The Vascular Neurology Milestone Project A Joint Initiative of The Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology July 2015
The Vascular Neurology Milestone Project The Milestones are designed only for use in evaluation of the fellow in the context of their participation in ACGME-accredited residency or fellowship programs. The Milestones provide a framework for assessment of the development of the fellow 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.
Vascular Neurology Milestones Chair: Shannon Kilgore, MD Working Group Harold Adams, MD Jose Biller, MD Laura Edgar, EdD, CAE Brett Kissela, MD, MS Louise King, MS Barney Stern, MD Advisory Group Larry Faulkner, MD Steven Lewis, MD* Mary Lieh-Lai, MD *Acknowledgement: Special thanks to Steven Lewis, MD, who was an active member of both the Working and Advisory Groups. ii
Milestone Reporting This document presents Milestones designed for programs to use in semi-annual review of fellow performance and reporting to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced. They are descriptors and targets for fellow performance as a fellow moves from entry into fellowship through graduation. In the initial years of implementation, the Review Committee will examine Milestone performance data for each program s fellows as one element in the Next Accreditation System (NAS) to determine whether fellows overall are progressing. For each period, review and reporting will involve selecting milestone levels that best describe a fellow s current performance and attributes. Milestones are arranged into numbered levels. Tracking from Level 1 to Level 5 is synonymous with moving from novice to expert in the subspecialty. Selection of a level implies that the fellow substantially demonstrates the milestones in that level, as well as those in lower levels (see the diagram on page v). Level 1: The fellow demonstrates milestones expected of an incoming fellow. Level 2: The fellow is advancing and demonstrates additional milestones, but is not yet performing at a mid-fellowship level. Level 3: The fellow continues to advance and demonstrate additional milestones, consistently including the majority of milestones targeted for fellowship. Level 4: The fellow has advanced so that he or she now substantially demonstrates the milestones targeted for fellowship. This level is designed as the graduation target. Level 5: The fellow has advanced beyond performance targets set for fellowship and is demonstrating aspirational goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional fellows will reach this level. iii
Additional Notes Level 4 is designed as the graduation target and does not represent a graduation requirement. Making decisions about readiness for graduation is the purview of the fellowship program director. Study of Milestone performance data will be required before the ACGME and its partners will be able to determine whether milestones in the first four levels appropriately represent the developmental framework, and whether Milestone data are of sufficient quality to be used for high-stakes decisions. Examples are provided with some milestones. Please note that the examples are not the required element or outcome; they are provided as a way to share the intent of the element. Some milestone descriptions include statements about performing independently. These activities must occur in conformity to the ACGME supervision guidelines, as well as institutional and program policies. For example, a fellow who performs a procedure independently must, at a minimum, be supervised through oversight. 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 ACGME Report Worksheet. For each reporting period, a fellow s performance on the milestones for each sub-competency will be indicated by selecting the level of milestones that best describes that fellow s performance in relation to those milestones. Selecting a response box 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). v
History Patient Care Efficiently obtains a complete, relevant, and organized neurologic history Obtains a relevant and organized vascular neurology history Obtains history that identifies stroke mimics Efficiently obtains a relevant and organized vascular neurology history appropriate to patient s acuity and clinical setting (e.g., clinic, emergency room) Obtains history that targets scoring of the modified Rankin Scale Consistently obtains a history sufficient to guide the subsequent vascular neurology examination, investigation, and treatment Obtains history that identifies unusual causes of stroke Serves as a role model for obtaining a vascular neurologic history Not yet achieved Level 1 purposes. 1
Vascular Neurological Examination Patient Care Performs a relevant vascular neurology examination Performs an examination to identify stroke mimics Administers and scores the National Institutes of Health Strokes Scale (NIHSS) Performs a relevant vascular neurology examination incorporating some additional maneuvers appropriate to the patient Acquires NIHSS certification Performs a relevant vascular neurology examination incorporating all maneuvers appropriate to the patient Proficiently administers and scores the NIHSS Consistently and efficiently performs a vascular neurology examination to guide and prioritize subsequent investigation and treatment Performs an examination to identify unusual causes of stroke Serves as a role model for performing a vascular neurology examination Not yet achieved Level 1 purposes. 2
