, the service is busy and the learner needs reminding to re-check the send-out labs. KSA-3, D-3, C-3
status uncovers unexplained findings on laboratory or physical examination. Findings are reported to supervisors as change with un-identified meaning (and potential concern). KSA-4, D-4, T-4
relieved when this practitioner is on-call because he typically invests much time and energy in searching for needed answers and meticulously reports back on all important developments. KSA-4, D-4, C-4, T-4
Comments:
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PROF6. Recognize that ambiguity is part of clinical medicine and to recognize the need for and to utilize appropriate resources in dealing with uncertainty
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Demonstrates state of being
overwhelmed and unsure when faced with uncertainty or ambiguity; communications with patients/families and development of therapeutic plan are approached in a limited and authoritarian manner;; patient/family numeracy (understanding of probability/risk) is presumed; seeks only self or self-available resources to manage response to this uncertainty, resulting in a response characterized by their (individual) preexisting state of risk aversion or risk taking; does not regard patient need for hope; feels compelled to make sure that patients understand full potential for negative outcome (defensive/protective of physician)
Expresses recognition of uncertainty and the tension/pressure from not knowing or knowing with limited control of outcomes; explains situation to the patient in framework most familiar to the physician, rather than framing it with terms, graphics, or analogies familiar to the patient; seeks rules and statistics and feels compelled to transfer all information to the patient immediately, regardless of patient readiness, patient goals, and patient ability to manage information
Anticipates and focuses on uncertainty, looking for resolution by seeking additional information; informs the patient of the more optimal outcome(s), framed by physician goals; does not manage overall balance of patient/family uncertainty with quality of life, need for hope, and ability to adhere to therapeutic plan; focuses on own risk management position for a given problem and does not suggest that more or less risk taking (different from physician’s position) could be chosen; still seeks patient/parent recitation of uncertainty/morbidity as proof that patient/family understands the uncertainty; unresolved balance of physician/patient expectations with physician expectations taking precedence
Anticipates that uncertainty at the time of diagnostic deliberation will be likely; uses such uncertainty or ambiguity as a prompt/motivation to seek information or understanding of unknown (to self or world); balances delivery of diagnosis with hope, information, and exploration of individual patient goals; works through concepts of risk versus hope using conceptual framework that includes cost (e.g., suffering, lifestyle changes, financial) versus benefit, framed by patient health care goals; expresses openness to patient position and patient uncertainty about his or her position and response
Acknowledges and manages personal level of risk aversion or risk-taking tendencies; seeks to understand patient/family goals for health and their capacity to achieve those goals,; engages in discussion with high sensitivity towards health literacy and numeracy, emphasizing patient/family control of choices; openly and comfortably discusses strategies and outcomes anticipated with the patient/family, emphasizing that all plans are subject to the imperfect knowledge and state of uncertainty; ongoing information sharing through changes as knowledge and patient health status evolve; remains flexible and committed to engagement with the patient/family throughout the patient’s illness, serving as a
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resource to gather information; constant revisiting of knowledge, uncertainty, and developed plans is balanced with acceptance of what is unknown; transparent communication of limits of treatment plan outcomes
Comments:
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ICS1. Communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Uses standard medical
interview template to prompt all questions; does not vary the approach based on a patient’s unique physical, cultural, socioeconomic, or situational needs; may feel intimidated or uncomfortable asking personal questions of patients
Uses the medical interview to establish rapport and focus on information exchange relevant to a patient’s or family’s primary concerns; identifies physical, cultural, psychological, and social barriers to communication, but often has difficulty managing them; begins to use non-judgmental questioning scripts in response to sensitive situations
Uses the interview to effectively establish rapport; is able to mitigate physical, cultural, psychological, and social barriers in most situations; verbal and non-verbal communication skills promote trust, respect, and understanding; develops scripts to approach most difficult communication scenarios
Uses communication to establish and maintain a therapeutic alliance; sees beyond stereotypes and works to tailor communication to the individual; a wealth of experience has led to development of scripts for the gamut of difficult communication scenarios; is able to adjust scripts ad hoc for specific encounters
Connects with patients and families in an authentic manner that fosters a trusting and loyal relationship; effectively educates patients, families, and the public as part of all communication; intuitively handles the gamut of difficult communication scenarios with grace and humility
Comments:
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ICS2. Demonstrate the insight and understanding into emotion and human response to emotion that allows one to appropriately develop and manage human interactions
Not yet Assessable
Level 1
Level 2
Level 3
Level 4
Level 5
Does not accurately anticipate
or read others’ emotions in verbal and non-verbal communication; is unaware of one’s own emotional and behavioral cues and may transmit emotions in communication (e.g., anxiety, exuberance, anger) that can precipitate unintended emotional responses in others; does not effectively manage strong emotions in oneself or others
Begins to use past experiences to anticipate and read (in real time) the emotional responses in himself and others across a limited range of medical communication scenarios, but does not yet have the ability or insight to moderate behavior to effectively manage the emotions; strong emotions in oneself and others may still become overwhelming
Anticipates, reads, and reacts to emotions in real time with appropriate and professional behavior in nearly all typical medical communication scenarios, including those evoking very strong emotions; uses these abilities to gain and maintain therapeutic alliances with others
Perceives, understands, uses, and manages emotions in a broad range of medical communication scenarios and learns from new or unexpected emotional experiences; effectively manages own emotions appropriately in all situations; effectively and consistently uses emotions to gain and maintain therapeutic alliances with others; is perceived as a humanistic provider
Intuitively perceives, understands, uses, and manages emotions to improve the health and well-being of others and to foster therapeutic relationships in any and all situations; is seen as an authentic role model of humanism in medicine
Comments:
July 2015
The Psychiatry Milestone Project
A Joint Initiative of
The Accreditation Council for Graduate Medical Education
and
The American Board of Psychiatry and Neurology
i
The Psychiatry Milestone Project
The Milestones are designed only for use in evaluation of resident physicians in the context of their participation
in ACGME-accredited residency or fellowship programs. The Milestones provide a framework for the assessment
of the development of the resident physician in key dimensions of the elements of physician competency in a
specialty or subspecialty. They neither represent the entirety of the dimensions of the six domains of physician
competency, nor are they designed to be relevant in any other context.
ii
Psychiatry Milestone Group
Christopher R. Thomas MD, Chair
Working Group Advisory Group
Sheldon Benjamin, MD Timothy Brigham, MDiv, PhD
Adrienne L. Bentman, MD Carol A. Bernstein, MD
Robert Boland , MD Beth Ann Brooks, MD
Deborah S. Cowley, MD Larry R. Faulkner, MD
Jeffrey Hunt, MD, MS Deborah Hales, MD
George A. Keepers, MD Victor I. Reus, MD
Louise King, MS Richard F. Summers, MD
Gail H. Manos, MD
Donald E. Rosen, MD
Kathy M. Sanders, MD
Mark E. Servis, MD
Kallie Shaw, MD
Susan Swing, PhD
Alik Widge, MD, PhD
iii
Milestone Reporting
This document presents milestones designed for programs to use in semi-annual review of resident performance and reporting to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced. They are descriptors and targets for resident performance as a resident progresses from entry into residency through graduation. In the initial years of implementation, the Review Committee will examine aggregate milestone performance data for each program’s residents as one element in the Next Accreditation System to determine whether residents overall are progressing. Thus, aggregate resident performance will be an additional measure of a program’s ability to educate its residents. Program directors have the responsibility of ensuring that residents’ progress on all 22 psychiatry subcompetencies (as identified in the top row of each milestone table) is documented every six months through the Clinical Competency Committee (CCC) review process. The CCC’s decisions should be guided by information gathered through formal and informal assessments of residents during the prior six-month period. The ACGME does not expect formal, written evaluations of all milestones (each numbered item within a subcompetency table) every six months. For example, formal evaluations, documented observed encounters in inpatient and outpatient settings, and multisource evaluation should focus on those subcompetencies and milestones that are central to the resident’s development during that time period. Progress through the Milestones will vary from resident to resident, depending on a variety of factors, including prior experience, education, and capacity to learn. Residents learn and demonstrate some skills in episodic or concentrated time periods (e.g., formal presentations, participation in quality improvement project, child/adolescent rotation scheduling, etc.). Milestones relevant to these activities can be evaluated at those times. The ACGME does not expect that resident progress will be linear in all areas or that programs organize their curricula to correspond year by year to the Psychiatry Milestones. All milestone threads (as indicated by the letter in each milestone reference number, the “A” in PC1, 1.1/A ) should be formally evaluated and discussed by the CCC on at least two occasions during a resident’s educational program. Thread names, preceded by their indicator letters, are listed in the top row of each milestone table. Each thread describes a type of activity, behavior, skill, or knowledge, and typically consists of two-to-four milestones at different levels. For example, the “B” thread for PC1, named “collateral information gathering and use,” consists of the set of progressively more advanced and comprehensive behaviors identified as 1.2/B, 2.3/B, 3.3/B, 4.2/B, 4.3/B and 5.2/A,B. The thread identifies the unit of observation and evaluation. For, PC1, thread “B,” faculty members would observe a resident’s evaluation of a patient to see whether he or she demonstrates the
iv
collateral information gathering and use behaviors described in that milestone. Threads do not always have milestones at each level 1-5; some threads may consist of only one milestone (see the diagram on page vi). For each six-month reporting period, review and reporting will involve selecting the level of milestones that best describes a resident’s current performance level. Milestones are arranged into numbered levels. These levels do not correspond with post-graduate year of education. Selection of a level for a subcompetency implies that the resident substantially demonstrates the milestones in that level, as well as those in lower levels (see the diagram on page vi). A general interpretation of levels for psychiatry is below:
Has not Achieved Level 1: The resident does not demonstrate the milestones expected of an incoming resident.
Level 1: The resident demonstrates milestones expected of an incoming resident.
Level 2: The resident is advancing and demonstrates additional milestones, but is not yet performing at a mid-residency level.
Level 3: The resident continues to advance and demonstrate additional milestones; the resident demonstrates the majority of milestones targeted for residency in this sub-competency.
Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target.*
Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level.
*Level 4 is designed as the graduation target and does not represent a graduation requirement. Making decisions about readiness
for graduation is the purview of the residency program (See the Milestones FAQ for further discussion of this issue: “Can a
resident/fellow graduate if he or she does not reach every milestone?”). Study of Milestone performance data will be required
before the ACGME and its partners will be able to determine whether Level 4 milestones and milestones in lower levels are in the
appropriate level within the developmental framework, and whether Milestone data are of sufficient quality to be used for high
stakes decisions.
v
Selecting the Appropriate Milestone Level for your Residents: The Role of Supervision Faculty supervisors, especially those overseeing clinical care, will directly assess many milestones. The CCC assessment is based on evaluations completed by these clinical supervisors along with other assessments, including performance on tests and evaluations from other sources. The process of Milestone assignment assumes that all residents are supervised in their clinical work, as outlined in the ACGME’s supervision levels and requirements. For the purposes of evaluating a resident’s progress in achieving Patient Care and Medical Knowledge Milestones, though, it is important that the evaluator(s) determine what the resident knows and can do, separate from the skills and knowledge of his or her supervisor. Implicit in milestone level evaluation of Patient Care (PC) and Medical Knowledge (MK) is the assumption that during the normal course of patient care activities and supervision, the evaluating faculty member and resident participate in a clinical discussion of the patient's care. During these reviews the resident should be prompted to present his or her clinical thinking and decisions regarding the patient. This may include evidence for a prioritized differential diagnosis, a diagnostic workup, or initiation, maintenance, or modification of the treatment plan, etc. In offering his or her independent ideas, the resident demonstrates his or her capacity for clinical reasoning and its application to patient care in real-time. As residents progress, their knowledge and skills should grow, allowing them to assume more responsibility and handle cases of greater complexity. They are afforded greater autonomy - within the bounds of the ACGME supervisory guidelines - in caring for patients. At Levels 1 and 2 of the Milestones, a resident's knowledge and independent clinical reasoning will meet the needs of patients with lower acuity, complexity, and level of risk, whereas, at Level 4, residents are expected to independently demonstrate knowledge and reasoning skills in caring for patients of higher acuity, complexity, and risk. Thus, one would expect residents achieving Level 4 milestones to be senior residents at an oversight level of supervision. In general, one would not expect beginning or junior residents to achieve Level 4 milestones. At all levels, it is important that residents ask for, listen to, and process the advice they receive from supervisors, consult the literature, and incorporate this supervisory input and evidence into their thinking. Additional Notes Please note that most milestone sets include explanatory footnotes for selected concepts. These appear at the bottom of each milestone table. The footnotes are essential tools in milestone evaluation.
vi
The diagram below presents an example set of milestones for one sub-competency in the same format as the milestone report
worksheet. For each reporting period, a resident’s performance on the milestones for each sub-competency will be indicated by:
selecting the level of milestones that best describes the resident’s performance in relation to those milestones or
selecting the “Has not Achieved Level 1” response option
Selecting a response box in the middle of a level implies that milestones in that level and in lower levels have been substantially demonstrated.
