Internal Medicine – Psychiatry (Combined)
programs must annually report on each
set of milestones.
The Internal Medicine Milestone Project
A Joint Initiative of
The Accreditation Council for Graduate Medical Education
and
The American Board of Internal Medicine
July 2015
The Internal Medicine 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.
i
Internal Medicine Milestone Group
Chair: William Iobst, MD
Eva Aagaard, MD
Hasan Bazari, MD
Timothy Brigham, MDiv, PhD
Roger W. Bush, MD
Kelly Caverzagie, MD
Davoren Chick, MD
Michael Green, MD
Kevin Hinchey, MD
Eric Holmboe, MD
Sarah Hood, MS
Gregory Kane, MD
Lynne Kirk, MD
Lauren Meade, MD
Cynthia Smith, MD
Susan Swing, PhD
ii
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 that describe the development
of competence from an early learner up to and beyond that expected for unsupervised 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.
The internal medicine milestones are arranged in columns of progressive stages of competence that do not correspond with post-graduate
year of education. For each reporting period, programs will need to review the milestones and identify those milestones that best describe a
resident’s current performance and ultimately select a box that best represents the summary performance for that sub-competency (See the
figure on page v.). Selecting a response box in the middle of a column implies that the resident has substantially demonstrated those
milestones, as well as those in previous columns. Selecting a response box on a line in between columns indicates that milestones in the
lower columns have been substantially demonstrated, as well as some milestones in the higher column.
A general interpretation of each column for internal medicine is as follows:
Critical Deficiencies: These learner behaviors are not within the spectrum of developing competence. Instead they indicate significant
deficiencies in a resident’s performance.
Column 2: Describes behaviors of an early learner.
Column 3: Describes behaviors of a resident who is advancing and demonstrating improvement in performance related to milestones.
Ready for Unsupervised Practice: Describes behaviors of a resident who substantially demonstrates the milestones identified for a
physician who is ready for unsupervised practice. This column is designed as the graduation target, but the resident may display these
milestones at any point during residency.
Aspirational: Describes behaviors of a resident who has advanced beyond those milestones that describe unsupervised practice. These
milestones reflect the competence of an expert or role model and can be used by programs to facilitate further professional growth. It is
expected that only a few exceptional residents will demonstrate these milestones behaviors.
For each ACGME competency domain, programs will also be asked to provide a summative evaluation of each resident’s learning trajectory.
iii
Additional Notes
The “Ready for Unsupervised Practice” milestones are designed as the graduation target but do 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 the “Ready for Unsupervised Practice” milestones and
all other milestones are in the appropriate stage 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 Milestones are available on the Milestones web page:
http://www.acgme.org/acgmeweb/Portals/0/MilestonesFAQ.pdf.
iv
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 column of milestones that best describes that resident’s performance
or
 selecting the “Critical Deficiencies” response box
Selecting a response box in the middle of a
column implies milestones in that column as
well as those in previous columns have been
substantially demonstrated.
Selecting a response box on the line in between
columns indicates that milestones in lower levels have
been substantially demonstrated as well as some
milestones in the higher columns(s).
v
Version 7/2014
INTERNAL MEDICINE MILESTONES
ACGME Report Worksheet
1. Gathers and synthesizes essential and accurate information to define each patient’s clinical problem(s). (PC1)
Critical Deficiencies
Does not collect
accurate historical
data
Does not use
physical exam to
confirm history
Relies exclusively on
documentation of
others to generate
own database or
differential diagnosis
Fails to recognize
patient’s central
clinical problems
Ready for unsupervised practice
Inconsistently able to
acquire accurate historical
information in an organized
fashion
Does not perform an
appropriately thorough
physical exam or misses key
physical exam findings
Does not seek or is overly
reliant on secondary data
Inconsistently recognizes
patients’ central clinical
problem or develops
limited differential
diagnoses
Consistently acquires accurate
and relevant histories from
patients
Seeks and obtains data from
secondary sources when
needed
Consistently performs
accurate and appropriately
thorough physical exams
Uses collected data to define
a patient’s central clinical
problem(s)
Aspirational
Acquires accurate histories
from patients in an efficient,
prioritized, and hypothesisdriven fashion
Obtains relevant historical
subtleties, including sensitive
information that informs the
differential diagnosis
Performs accurate physical
exams that are targeted to the
patient’s complaints
Identifies subtle or unusual
physical exam findings
Efficiently utilizes all sources
Synthesizes data to generate a of secondary data to inform
prioritized differential diagnosis differential diagnosis
and problem list
Role models and teaches the
Effectively uses history and
effective use of history and
physical examination skills to
physical examination skills to
minimize the need for further
minimize the need for further
diagnostic testing
diagnostic testing
Fails to recognize
potentially life
threatening
problems
Comments:
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2. Develops and achieves comprehensive management plan for each patient. (PC2)
Critical Deficiencies
Care plans are
consistently
inappropriate or
inaccurate
Does not react to
situations that
require urgent or
emergent care
Does not seek
additional guidance
when needed
Ready for unsupervised practice
Inconsistently develops an
appropriate care plan
Consistently develops
appropriate care plan
Inconsistently seeks
additional guidance when
needed
Recognizes situations
requiring urgent or emergent
care
Seeks additional guidance
and/or consultation as
appropriate
Aspirational
Appropriately modifies care plans Role models and teaches
based on patient’s clinical course, complex and patient-centered
additional data, and patient
care
preferences
Develops customized,
Recognizes disease
prioritized care plans for the
presentations that deviate from most complex patients,
common patterns and require
incorporating diagnostic
complex decision- making
uncertainty and cost
effectiveness principles
Manages complex acute and
chronic diseases
Comments:
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3. Manages patients with progressive responsibility and independence. (PC3)
Critical Deficiencies
Cannot advance
beyond the need for
direct supervision in
the delivery of
patient care
Cannot manage
patients who
require urgent or
emergent care
Does not assume
responsibility for
patient
management
decisions
Ready for unsupervised practice
Requires direct supervision
to ensure patient safety
and quality care
Requires indirect supervision
to ensure patient safety and
quality care
Inconsistently manages
simple ambulatory
complaints or common
chronic diseases
Provides appropriate
preventive care and chronic
disease management in the
ambulatory setting
Inconsistently provides
preventive care in the
ambulatory setting
Provides comprehensive care
for single or multiple
diagnoses in the inpatient
setting
Inconsistently manages
patients with
straightforward diagnoses
in the inpatient setting
Unable to manage complex
inpatients or patients
requiring intensive care
Under supervision, provides
appropriate care in the
intensive care unit
Aspirational
Independently manages patients Manages unusual, rare, or
across inpatient and ambulatory complex disorders
clinical settings who have a
broad spectrum of clinical
disorders including
undifferentiated syndromes
Seeks additional guidance
and/or consultation as
appropriate
Appropriately manages
situations requiring urgent or
emergent care
Effectively supervises the
management decisions of the
team
Initiates management plans
for urgent or emergent care
Cannot independently
supervise care provided by
junior members of the
physician-led team
Comments:
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4. Skill in performing procedures. (PC4)
Critical Deficiencies
Attempts to
perform procedures
without sufficient
technical skill or
supervision
Unwilling to
perform procedures
when qualified and
necessary for
patient care
Ready for unsupervised practice
Possesses insufficient
technical skill for safe
completion of common
procedures
Possesses basic technical skill
for the completion of some
common procedures
Possesses technical skill and has
successfully performed all
procedures required for
certification
Aspirational
Maximizes patient comfort
and safety when performing
procedures
Seeks to independently
perform additional procedures
(beyond those required for
certification) that are
anticipated for future practice
Teaches and supervises the
performance of procedures by
junior members of the team
Comments:
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5. Requests and provides consultative care. (PC5)
Critical Deficiencies
Is unresponsive to
questions or
concerns of others
when acting as a
consultant or
utilizing consultant
services
Unwilling to utilize
consultant services
when appropriate
for patient care
Ready for unsupervised practice
Inconsistently manages
patients as a consultant to
other physicians/health
care teams
Inconsistently applies risk
assessment principles to
patients while acting as a
consultant
Provides consultation services
for patients with clinical
problems requiring basic risk
assessment
Asks meaningful clinical
questions that guide the input
of consultants
Inconsistently formulates a
clinical question for a
consultant to address
Provides consultation services
for patients with basic and
complex clinical problems
requiring detailed risk
assessment
Appropriately weighs
recommendations from
consultants in order to
effectively manage patient care
Aspirational
Switches between the role of
consultant and primary
physician with ease
Provides consultation services
for patients with very complex
clinical problems requiring
extensive risk assessment
Manages discordant
recommendations from
multiple consultants
Comments:
Patient Care
The resident is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in training. He/she is
demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe,
effective, patient-centered, timely, efficient and equitable care.