Ischemic Stroke Reperfusion Treatment and Management Patient Care Treats ischemic stroke patients with intravenous (IV) thrombolysis Treats complex patients with ischemic stroke with IV thrombolysis Manages non-bleeding complications associated with IV thrombolysis Engages a multidisciplinary team in management of a complex case Leads a multidisciplinary team within a stroke center Manages bleeding complications associated with IV thrombolysis Identifies potential candidates for endovascular recanalization Manages complications of endovascular therapies for acute ischemic stroke Incorporates multimodality imaging in the assessment of the patient Provides remote consultation of acute stroke patients Engages in scholarly activity on ischemic stroke reperfusion treatment and management Not yet achieved Level 1 purposes. 3
Treatment and Management of Patients with Cerebrovascular Disease Patient Care Manages patients at high risk for ischemic stroke Manages risk factors for ischemic stroke Provides emergent care to patients with acute stroke Manages patients at high risk for intracerebral hemorrhage Manages risk factors for intracerebral hemorrhage Identifies patients for surgical or endovascular intervention to prevent ischemic stroke Coordinates interdisciplinary management of patients at high risk for stroke Identifies patients for surgical or endovascular intervention to prevent intracerebral or subarachnoid hemorrhage Provides acute and chronic management of patients with uncommon or complex cerebrovascular diseases Coordinates post-stroke care and reintegration into the community, as part of a multidisciplinary team Engages in scholarly activity on the treatment and management of patients with cerebrovascular disease Provides management to prevent or treat acute/subacute complications of stroke Manages patients with cerebral venous thrombosis Evaluates and manages long-term sequelae of stroke (e.g., vascular dementia, spasticity) Not yet achieved Level 1 purposes. 4
Localization Medical Knowledge Accurately localizes vascular lesions to specific regions of the nervous system Promptly and accurately localizes vascular lesions to specific arterial and venous territories of the of vascular neuroanatomy to localize uncommon syndromes of the brain, nervous system eye, and spinal cord Describes basic vascular neuroanatomy of normal vascular anatomic variations and collaterals Promptly and accurately localizes vascular lesions based on advanced knowledge of the specific arterial and venous territories of the nervous system of vascular neuroanatomy to localize common syndromes of the brain, eye, and spinal cord Consistently demonstrates sophisticated and detailed knowledge of vascular neuroanatomy in localizing lesions of the brain, eye, and spinal cord Serves as a role model for teaching localization of vascular lesions of the brain, eye, and spinal cord Not yet achieved Level 1 purposes. 5
Formulation Medical Knowledge Synthesizes information to focus and prioritize diagnostic possibilities Correlates the clinical presentation with presumed type of vascular event (e.g., ischemic vs. hemorrhagic) Efficiently synthesizes information to focus and prioritize diagnostic possibilities Correlates the clinical presentation with presumed pathophysiology (e.g., embolism, thrombosis, hypoperfusion) Correlates the clinical presentation with presumed etiologic subtype (e.g., cardioembolism, aneurysm, cerebral amyloid angiopathy) Reconsiders appropriate diagnostic differential in response to new information Correlates the atypical presentations of common vascular lesions of the brain, eye, and spinal cord with presumed etiology Correlates the typical clinical presentations of uncommon vascular lesions of the brain, eye, and spinal cord with presumed etiology Consistently demonstrates sophisticated pathophysiologic knowledge of vascular diseases of the nervous system Serves as a role model for sophisticated diagnostic reasoning Not yet achieved Level 1 purposes. 6
Imaging in Vascular Neurology (e.g., computed tomography [CT], magnetic resonance [MR], angiography, ultrasonography) Medical Knowledge Recognizes emergent imaging findings on brain MR and CT Uses imaging findings in planning patient management Recognizes subtle abnormalities on brain imaging Recognizes subtle abnormalities on vascular imaging Serves as a role model for use of imaging studies in patient management Recognizes major abnormalities on vascular imaging Differentiates normal from abnormal findings and identifies potential significance Describes risks and benefits of administration of contrast agents Selects imaging protocols based on patient comorbidities and/or provisional diagnosis Selects imaging modalities based on comparative effectiveness and cost Identifies risks and benefits of various imaging tests as they pertain to an individual patient of indications for, and limitations of, anatomic and physiologic imaging studies Not yet achieved Level 1 purposes. 7