Selecting a response box on the line in between levels indicates that milestones in lower levels have been substantially demonstrated as well as some milestones in the higher level(s).
Competency Domain
Subcompetency Thread for: “Development as a teacher” (all milestones with “A”) Thread Names
Milestone
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PSYCHIATRY MILESTONES ACGME Report Worksheet
PC1. Psychiatric Evaluation A: General interview skills B: Collateral information gathering and use C: Safety assessment D: Use of clinician's emotional response
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Obtains general medical and psychiatric history and completes a mental status examination
1.2/B Obtains relevant collateral information from secondary sources
1.3/C Screens for patient safety, including suicidal and homicidal ideation
2.1/A Acquires efficient, accurate, and relevant history customized to the patient’s complaints 2.2/A Performs a targeted examination, including neurological examination, relevant to the patient’s complaints
2.3/B Obtains information that is sensitive and not readily offered by the patient
2.4/C Assesses patient safety, including suicidal and homicidal ideation 2.5/D Recognizes that the clinician’s emotional responses have diagnostic value1
3.1/A Consistently obtains complete, accurate, and relevant history
3.2/A Performs efficient interview and examination with flexibility appropriate to the clinical setting and workload demands 3.3/B Selects laboratory and diagnostic tests appropriate to the clinical presentation 3.4/B Uses hypothesis-driven information gathering techniques2
4.1/A Routinely identifies subtle and unusual findings
4.2/B Follows clues to identify relevant historical findings in complex clinical situations and unfamiliar circumstances 4.3/D Begins to use the clinician's emotional responses to the patient as a diagnostic tool
5.1/A Serves as a role model for gathering subtle and reliable information from the patient 5.2/A, B Teaches and supervises other learners in clinical evaluation
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Comments:
Footnotes: 1This milestone refers to the use of the resident’s own emotional response to the patient’s presentation as a source of information to generate ideas about the patient’s own inner emotional state, both conscious and unconsious.
2This milestone focuses on the efficient and deductive conduct of the interview in accordance with diagnostic hypotheses to refine the differential diagnosis.
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PC2. Psychiatric Formulation and Differential Diagnosis1 A: Organizes and summarizes findings and generates differential diagnosis B: Identifies contributing factors and contextual features and creates a formulation
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Organizes and accurately summarizes, reports, and presents to colleagues information obtained from the patient evaluation
1.2/A Develops a working diagnosis based on the patient evaluation
2.1/A Identifies patterns and recognizes phenomenology from the patient's presentation to generate a diagnostic hypotheses
2.2/A Develops a basic differential diagnosis for common syndromes and patient presentations
2.3/B Describes patients’ symptoms and problems, precipitating stressors or events, predisposing life events or stressors, perpetuating and protective factors, and prognosis
3.1/A Develops a full differential diagnosis while avoiding premature closure 3.2/B Organizes formulation around comprehensive models of phenomenology that take etiology into account 2
4.1/A Incorporates subtle, unusual, or conflicting findings into hypotheses and formulations 4.2/B Efficiently synthesizes all information into a concise but comprehensive formulation
5.1/B Serves as a role model of efficient and accurate formulation
5.2/B Teaches formulation to advanced learners
Comments: Footnotes:
1A psychiatric formulation is a theoretically-based conceptualization of the patient’s mental disorder(s). It provides an organized summary of those individual factors thought to contribute to the patient’s unique psychopathology. This includes elements of possible etiology, as well as those that modify or influence presentation, such as risk and protective factors. It is therefore distinct from a differential diagnosis that lists the possible diagnoses for a patient, or an assessment that summarizes the patient’s signs and symptoms, as it seeks to understand the underlying mechanisms of the patient’s unique problems by proposing a hypothesis as to the causes of mental disorders.
2Models of formulation include those based on either major theoretical systems of the etiology of mental disorders, such as behavioral, biological, cognitive, cultural, psychological, psychoanalytic, sociological, or traumatic, or comprehensive frameworks of understanding, such as bio-psycho-social or predisposing, precipitating, perpetuating, and prognostic outlines. Models of formulation set forth a hypothesis about the unique features of a patient’s illness that can serve to guide further
evaluation or develop individualized treatment plans.
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PC3. Treatment Planning and Management A: Creates treatment plan B: Manages patient crises, recognizing need for supervision when indicated C: Monitors and revises treatment when indicated
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Identifies potential treatment options 1.2/B Recognizes patient in crisis or acute presentation 1.3/C Recognizes patient readiness for treatment
2.1/A Sets treatment goals in collaboration with the patient 2.2/A Incorporates a clinical practice guideline or treatment algorithm when available 2.3/A Recognizes co-morbid conditions and side effects’ impact on treatment 2.4/B Manages patient crises with supervision 2.5/C Monitors treatment adherence and response
3.1/A Incorporates manual-based treatment1 when appropriate 3.2/A Applies an understanding of psychiatric, neurologic, and medical co-morbidities to treatment selection2
3.3/A Links treatment to formulation 3.4/B Recognizes need for consultation and supervision for complicated or refractory cases 3.5/C Re-evaluates and revises treatment approach based on new information and or response to treatment
4.1/A Devises individualized treatment plan for complex presentations 4.2/A Integrates multiple modalities and providers in comprehensive approach3 4.3/C Appropriately modifies treatment techniques and flexibly applies practice guidelines to fit patient need
5.1/A Supervises treatment planning of other learners and multidisciplinary providers 5.2/A Integrates emerging neurobiological and genetic knowledge into treatment plan4
Comments: Footnotes: 1Manual-based treatment is any psychotherapy that relies on written instructions for the therapist on the steps and conduct of treatment, often including specific
indications, techniques, goals, and objectives. Manual-based treatments are frequently theory-driven and evidence-based. Examples of manual-based treatments include Interpersonal Psychotherapy, Dialectical-Behavioral Therapy, and many Cognitive-Behavioral Therapies.
2Examples might include psychopharmacology in the presence of neurodegenerative disorders, traumatic brain injury, critical medical illness, and cancer treatment, as well as understanding the family, systems, and multidisciplinary team efforts for the best outcome for treatment.
3Understanding and use of an array of modalities and providers may include consideration of complementary and alternative medicine, occupational therapy, and
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physical therapy. 4Examples may include cytochrome genetics, ethnic differences, and family counseling, etc.
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PC4. Psychotherapy Refers to 1) the practice and delivery of psychotherapies, including psychodynamic1, cognitive-behavioral2, and supportive therapies3; 2) exposure to couples, family, and group therapies; and 3) integrating psychotherapy with psychopharmacology A: Empathy and process B: Boundaries C: The alliance and provision of psychotherapies D: Seeking and providing psychotherapy supervision
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Accurately identifies patient emotions, particularly sadness, anger, and fear4
1.2/B Maintains appropriate professional boundaries 1.3/C Demonstrates a professional interest and curiosity in a patient’s story
2.1/A Identifies and reflects the core feeling and key issue for the patient during a session 2.2/B Maintains appropriate professional boundaries in psychotherapeutic relationships while being responsive to the patient5 2.3/C Establishes and maintains a therapeutic alliance with patients with uncomplicated problems6
2.4/C Utilizes elements of supportive therapy in treatment of patients
3.1/A Identifies and reflects the core feeling, key issue, and what the issue means to the patient 3.2/B Recognizes and avoids potential boundary violations
3.3/C Establishes and maintains a therapeutic alliance with, and provides psychotherapies (at least supportive, psychodynamic, and cognitive-behavioral) to, patients with uncomplicated problems 3.4/C Manages the emotional content of, and feelings aroused during, sessions 3.5/C Integrates the selected psychotherapy with other treatment modalities and other treatment providers 7
4.1/A Links feelings, behavior, recurrent/central themes/schemas, and their meaning to the patient as they shift within and across sessions 4.2/B Anticipates and appropriately manages potential boundary crossings and avoids boundary violations
4.3/C Provides different modalities of psychotherapy (including supportive therapy and at least one of psychodynamic or cognitive behavioral therapies) to patients with moderately complicated problems 4.4/C Selects a psychotherapeutic modality and tailors the selected psychotherapy to the patient on the basis of an appropriate case formulation
4.5/C Successfully guides
5.1/C Provides psychotherapies to patients with very complicated and/or refractory disorders/problems
5.2/C Personalizes treatment based on awareness of one’s own skill sets, strengths, and limitations
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3.6/D Balances autonomy with needs for consultation and supervision
the patient through the different phases of psychotherapy, including termination 4.6/C, D Recognizes, seeks appropriate consultation about, and manages treatment impasses
5.3/D Provides psychotherapy supervision to others
Comments: Footnotes:
1Psychodynamic therapy includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to understand the concepts of resistance/defenses, transference/countertransference.
2Cognitive-behavioral therapy includes the capacity to generate a case formulation, to demonstrate techniques of intervention, including behavior change, skills acquisition, and to address cognitive distortions.
3Supportive therapy includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to strengthen the patient’s adaptive defenses, resilience, and social supports.
4This thread (A), consisting of the first items in Levels 1-4, regarding the development of empathy across residency, is adapted from the American Association of Directors of Psychiatric Residency Training (AADPRT) Psychotherapy Workgroup’s document “Benchmarks for Psychotherapy Training.”
5This refers to the ability to maintain professional boundaries in psychotherapy without being aloof or overly detached. 6Examples of uncomplicated problems are major depression or panic disorder without co-morbidity. 7At this level, the resident is expected to be able to integrate both psychotherapy and psychopharmacology in combined treatment of a patient, to deliver psychotherapy
or psychopharmacology in collaboration with another provider who is doing the other treatment (shared treatment), and to be able to anticipate, discuss, and manage issues that result from a patient’s receiving other treatments (e.g., family, couples, or group therapy; psychopharmacology) at the same time as individual psychotherapy.
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PC5. Somatic Therapies Somatic therapies including psychopharmacology, electroconvulsive therapy (ECT), and emerging neuromodulation therapies A: Using psychopharmacologic agents in treatment B: Education of patient about medications C: Monitoring of patient response to treatment and adjusting accordingly D: Other somatic treatments
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Lists commonly used psychopharmacologic agents and their indications to target specific psychiatric symptoms (e.g., depression, psychosis) 1.2/B Reviews with the patient/family general indications, dosing parameters, and common side effects for commonly prescribed psychopharmacologic agents
2.1/A Appropriately prescribes1 commonly used psychopharmacologic agents 2.2/B Incorporates basic knowledge of proposed mechanisms of action and metabolism of commonly prescribed psychopharmacologic agents in treatment selection, and explains rationale to patients/families 2.3/C Obtains basic physical exam and lab studies necessary to initiate treatment with commonly prescribed medications 2.4/D Seeks consultation and
3.1/A Manages pharmacokinetic and pharmacodynamic drug interactions when using multiple medications concurrently 3.2/C Monitors relevant lab studies throughout treatment, and incorporates emerging physical and laboratory findings into somatic treatment strategy 3.3/C Uses augmentation strategies, with supervision, when primary pharmacological interventions are only partially successful1
4.1/A Titrates dosage and manages side effects of multiple medications 4.2/C Appropriately selects evidence-based somatic treatment options (including second and third line agents and other somatic treatments2) for patients whose symptoms are partially responsive or not responsive to treatment
5.1/B Explains less common somatic treatment choices to patients/families in terms of proposed mechanisms of action 5.2/C Integrates emerging studies of somatic treatments into clinical practice
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supervision regarding potential referral for ECT
Comments: Footnotes:
1This includes: (a) selection of agent, dose, and titration, based on psychiatric diagnoses, target symptoms, and specifics of patient’s history; (b) discussion of potential risks and benefits with patients (and family members, where appropriate); (c) decision regarding whether or not to prescribe a medication (or medication versus other type of treatment).
2Examples of other somatic therapies include neuromodulation, biofeedback, and phototherapy.