_____ Yes
_____ No _____ Conditional on Improvement
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6. Clinical knowledge (MK1)
Critical Deficiencies
Lacks the scientific,
socioeconomic or
behavioral
knowledge required
to provide patient
care
Ready for unsupervised practice
Possesses insufficient
scientific, socioeconomic
and behavioral knowledge
required to provide care for
common medical
conditions and basic
preventive care
Possesses the scientific,
socioeconomic and behavioral
knowledge required to
provide care for common
medical conditions and basic
preventive care
Possesses the scientific,
socioeconomic and behavioral
knowledge required to provide
care for complex medical
conditions and comprehensive
preventive care
Aspirational
Possesses the scientific,
socioeconomic and behavioral
knowledge required to
successfully diagnose and
treat medically uncommon,
ambiguous and complex
conditions
Comments:
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7. Knowledge of diagnostic testing and procedures. (MK2)
Critical Deficiencies
Lacks foundational
knowledge to apply
diagnostic testing
and procedures to
patient care
Ready for unsupervised practice
Inconsistently interprets
basic diagnostic tests
accurately
Consistently interprets basic
diagnostic tests accurately
Needs assistance to
Does not understand the
understand the concepts of
concepts of pre-test
pre-test probability and test
probability and test
performance characteristics
performance characteristics
Fully understands the
Minimally understands the rationale and risks associated
rationale and risks
with common procedures
associated with common
procedures
Interprets complex diagnostic
tests accurately
Understands the concepts of
pre-test probability and test
performance characteristics
Teaches the rationale and risks
associated with common
procedures and anticipates
potential complications when
performing procedures
Aspirational
Anticipates and accounts for
pitfalls and biases when
interpreting diagnostic tests
and procedures
Pursues knowledge of new
and emerging diagnostic tests
and procedures
Comments:
Medical Knowledge
The resident is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in training. He/she is
demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe,
effective, patient-centered, timely, efficient and equitable care.
_____ Yes
_____ No _____ Conditional on Improvement
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8. Works effectively within an interprofessional team (e.g. peers, consultants, nursing, ancillary professionals and other support
personnel).
(SBP1)
Critical Deficiencies
Refuses to recognize
the contributions of
other
interprofessional
team members
Frustrates team
members with
inefficiency and
errors
Ready for unsupervised practice
Identifies roles of other
team members but does
not recognize how/when to
utilize them as resources
Understands the roles and
responsibilities of all team
members but uses them
ineffectively
Understands the roles and
responsibilities of and
effectively partners with, all
members of the team
Frequently requires
reminders from team to
complete physician
responsibilities (e.g. talk to
family, enter orders)
Participates in team
discussions when required but
does not actively seek input
from other team members
Actively engages in team
meetings and collaborative
decision-making
Aspirational
Integrates all members of the
team into the care of patients,
such that each is able to
maximize their skills in the
care of the patient
Efficiently coordinates
activities of other team
members to optimize care
Viewed by other team
members as a leader in the
delivery of high quality care
Comments:
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9. Recognizes system error and advocates for system improvement. (SPB2)
Critical Deficiencies
Ignores a risk for
error within the
system that may
impact the care of a
patient
Ignores feedback
and is unwilling to
change behavior in
order to reduce the
risk for error
Ready for unsupervised practice
Does not recognize the
potential for system error
Recognizes the potential for
error within the system
Makes decisions that could
lead to error which are
otherwise corrected by the
system or supervision
Identifies obvious or critical
causes of error and notifies
supervisor accordingly
Recognizes the potential risk
Resistant to feedback about for error in the immediate
decisions that may lead to
system and takes necessary
error or otherwise cause
steps to mitigate that risk
harm
Willing to receive feedback
about decisions that may lead
to error or otherwise cause
harm
Aspirational
Identifies systemic causes of
medical error and navigates
them to provide safe patient
care
Advocates for system
leadership to formally engage
in quality assurance and
quality improvement activities
Advocates for safe patient care
and optimal patient care
systems
Viewed as a leader in
identifying and advocating for
the prevention of medical
error
Activates formal system
resources to investigate and
mitigate real or potential
medical error
Teaches others regarding the
importance of recognizing and
mitigating system error
Reflects upon and learns from
own critical incidents that may
lead to medical error
Comments:
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10. Identifies forces that impact the cost of health care, and advocates for, and practices cost-effective care. (SBP3)
Critical Deficiencies
Ignores cost issues
in the provision of
care
Demonstrates no
effort to overcome
barriers to costeffective care
Lacks awareness of external
factors (e.g. socioeconomic, cultural, literacy,
insurance status) that
impact the cost of health
care and the role that
external stakeholders (e.g.
providers, suppliers,
financers, purchasers) have
on the cost of care
Does not consider limited
health care resources when
ordering diagnostic or
therapeutic interventions
Recognizes that external
factors influence a patient’s
utilization of health care and
may act as barriers to costeffective care
Minimizes unnecessary
diagnostic and therapeutic
tests
Possesses an incomplete
understanding of costawareness principles for a
population of patients (e.g.
screening tests)
Ready for unsupervised practice
Aspirational
Consistently works to address
patient specific barriers to costeffective care
Teaches patients and
healthcare team members to
recognize and address
common barriers to costeffective care and appropriate
utilization of resources
Advocates for cost-conscious
utilization of resources (i.e.