Diagnostic Investigation in Vascular Neurology Medical Knowledge Demonstrates general knowledge of diagnostic tests in vascular neurology Individualizes diagnostic approach to the specific patient Explains diagnostic yield and cost-effectiveness of testing Discusses general diagnostic approach appropriate to clinical presentation Explains risks and benefits of tests to patient Accurately interprets results of common diagnostic tests Recognizes indications and implications of less common testing (e.g., genetic testing, coagulation testing) Accurately interprets results of less common diagnostic testing Recognizes indications for advanced imaging and other diagnostic studies Demonstrates sophisticated knowledge of diagnostic testing and controversies Not yet achieved Level 1 purposes. 8
Ischemic Stroke Medical Knowledge Describes and identifies risk factors for stroke of the warning signs and symptoms of stroke of most common causes of ischemic stroke of the importance of emergency stroke treatment of common causes of stroke in children and young adults Demonstrates understanding of the non-atherosclerotic causes of stroke Demonstrates understanding of the acute complications of stroke and stroke treatment Demonstrates understanding of the strategies to prevent stroke of the issues in regards to treating patients with stroke in complex situations (e.g., pregnancy, perioperative, spinal cord ischemia) of various cardiac and hematologic diseases that predispose to stroke of biology of atherosclerotic disease of basic scientific underpinnings of acute brain ischemia Engages in scholarly activity on ischemic stroke pathophysiology of thrombolytic treatment for stroke Demonstrates understanding of the indications and limitations for surgical interventions to prevent or treat stroke of the pharmacologic interventions of stroke Not yet achieved Level 1 purposes. 9
Intracerebral Hemorrhage Medical Knowledge Describes and identifies risk factors for intracerebral hemorrhage of the clinical presentation of intracerebral hemorrhage of most common causes of intracerebral hemorrhage of the importance of emergency intracerebral hemorrhage treatment Demonstrates understanding of uncommon causes of intracerebral hemorrhage of the pharmacologic treatments for intracerebral hemorrhage Demonstrates understanding of the acute complications of intracerebral hemorrhage of causes of intracerebral hemorrhage in children and young adults of the issues related to the treatment of patients with hemorrhage in complex situations (e.g., pregnancy, systemic disease, spinal cord hemorrhage) of hematologic diseases that predispose to intracerebral hemorrhage of basic scientific underpinnings of acute brain hemorrhage Demonstrates understanding of the indications, complications, and limitations of surgical interventions for intracerebral hemorrhage Engages in scholarly activity on intracerebral hemorrhage Not yet achieved Level 1 purposes. 10
Subarachnoid Hemorrhage Medical Knowledge Describes and identifies risk factors for subarachnoid hemorrhage of the clinical presentation of subarachnoid hemorrhage of most common causes of subarachnoid hemorrhage of emergency subarachnoid hemorrhage diagnosis and treatment Demonstrates understanding of uncommon causes of subarachnoid hemorrhage of the pharmacologic treatments for subarachnoid hemorrhage Demonstrates understanding of the acute/subacute complications of subarachnoid hemorrhage of causes of subarachnoid hemorrhage in children and young adults of the issues related to the treatment of patients with subarachnoid hemorrhage in complex situations (e.g., pregnancy, systemic disease) of the natural history and management of unruptured aneurysms of basic scientific underpinnings of subarachnoid hemorrhage and its complications Demonstrates understanding of the indications, complications, and limitations of surgical and endovascular interventions for subarachnoid hemorrhage Demonstrates understanding of the longterm sequelae of subarachnoid hemorrhage Engages in scholarly activity on subarachnoid hemorrhage Not yet achieved Level 1 purposes. 11
Cost- and risk/benefit-appropriate practice Systems-based Practice Describes basic cost and risk implications of care Describes cost- and riskbenefit ratios in patient care Makes clinical decisions that balance cost- and riskbenefit ratios Incorporates available quality measures in patient care Engages in scholarly activity regarding costand risk-effective practice in vascular neurology Work in interprofessional teams to enhance patient safety Systems-based Practice Describes team members roles in maintaining patient safety Identifies and reports errors and near misses Participates in a teambased approach to medical error analysis Describes potential sources of system failure in clinical care, such as minor, major, and sentinel events Engages in scholarly activity regarding error analysis and patient safety in vascular neurology purposes. 12