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MK1. Development through the life cycle (including the impact of psychopathology on the trajectory of development and development on the expression of psychopathology) A: Knowledge of human development B: Knowledge of pathological and environmental influences on development C: Incorporation of developmental concepts in understanding
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Describes the basic
stages of normal physical, social, and cognitive development through the life cycle1
2.1/A Describes neural development across the life cycle2 2.2/A Recognizes deviation from normal development, including arrests and regressions at a basic level 2.3/B Describes the effects of emotional and sexual abuse on the development of personality and psychiatric disorders in infancy, childhood, adolescence, and adulthood at a basic level 2.4/C Utilizes developmental concepts in case formulation
3.1/A Explains developmental tasks and transitions throughout the life cycle, utilizing multiple conceptual models3 3.2/B Describes the influence of psychosocial factors (gender, ethnic, cultural, economic), general medical, and neurological illness on personality development
3.2 De 3.3/C Utilizes appropriate
conceptual models of development in case formulation
4.1/B Describes the influence of acquisition and loss of specific capacities in the expression of psychopathology across the life cycle 4.2/B Gives examples of gene-environment interaction influences on development and psychopathology4
5.1/A Incorporates new neuroscientific knowledge into his or her understanding of development
Comments: Footnotes:
1Includes knowledge of motoric, linguistic, and cognitive development at the level required to pass the United States Medical Licensing Examination (USMLE) Step 2, and also knowledge of developmental milestones in infancy through senescence, such as language acquisition, Piagetian cognitive development, and social and emotional development, such as the emergence of stranger wariness in infancy and the theme of independence versus dependence in adolescence.
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2Knowledge of fetal, childhood, adolescent, and early adult brain development, including abnormal brain development caused by genetic disorders (Tay-Sachs), environmental toxins, malnutrition, social deprivation, and other factors.
3Using the theoretical models proposed by psychodynamic, cognitive, and behavioral theorists. 4An example is bipolar disorder with genetic diathesis + environmental stress leading to manic behavior.
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MK2. Psychopathology1 Includes knowledge of diagnostic criteria, epidemiology, pathophysiology, course of illness, co-morbidities, and differential diagnosis of psychiatric disorders, including substance use disorders and presentation of psychiatric disorders across the life cycle and in diverse patient populations (e.g., different cultures, families, genders, sexual orientation, ethnicity, etc.) A: Knowledge to identify and treat psychiatric conditions B: Knowledge to assess risk and determine level of care C: Knowledge at the interface of psychiatry and the rest of medicine
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Identifies the major psychiatric diagnostic system (DSM) 1.2/B Lists major risk and protective factors for danger to self and others 1.3/C Gives examples of interactions between medical and psychiatric symptoms and disorders
2.1/A Demonstrates sufficient knowledge to identify and treat common psychiatric conditions in adults in inpatient and emergency settings (e.g., depression, mania, acute
psychosis) 2.2/B Demonstrates knowledge of, and ability to weigh risks and protective factors for, danger to self and/or others in emergency and inpatient settings 2.3/C Shows sufficient knowledge to perform an initial medical and neurological evaluation in psychiatric inpatients 2.4/C Demonstrates sufficient knowledge to identify common medical conditions (e.g., hypothyroidism,
3.1/A Demonstrates sufficient knowledge to identify and treat most psychiatric conditions throughout the life cycle and in a variety of settings2 3.2/B Displays knowledge of, and the ability to weigh, risk and protective factors for, danger to self and/or others across the life cycle, as well as the ability to determine the need for acute psychiatric hospitalization 3.3/C Shows sufficient knowledge to identify and treat common psychiatric manifestations of medical illness (e.g., delirium, depression, steroid-induced syndromes) 3.4/C Demonstrates sufficient knowledge to include relevant medical
4.1/A Demonstrates sufficient knowledge to identify and treat atypical and complex psychiatric conditions throughout the life cycle and in a range of settings (inpatient, outpatient, emergency, consultation liaison)3
4.2/B Displays knowledge sufficient to determine the appropriate level of care for patients expressing, or who may represent, danger to self and/or others, across the life cycle and in a full range of treatment settings 4.3/C Shows knowledge sufficient to identify and treat a wide range of psychiatric conditions in patients with medical disorders 4.4/C Demonstrates sufficient knowledge to systematically screen for, evaluate, and diagnose
5.1/B Displays knowledge sufficient to teach assessment of risks and the appropriate level of care for patients who may represent a danger to self and/or others 5.2/C Shows sufficient knowledge to identify and treat uncommon psychiatric conditions in patients with medical disorders
5.3/C Demonstrates sufficient knowledge to detect and ensure appropriate treatment of
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hyperlipidemia, diabetes) in psychiatric patients
and neurological conditions in the differential diagnoses of psychiatric patients
common medical conditions in psychiatric patients, and to ensure appropriate further evaluation and treatment of these conditions in collaboration with other medical providers
uncommon medical conditions in patients with psychiatric disorders
Comments: Footnotes:
1This milestone focuses on knowledge needed for patient care. Thus, knowledge of psychopathology can be assessed through multiple choice knowledge examinations (e.g., the Psychiatry Resident In-Training Examination (PRITE)), and/or through evaluations of the application of knowledge of psychopathology to patient care, such as standardized patients or case vignettes, clinical skills evaluations, and knowledge evidenced during clinical rotations and the routine, supervised care of patients during residency.
2This level includes identification and treatment of a wider array of conditions, across the life cycle (including childhood, adolescent, adult, and geriatric conditions), and in a variety of settings (e.g., outpatient, consultation liaison, subspecialty settings).
3“Atypical” and “complex” psychiatric conditions refer to unusual presentations of common disorders, co-occurring disorders in patients with multiple co-morbid conditions, and diagnostically challenging clinical presentations.
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MK3. Clinical Neuroscience1 Includes knowledge of neurology, neuropsychiatry, neurodiagnostic testing, and relevant neuroscience and their application in clinical settings A: Neurodiagnostic testing B: Neuropsychological testing C: Neuropsychiatric co-morbidity D: Neurobiology E: Applied neuroscience
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Knows commonly available neuroimaging and neurophysiologic diagnostic modalities and how to order them 1.2/B Knows how to order neuropsychological testing
2.1/A Knows indications for structural neuroimaging (cranial computed tomography [CT] and magnetic resonance imaging [MRI]) and neurophysiological testing (electroencephalography [EEG], evoked potentials, sleep studies)
2.2/B Describes common neuropsychological tests and their indications2 2.3/C Describes psychiatric disorders co-morbid with common neurologic disorders3 and neurological disorders frequently seen in psychiatric patients4
3.1/A Recognizes the significance of abnormal findings in routine neurodiagnostic test6 reports in psychiatric patients 3.2/B Knows indications for specific neuropsychological tests and understands meaning of common abnormal findings 3.3/D Describes neurobiological and genetic hypotheses of common psychiatric disorders and their limitations
4.1/A Explains the significance of routine neuroimaging, neurophysiological, and neuropsychological testing abnormalities to patients 4.2/A Knows clinical indications and limitations of functional neuroimaging7
4.3/C Describes psychiatric co-morbidities of less common neurologic disorders8 and less common neurologic co-morbidities of psychiatric disorders9
4.4/D Explains neurobiological hypotheses and genetic risks of common psychiatric disorders to patients
5.1/A Integrates recent neurodiagnostic research into understanding of psychopathology 5.2/B Flexibly applies knowledge of neuropsychological findings to the differential diagnoses of complex patients 5.3/D Explains neurobiological hypotheses and genetic risks of less common psychiatric disorders11 to patients
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2.4/E Identifies the brain areas thought to be important in social and emotional behavior5
4.5/E Demonstrates sufficient knowledge to incorporate leading neuroscientific hypotheses of emotions and social behaviors10 into case formulation
5.4/D Integrates knowledge of neurobiology into advocacy for psychiatric patient care and stigma reduction12
Comments: Footnotes:
1This milestone focuses on knowledge needed for patient care. Thus, knowledge of clinical neuroscience can be assessed through multiple choice knowledge examination (e.g., PRITE), and/or through evaluations of the application of knowledge of clinical neuroscience to patient care, such as standardized patients or case vignettes, clinical skills evaluations, and knowledge evidenced during clinical rotations and the routine, supervised care of patients during residency.
2Common neuropsychological tests include the Montreal Cognitive Assessment (or Mini Mental State Examination), Wechsler Adult Intelligence Scale (or Halstead-Reitan battery), Wechsler Memory Scale, Wide Range Achievement Test, Wisconsin Card Sorting Test, Clock Drawing Test.
3Examples include psychosis, mood disorders, personality changes, and cognitive impairments seen in common neurological disorders. 4These include drug-induced and idiopathic extrapyramidal syndromes, neuropathies, traumatic brain injury (TBI), vascular lesions, dementias, and encephalopathies. 5Areas might include dorsolateral prefrontal cortex, anterior cingulate, amygdala, hippocampus, etc. 6These include structural imaging and electrophysiologic testing. 7For example, positron emission tomography (PET)/single-photon emission computed tomography (SPECT) in the diagnosis of Alzheimer’s disease (supportive but non-diagnostic); functional magnetic resonance imaging (fMRI) is not yet reimbursable for clinical use.
8Examples include: mood disorder due to neurological condition, manic type, in right hemisphere or orbitofrontal strokes/tumors; depression in peri-basal ganglionic infarcts; manic behavior in limbic encephalitis.
9Examples include: neuroleptic malignant syndrome; lethal catatonia; “Parkinson plus” syndromes (e.g., multisystem atrophy, dementia with Lewy bodies, etc).
10Social behaviors might include attachment, empathy, attraction, reward/addiction, aggression, appetites, etc. 11Examples include : Obsessive-Compulsive Disorder (OCD); eating disorders ; Gilles de la Tourette syndrome. 12Uses neurobiologic hypotheses of psychiatric disorders to advocate for health coverage, treatment availability, etc.
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MK4. Psychotherapy Refers to knowledge regarding: 1) individual psychotherapies, including but not limited to psychodynamic1, cognitive-behavioral2, and supportive therapies3; 2) couples, family, and group therapies; and, 3) integrating psychotherapy and psychopharmacology A: Knowledge of psychotherapy: theories B: Knowledge of psychotherapy: practice C: Knowledge of psychotherapy: evidence base
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Identifies psycho-dynamic, cognitive-behavioral, and supportive therapies as major psychotherapeutic modalities
2.1/A Describes the basic principles of each of the three core individual psychotherapy modalities4 2.2/A Discusses common factors across psychotherapies5 2.3/B Lists the basic indications, contraindications, benefits, and risks of supportive, psychodynamic and cognitive behavioral psychotherapies
3.1/A Describes differences among the three core individual therapies 3.2/A Describes the historical and conceptual development of psychotherapeutic paradigms 3.3/B Describes the basic techniques of the three core individual therapies 3.4/B Describes the basic principles, indications, contraindications, benefits, and risks of couples, group, and family therapies 3.5/C Summarizes the evidence base for each of the three core individual therapies
4.1/A Describes proposed mechanisms of therapeutic change 4.2/C Discusses the evidence base for combining different psychotherapies and psychopharmacology 4.3/C Critically appraises the evidence for efficacy of psychotherapies
5.1/A Incorporates new theoretical developments into knowledge base
5.2/A, B Demonstrates sufficient knowledge of psychotherapy to teach others effectively
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Comments: Footnotes:
1This includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to understand the concepts of resistance/defenses, and transference/countertransference.
2This includes the capacity to generate a case formulation, and to demonstrate techniques of intervention, including behavior change, skills acquisition, and addressing cognitive distortions.
3This includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to strengthen the patient’s adaptive defenses, resilience, and social supports.
4Throughout this subcompetency, the three “core” or “major” individual psychotherapies refer to supportive, psychodynamic, and cognitive-behavioral therapy. 5Common factors refer to elements that different psychotherapeutic modalities have in common, and that are considered central to the efficacy of psychotherapy. These
include accurate empathy, therapeutic alliance, and appropriate professional boundaries.