emergency department visits,
hospital readmissions)
Incorporates cost-awareness
principles into standard clinical
judgments and decision-making,
including screening tests
Actively participates in
initiatives and care delivery
models designed to overcome
or mitigate barriers to costeffective high quality care
Comments:
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11. Transitions patients effectively within and across health delivery systems. (SBP4)
Critical Deficiencies
Disregards need for
communication at
time of transition
Does not respond to
requests of
caregivers in other
delivery systems
Ready for unsupervised practice
Inconsistently utilizes
available resources to
coordinate and ensure safe
and effective patient care
within and across delivery
systems
Written and verbal care
plans during times of
transition are incomplete
or absent
Inefficient transitions of
care lead to unnecessary
expense or risk to a patient
(e.g. duplication of tests
readmission)
Recognizes the importance of
communication during times
of transition
Communication with future
caregivers is present but with
lapses in pertinent or timely
information
Aspirational
Appropriately utilizes available
resources to coordinate care
and ensures safe and effective
patient care within and across
delivery systems
Coordinates care within and
across health delivery systems
to optimize patient safety,
increase efficiency and ensure
high quality patient outcomes
Proactively communicates with
past and future care givers to
ensure continuity of care
Anticipates needs of patient,
caregivers and future care
providers and takes
appropriate steps to address
those needs
Role models and teaches
effective transitions of care
Comments:
Systems-based Practice
The resident is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in training. He/she is
demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe,
effective, patient-centered, timely, efficient and equitable care.
_____ Yes _____ No _____ Conditional on Improvement
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12. Monitors practice with a goal for improvement. (PBLI1)
Critical Deficiencies
Unwilling to selfreflect upon one’s
practice or
performance
Not concerned with
opportunities for
learning and selfimprovement
Ready for unsupervised practice
Unable to self-reflect upon
one’s practice or
performance
Misses opportunities for
learning and selfimprovement
Inconsistently self-reflects
upon one’s practice or
performance and
inconsistently acts upon those
reflections
Inconsistently acts upon
opportunities for learning and
self-improvement
Regularly self-reflects upon
one’s practice or performance
and consistently acts upon those
reflections to improve practice
Recognizes sub-optimal practice
or performance as an
opportunity for learning and
self-improvement
Aspirational
Regularly self-reflects and
seeks external validation
regarding this reflection to
maximize practice
improvement
Actively engages in selfimprovement efforts and
reflects upon the experience
Comments:
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13. Learns and improves via performance audit. (PBLI2)
Critical Deficiencies
Ready for unsupervised practice
Disregards own
clinical performance
data
Limited awareness of or
desire to analyze own
clinical performance data
Demonstrates no
inclination to
participate in or
even consider the
results of quality
improvement
efforts
Nominally participates in a
quality improvement
projects
Not familiar with the
principles, techniques or
importance of quality
improvement
Analyzes own clinical
performance data and
identifies opportunities for
improvement
Effectively participates in a
quality improvement project
Understands common
principles and techniques of
quality improvement and
appreciates the responsibility
to assess and improve care for
a panel of patients
Aspirational
Analyzes own clinical
performance data and actively
works to improve performance
Actively monitors clinical
performance through various
data sources
Actively engages in quality
improvement initiatives
Is able to lead a quality
improvement project
Demonstrates the ability to
apply common principles and
techniques of quality
improvement to improve care
for a panel of patients
Utilizes common principles
and techniques of quality
improvement to continuously
improve care for a panel of
patients
Comments:
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14. Learns and improves via feedback. (PBLI3)
Critical Deficiencies
Never solicits
feedback
Actively resists
feedback from
others
Ready for unsupervised practice
Rarely seeks feedback
Responds to unsolicited
feedback in a defensive
fashion
Temporarily or superficially
adjusts performance based
on feedback
Solicits feedback only from
supervisors
Is open to unsolicited
feedback
Inconsistently incorporates
feedback
Aspirational
Solicits feedback from all
members of the
interprofessional team and
patients
Performance continuously
reflects incorporation of
solicited and unsolicited
feedback
Welcomes unsolicited feedback
Able to reconcile disparate or
conflicting feedback
Consistently incorporates
feedback
Comments:
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15. Learns and improves at the point of care. (PBLI4)
Critical Deficiencies
Fails to acknowledge
uncertainty and
reverts to a reflexive
patterned response
even when
inaccurate
Fails to seek or
apply evidence
when necessary
Ready for unsupervised practice
Aspirational
Rarely “slows down” to
reconsider an approach to
a problem, ask for help, or
seek new information
Inconsistently “slows down”
to reconsider an approach to a
problem, ask for help, or seek
new information
Routinely “slows down” to
reconsider an approach to a
problem, ask for help, or seek
new information
Searches medical information
resources efficiently, guided
by the characteristics of
clinical questions
Can translate medical
information needs into
well-formed clinical
questions with assistance
Can translate medical
information needs into wellformed clinical questions
independently
Routinely translates new
medical information needs into
well-formed clinical questions
Role models how to appraise
clinical research reports based
on accepted criteria
Utilizes information technology
with sophistication
Has a systematic approach to
track and pursue emerging
clinical questions
Unfamiliar with strengths
and weaknesses of the
medical literature
Aware of the strengths and
weaknesses of medical
information resources but
utilizes information
Has limited awareness of or technology without
sophistication
ability to use information
technology
With assistance, appraises
clinical research reports,
Accepts the findings of
based on accepted criteria
clinical research studies
without critical appraisal
Independently appraises clinical
research reports based on
accepted criteria
Comments:
Practice-Based Learning and Improvement
The resident is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in training. He/she is
demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe,
effective, patient-centered, timely, efficient and equitable care.