Continuum of Care Systems-based Practice Identifies responsibilities and duties of allied health professionals involved in the care of patients with vascular disease Utilizes post-hospital rehabilitation and followup services, including primary care and vascular neurology Engages pre-hospital emergency medical services (EMS) in the optimal care of the stroke patient Appropriately utilizes and consults with allied health professionals involved in the care of patients with vascular disease Identifies community resources for caregivers Understands the differences in expectations of care in stroke-ready hospitals, primary stroke centers, and comprehensive stroke centers Understands the options for providing remote consultation for evaluation and management of acute stroke patients Utilizes the entire system of stroke care throughout the continuum: stroke prevention, emergency stroke care, rehabilitation and recovery, and community reintegration Understands the practice and responsibilities of allied health professionals in the continuum of care Engages in scholarly activity regarding continuum of care for vascular neurology patients purposes. 13
Self-directed Learning Practice-based Learning and Improvement Identify strengths, deficiencies, and limits in one s knowledge and expertise Set learning and improvement goals Identify and perform appropriate learning activities Use information technology to optimize learning Acknowledges gaps in knowledge and expertise in vascular neurology Incorporates feedback Develops an appropriate learning plan based upon clinical experience Completes an appropriate learning plan based upon clinical experience Engages in scholarly activity regarding practicebased learning and improvement in vascular neurology Locate, Appraise, and Assimilate Evidence from Scientific Studies Related to the Patient s Health Problems Practice-based Learning and Improvement Uses information technology to search and access relevant, valid, medical information Uses scholarly articles and guidelines to address patient care issues Critically evaluates scientific literature Incorporates appropriate evidence-based information into patient care Understands the limits of evidence-based medicine in patient care Engages in scholarly activity regarding evidence-based medicine in vascular neurology purposes. 14
Compassion, Integrity, Accountability, and Respect for Self and Others Professionalism Demonstrates compassion, sensitivity, and responsiveness to patients and families Describes effects of sleep deprivation and substance abuse on performance Demonstrates compassionate practice of medicine, even in the context of disagreement Mentors others in the compassionate practice of medicine, even in the context of disagreement with patient beliefs with patient beliefs Demonstrates nondiscriminatory behavior in all interactions, including with diverse and vulnerable populations Consistently demonstrates professional behavior, including dress and timeliness Demonstrates appropriate steps to address impairment in self Incorporates patients socio-cultural needs and beliefs into patient care Demonstrates appropriate steps to address impairment in colleagues Mentors others in sensitivity and responsiveness to diverse and vulnerable populations Advocates for quality patient care Engages in scholarly activity regarding professionalism in vascular neurology purposes. 15
Knowledge About and Adherence to the Ethical Principles Relevant to the Practice of Medicine Professionalism Describes basic ethical Determines presence of principles ethical issues in practice Analyzes and manages ethical issues in straightforward clinical situations Analyzes and describes ethical issues inherent in clinical research Analyzes and manages ethical issues in complex clinical situations, including end-of-life and withdrawal of care Demonstrates leadership and mentorship in applying ethical principles in vascular neurology settings purposes. 16
Relationship Development, Teamwork, and Managing Conflict Interpersonal and Communication Skills Develops a positive relationship with patients in uncomplicated situations Manages patient-and/or family-related conflicts Manages conflict in complex situations Manages conflict across specialties and systems of care Actively participates in team-based care Engages patients in shared decision making Uses easy-to-understand language in all phases of communication Leads team-based patient care activities Engages in scholarly activity regarding teamwork and conflict management purposes. 17
Information Sharing, Gathering, and Technology Interpersonal and Communication Skills Effectively communicates during patient hand-overs using a structured communication tool Provides effective and timely communication during team meetings, discharge planning, and Effectively communicates the results of a neurologic consultation in a timely manner Effectively leads family meetings, including those related to end-of-life decisions and withdrawal other transitions of care of care Accurately documents transitions of care Completes documentation in a timely fashion Educates patients and caregivers about the disease and management, including risks and benefits of treatment options Effectively gathers information from collateral sources when necessary Completes all documentation accurately, including use of electronic health records (EHR), to promote patient safety Provides effective and timely communication regarding changes in patient status Demonstrates synthesis, formulation, and thought process in documentation Effectively and ethically uses all forms of communication Mentors colleagues in timely, accurate, and efficient documentation Develops patient education materials regarding vascular neurology Engages in scholarly activity regarding interpersonal communication in vascular neurology purposes. 18