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MK5. Somatic Therapies Medical Knowledge of somatic therapies, including psychopharmacology, ECT, and emerging somatic therapies, such as transcranial magnetic stimulation (TMS) and vagnus nerve stimulation (VNS) A: Knowledge of indications, metabolism and mechanism of action for medications B: Knowledge of ECT and other emerging somatic treatments C: Knowledge of lab studies and measures in monitoring treatment
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Describes general indications and common side effects for commonly prescribed psychopharmacologic agents 1.2/B Describes indications for ECT
2.1/A Describes hypothesized mechanisms of action and metabolism for commonly prescribed psychopharmacologic agents 2.2/A Describes indications for second- and third-line pharmacologic agents 2.3/A Describes less frequent but potentially serious/dangerous adverse effects for commonly prescribed psychopharmacological agents 2.4/A Describes expected time course of response for commonly prescribed classes of psychotropic agents 2.5/B Describes length and frequency of ECT treatments, as well as relative contraindications 2.6/C Describes the physical
3.1/A Demonstrates an understanding of pharmacokinetic and pharmacodynamic drug interactions 3.2/A Demonstrates an understanding of psychotropic selection based on current practice guidelines or treatment algorithms for common psychiatric disorders 3.3/B Describes specific techniques in ECT 3.4/B Lists emerging neuro-modulation therapies1
4.1/A Describes the evidence supporting the use of multiple medications in certain treatment situations (e.g., polypharmacy and augmentation) 4.2/ C Integrates knowledge
5.1/A Integrates emerging studies of somatic treatments into knowledge base 5.2/A Effectively teaches at a post-graduate level evidence-based or best somatic treatment practices
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and lab studies necessary to initiate treatment with commonly prescribed medications
of the titration and side effect management of multiple medications, monitoring the appropriate lab studies, and how emerging physical and laboratory findings impact somatic treatments
Comments: Footnotes:
1Examples of neuromodulation techniques include TMS and variations, VNS, Deep Brain Stimulation, etc.
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MK6. Practice of Psychiatry A: Ethics B: Regulatory compliance C: Professional development and frameworks
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Lists common ethical issues in psychiatry 1.2/B Recognizes and describes institutional policies and procedures1
1.3/C Lists ACGME Competencies
2.1/A Lists and discusses sources of professional standards of ethical practice 2.2/A Lists situations that mandate reporting or breach of confidentiality 2.3/C Describes how to keep current on regulatory and practice management issues
3.1/A Discusses conflict of interest and management 3.2/B Describes applicable regulations for billing and reimbursement
4.1/B Describes the existence of state and regional variations regarding practice, involuntary treatment, health regulations, and psychiatric forensic evaluation 4.2/C Describes professional advocacy2
4.3/C Describes how to seek out and integrate new information on the practice of psychiatry
5.1/B Describes international variations regarding practice, involuntary treatment, and health regulations 5.2/C Proposes advocacy activities, policy development, or scholarly contributions related to professional standards
Comments: Footnotes:
1“Institutional policies and procedures” refers to those related to the practice of medicine and psychiatry at the specific institution where the resident is credentialed. These include a Code of Conduct (addressing gifts, etc.) and privacy policies (related to HIPAA, etc.), but not patient safety policies. These are usually covered during an orientation to the institution and program.
2 Advocacy includes efforts to promote the wellbeing and interests of patients and their families, the mental health care system, and the profession of psychiatry. While advocacy can include work on behalf of specific individuals, it is usually focused on broader system issues, such as access to mental health care services or public
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awareness of mental health issues. The focus on larger societal problems typically involves work with policy makers (state and federal legislators) and peer or professional organizations (American Psychiatry Association (APA), National Alliance on Mental Illness (NAMI), etc.).
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SBP1. Patient Safety and the Health care Team A: Medical errors and improvement activities B: Communication and patient safety C: Regulatory and educational activities related to patient safety
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Differentiates among medical errors, near misses, and sentinel events 1.2/B Recognizes failure in teamwork and communication as leading cause of preventable patient harm 1.3/C Follows institutional safety policies, including reporting of problematic behaviors and processes, errors, and near misses
2.1/A Describes the common system causes for errors 2.2/B Consistently uses structured communication tools to prevent adverse events (e.g., checklists, safe hand-off procedures, briefings) 2.3/C Actively participates in conferences focusing on systems-based errors in patient care
3.1/A Describes systems and procedures that promote patient safety
4.1/A Participates in formal analysis (e.g., root-cause analysis, failure mode effects analysis) of medical errors and sentinel events 4.2/C Develops content for and facilitates a patient safety presentation or conference focusing on systems-based errors in patient care (i.e., a morbidity and mortality [M&M] conference)
5.1/A Leads multidisciplinary teams (e.g., human factors engineers1, social scientists) to address patient safety issues 5.2/A, C Provides consultation to organizations to improve personal and patient safety
Comments: Footnotes:
1 Human Factors Engineering (HFE) is a framework for efficient and constructive thinking which includes methods and tools to help health care teams perform patient safety analyses (see: Gosbee J, Human factors engineering and patient safety, Quality and Safety in Health Care, 2002;11:352–354).
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SBP2. Resource Management (may include diagnostics, medications, level of care, other treatment providers, access to community assistance) A: Costs of care and resource management
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Recognizes need for efficient and equitable use of resources
2.1/A Recognizes disparities in health care at individual and community levels
2.2/A Knows the relative cost of care (e.g., medication costs, diagnostic costs, level of care costs, procedure costs)
3.2/A Coordinates patient access to community and system resources
4.1/A Practices cost-effective, high-value clinical care1, using evidence-based tools and information technologies to support decision making
4.2/A Balances the best interests of the patient with the availability of resources
5.1/A Designs measurement tools to monitor and provide feedback to providers/teams on resource consumption to facilitate improvement 5.2/A Advocates for improved access to and additional resources within systems of care
Comments: Footnotes: 1 Examples include: avoids higher-cost, newer antipsychotics when older formulations are adequate; recommends levels of care that are matched to clinical need and
available in the community.
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SBP3. Community-Based Care A: Community-based programs B: Self-help groups C: Prevention D: Recovery and rehabilitation
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Gives examples of
community mental health systems of care 1.2/B Gives examples of self-help groups (Alcoholics Anonymous [AA], Narcotics Anonymous [NA]), other community resources (church, school) and social networks (e.g., family, friends, acquaintances)
2.1/A Coordinates care with community mental health agencies, including with case managers 2.2/B Recognizes role and explains importance of self-help groups and community resource groups (e.g., disorder-specific support and advocacy groups) 2.3/C Describes individual and population risk factors for mental illness
3.1/B Incorporates disorder-specific support and advocacy groups in clinical care 3.2/C Describes prevention measures: universal, selective and indicated1 3.3/D Describes rehabilitation programs (vocational, brain injury, etc.) and the recovery model2
4.1/B Routinely uses self-help groups, community resources, and social networks in treatment3
4.2/C Employs prevention and risk reduction strategies in clinical care 4.3/D Appropriately refers to rehabilitation and recovery programs 4.4/D Uses principles of evidence-based practice and patient centered care in management of chronically ill patients
5.1/A Participates in the administration of community-based treatment programs
5.2/A Participates in creating new community-based programs 5.3/D Practices effectively in a rehabilitation and/or recovery-based program
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Comments: Footnotes: 1Universal prevention strategies are designed to reach the entire population; selective prevention are designed for a targeted subgroup of the general population; and indicated prevention intervention targets individuals. 2The Substance Abuse and Mental Health Services Administration (SAMHSA) has a working definition for the recovery model applied to mental health and addictions. This definition acknowledges that recovery is a process of change for an individual consumer to improve health and wellness, live a self-directed life, and strive and reach his or her full potential. The guiding principles that inform a recovery model of care include hope, person-driven, holistic, peer supports, social networks, culturally-based, trauma-informed, strength-based, responsibility, and respect (see: http://www.samhsa.gov/newsroom/advisories/1112223420.aspx). 3These community resources include supports and services from both the peer and professional workforces.
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SBP4. Consultation to non-psychiatric medical providers and non-medical systems (e.g., military, schools, businesses, forensic ) A: Distinguishes care provider roles related to consultation B: Provides care as a consultant and collaborator C: Specific consultative activities
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Describes the difference between consultant and primary treatment provider
2.1/A Describes differences in providing consultation for the system or team versus the individual patient
2.2/B Provides consultation to other medical services 2.3/C Clarifies the consultation question 2.4/C Conducts and reports a basic decisional capacity evaluation
3.1/C Assists primary treatment care team in identifying unrecognized clinical care issues
3.2/C Identifies system issues in clinical care and provides recommendations 3.3/C Discusses methods for integrating mental health and medical care in treatment planning
4.1/B Provides integrated care for psychiatric patients through collaboration with other physicians1
4.2/C Manages complicated and challenging consultation requests
5.1/B Provides psychiatric consultations to larger systems
5.2/B Leads a consultation team
Comments: Footnotes: 1 Provides communication back to the primary care physicians in the outpatient setting, including collaborative and co-located settings such as a medical home.
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PBLI1. Development and execution of lifelong learning through constant self-evaluation, including critical evaluation of research and clinical evidence A: Self-Assessment and self-Improvement B: Evidence in the clinical workflow
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Uses feedback from teachers, colleagues, and patients to assess own level of knowledge and expertise 1.2/A Recognizes limits of one’s knowledge and skills and seeks supervision 1.3/B Describes and ranks levels of clinical evidence1
2.1/A Regularly seeks and incorporates feedback to improve performance
2.2/A Identifies self-directed learning goals and periodically reviews them with supervisory guidance 2.3/B Formulates a searchable question from a clinical question2
3.1/A Demonstrates a balanced and accurate self-assessment of competence, using clinical outcomes to identify areas for continued improvement 3.2/B Selects an appropriate, evidence-based information tool1 to meet self-identified learning goals
3.3/B Critically appraises different types of research, including randomized controlled trials (RCTs), systematic reviews, meta-analyses, and practice guidelines
4.1/A Demonstrates improvement in clinical practice based on continual self-assessment and evidence-based information 4.2/A Identifies and meets self-directed learning goals with little external guidance 4.3/A, B Demonstrates use of a system or process for keeping up with relevant changes in medicine2
4.4/B Independently searches for and discriminates evidence relevant to clinical practice problems
5.1/A, B Sustains practice of self-assessment and keeping up with relevant changes in medicine, and makes informed, evidence-based clinical decisions 5.2/B Teaches others techniques to efficiently incorporate evidence gathering into clinical workflow 5.3/B Independently teaches appraisal of clinical evidence
Comments: Footnotes:
1Examples include: practice guidelines; PubMed Clinical Queries; Cochrane, DARE, or other evidence-based reviews; Up-to-Date, etc. 2Examples include: a performance-in-practice (PIP) module as included in the American Board of Psychiatry and Neurology (ABPN) Maintenance of Certification (MOC)
process; or regular and structured readings of specific evidence sources.
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PBLI2. Formal practice-based quality improvement based on established and accepted methodologies1
A: Specific quality improvement project B: Quality improvement didactic knowledge
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Recognizes potential gaps in quality of care and system-level inefficiencies2 1.2/B Discusses with supervisors possible quality gaps and problems with psychiatric care delivery
2.1/A Narrows problems within own clinical service(s) to a specific and achievable aim for a quality improvement (QI) project
2.2/B Outlines factors and causal chains contributing to quality gaps within own institution and practice3
3.1/A Involves appropriate stakeholders in design of a QI project4
3.2/B Lists common responses of teams and individuals to changes in clinical operations and describes strategies for managing same
4.1/A Substantially contributes to a supervised project to address specific quality deficit within own clinical service(s), and measures relevant outcomes
4.2/B Describes basic methods for implementation and evaluation of clinical QI projects5
5.1/A Independently proposes and leads projects to enhance patient care
5.2/A Uses advanced quality measurement and “dashboard” tools 5.3/B Describes core concepts of advanced QI methodologies and business processes6
Comments:
Footnotes: 1Many of these requirements would be satisfied by active participation in an individual or group project within the residency program, department, or institution.