_____ Yes _____ No _____ Conditional on Improvement
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16. Has professional and respectful interactions with patients, caregivers and members of the interprofessional team (e.g. peers,
consultants, nursing, ancillary professionals and support personnel). (PROF1)
Critical Deficiencies
Lacks empathy and
compassion for
patients and
caregivers
Disrespectful in
interactions with
patients, caregivers
and members of the
interprofessional
team
Sacrifices patient
needs in favor of
own self-interest
Blatantly disregards
respect for patient
privacy and
autonomy
Ready for unsupervised practice
Inconsistently
demonstrates empathy,
compassion and respect for
patients and caregivers
Inconsistently
demonstrates
responsiveness to patients’
and caregivers’ needs in an
appropriate fashion
Inconsistently considers
patient privacy and
autonomy
Consistently respectful in
interactions with patients,
caregivers and members of
the interprofessional team,
even in challenging situations
Is available and responsive to
needs and concerns of
patients, caregivers and
members of the
interprofessional team to
ensure safe and effective care
Emphasizes patient privacy
and autonomy in all
interactions
Demonstrates empathy,
compassion and respect to
patients and caregivers in all
situations
Anticipates, advocates for, and
proactively works to meet the
needs of patients and caregivers
Demonstrates a responsiveness
to patient needs that
supersedes self-interest
Positively acknowledges input of
members of the
interprofessional team and
incorporates that input into plan
of care as appropriate
Aspirational
Role models compassion,
empathy and respect for
patients and caregivers
Role models appropriate
anticipation and advocacy for
patient and caregiver needs
Fosters collegiality that
promotes a high-functioning
interprofessional team
Teaches others regarding
maintaining patient privacy
and respecting patient
autonomy
Comments:
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17. Accepts responsibility and follows through on tasks. (PROF2)
Critical Deficiencies
Is consistently
unreliable in
completing patient
care responsibilities
or assigned
administrative tasks
Shuns
responsibilities
expected of a
physician
professional
Ready for unsupervised practice
Completes most assigned
tasks in a timely manner
but may need multiple
reminders or other support
Completes administrative and
patient care tasks in a timely
manner in accordance with
local practice and/or policy
Prioritizes multiple competing
demands in order to complete
tasks and responsibilities in a
timely and effective manner
Accepts professional
responsibility only when
assigned or mandatory
Completes assigned
professional responsibilities
without questioning or the
need for reminders
Willingness to assume
professional responsibility
regardless of the situation
Aspirational
Role models prioritizing
multiple competing demands
in order to complete tasks and
responsibilities in a timely and
effective manner
Assists others to improve their
ability to prioritize multiple,
competing tasks
Comments:
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17
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18. Responds to each patient’s unique characteristics and needs. (PROF3)
Critical Deficiencies
Is insensitive to
differences related
to culture,
ethnicity, gender,
race, age, and
religion in the
patient/caregiver
encounter
Is unwilling to
modify care plan to
account for a
patient’s unique
characteristics and
needs
Ready for unsupervised practice
Is sensitive to and has basic
awareness of differences
related to culture,
ethnicity, gender, race, age
and religion in the
patient/caregiver
encounter
Requires assistance to
modify care plan to account
for a patient’s unique
characteristics and needs
Seeks to fully understand each
patient’s unique
characteristics and needs
based upon culture, ethnicity,
gender, religion, and personal
preference
Modifies care plan to account
for a patient’s unique
characteristics and needs with
partial success
Aspirational
Recognizes and accounts for the Role models professional
unique characteristics and needs interactions to negotiate
of the patient/ caregiver
differences related to a
patient’s unique
Appropriately modifies care plan characteristics or needs
to account for a patient’s unique
characteristics and needs
Role models consistent
respect for patient’s unique
characteristics and needs
Comments:
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The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes.
18
Version 7/2014
19. Exhibits integrity and ethical behavior in professional conduct. (PROF4)
Critical Deficiencies
Dishonest in clinical
interactions,
documentation,
research, or
scholarly activity
Refuses to be
accountable for
personal actions
Does not adhere to
basic ethical
principles
Blatantly disregards
formal policies or
procedures.
Ready for unsupervised practice
Honest in clinical
interactions,
documentation, research,
and scholarly activity.
Requires oversight for
professional actions
Has a basic understanding
of ethical principles, formal
policies and procedures,
and does not intentionally
disregard them
Aspirational
Honest and forthright in
clinical interactions,
documentation, research, and
scholarly activity
Demonstrates integrity,
honesty, and accountability to
patients, society and the
profession
Demonstrates accountability
for the care of patients
Actively manages challenging
ethical dilemmas and conflicts of Role models integrity,
interest
honesty, accountability and
professional conduct in all
aspects of professional life
Identifies and responds
appropriately to lapses of
professional conduct among
Regularly reflects on personal
peer group
professional conduct
Adheres to ethical principles
for documentation, follows
formal policies and
procedures, acknowledges
and limits conflict of interest,
and upholds ethical
expectations of research and
scholarly activity
Assists others in adhering to
ethical principles and
behaviors including integrity,
honesty, and professional
responsibility
Comments:
Professionalism
The resident is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in training. He/she is
demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe,
effective, patient-centered, timely, efficient and equitable care.
_____ Yes _____ No _____ Conditional on Improvement
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The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes.
19
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20. Communicates effectively with patients and caregivers. (ICS1)
Critical Deficiencies
Ignores patient
preferences for plan
of care
Makes no attempt
to engage patient in
shared decisionmaking
Routinely engages
in antagonistic or
counter-therapeutic
relationships with
patients and
caregivers
Ready for unsupervised practice
Engages patients in
discussions of care plans
and respects patient
preferences when offered
by the patient, but does not
actively solicit preferences.
Attempts to develop
therapeutic relationships
with patients and
caregivers but is often
unsuccessful
Defers difficult or
ambiguous conversations
to others
Engages patients in shared
decision making in
uncomplicated conversations
Requires assistance facilitating
discussions in difficult or
ambiguous conversations
Requires guidance or
assistance to engage in
communication with persons
of different socioeconomic
and cultural backgrounds
Aspirational
Identifies and incorporates
patient preference in shared
decision making across a wide
variety of patient care
conversations
Role models effective
communication and
development of therapeutic
relationships in both routine
and challenging situations
Quickly establishes a
therapeutic relationship with
patients and caregivers,
including persons of different
socioeconomic and cultural
backgrounds
Models cross-cultural
communication and
establishes therapeutic
relationships with persons of
diverse socioeconomic
backgrounds
Incorporates patient-specific
preferences into plan of care
Comments:
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20
Version 7/2014
21. Communicates effectively in interprofessional teams (e.g. peers, consultants, nursing, ancillary professionals and other support
personnel). (ICS2)
Critical Deficiencies
Utilizes
communication
strategies that
hamper
collaboration and
teamwork
Verbal and/or nonverbal behaviors
disrupt effective
collaboration with
team members
Ready for unsupervised practice
Uses unidirectional
communication that fails to
utilize the wisdom of the
team
Inconsistently engages in
collaborative communication
with appropriate members of
the team
Consistently and actively
engages in collaborative
communication with all
members of the team
Resists offers of
collaborative input
Inconsistently employs verbal,
non-verbal, and written
communication strategies that
facilitate collaborative care
Verbal, non-verbal and written
communication consistently acts
to facilitate collaboration with
the team to enhance patient
care
Aspirational
Role models and teaches
collaborative communication
with the team to enhance
patient care, even in
challenging settings and with
conflicting team member
opinions
Comments:
Copyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Internal Medicine. All rights reserved.
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21
Version 7/2014
22. Appropriate utilization and completion of health records. (ICS3)
Critical Deficiencies
Health records are
absent or missing
significant portions
of important clinical
data
Ready for unsupervised practice
Health records are
disorganized and
inaccurate
Health records are organized
and accurate but are
superficial and miss key data
or fail to communicate clinical
reasoning
Health records are organized,
accurate, comprehensive, and
effectively communicate clinical
reasoning
Aspirational
Role models and teaches
importance of organized,
accurate and comprehensive
health records that are
succinct and patient specific
Health records are succinct,
relevant, and patient specific
Comments:
Interpersonal and Communications Skills
The resident is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in training. He/she is
demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe,
effective, patient-centered, timely, efficient and equitable care.
_____ Yes _____ No _____ Conditional on Improvement
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Overall Clinical Competence
This rating represents the assessment of the resident's development of overall clinical competence during this year of training:
____
Superior: Far exceeds the expected level of development for this year of training
____
Satisfactory: Always meets and occasionally exceeds the expected level of development for this year of training
____
Conditional on Improvement: Meets some developmental milestones but occasionally falls short of the expected level of development
for this year of training. An improvement plan is in place to facilitate achievement of competence appropriate to the level of training.