Active participation, at a minimum, should include observation and participation through a full feedback cycle (e.g., one Plan-Do-Study-Act loop). Some didactic material or assigned readings may be helpful to supplement the case-based learning. Resources for didactics include the Institute for Health Care Improvement Open School (http://www.ihi.org/offerings/IHIOpenSchool/), World Health Organization Patient Safety Curriculum (http://www.who.int/patientsafety/education /curriculum/download/en/index.html), and Department of Veterans Affairs Patient Safety Curriculum (http://www.patientsafety.va.gov/curriculum/index.html). 2 Examples include: problems with transfer of information during sign-out or patient movement between care areas; difficulty in moving needed resources to a patient’s location; prescribing practices that markedly deviate from guidelines. 3 Chooses an inefficient/ineffective practice or recent adverse outcome, identifies some factors contributing to the status quo, and displays some sense of which factors are amenable to intervention. 4 Examples include, for a project involving a standard order protocol on an inpatient unit: meets with nurse managers and ancillary clinical staff members and learns about their needs/constraints before designing intervention; recognizes fear of change as a common characteristic in clinical environments and provides staff members space/time to adequately process and modify proposals. At this stage, requires supervision/guidance in such efforts. 5 This might include variations on the Plan-Do-Study-Act theme (i.e., stating an understanding that an effective project should include a target population and intervention, an outcome measure, and some form of iterative refinement). 6 Can state some core philosophical concepts of Lean Production, the Six-Sigma/Total Quality Management methods, or other emerging management philosophies, and gives examples of how these could apply in health care.
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PBLI3. Teaching A: Development as a teacher B: Observable teaching skills
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Recognizes role of physician as teacher
2.1/A Assumes a role in the clinical teaching of early learners 2.2/B Communicates goals and objectives for instruction of early learners 2.3/B Evaluates and provides feedback to early learners
3.1/A Participates in activities designed to develop and improve teaching skills
3.2/B Organizes content and methods for individual instruction for early learners
4.1/A Gives formal didactic presentation to groups (e.g., grand rounds, case conference, journal club) 4.2/B Effectively uses feedback on teaching to improve teaching methods and approaches
5.1/A Educates broader professional community and/or public (e.g., presents at regional or national meeting) 5.2/B Organizes and develops curriculum materials
Comments:
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PROF1.1 Compassion, integrity, respect for others, sensitivity to diverse patient populations2, 3, adherence to ethical principles A: Compassion, reflection, sensitivity to diversity B: Ethics
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Demonstrates behaviors that convey caring, honesty, genuine interest, and respect for patients and their families 1.2/A Recognizes that patient diversity affects patient care 1.3/B Displays familiarity with some basic ethical principles (e.g., confidentiality, informed consent, professional boundaries)
2.1/A Demonstrates capacity for self-reflection, empathy, and curiosity about and openness to different beliefs and points of view, and respect for diversity 2.2/A Provides examples of the importance of attention to diversity in psychiatric evaluation and treatment 2.3/B Recognizes ethical conflicts in practice and seeks supervision to manage them
3.1/A Elicits beliefs, values, and diverse practices of patients and their families, and understands their potential impact on patient care 3.2/A Routinely displays sensitivity to diversity in psychiatric evaluation and treatment 3.3/B Recognizes ethical issues in practice and is able to discuss, analyze, and manage these in common clinical situations
4.1/A Develops a mutually agreeable care plan in the context of conflicting physician and patient and/or family values and beliefs 4.2/A Discusses own cultural background and beliefs and the ways in which these affect interactions with patients
5.1/A Serves as a role model and teacher of compassion, integrity, respect for others, and sensitivity to diverse patient populations 5.2/B Leads resident case discussions regarding ethical issues 5.3/B Adapts to evolving ethical standards (i.e. can manage conflicting ethical standards and values and can apply these to practice) 5.4/B Systematically analyzes and manages ethical issues in complicated and challenging clinical situations
Comments:
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Footnotes: 1The two Professionalism subcompetencies (PROF1 and PROF2) reflect the following overall values: Residents must demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles. Residents must develop and acquire a professional identity consistent with values of oneself, the specialty, and the practice of medicine. Residents are expected to demonstrate compassion, integrity, and respect for others; sensitivity to diverse populations; responsibility for patient care that supersedes self-interest; and accountability to patients, society, and the profession. 2Diversity refers to unique aspects of each individual patient, including gender, age, socioeconomic status, culture, race, religion, disabilities, and sexual orientation. 3For milestones regarding health disparities, please see SBP2.
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PROF2. Accountability to self, patients, colleagues, and the profession A: Fatigue management and work balance B: Professional behavior and participation in professional community C: Ownership of patient care
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Understands the need for sleep, and the impact of fatigue on work 1.2/A Lists ways to manage fatigue, and seeks back-up as needed to ensure good patient care
1.3/B Exhibits core professional behaviors1 1.4/B Displays openness to feedback 1.5/C Introduces self as patient’s physician
2.1/A Notifies team and enlists back-up when fatigued or ill, so as to ensure good patient care 2.2/B Follows institutional policies for physician conduct 2.3/C Accepts the role of the patient’s physician and takes responsibility (under supervision) for ensuring that the patient receives the best possible care
3.1/A Identifies and manages situations in which maintaining personal emotional, physical, and mental health is challenged, and seeks assistance when needed 3.2/A Recognizes the tension between the needs of personal/family life and professional responsibilities, and its effect on medical care 3.3/B Recognizes the importance of participating in one’s professional community
3.4/C Is recognized by self, patient, patient’s family, and medical staff members as the patient’s primary psychiatric provider
4.1/A Knows how to take steps to address impairment in self and in colleagues
4.2/A Prioritizes and balances conflicting interests of self, family, and others to optimize medical care and practice of profession2 4.3/B Prepares for obtaining and maintaining board certification 4.4/C Displays increasing autonomy and leadership in taking responsibility for ensuring that patients receive the best possible care
5.1/A Develops physician wellness programs or interventions
5.2/B Develops organizational policies, programs, or curricula for physician professionalism 5.3/B Participates in the professional community (e.g., professional societies, patient advocacy groups, community service organizations) 5.4/C Serves as a role model in demonstrating responsibility for ensuring that patients receive the best possible care
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Comments:
Footnotes: 1Professional behavior refers to the global comportment of the resident in carrying out clinical and professional responsibilities. This includes:
a. timeliness (e.g., reports for duty, answers pages, and completes work assignments on time); b. maintaining professional appearance and attire; c. being reliable, responsible, and trustworthy (e.g., knows and fulfills assignments without needing reminders); d. being respectful and courteous (e.g., listens to the ideas of others, is not hostile or disruptive, maintains measured emotional responses and equanimity despite
stressful circumstances); e. maintaining professional boundaries; and, f. understanding that the role of a physician involves professionalism and consistency of one’s behaviors, both on and off duty.
These descriptors and examples are not intended to represent all elements of professional behavior. 2Residents are expected to demonstrate responsibility for patient care that supersedes self-interest. It is important that residents recognize the inherent conflicts and competing values involved in balancing dedication to patient care with attention to the interests of their own well-being and responsibilities to their families and others. Balancing these interests while maintaining an overriding commitment to patient care requires, for example, ensuring excellent transitions of care, sign-out, and continuity of care for each patient during times that the resident is not present to provide direct care for the patient.
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ICS1. Relationship development and conflict management with patients, families, colleagues, and members of the health care team A: Relationship with patients B: Conflict management C: Team-based care
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Cultivates positive relationships with patients, families, and team members
1.2/B Recognizes communication conflicts in work relationships
1.3/C Identifies team-based care as preferred treatment approach, and collaborates as a member of the team
2.1/A Develops a therapeutic relationship with patients in uncomplicated situations
2.2/A Develops working relationships across specialties and systems of care in uncomplicated situations
2.3/B Negotiates and manages simple patient/family-related conflicts
2.4/C Actively participates in team-based care; supports activities of other team members, and communicates their value to the patient and family
3.1/A Develops therapeutic relationships in complicated situations
3.2/B Sustains working relationships in the face of conflict
3.3/C Facilitates team-based activities in clinical and/or non-clinical situations (including on committees)
4.1/A Sustains therapeutic and working relationships during complex and challenging situations, including transitions of care 4.2/C Leads a multidisciplinary care team
5.1/A Sustains relationships across systems of care and with patients during long-term follow-up 5.2/A, B Develops models/approaches to managing difficult communications
5.3/B, C Manages treatment team conflicts as team leader 5.4/C Leads and facilitates meetings within the organization/system
Comments:
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ICS2. Information sharing and record keeping A: Accurate and effective communication with health care team B: Effective communications with patients C: Maintaining professional boundaries in communication D: Knowledge of factors which compromise communication
Has not Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Level 5
1.1/A Ensures transitions of
care are accurately documented, and optimizes communication across systems and continuums of care 1.2/A Ensures that the written record (electronic medical record [EMR], personal health records [PHR]/patient portal, hand-offs, discharge summaries, etc.) are accurate and timely, with attention to preventing confusion and error, consistent with institutional policies 1.3/B Engages in active listening, “teach back,” and other strategies to ensure patient and family understanding 1.4/C Maintains appropriate boundaries in sharing information by electronic communication
2.1/A, B Organizes both written and oral information to be shared with patient, family, team, and others 2.2/B Consistently demonstrates communication strategies to ensure patient and family understanding 2.3/B Demonstrates appropriate face-to-face interaction while using EMR 2.4/C Understands issues raised by the use of social media by patients and providers
3.1/ A, B Uses easy-to-understand language in all phases of communication, including working with interpreters
3.2/B Consistently engages patients and families in shared decision making
4.1/A, B Demonstrates effective verbal communication with patients, families, colleagues, and other health care providers that is appropriate, efficient, concise, and pertinent
4.2/A, B Demonstrates written communication with patients, families, colleagues, and other health care providers that is appropriate, efficient, concise, and pertinent
4.3/C Uses discretion and judgment in the inclusion of sensitive patient material in the medical record
5.1/A Models continuous improvement in record keeping 5.2/C Participates in the development of changes in rules, policies, and procedures related to technology
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2.5/D Lists factors that affect information sharing (e.g., intended audience, purpose, need to know) 2.6/D Lists effects of computer use on accuracy of information gathering and recording and potential disruption of the physician/patient/family relationship
3.3/D Gives examples of situations in which communication can be compromised (e.g., perceptual impairment, cultural differences, transference, limitations of electronic media)
4.4/C Uses discretion and judgment in electronic communication with patients, families, and colleagues
Comments:
July 2015
The Child & Adolescent Psychiatry Milestone Project
A Joint Initiative of
The Accreditation Council for Graduate Medical Education
and
The American Board of Psychiatry and Neurology
1
The Child and Adolescent Psychiatry Milestone Project
The Milestones are designed only for use in evaluation of fellows in the context of their participation in ACGME-
accredited residency or fellowship programs. The Milestones provide a framework for the assessment of the
development of the resident physician in key dimensions of the elements of physician competency in a specialty
or subspecialty. They neither represent the entirety of the dimensions of the six domains of physician
competency, nor are they designed to be relevant in any other content.
2
Child and Adolescent Psychiatry Milestone Group
Psychiatry Subspecialty Milestones Chair: Christopher R. Thomas, MD
Working Group
Chair: Jeffrey Hunt, MD
Sandra M. DeJong, MD
Laura Edgar, EdD, CAE
Howard Liu, MD
Cynthia Santos, MD
Advisory Group
Chair: George A. Keepers, MD
Larry R. Faulkner, MD
Paramjit T. Joshi, MD
Christopher K. Varley, MD
3
Milestone Reporting
This document presents Milestones designed for programs to use in semi-annual review of performance and reporting to the
ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a
developmental framework from less to more advanced. They are descriptors and targets for fellow performance as a fellow moves
from entry into fellowship through graduation. In the initial years of implementation, the Review Committee will examine Milestone
performance data for each program’s fellows as one element in the Next Accreditation System (NAS) to determine whether fellows
overall are progressing.
For each period, review and reporting will involve selecting milestone levels that best describe each fellow’s current performance
and attributes. Milestones are arranged into numbered levels. Tracking from Level 1 to Level 5 is synonymous with moving from
novice to expert in the subspecialty. These levels do not correspond with post-graduate year of education.
Selection of a level implies that the fellow substantially demonstrates the milestones in that level, as well as those in lower levels
(see the diagram on page v).
Level 1: The fellow demonstrates milestones expected of an incoming fellow.
Level 2: The fellow is advancing and demonstrates additional milestones, but is not yet performing at a mid-fellowship level.
Level 3: The fellow continues to advance and demonstrate additional milestones, consistently including the majority of
milestones targeted for fellowship.
Level 4: The fellow has advanced so that he or she now substantially demonstrates the milestones targeted for fellowship.
This level is designed as the graduation target.
Level 5: The fellow has advanced beyond performance targets set for fellowship and is demonstrating “aspirational” goals
which might describe the performance of someone who has been in practice for several years. It is expected that only
a few exceptional fellows will reach this level.
4
Additional Notes
Level 4 is designed as the graduation target and does not represent a graduation requirement. Making decisions about readiness for
graduation is the purview of the fellowship program director. Study of Milestone performance data will be required before the
ACGME and its partners will be able to determine whether milestones in the first four levels appropriately represent the
developmental framework, and whether Milestone data are of sufficient quality to be used for high-stakes decisions.
Some milestone descriptions include statements about performing independently. These activities must occur in conformity to the
ACGME supervision guidelines, as well as to institutional and program policies. For example, a fellow who performs a procedure
independently must, at a minimum, be supervised through oversight.
Definitions used in this document:
Systems – includes schools, courts, community based organizations (advocacy, community mental health), governmental agencies
(e.g. child protective agencies), health care (primary care, etc.).
Families – includes parents, foster parents, legal guardians
Developmental domains – includes social/emotional, cognitive, behavioral, gross motor, fine motor, speech and language
development
Answers to Frequently Asked Questions about Milestones are available on the Milestones web page:
http://www.acgme.org/acgmeweb/Portals/0/MilestonesFAQ.pdf.
5
The diagram below presents an example set of milestones for one sub-competency in the same format as the ACGME Report
Worksheet. For each reporting period, a fellow’s performance on the milestones for each sub-competency will be indicated
by selecting the level of milestones that best describes that fellow’s performance in relation to those milestones.
Selecting a response box on the line in between levels indicates that milestones in lower levels have been substantially demonstrated as well as some milestones in the higher level(s).
Selecting a response box in the middle of a level implies that milestones in that level and in lower levels have been substantially demonstrated.
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PC1 — Psychiatric Evaluation
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 For adolescents,
acquires accurate
history and mental
status examination
findings, customized to
the patient’s complaints
1.2 Assesses patient
safety, including suicidal
and homicidal ideation,
and considers the
potential for trauma,
abuse, aggression, and
high-risk behaviors
1.3 Demonstrates a
respectful manner with
children and adolescents
and their families
1.4 Seeks supervision
appropriately
2.1 For adolescents, obtains
information that is sensitive and
not readily offered by the patient
2.2 Considers the structure and
functioning of the family, including
strengths, vulnerabilities, and
cultural factors, as they pertain to
the child
2.3 Conducts assessment that
includes observation of child’s
interaction with caretakers
2.4 Conducts basic assessment of
the child’s development
2.5 Selects laboratory and
diagnostic tests (medical work-up)
appropriate to the clinical
presentation
2.6 Uses hypothesis-driven
information-gathering techniques
2.7 Begins to use the clinician's
emotional responses to the patient
and family as a diagnostic tool
3.1 Evaluates the structure and
functioning of the family, including
strengths, vulnerabilities, and
cultural factors, as they pertain to
the child
3.2 Assesses development across
all domains
3.3 For school-age and adolescent
patients, obtains information that
is sensitive and not readily offered
by the patient
3.4 Selects and uses appropriate
diagnostic tests (screening
instruments, rating scales,
psychoeducational testing)
appropriate to the clinical
presentation
3.5 Regularly uses the clinician's
emotional responses to the patient
and family as a diagnostic tool
3.6 Demonstrates ability to shift
focus when verbal and non-verbal
information is conflicting
4.1 Acquires efficient,
accurate, thorough and
relevant history for
preschool, school-age, and
adolescent patients,
customized to each patient’s
complaints
4.2 Modifies interview
approach to assess patients
at different developmental
levels, including use of non-
verbal techniques and play
4.3 Effectively assesses
development, including
atypical development
(intellectual disability, etc.)
4.4 Collects information from
the pertinent systems
4.5 Assesses the family in a
sophisticated and culturally-
sensitive manner
5.1 Incorporates
therapeutic interventions
as part of the evaluation
patients and families
5.2 Utilizes creative use of
evaluation techniques,
both verbal and non-
verbal
5.3 Serves as a role model
for gathering subtle and
reliable information from
the patient
5.4 Independently teaches
and supervises other
learners in clinical
evaluation
Comments:
Not yet achieved Level 1
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PC2 — Psychiatric Formulation and Differential Diagnosis1
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Organizes and accurately
summarizes, reports, and
presents information from
the patient, family, and
collateral sources to
colleagues
1.2 Develops a working
diagnosis based on patient
evaluation
2.1 Develops comprehensive
differential diagnosis for
common syndromes,
synthesizing data from the
patient, family, and
collateral sources
2.2 Describes patients’
symptoms and problems,
precipitating stressors or
events, predisposing life
events or stressors,
perpetuating and protective
factors, and prognosis
3.1 Describes how
development influences the
presentation of
psychopathology
3.2 Develops a comprehensive
differential diagnosis while
avoiding premature closure
3.3 Organizes formulation in a
systematic manner that
follows a conceptual model2
4.1 Efficiently synthesizes all
information into a concise but
comprehensive formulation
4.2 Incorporates subtle,
unusual, or conflicting reports
into hypotheses and
formulations, including
developmental, family, and
systems factors
4.3 Includes the interaction
between contributing factors in
the diagnostic formulation
5.1 Formulates a case
based on different
conceptual models
5.2 Expands the
differential diagnosis to
include subtle or rare
presentations or
disorders
5.3 Serves as a role
model of efficient and
accurate formulation
5.4 Teaches formulation
to advanced learners
Comments:
Footnotes: 1A psychiatric formulation is a theoretically-based conceptualization of the patient’s mental disorder(s). It provides an organized summary of those individual factors thought to contribute to the patient’s unique psychopathology. This includes elements of possible etiology, as well as those that modify or influence presentation, such as risk and protective factors. It is therefore distinct from a differential diagnosis that lists the possible diagnoses for a patient, or an assessment that summarizes the patient’s signs and symptoms, as it seeks to understand the underlying mechanisms of the patient’s unique problems by proposing a hypothesis as to the causes of mental disorders.
2Models of formulation include those based on either major theoretical systems of the etiology of mental disorders (such as behavioral, biological, cognitive, cultural, psychological, psychoanalytic, sociological, or traumatic), or comprehensive frameworks of understanding (such as bio-psycho-social or predisposing, precipitating, perpetuating, protective, and prognostic outlines). Models of formulation set forth a hypothesis about the unique features of a patient’s illness that can serve to guide further evaluation or develop individualized treatment plans.
Not yet achieved Level 1
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PC3 — Treatment Planning and Management
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Sets treatment goals in
collaboration with the
patient and family
1.2 Manages patient crises
and safety concerns with
supervision
1.3 Monitors treatment
adherence and response
2.1 Incorporates a clinical
practice guideline or
treatment algorithm when
available
2.2 Links treatment to
formulation
2.3 Recognizes need for
consultation and supervision
for complicated or
refractory cases
2.4 Re-evaluates and revises
treatment approach based
on new information and or
response to treatment
3.1 Applies an understanding
of psychiatric, neurologic, and
medical co-morbidities to
treatment selection
3.2 Applies an understanding
of family strengths and
vulnerabilities in the
treatment plan and its
implementation
4.1 Devises individualized,
developmentally-sensitive,
and systems-informed
treatment plans for complex
presentations
4.2 Integrates multiple
modalities and systems, as
appropriate, with a
comprehensive approach
4.3 Integrates
neurobiological and genetic
knowledge into treatment
plan
4.4 Appropriately modifies
treatment techniques and
flexibly applies practice
guidelines to fit patient
needs
5.1 Supervises treatment
planning of other learners
and multidisciplinary
providers
5.2 Integrates emerging
neurobiological and genetic
knowledge into treatment
plan
5.3 Demonstrates ability to
mobilize appropriate
systems of care to optimize
patient outcomes
Comments:
Not yet achieved Level 1
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PC4 — Psychotherapy
Level 1 Level 2 Level 3 Level 4 Level 5 1.1 For all child and
adolescent age
groups, approaches
the therapeutic
encounter with
curiosity and
empathy, and
substantially
recognizes and starts
to manage own
anxiety
1.2 Begins to identify
patient emotions
across the
developmental
spectrum
1.3 Able to use non-
verbal techniques to
start to build an
alliance with children
and adolescents
1.4 Establishes
appropriate
professional
boundaries and avoids
boundary violations
2.1 Recognizes that overt
affect and behavior may
mask underlying feelings
2.2 Selects and implements
a psychotherapeutic
modality based on an
appropriate formulation
2.3 Discusses the structure/
frame of psychotherapy,
including the limits of
confidentiality, with patient
and family
2.4 Maintains
developmentally-
appropriate professional
boundaries in
psychotherapeutic
relationships while being
responsive to the patient
and family
2.5 Establishes and
maintains a therapeutic
alliance with both patients
and families
3.1 Establishes and maintains a
therapeutic alliance with, and
provides psychotherapies to,
patients with uncomplicated
problems
3.2 Uses verbal and non-verbal
strategies to access internal
processes of the patient
3.3 Links feelings, behavior,
recurrent/central
themes/schemas, and their
meaning to the patient as they
shift within and across sessions
3.4 Successfully guides the patient
and family through the different
phases of psychotherapy in a
developmentally-appropriate way
3.5 Balances autonomy with need
for consultation and supervision
3.6 Integrates the selected
psychotherapy with other
treatment modalities and other
treatment providers
4.1 For all child and adolescent age groups,
demonstrates capacity to listen and observe
and use information obtained this way in
psychotherapy
4.2 Substantially manages the
structure/frame of psychotherapy with
patient and/or family
4.3 Anticipates and appropriately manages
potential boundary crossings and avoids
boundary violations
4.4 Consistently uses developmentally-
appropriate psychotherapeutic techniques,
including non-verbal strategies
4.5 Provides different modalities of
psychotherapy (including family or supportive
therapy and at least one psychodynamic or
cognitive behavioral therapy) to patients with
moderately complicated problems
4.6 Recognizes and manages treatment
impasses
4.7 Appropriately manages own feelings
elicited by work with patients and families
5.1 Creatively
integrates different
therapy modalities
tailored to the
individual patient
and family
5.2 Provides
psychotherapies to
patients with very
complicated and/or
refractory
disorders/problems
5.3 Personalizes
treatment based on
awareness of one’s
own skill set,
strengths, and
limitations
5.4 Provides
psychotherapy
supervision to others
Comments:
Not yet achieved Level 1
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PC5 — Somatic Therapies, including Psychopharmacology and Other Somatic Treatments
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 With supervision,
selects and prescribes
commonly used
psychopharmacologic
agents targeting specific
child and adolescent
psychiatric disorders
1.2 Engages in an
informed
consent/assent process
with family and patient,
including general
indications, dosing
parameters, and
common side effects for
commonly prescribed
medications
1.3 Obtains basic
physical exam and lab
studies necessary to
initiate treatment with
commonly prescribed
medications
2.1 Discusses medication use
with children in a
developmentally-appropriate
manner
2.2 Applies appropriate judgment
about off-label use of somatic
treatments with supervision
2.3 Describes contraindications
and adverse effects of commonly
prescribed medications
2.4 Titrates medication dosage
and prevents or manages side
effects with a single medication
2.5 Incorporates basic knowledge
of mechanisms of action and
metabolism across development
in treatment selection
2.6 Monitors and responds to
relevant lab studies throughout
treatment
3.1 Independently applies
appropriate judgment about
off-label use of somatic
treatments
3.2 Manages
pharmacokinetic and
pharmacodynamic drug
interactions when using
multiple medications
concurrently
3.3 Appropriately selects
evidence-based somatic
treatment options and
incorporates evidence into
psychoeducation of patient
and family
3.4 With supervision, uses
evidenced-based
augmentation strategies
when primary
pharmacological
interventions are only
partially successful
4.1 Appropriately titrates dosage
and prevents and manages side
effects, including when patients
are on multiple medications
4.2 Appropriately selects
evidence-based somatic
treatment options and safely
manages patients when the
evidence base is limited
4.3 Follows practice guidelines
for management of multiple
medications, and if deviating
from guidelines, provides
appropriate rationale
4.4 Engages in a fully-informed
consent/assent process with
families and patients, including
off-label use, specific
contraindications, level of
evidence, etc.