____
Unsatisfactory: Consistently falls short of the expected level of development for this year of training.
Copyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Internal Medicine. All rights reserved.
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23
The Psychiatry Milestone Project
A Joint Initiative of
The Accreditation Council for Graduate Medical Education
and
The American Board of Psychiatry and Neurology
July 2015
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.
i
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
ii
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
iii
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 postgraduate 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.
iv
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.
v
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
Competency Domain
Subcompetency
Thread Names
Thread for: “Development as a
teacher” (all milestones with “A”)
Milestone
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).
vi
11/15/2013
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
1.1/A Obtains general
medical and psychiatric
history and completes a
mental status examination
Level 2
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
1.2/B Obtains relevant
collateral information from
secondary sources
2.3/B Obtains information that
is sensitive and not readily
offered by the patient
Level 3
3.1/A Consistently obtains
complete, accurate, and
relevant history
Level 4
4.1/A Routinely identifies
subtle and unusual findings
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
4.2/B Follows clues to
identify relevant historical
findings in complex clinical
situations and unfamiliar
circumstances
Level 5
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
3.4/B Uses hypothesisdriven information
gathering techniques2
1.3/C Screens for patient
safety, including suicidal
and homicidal ideation
2.4/C Assesses patient safety,
including suicidal and
homicidal ideation
2.5/D Recognizes that the
clinician’s emotional responses
have diagnostic value1
4.3/D Begins to use the
clinician's emotional
responses to the patient as a
diagnostic tool
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
1
11/15/2013
Comments:
Footnotes:
1
This 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.
2
This milestone focuses on the efficient and deductive conduct of the interview in accordance with diagnostic hypotheses to refine the differential diagnosis.
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
2
11/15/2013
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
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
Level 2
2.1/A Identifies patterns
and recognizes
phenomenology from the
patient's presentation to
generate a diagnostic
hypotheses
Level 3
Level 4
3.1/A Develops a full
differential diagnosis while
avoiding premature
closure
4.1/A Incorporates subtle,
unusual, or conflicting
findings into hypotheses
and formulations
3.2/B Organizes
formulation around
comprehensive models of
phenomenology that take
etiology into account 2
4.2/B Efficiently synthesizes
all information into a
concise but comprehensive
formulation
Level 5
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
5.1/B Serves as a role
model of efficient and
accurate formulation
5.2/B Teaches
formulation to advanced
learners
Comments:
Footnotes:
1
A 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.
2
Models 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.
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
3
11/15/2013
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
1.1/A Identifies potential
treatment options
Level 2
Level 3
Level 4
2.1/A Sets treatment goals
in collaboration with the
patient
3.1/A Incorporates
manual-based treatment1
when appropriate
4.1/A Devises individualized
treatment plan for complex
presentations
2.2/A Incorporates a clinical
practice guideline or
treatment algorithm when
available
3.2/A Applies an
understanding of
psychiatric, neurologic,
and medical co-morbidities
to treatment selection2
4.2/A Integrates multiple
modalities and providers in
comprehensive approach3
2.3/A Recognizes co-morbid
conditions and side effects’
impact on treatment
Level 5
5.1/A Supervises
treatment planning of
other learners and
multidisciplinary
providers
5.2/A Integrates
emerging neurobiological
and genetic knowledge
into treatment plan4
3.3/A Links treatment to
formulation
1.2/B Recognizes patient in
crisis or acute presentation
2.4/B Manages patient
crises with supervision
3.4/B Recognizes need for
consultation and
supervision for
complicated or refractory
cases
1.3/C Recognizes patient
readiness for treatment
2.5/C Monitors treatment
adherence and response
3.5/C Re-evaluates and
revises treatment
approach based on new
information and or
response to treatment
4.3/C Appropriately
modifies treatment
techniques and flexibly
applies practice guidelines
to fit patient need
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.
2
Examples 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.
3
Understanding and use of an array of modalities and providers may include consideration of complementary and alternative medicine, occupational therapy, and
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
4
11/15/2013
physical therapy.
Examples may include cytochrome genetics, ethnic differences, and family counseling, etc.
4
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
5
11/15/2013
PC4. Psychotherapy
Refers to 1) the practice and delivery of psychotherapies, including psychodynamic 1, 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
1.1/A Accurately identifies
patient emotions,
particularly sadness, anger,
and fear4
2.1/A Identifies and reflects
the core feeling and key
issue for the patient during
a session
3.1/A Identifies and reflects
the core feeling, key issue,
and what the issue means to
the patient
4.1/A Links feelings,
behavior, recurrent/central
themes/schemas, and their
meaning to the patient as
they shift within and across
sessions
1.2/B Maintains appropriate
professional boundaries
2.2/B Maintains appropriate
professional boundaries in
psychotherapeutic
relationships while being
responsive to the patient5
3.2/B Recognizes and avoids
potential boundary
violations
4.2/B Anticipates and
appropriately manages
potential boundary
crossings and avoids
boundary violations
1.3/C Demonstrates a
professional interest and
curiosity in a patient’s story
2.3/C Establishes and
maintains a therapeutic
alliance with patients with
uncomplicated problems6
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
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
3.4/C Manages the
emotional content of, and
feelings aroused during,
sessions
4.4/C Selects a
psychotherapeutic modality
and tailors the selected
psychotherapy to the
patient on the basis of an
appropriate case
formulation
2.4/C Utilizes elements of
supportive therapy in
treatment of patients
3.5/C Integrates the selected
psychotherapy with other
treatment modalities and
other treatment providers 7
Level 5
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
4.5/C Successfully guides
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
6
11/15/2013
the patient through the
different phases of
psychotherapy, including
termination
3.6/D Balances autonomy
with needs for consultation
and supervision
4.6/C, D Recognizes, seeks
appropriate consultation
about, and manages
treatment impasses
5.3/D Provides
psychotherapy
supervision to others
Comments:
Footnotes:
1
Psychodynamic therapy includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to understand the concepts of
resistance/defenses, transference/countertransference.
2
Cognitive-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.
3
Supportive 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.
4
This 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.”
5
This refers to the ability to maintain professional boundaries in psychotherapy without being aloof or overly detached.
6
Examples of uncomplicated problems are major depression or panic disorder without co-morbidity.
7
At 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.
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
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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
1.1/A Lists commonly used
psychopharmacologic agents
and their indications to
target specific psychiatric
symptoms (e.g., depression,
psychosis)
2.1/A Appropriately
prescribes1 commonly used
psychopharmacologic agents
1.2/B Reviews with the
patient/family general
indications, dosing
parameters, and common
side effects for commonly
prescribed
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
Level 3
3.1/A Manages
pharmacokinetic and
pharmacodynamic drug
interactions when using
multiple medications
concurrently
Level 4
Level 5
4.1/A Titrates dosage and
manages side effects of
multiple medications
5.1/B Explains less
common somatic
treatment choices to
patients/families in terms
of proposed mechanisms
of action
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
4.2/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
5.2/C Integrates emerging
studies of somatic
treatments into clinical
practice
2.4/D Seeks consultation and
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
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11/15/2013
supervision regarding
potential referral for ECT
Comments:
Footnotes:
1
This 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).