4.5 Recognizes limitations of
psychopharmacological
treatment
5.1 Integrates
emerging studies of
somatic treatments
into clinical practice
5.2 Skillfully
demonstrates
management of
complex patients using
multimodal somatic
treatments
Comments:
Not yet achieved Level 1
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MK1 — Development in Infancy, Childhood, and Adolescence, Including the Impact of Psychopathology on the Trajectory of Development and Development on the Expression of Psychopathology
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Describes the basic
stages of normal physical,
social, and cognitive
development from infancy
to young adulthood
2.1 Demonstrates basic
knowledge of the major
developmental theories
across all developmental
domains
2.2 Describes the effects of
trauma, neglect, and early
adverse events on
development
2.3 Recognizes deviation
from normal development,
including arrests and
regressions
2.4 Utilizes developmental
concepts in case
formulation
2.5 Describes family
development
3.1 Explains developmental
tasks and transitions
throughout the life cycle,
utilizing multiple conceptual
models
3.2 Gives examples of gene-
environment interaction
influences on development and
psychopathology
3.3 Describes the influence of
psychosocial factors (gender,
ethnic, cultural, economic),
medical conditions, perinatal
factors, and neurological illness
on development
3.4 Describes interaction
between family organization
and development and
developmental stages of all
family members
3.4 Describe the
4.1 Describes in detail the
stages of normal physical,
social/emotional, speech
and language, sexual,
gender identity, and
cognitive development from
infancy to young adulthood
4.2 Describes how
developmental capacities
and limitations influence the
differing presentation of
psychopathology from
infancy to young adulthood
4.3 Describes the impact of
cultural factors on
development
4.4 Interprets the impact of
major life events in the
context of the patient’s
developmental stage
5.1 Teaches or develops
curricula on the stages of
normal physical (gross
motor, fine motor, sensory
integration),
social/emotional, speech
and language, sexual,
gender identity, and
cognitive development from
infancy to young adulthood
5.2 Incorporates new
neuroscientific knowledge
into his/her understanding
of development
Comments:
Not yet achieved Level 1
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MK2 — Psychopathology and Wellness, including Knowledge of Diagnostic Criteria, Epidemiology, Risk and Protective Factors, Pathophysiology, Course
of Illness, Co-morbidities, and Differential Diagnosis of Psychiatric Disorders
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Lists common
Diagnostic and Statistical
Manual of Mental
Disorders, Fifth Edition
(DSM-5) diagnoses that
begin in infancy,
childhood, and
adolescence
1.2 Lists major risk and
protective factors for
danger to self and others
and abuse/neglect
1.3 Gives examples of
interactions between
medical and psychiatric
symptoms and disorders
1.4 Lists examples of
interactions between
psychiatric symptoms and
psychosocial stressors
2.1 Demonstrates sufficient
knowledge to identify and
treat common psychiatric
conditions in youth in a
variety of settings
2.2 Demonstrates sufficient
knowledge to identify co-
morbid medical conditions
in psychiatric patients
2.3 Identifies factors that
contribute to wellness
3.1 Demonstrates sufficient
knowledge to identify and treat
most psychiatric conditions
from infancy to young
adulthood and in a variety of
settings
3.2 Displays knowledge to
conduct a risk assessment and
determine the appropriate
level of care for older children
and adolescents
3.3 Shows sufficient knowledge
to identify and treat common
psychiatric manifestations of
medical illness
3.4 Demonstrates sufficient
knowledge to include relevant
medical and neurological
conditions in the differential
diagnoses of psychiatric
patients
4.1 Demonstrates sufficient
knowledge to identify and
treat complex psychiatric
conditions from infancy
through young adulthood and
in a range of settings
4.2 Demonstrates the
knowledge of the appropriate
level of care for patients at
risk of harm to self or others
from infancy to young
adulthood and in a full range
of treatment settings
4.3 Shows knowledge
sufficient to identify and treat
a wide range of psychiatric
conditions in patients with
medical disorders
5.1 Displays knowledge
sufficient to teach risk
assessment
5.2 Demonstrates a
sophisticated understanding
of current controversies in
diagnosis
5.3 Shows sufficient
knowledge to identify and
treat uncommon psychiatric
conditions in patients with
medical disorders
Comments:
Not yet achieved Level 1
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MK3 — Clinical Neuroscience and Genetics, including Knowledge of Neurology, Neuropsychiatry, Neurodiagnostic Testing, and Relevant Neuroscience and their Application in Clinical Settings
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Demonstrates
knowledge of commonly
available neuroimaging
and neurophysiologic
diagnostic modalities and
how to order them
1.2 Lists common factors
in neural development
that may impact the
overall development and
the presentation of
psychiatric symptoms
2.1 Demonstrates
knowledge of general
indications for structural
neuroimaging, magnetic
resonance imaging [MRI]),
and neurophysiological
testing
2.2 Describes common
neuropsychological tests
and their indications
2.3 Describes psychiatric
disorders co-morbid with
common neurologic
disorders and neurological
disorders frequently seen in
psychiatric patients
2.4 Identifies the brain areas
thought to be important in
social and emotional
behavior
3.1 Describes neural
development from infancy
to young adulthood
3.2 Recognizes the
significance of abnormal
findings in routine
neurodiagnostic test
reports in psychiatric
patients
3.3 Demonstrates
knowledge of indications
for specific
neuropsychological tests
and understands meaning
of common abnormal
findings
3.4 Describes
neurobiological and genetic
hypotheses of common
psychiatric disorders and
their limitations
4.1 Explains the significance of
routine neuroimaging,
neurophysiological,
neuropsychological testing, and
genetic abnormalities to patients
and families
4.2 Demonstrates knowledge of
clinical indications and limitations of
functional neuroimaging
4.3 Explains neurobiological
hypotheses and genetic risks of
common psychiatric disorders to
patients
4.4 Describes psychiatric co-
morbidities of less common
neurologic and genetic disorders and
less common neurologic co-
morbidities of psychiatric disorders
4.5 Demonstrates sufficient
knowledge to incorporate pertinent
neuroscientific and genetic
hypotheses of emotions and social
behaviors into case formulation
5.1 Integrates recent
neurodiagnostic research
into understanding of
psychopathology
5.2 Flexibly applies
knowledge of
neuropsychological
findings to the differential
diagnoses of complex
patients
5.3 Explains
neurobiological
hypotheses and genetic
risks of less common
psychiatric disorders to
patients
5.4 Integrates knowledge
of neurobiology into
advocacy for psychiatric
patient care, prevention,
and stigma reduction
Comments:
Not yet achieved Level 1
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MK4 — Psychotherapy: Refers to knowledge regarding: 1) individual psychotherapies, including psychodynamic1, IPT, cognitive-behavioral2, and supportive therapies3; 2) family and group therapies; 3) dyadic therapies (PCIT, etc.); and 4) integrating psychotherapy and psychopharmacology
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Identifies psycho-
dynamic, cognitive-
behavioral, family, dyadic,
and supportive therapies as
major psychotherapeutic
modalities in relationship
to child and adolescent
patients
1.2 Recognizes the core
differences in therapeutic
approaches when working
with children vs. adults
2.1 Describes the basic
principles of each of the
psychotherapy modalities4
2.2 Discusses common
factors across psychotherapy
modalities5
2.3 Lists the basic indications,
contraindications, benefits,
and risks of each of the
psychotherapy modalities,
including whether to use
individual vs. family-based
approaches
3.1 Describes the basic
techniques of the core
psychotherapy modalities4
3.2 Summarizes the evidence
base for the core
psychotherapy modalities4
4.1 Describes proposed
mechanisms of therapeutic
change
4.2 Discusses the evidence
base for combining different
psychotherapies and
psychopharmacology
4.3 Critically appraises the
evidence for efficacy of the
core psychotherapies
5.1 Incorporates new
theoretical developments
into knowledge base
5.2 Demonstrates sufficient
knowledge of psychotherapy
to teach and supervise
others effectively
Comments:
Footnotes: 1This includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to understand the concepts of resistance/defenses, and transference/countertransference.
2This includes the capacity to generate a case formulation, and to demonstrate techniques of intervention, including behavior change, skills acquisition, and addressing cognitive distortions.
3This includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to strengthen the patient’s adaptive defenses, resilience, and social supports.
4Throughout this subcompetency, the three “major” or “core” individual psychotherapies refer to supportive, psychodynamic, and cognitive-behavioral therapies.
5“Common factors” refers to elements that different psychotherapeutic modalities have in common and that are considered central to the efficacy of psychotherapy. These include accurate empathy, therapeutic alliance, and appropriate professional boundaries.
Not yet achieved Level 1
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MK5 — Somatic Therapies: Medical Knowledge of Somatic Therapies, including Psychopharmacology, ECT, and Emerging Somatic Therapies, such as
Transcranial Magnetic Stimulation (TMS) and Vagal Nerve Stimulation (VNS)
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Describes general
indications and common
side effects for commonly
prescribed
psychopharmacologic
agents for children and
adolescents
1.2 Accesses practice
parameters and other
appropriate resources to
answer questions about
somatic treatments
2.1 Describes hypothesized
mechanisms of action and
metabolism for commonly
prescribed
psychopharmacologic
agents
2.2 Describes less frequent,
but potentially serious,
adverse effects for
commonly prescribed
psychopharmacological
agents
2.3 Describes practical
issues for initiation or
maintenance of medications
for children and adolescents
2.4 Describes the physical
and lab studies necessary to
initiate treatment with
commonly prescribed
medications
3.1 Demonstrates an
understanding of developmental
impacts on pharmacokinetics and
pharmacodynamic drug
interactions
3.2 Demonstrates an
understanding of the potential
impact of medication on
development
3.3 Demonstrates an
understanding of psychotropic
selection based on current
practice guidelines or treatment
algorithms for common
psychiatric disorders in children
and adolescents
3.4 Describes indications for
second- and third-line
pharmacologic agents
3.5 Lists indications, evidence-
base, and how to implement non-
medication somatic treatments
4.1 Describes the
strengths and limitations
of the evidence
supporting the use of
medications and other
somatic therapies in
certain treatment
situations in children and
adolescents
4.2 When deviating from
practice guidelines,
demonstrates knowledge
of the potential risks and
appropriate management
for children and
adolescents
5.1 Integrates emerging
studies of somatic
treatments into
knowledge base
5.2 Effectively teaches
evidence-based or best
somatic treatment
practices
Comments:
Not yet achieved Level 1
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MK6 — Practice of Psychiatry
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Lists common ethical
issues in child and
adolescent psychiatry
1.2 Recognizes and
describes institutional
policies and procedures
2.1 Demonstrates
knowledge of the regulatory
compliance requirements of
his/her own jurisdiction
(e.g., mandatory reporting,
age of consent, etc.)