2
Examples of other somatic therapies include neuromodulation, biofeedback, and phototherapy.
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
9
11/15/2013
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
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
3.1/A Explains
developmental tasks and
transitions throughout the
life cycle, utilizing multiple
conceptual models3
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
3.2/B Describes the
influence of psychosocial
factors (gender, ethnic,
cultural, economic),
general medical, and
neurological illness on
personality development
2.4/C
3.2Utilizes
De
developmental concepts in
case formulation
3.3/C Utilizes appropriate
conceptual models of
development in case
formulation
Level 4
Level 5
5.1/A Incorporates new
neuroscientific
knowledge into his or her
understanding of
development
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
Comments:
Footnotes:
1
Includes 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.
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
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2
Knowledge 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.
3
Using the theoretical models proposed by psychodynamic, cognitive, and behavioral theorists.
4
An example is bipolar disorder with genetic diathesis + environmental stress leading to manic behavior.
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
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11/15/2013
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
1.1/A Identifies the major
psychiatric diagnostic system
(DSM)
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)
3.1/A Demonstrates
sufficient knowledge to
identify and treat most
psychiatric conditions
throughout the life cycle
and in a variety of settings2
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
1.2/B Lists major risk and
protective factors for danger to
self and others
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
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
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
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
1.3/C Gives examples of
interactions between medical
and psychiatric symptoms and
disorders
2.3/C Shows sufficient
knowledge to perform an
initial medical and
neurological evaluation in
psychiatric inpatients
3.3/C Shows sufficient
knowledge to identify and
treat common psychiatric
manifestations of medical
illness (e.g., delirium,
depression, steroidinduced syndromes)
4.3/C Shows knowledge
sufficient to identify and
treat a wide range of
psychiatric conditions in
patients with medical
disorders
5.2/C Shows sufficient
knowledge to identify and
treat uncommon
psychiatric conditions in
patients with medical
disorders
4.4/C Demonstrates
sufficient knowledge to
systematically screen for,
evaluate, and diagnose
5.3/C Demonstrates
sufficient knowledge to
detect and ensure
appropriate treatment of
2.4/C Demonstrates
sufficient knowledge to
identify common medical
conditions (e.g.,
hypothyroidism,
3.4/C Demonstrates
sufficient knowledge to
include relevant medical
Level 4
Level 5
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
12
11/15/2013
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:
1
This 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.
2
This 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.
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
13
11/15/2013
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
1.1/A Knows commonly
available neuroimaging and
neurophysiologic diagnostic
modalities and how to order
them
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)
3.1/A Recognizes the
significance of abnormal
findings in routine
neurodiagnostic test6
reports in psychiatric
patients
2.2/B Describes common
neuropsychological tests
and their indications2
3.2/B Knows indications
for specific
neuropsychological tests
and understands meaning
of common abnormal
findings
1.2/B Knows how to order
neuropsychological testing
Level 3
Level 4
Level 5
4.1/A Explains the significance
of routine neuroimaging,
neurophysiological, and
neuropsychological testing
abnormalities to patients
5.1/A Integrates recent
neurodiagnostic research
into understanding of
psychopathology
4.2/A Knows clinical indications
and limitations of functional
neuroimaging7
2.3/C Describes psychiatric
disorders co-morbid with
common neurologic
disorders3 and neurological
disorders frequently seen in
psychiatric patients4
5.2/B Flexibly applies
knowledge of
neuropsychological
findings to the differential
diagnoses of complex
patients
4.3/C Describes psychiatric comorbidities of less common
neurologic disorders8 and less
common neurologic comorbidities of psychiatric
disorders9
3.3/D Describes
neurobiological and
genetic hypotheses of
common psychiatric
disorders and their
limitations
4.4/D Explains neurobiological
hypotheses and genetic risks of
common psychiatric disorders
to patients
5.3/D Explains
neurobiological
hypotheses and genetic
risks of less common
psychiatric disorders11 to
patients
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
14
11/15/2013
5.4/D Integrates
knowledge of
neurobiology into
advocacy for psychiatric
patient care and stigma
reduction12
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
Comments:
Footnotes:
1
This 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.
2
Common neuropsychological tests include the Montreal Cognitive Assessment (or Mini Mental State Examination), Wechsler Adult Intelligence Scale (or HalsteadReitan battery), Wechsler Memory Scale, Wide Range Achievement Test, Wisconsin Card Sorting Test, Clock Drawing Test.
3
Examples include psychosis, mood disorders, personality changes, and cognitive impairments seen in common neurological disorders.
4
These include drug-induced and idiopathic extrapyramidal syndromes, neuropathies, traumatic brain injury (TBI), vascular lesions, dementias, and encephalopathies.
5
Areas might include dorsolateral prefrontal cortex, anterior cingulate, amygdala, hippocampus, etc.
6
These include structural imaging and electrophysiologic testing.
7
For example, positron emission tomography (PET)/single-photon emission computed tomography (SPECT) in the diagnosis of Alzheimer’s disease (supportive but nondiagnostic); functional magnetic resonance imaging (fMRI) is not yet reimbursable for clinical use.
8
Examples 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.
9
Examples include: neuroleptic malignant syndrome; lethal catatonia; “Parkinson plus” syndromes (e.g., multisystem atrophy, dementia with Lewy bodies, etc).
10
Social behaviors might include attachment, empathy, attraction, reward/addiction, aggression, appetites, etc.
11
Examples include : Obsessive-Compulsive Disorder (OCD); eating disorders ; Gilles de la Tourette syndrome.
12
Uses neurobiologic hypotheses of psychiatric disorders to advocate for health coverage, treatment availability, etc.
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
15
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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
1.1/A Identifies psychodynamic, cognitive-behavioral,
and supportive therapies as
major psychotherapeutic
modalities
Level 2
Level 3
2.1/A Describes the basic
principles of each of the
three core individual
psychotherapy modalities4
3.1/A Describes
differences among the
three core individual
therapies
2.2/A Discusses common
factors across
psychotherapies5
3.2/A Describes the
historical and conceptual
development of
psychotherapeutic
paradigms
2.3/B Lists the basic
indications,
contraindications, benefits,
and risks of supportive,
psychodynamic and
cognitive behavioral
psychotherapies
Level 4
Level 5
4.1/A Describes proposed
mechanisms of therapeutic
change
5.1/A Incorporates new
theoretical developments
into knowledge base
5.2/A, B Demonstrates
sufficient knowledge of
psychotherapy to teach
others effectively
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
4.2/C Discusses the
evidence base for
combining different
psychotherapies and
psychopharmacology
4.3/C Critically appraises
the evidence for efficacy of
psychotherapies
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
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Comments:
Footnotes:
1
This includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to understand the concepts of resistance/defenses, and
transference/countertransference.
2
This includes the capacity to generate a case formulation, and to demonstrate techniques of intervention, including behavior change, skills acquisition, and addressing
cognitive distortions.
3
This 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.
4
Throughout this subcompetency, the three “core” or “major” individual psychotherapies refer to supportive, psychodynamic, and cognitive-behavioral therapy.
5
Common 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.
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
17
11/15/2013
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
1.1/A Describes general
indications and common side
effects for commonly
prescribed
psychopharmacologic agents
Level 2
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
Level 3
3.1/A Demonstrates an
understanding of
pharmacokinetic and
pharmacodynamic drug
interactions
Level 4
4.1/A Describes the
evidence supporting the use
of multiple medications in
certain treatment situations
(e.g., polypharmacy and
augmentation)
3.2/A Demonstrates an
understanding of
psychotropic selection
based on current practice
guidelines or treatment
algorithms for common
psychiatric disorders
Level 5
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
2.4/A Describes expected
time course of response for
commonly prescribed
classes of psychotropic
agents
1.2/B Describes indications for
ECT
2.5/B Describes length and
frequency of ECT
treatments, as well as
relative contraindications
2.6/C Describes the physical
3.3/B Describes specific
techniques in ECT
3.4/B Lists emerging
neuro-modulation
therapies1
4.2/ C Integrates knowledge
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
18
11/15/2013
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:
1
Examples of neuromodulation techniques include TMS and variations, VNS, Deep Brain Stimulation, etc.
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
19
11/15/2013
MK6. Practice of Psychiatry
A: Ethics
B: Regulatory compliance
C: Professional development and frameworks
Has not
Achieved
Level 1
Level 1
1.1/A Lists common ethical
issues in psychiatry
Level 2
2.1/A Lists and discusses
sources of professional
standards of ethical
practice
Level 3
Level 4
Level 5
3.1/A Discusses conflict of
interest and management
2.2/A Lists situations that
mandate reporting or
breach of confidentiality
1.2/B Recognizes and describes
institutional policies and
procedures1
1.3/C Lists ACGME
Competencies
3.2/B Describes applicable
regulations for billing and
reimbursement
2.3/C Describes how to
keep current on regulatory
and practice management
issues
4.1/B Describes the
existence of state and
regional variations
regarding practice,
involuntary treatment,
health regulations, and
psychiatric forensic
evaluation
5.1/B Describes
international variations
regarding practice,
involuntary treatment,
and health regulations
4.2/C Describes
professional advocacy2
5.2/C Proposes advocacy
activities, policy
development, or scholarly
contributions related to
professional standards
4.3/C Describes how to seek
out and integrate new
information on the practice
of psychiatry
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
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
20
11/15/2013
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.).
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
21
11/15/2013
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
1.1/A Differentiates among
medical errors, near misses,
and sentinel events
2.1/A Describes the
common system causes for
errors
1.2/B Recognizes failure in
teamwork and communication
as leading cause of preventable
patient harm
2.2/B Consistently uses
structured communication
tools to prevent adverse
events (e.g., checklists, safe
hand-off procedures,
briefings)
1.3/C Follows institutional
safety policies, including
reporting of problematic
behaviors and processes,
errors, and near misses
2.3/C Actively participates
in conferences focusing on
systems-based errors in
patient care
Level 3
3.1/A Describes systems
and procedures that
promote patient safety
Level 4
4.1/A Participates in formal
analysis (e.g., root-cause
analysis, failure mode
effects analysis) of medical
errors and sentinel events
Level 5
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
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)
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).
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
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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
1.1/A Recognizes need for
efficient and equitable use of
resources
Level 2
Level 3
Level 4
Level 5
2.1/A Recognizes disparities
in health care at individual
and community levels
3.2/A Coordinates patient
access to community and
system resources
4.1/A Practices costeffective, high-value clinical
care1, using evidence-based
tools and information
technologies to support
decision making
5.1/A Designs
measurement tools to
monitor and provide
feedback to
providers/teams on
resource consumption to
facilitate improvement
2.2/A Knows the relative
cost of care (e.g.,
medication costs,
diagnostic costs, level of
care costs, procedure costs)
4.2/A Balances the best
interests of the patient with
the availability of resources
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.
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
23
11/15/2013
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
1.1/A Gives examples of
community mental health
systems of care
Level 2
Level 3
Level 4
2.1/A Coordinates care with
community mental health
agencies, including with
case managers
Level 5
5.1/A Participates in the
administration of
community-based
treatment programs
5.2/A Participates in
creating new communitybased programs
1.2/B Gives examples of selfhelp groups (Alcoholics
Anonymous [AA], Narcotics
Anonymous [NA]), other
community resources (church,
school) and social networks
(e.g., family, friends,
acquaintances)
2.2/B Recognizes role and
explains importance of selfhelp groups and community
resource groups
(e.g., disorder-specific
support and advocacy
groups)
3.1/B Incorporates
disorder-specific support
and advocacy groups in
clinical care
4.1/B Routinely uses selfhelp groups, community
resources, and social
networks in treatment3
2.3/C Describes individual
and population risk factors
for mental illness
3.2/C Describes prevention
measures: universal,
selective and indicated1
4.2/C Employs prevention
and risk reduction
strategies in clinical care
3.3/D Describes
rehabilitation programs
(vocational, brain injury,
etc.) and the recovery
model2
4.3/D Appropriately refers
to rehabilitation and
recovery programs
5.3/D Practices effectively
in a rehabilitation and/or
recovery-based program
4.4/D Uses principles of
evidence-based practice
and patient centered care in
management of chronically
ill patients
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
24
11/15/2013
Comments:
Footnotes:
1
Universal 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.
2
The 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).
3
These community resources include supports and services from both the peer and professional workforces.
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
25
11/15/2013
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
1.1/A Describes the
difference between
consultant and primary
treatment provider
Level 2
Level 3
Level 4
Level 5
4.1/B Provides integrated
care for psychiatric patients
through collaboration with
other physicians1
5.1/B Provides psychiatric
consultations to larger
systems
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
5.2/B Leads a
consultation team
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
4.2/C Manages complicated
and challenging
consultation requests
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
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.
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
26
11/15/2013
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
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
Level 2
2.1/A Regularly seeks and
incorporates feedback to
improve performance
2.2/A Identifies selfdirected learning goals and
periodically reviews them
with supervisory guidance
2.3/B Formulates a
searchable question from a
clinical question2
Level 3
Level 4
3.1/A Demonstrates a
balanced and accurate selfassessment of competence,
using clinical outcomes to
identify areas for continued
improvement
4.1/A Demonstrates
improvement in clinical
practice based on continual
self-assessment and
evidence-based information
Level 5
4.2/A Identifies and meets
self-directed learning goals
with little external guidance
3.2/B Selects an
appropriate, evidencebased information tool1 to
meet self-identified
learning goals
3.3/B Critically appraises
different types of research,
including randomized
controlled trials (RCTs),
systematic reviews, metaanalyses, and practice
guidelines
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:
1
Examples include: practice guidelines; PubMed Clinical Queries; Cochrane, DARE, or other evidence-based reviews; Up-to-Date, etc.
2
Examples 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.