2.2 Lists and discusses
sources of professional
standards of ethical practice
2.3 Describes how to keep
current on regulatory and
practice management issues
2.4 Demonstrates
knowledge of telehealth as a
modality of care
3.1 Discusses potential
conflicts of interest related to
having multiple professional
roles
3.2 Discusses potential
conflicting interests and
obligations of the patient,
family, and systems of care
3.3 Describes applicable
regulations for billing and
reimbursement
3.4 Demonstrates familiarity
with the American Academy
of Child and Adolescent
Psychiatry (AACAP) Code of
Ethics
3.5 Demonstrates knowledge
of educational laws
4.1 Understands that there
are state and regional
differences regarding
practice, involuntary
treatment, health
regulations, and psychiatric
forensic evaluation
4.2 Describes ways to
advocate for patients and
the profession
4.3 Describes how to seek
out and integrate new
information on the practice
of child and adolescent
psychiatry
5.1 Describes evolving issues
regarding practice,
involuntary treatment, and
health regulations
5.2 Proposes advocacy
activities, policy
development, or scholarly
contributions related to
professional standards
Comments:
Not yet achieved Level 1
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SBP1 — Patient Safety and the Health Care Team
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Describes the common
system causes for errors
1.2 Follows institutional
safety policies, including
reporting of problematic
behaviors and processes,
errors, and near misses
1.3 Actively participates in
conferences focusing on
systems-based errors in
patient care
2.1 Describes systems and
procedures that promote
patient safety
2.2 Effectively and regularly
utilizes all appropriate forms
of communication to ensure
safe transitions of care and
optimize communication
across systems and the
continuum of care
2.3 Follows regulatory
requirements related to
prescribing practices
3.1 Recognizes special patient
or family circumstances that
will affect discharge planning
3.2 Negotiates patient-
centered care among multiple
care providers and systems
4.1 Participates in a team-
based approach to medical
error or root-cause analysis,
including quality
improvement projects
4.2 Takes a leadership role
in ensuring safe transitions
of care and optimizing
communication across
systems and the continuum
of care
4.3 Participates in a patient
safety presentation or a
critical case conference
focusing on systems-based
errors in patient care
5.1 Leads multidisciplinary
teams (e.g., human factors
engineers, social scientists)
to address patient safety
issues
5.2 Provides consultation to
organizations to improve
the health care team and
patient safety
Comments:
Not yet achieved Level 1
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SBP2 — Resource Management
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Recognizes disparities in
health care access at
individual and community
levels
1.2 Knows the relative costs
of care and reimbursement
2.1 Coordinates, or oversees
the coordination of, patient
access to community and
system resources
2.2 Is aware of health care
funding and regulations
related to organization of
health care services
3.1 Balances the best interests
of the patient and family with
the availability of resources
3.2 Uses available resources
(e.g., Electronic Medical
Record [EMR]) to improve
patient safety and quality
4.1 Practices cost-effective,
high-value clinical care,
using evidence-based tools
and information
technologies to support
decision making
5.1 Designs measurement
tools to monitor and
provide feedback to
providers/teams on
resource consumption to
facilitate improvement
5.2 Advocates for improved
access to and additional
resources within systems of
care
Comments:
Not yet achieved Level 1
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SBP3 — Community-based Care
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Understands the local
health care delivery systems
and other community
organizations, including
advocacy groups
2.1 Understands cultural
and community differences
in use of systems
2.2 Recognizes role and
explains importance of self-
help groups and community
resource groups (e.g.,
family-based and disorder-
specific support and
advocacy groups)
2.3 Identifies community-
based systems of care for
the chronically mentally ill
and disabled
3.1 Participates in planning
care with community mental
health agencies, schools, and
community organizations
3.2 Incorporates self-help
groups, community resources,
and social networks in
treatment and clinical care
4.1 Demonstrates capacity
to provide medical-
psychiatric leadership to
health care facilities
4.2 Assists families in
coordinating long-term
treatment and care of
patients in a community
setting
5.1 Participates in the
administration of
community-based
treatment programs
5.2 Participates in creating
new community-based
programs
Comments:
Not yet achieved Level 1
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SBP4 — Consultation to and Integration with Non-psychiatric Medical Providers and Non-medical Systems (e.g., primary care providers, schools,
community-based agencies, forensics)
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Describes various
consultative approaches
and the basic consultative
frame
2.1 Provides basic
consultation to non-
psychiatric medical
providers
2.2 Discusses methods for
integrating mental health
and medical care in
treatment planning
3.1 Describes consultative
frames across a variety of
community-based systems
3.2 Identifies systems issues
and provides basic
recommendations for change
in the settings where
consultation occurs
4.1 Skillfully provides
consultation to non-
psychiatric medical
providers, including in
complex cases
4.2 Provides integrated care
for psychiatric patients and
families through
collaboration with
physicians and other health
care providers at
community-based sites
4.3 Skillfully provides
consultation to a variety of
community-based systems
(e.g., schools, courts)
5.1 Designs novel ways to
improve mental health care
delivery to other systems
5.2 Leads a consultation
team
5.3 Supervises junior
learners in consultation to
other systems
Comments
Not yet achieved Level 1
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PBLI1 — Development and Execution of Lifelong Learning through Constant Self-evaluation, including Critical Evaluation of Research and Clinical Evidence
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Regularly seeks and
incorporates feedback to
improve performance
1.2 Identifies self-directed
learning goals and
periodically reviews them
with supervisory guidance
1.3 Formulates a searchable
question from a clinical
practice problem [see 3.3]
and conducts a basic online
search to answer it
2.1 Demonstrates a
balanced and accurate self-
assessment of competence,
using clinical outcomes to
identify areas for continued
improvement
2.2 Selects an appropriate,
evidence-based information
tool to meet self-identified
learning goals
3.1 Critically appraises
different types of research,
including randomized
controlled trials (RCTs),
systematic reviews, meta-
analyses, and practice
guidelines
3.2 Demonstrates
improvement in clinical
practice based on continual
self-assessment and evidence-
based information
3.3 Independently searches
for and discriminates among
evidence relevant to clinical
practice problems
4.1 Identifies and meets
self-directed learning goals
with little external guidance
4.2 Demonstrates use of a
system or process for
keeping up with relevant
changes in medicine
4.3 Sustains a practice of
self-assessment and keeping
up with relevant changes in
medicine, and applies the
evidence appropriately to
practice
5.1 Teaches others
techniques to efficiently
incorporate evidence
gathering into clinical
workflow
5.2 Contributes to the
knowledge base and
disseminates new
information through peer-
reviewed publication and
other scholarly activity
Comments:
Not yet achieved Level 1
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PBLI2 — Teaching
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Assumes a role in the
clinical teaching of early
learners
1.2 Communicates goals and
objectives for instruction of
early learners
2.1 Participates in activities
designed to develop and
improve teaching skills
2.2 Provides feedback to
early and advanced-level
learners
2.3 Describes basic
principles of adult learning
3.1 Teaches groups and
individuals in clinical settings
3.2 Teaches in formal didactic
presentations to groups (e.g.,
grand rounds, departmental
case conference)
3.3 Participates in and
contributes to educational
program review (e.g., resident
retreat, annual program
evaluation, education
committees)
4.1 Develops and gives
specialty- and subspecialty-
specific presentations to
groups
4.2 Effectively uses feedback
on teaching to improve
teaching methods and
approaches
4.3 Implements basic
principles of adult learning
in his/her teaching
5.1 Educates broader
professional community
and/or public (e.g., presents
at regional or national
meeting)
5.2 Organizes, develops, and
delivers curricular materials
Comments:
Not yet achieved Level 1
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PROF1 — Compassion, Integrity, Respect for Others, Sensitivity to Diverse Patient Populations, Adherence to Ethical Principles
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Demonstrates respect
for trainees and other
members of the treatment
team
1.2 Demonstrates capacity
for self-reflection, empathy,
curiosity about patient and
family, and openness to
different beliefs and points
of view
1.3 Provides examples of
the importance of attention
to diversity in psychiatric
evaluation and treatment
1.4 Recognizes basic ethical
conflicts in practice and
seeks supervision to manage
them
2.1 Elicits beliefs, values,
and diverse cultural
practices of patients and
their families, and
understands their potential
impact on patient care
2.2 Routinely displays
sensitivity to diversity in
psychiatric evaluation and
treatment
2.3 Recognizes ethical issues
in practice and is able to
discuss, analyze, and
manage them in common
clinical situations
3.1 Discusses, in educational
settings, his/her own cultural
background and beliefs and
the ways in which these affect
interactions with patients
3.2 Recognizes ethical
conflicts in child psychiatry
practice and seeks supervision
to manage them
4.1 Adapts clinical approach
to meet the needs of diverse
patients and populations
4.2 Incorporates ethical
issues into case discussion
and clinical care
4.3 Recognizes and skillfully
manages ethical conflicts in
child psychiatry practice and
seeks consultation
appropriately
4.4 Develops a mutually
agreeable care plan in the
context of conflicting
physician and patient
and/or family values and
beliefs
5.1 Leads educational
activities and case
discussions regarding ethical
issues specific to child
psychiatry
5.2 Serves as a role model
and teacher of compassion,
integrity, respect for others,
and sensitivity to diverse
patient populations
5.3 Identifies emerging
ethical issues within
subspecialty practice, and
can discuss opposing
viewpoints
Comments:
Not yet achieved Level 1
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PROF2 — Accountability to Self, Patients, Colleagues, and the Profession
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Follows procedures for
coverage for clinical and
non-clinical responsibilities
1.2 Follows institutional
policies for physician
conduct and responsibility
1.3 Accepts the role as the
patient’s physician and
takes responsibility (under
supervision) for ensuring
that the patient receives
the best possible care
1.4 Demonstrates ability to
accept professional
feedback from supervisors
2.1 Identifies and manages
situations in which
maintaining personal
emotional, physical, and
mental health is challenged,
and seeks assistance when
needed
2.2 Describes the importance
of participating in one’s
professional community
2.3 Is recognized by self,
patient, patient’s family, and
medical staff members as an
active member of the clinical
team
2.4 Displays increasing
autonomy and leadership in
taking primary responsibility
for patient care
3.1 Knows appropriate steps
for addressing impairment in
self and colleagues
3.2 Prepares for obtaining
and maintaining board
certification
3.3 Covers professional
duties for colleagues when
appropriate
4.1 Appropriately prioritizes
and balances conflicting
interests of patient, family,
self, co-workers, and others to
optimize clinical care and the
work environment
4.2 Participates in the
professional community (e.g.,
house officer association,
professional societies, patient
advocacy groups, community
service organizations)
4.3 When relevant, takes
appropriate steps in
addressing impairment in self
and colleagues
4.4 Applies ethical principles
to practice based on AACAP’s
Code of Ethics
5.1 Demonstrates
leadership in covering
professional duties for
colleagues when
appropriate
5.2 Participates in physician
wellness programs or
interventions and
organizations that address
physician wellness
5.3 Develops
professionalism policies,
programs, or curricula for
child psychiatry
Comments:
Not yet achieved Level 1
Version 9/2014 Child and Adolescent Psychiatry Milestones: ACGME Report Worksheet
Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Child and Adolescent Psychiatry Milestones on a non-exclusive bases for educational purposes. 20
ICS1 — Relationship Development and Conflict Management with Patients and Families, Colleagues, Members of the Health Care team, and Other Systems
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Develops therapeutic
relationship with patients
and their families in
uncomplicated situations
1.2 Describes and respects
cultural and linguistic
diversity in communicating
with people of different
backgrounds
1.3 Recognizes
communication conflicts in
work relationships
2.1 Develops working
relationships across
specialties and systems in
uncomplicated situations
2.2 Manages simple
patient/family-related
conflicts
2.3 Actively participates in
and supports activities of
team-based care
3.1 Develops therapeutic
relationships with patients
and families in complicated
situations
3.2 Sustains working
relationships with co-workers
in the face of conflict
3.3 Takes a leadership role in a
multidisciplinary care team
3.4 Recognizes differing
philosophies within and
between different disciplines
in care provision
4.1 Skillfully manages
therapeutic and working
relationships during
complex and challenging
situations, including
transitions of care
4.2. Sustains relationships
across systems of care and
with patients and families
during long-term follow-up
4.3 Takes a leadership role
in managing team conflicts
4.4 Effectively leads
multidisciplinary patient
care and family meetings
5.1 Develops
models/approaches to
managing difficult
communications
5.2 Effectively mentors
other health care providers
in leadership,
communication skills, and
conflict management
5.3 Leads and facilitates
meetings within the
organization/system
Comments:
Not yet achieved Level 1
Version 9/2014 Child and Adolescent Psychiatry Milestones: ACGME Report Worksheet
Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Child and Adolescent Psychiatry Milestones on a non-exclusive bases for educational purposes. 21
ICS2 — Information Sharing and Record Keeping
Level 1 Level 2 Level 3 Level 4 Level 5
1.1 Ensures transitions of
care are optimally
communicated across
systems and continuums of
care
1.2 Sufficiently documents
clinical encounters in the
medical record in an
accurate and timely way
consistent with institutional
policies
1.3 Effectively
communicates information
with patients and families in
clinical encounters
1.4 Maintains appropriate
boundaries in sharing
information by electronic
communication and in the
use of social media
2.1 Uses developmentally-
appropriate language in all
phases of communication
with patients
2.2 Communicates with
families at an appropriate
level of sophistication
2.3 Consistently
demonstrates
communication strategies
to ensure patient and family
understanding
3.1 Demonstrates written
communication with patients,
families, colleagues, and other
health care providers that is
appropriate, efficient, concise,
and pertinent
3.2 Appropriately balances
patient confidentiality and the
family’s right to know
information
3.3 Appropriately balances
patient confidentiality and
communication with the
treatment team
3.4 Consistently engages
patients and families in shared
decision making
3.5 Demonstrates appropriate
face-to-face interaction while
using EMR
4.1 Demonstrates skillful
communication that is
appropriate, efficient,
concise, and pertinent with
patients and families,
colleagues, and co-workers
4.2 Recruits appropriate
assistance from external
sources when cultural
differences create barriers
to patient care
4.3 Thoroughly and
efficiently documents
patient encounters and uses
discretion and judgment in
the inclusion of sensitive
patient material in the
medical record
4.4 Uses discretion and
judgment in electronic
communication with
patients, families, and
colleagues
5.1 Participates in the
development of changes in
rules, policies, and
procedures related to
technology
5.2 Engages in scholarly
activity regarding effective
communication and
documentation
Comments:
Not yet achieved Level 1