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
27
11/15/2013
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
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
Level 2
Level 3
Level 4
2.1/A Narrows problems
within own clinical service(s)
to a specific and achievable
aim for a quality
improvement (QI) project
3.1/A Involves appropriate
stakeholders in design of a
QI project4
4.1/A Substantially
contributes to a supervised
project to address specific
quality deficit within own
clinical service(s), and
measures relevant
outcomes
5.1/A Independently
proposes and leads
projects to enhance
patient care
4.2/B Describes basic
methods for
implementation and
evaluation of clinical QI
projects5
5.3/B Describes core
concepts of advanced QI
methodologies and
business processes6
2.2/B Outlines factors and
causal chains contributing to
quality gaps within own
institution and practice3
3.2/B Lists common
responses of teams and
individuals to changes in
clinical operations and
describes strategies for
managing same
Level 5
5.2/A Uses advanced
quality measurement and
“dashboard” tools
Comments:
Footnotes:
1
Many 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.
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
28
11/15/2013
PBLI3. Teaching
A: Development as a teacher
B: Observable teaching skills
Has not
Achieved
Level 1
Level 1
1.1/A Recognizes role of
physician as teacher
Level 2
Level 3
Level 4
Level 5
2.1/A Assumes a role in the
clinical teaching of early learners
3.1/A Participates in
activities designed to
develop and improve
teaching skills
4.1/A Gives formal didactic
presentation to groups
(e.g., grand rounds, case
conference, journal club)
5.1/A Educates broader
professional community
and/or public (e.g.,
presents at regional or
national meeting)
2.2/B Communicates goals and
objectives for instruction of
early learners
3.2/B Organizes content
and methods for individual
instruction for early
learners
4.2/B Effectively uses
feedback on teaching to
improve teaching methods
and approaches
5.2/B Organizes and
develops curriculum
materials
2.3/B Evaluates and provides
feedback to early learners
Comments:
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
29
11/15/2013
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
1.1/A Demonstrates behaviors
that convey caring, honesty,
genuine interest, and respect
for patients and their families
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
3.1/A Elicits beliefs, values,
and diverse practices of
patients and their families,
and understands their
potential impact on
patient care
4.1/A Develops a mutually
agreeable care plan in the
context of conflicting
physician and patient
and/or family values and
beliefs
3.2/A Routinely displays
sensitivity to diversity in
psychiatric evaluation and
treatment
4.2/A Discusses own
cultural background and
beliefs and the ways in
which these affect
interactions with patients
1.2/A Recognizes that patient
diversity affects patient care
2.2/A Provides examples of
the importance of attention
to diversity in psychiatric
evaluation and treatment
1.3/B Displays familiarity with
some basic ethical principles
(e.g., confidentiality, informed
consent, professional
boundaries)
2.3/B Recognizes ethical
conflicts in practice and
seeks supervision to
manage them
3.3/B Recognizes ethical
issues in practice and is
able to discuss, analyze,
and manage these in
common clinical situations
Level 4
Level 5
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:
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
30
11/15/2013
Footnotes:
1
The 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.
2
Diversity refers to unique aspects of each individual patient, including gender, age, socioeconomic status, culture, race, religion, disabilities, and sexual orientation.
3
For milestones regarding health disparities, please see SBP2.
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
31
11/15/2013
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
1.1/A Understands the need
for sleep, and the impact of
fatigue on work
Level 2
2.1/A Notifies team and
enlists back-up when
fatigued or ill, so as to
ensure good patient care
1.2/A Lists ways to manage
fatigue, and seeks back-up as
needed to ensure good
patient care
Level 3
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
1.3/B Exhibits core
professional behaviors1
2.2/B Follows institutional
policies for physician
conduct
3.3/B Recognizes the
importance of participating in
one’s professional community
Level 4
4.1/A Knows how to take
steps to address
impairment in self and in
colleagues
Level 5
5.1/A Develops physician
wellness programs or
interventions
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
1.4/B Displays openness to
feedback
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)
1.5/C Introduces self as
patient’s physician
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
3.4/C Is recognized by self,
patient, patient’s family, and
medical staff members as the
patient’s primary psychiatric
provider
4.4/C Displays increasing
autonomy and leadership in
taking responsibility for
ensuring that patients
receive the best possible
care
5.4/C Serves as a role
model in demonstrating
responsibility for ensuring
that patients receive the
best possible care
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
32
11/15/2013
Comments:
Footnotes:
Professional 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.
2
Residents 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.
1
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
33
11/15/2013
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
1.1/A Cultivates positive
relationships with patients,
families, and team members
Level 2
2.1/A Develops a therapeutic
relationship with patients in
uncomplicated situations
Level 3
3.1/A Develops
therapeutic relationships
in complicated situations
2.2/A Develops working
relationships across
specialties and systems of
care in uncomplicated
situations
Level 4
Level 5
4.1/A Sustains therapeutic
and working relationships
during complex and
challenging situations,
including transitions of care
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
1.2/B Recognizes
communication conflicts in
work relationships
2.3/B Negotiates and
manages simple
patient/family-related
conflicts
3.2/B Sustains working
relationships in the face of
conflict
1.3/C Identifies team-based
care as preferred treatment
approach, and collaborates as
a member of the team
2.4/C Actively participates in
team-based care; supports
activities of other team
members, and
communicates their value to
the patient and family
3.3/C Facilitates teambased activities in clinical
and/or non-clinical
situations (including on
committees)
5.3/B, C Manages
treatment team conflicts
as team leader
4.2/C Leads a
multidisciplinary care team
5.4/C Leads and
facilitates meetings
within the
organization/system
Comments:
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
34
11/15/2013
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
1.1/A Ensures transitions of
care are accurately
documented, and optimizes
communication across
systems and continuums of
care
Level 2
2.1/A, B Organizes both written
and oral information to be shared
with patient, family, team, and
others
1.2/A Ensures that the
written record (electronic
medical record [EMR],
personal health records
[PHR]/patient portal, handoffs, 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
2.2/B Consistently demonstrates
communication strategies to
ensure patient and family
understanding
Level 3
3.1/ A, B Uses easy-tounderstand language in all
phases of communication,
including working with
interpreters
3.2/B Consistently engages
patients and families in
shared decision making
Level 4
4.1/A, B Demonstrates
effective verbal
communication with
patients, families,
colleagues, and other
health care providers
that is appropriate,
efficient, concise, and
pertinent
Level 5
5.1/A Models
continuous
improvement in record
keeping
4.2/A, B Demonstrates
written communication
with patients, families,
colleagues, and other
health care providers
that is appropriate,
efficient, concise, and
pertinent
2.3/B Demonstrates appropriate
face-to-face interaction while
using EMR
1.4/C Maintains appropriate
boundaries in sharing
information by electronic
communication
2.4/C Understands issues raised by
the use of social media by patients
and providers
4.3/C Uses discretion
and judgment in the
inclusion of sensitive
patient material in the
medical record
5.2/C Participates in the
development of changes
in rules, policies, and
procedures related to
technology
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
35
11/15/2013
4.4/C Uses discretion
and judgment in
electronic
communication with
patients, families, and
colleagues
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)
Comments:
The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and
Neurology.
36