Pathology Milestones

The Accreditation Council for Graduate Medical Education

Second Revision: February 2019 First Revision: September 2013

The Milestones are designed only for use in evaluation of resident in the context of their participation in ACGME- accredited residency programs. The Milestones provide a framework for the assessment of the development of the resident 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.

Pathology Milestones

Work Group Scott Anderson, MD Elaine Keung, MD, MPH Adam Booth, MD Janna Neltner, MD Barbara Castleberry, MT(ASCP), PhD Gary Procop, MD, MS Laura Edgar, EdD, CAE Alan Shienbaum, DO Melissa George, DO James Stubbs, MD Kate Hatlak, MSEd Charles Timmons, MD, PhD Andrew Hoofnagle, MD, PhD Laura Warmke, MD Kathleen Jones, MD Allecia Wilson, MD Karen Kaul, MD, PhD

The ACGME would like to thank the following organizations for their continued support in the development of the Milestones:

American Board of Pathology

Program Directors Section (PRODS) of APC

ACGME Pathology Review Committee

American Association of Colleges of Osteopathic Medicine

Association of American Medical Colleges

Resident Forum Executive Committee - CAP

Understanding Milestone Levels and Reporting

This document presents the Milestones, which programs use in a semi-annual review of resident performance, and then report to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME Competencies organized in a developmental framework. The narrative descriptions are targets for resident performance throughout their educational program.

Milestones are arranged into levels. Tracking from Level 1 to Level 5 is synonymous with moving from novice to expert resident in the specialty or subspecialty. For each reporting period, the Clinical Competency Committee will review the completed evaluations to select the milestone levels that best describe each learner’s current performance, abilities, and attributes for each subcompetency.

These levels do not correspond with post-graduate year of education. Depending on previous experience, a junior resident may achieve higher levels early in his/her educational program just as a senior resident may be at a lower level later in his/her educational program. There is no predetermined timing for a resident to attain any particular level. Residents may also regress in achievement of their milestones. This may happen for many reasons, such as over scoring in a previous review, a disjointed experience in a particular procedure, or a significant act by the resident.

Selection of a level implies the resident substantially demonstrates the milestones in that level, as well as those in lower levels (see the diagram on page v).

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Additional Notes

Level 4 is designed as a graduation goal but does not represent a graduation requirement. Making decisions about readiness for graduation and unsupervised practice is the purview of the program director. Furthermore, Milestones 2.0 include revisions and changes that preclude using Milestones as a sole assessment in high-stakes decisions (i.e., determination of eligibility for certification or credentialing). Level 5 is designed to represent an expert resident whose achievements in a subcompetency are greater than the expectation. Milestones are primarily designed for formative, developmental purposes to support continuous quality improvement for individual learners, education programs, and the specialty. The ACGME and its partners will continue to evaluate and perform research on the Milestones to assess their impact and value.

Examples are provided for some milestones within this document. Please note: 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 ACGME supervision guidelines as described in the Program Requirements, as well as to institutional and program policies. For example, a resident who performs a procedure independently must, at a minimum, be supervised through oversight.

A Supplemental Guide is also available to provide the intent of each subcompetency, examples for each level, assessment methods or tools, and other available resources. The Supplemental Guide, like examples contained within the Milestones, is designed only to assist the program director and Clinical Competency Committee, and is not meant to demonstrate any required element or outcome.

Additional resources are available in the Milestones section of the ACGME website. Follow the links under “What We Do” at www.acgme.org.

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 resident’s performance on the milestones for each sub-competency will be indicated by selecting the level of milestones that best describes that resident’s performance in relation to those milestones.

Selecting a response box in the Selecting a response box on the line in middle of a level implies that between levels indicates that milestones milestones in that level and in lower in lower levels have been substantially levels have been substantially demonstrated as well as some demonstrated. milestones in the higher level(s).

Version 2 Pathology Milestones, ACGME Report Worksheet

Patient Care 1: Reporting (Anatomic Pathology/Clinical Pathology [AP/CP])

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies the key Generates a timely report Generates a timely report Independently Independently generates elements of a report and for a simple case, with that includes synoptic generates timely a nuanced report that demonstrates assistance templates and/or ancillary integrated reports for expresses the ambiguity understanding of timely testing for a complex complex cases and uncertainty for a reporting case, with assistance; complex case independently generates reports for a simple case

Generates an Generates an amended/addended amended/addended report that includes report and documents updated information, with communication with the assistance clinical team, as appropriate

Identifies the importance Identifies implications of Generates a report that Independently of a complete pathology the diagnosis in the report includes the language of generates a report that report for optimal patient and makes simple uncertainty, as includes the language care recommendations appropriate, with of uncertainty and assistance complex recommendations

Comments: Not Yet Completed Level 1 Not Yet Rotated

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Patient Care 2: Grossing (AP)

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies the importance Samples and documents Triages, samples, and Independently triages, Applies innovative of grossing and uses simple cases, with documents complex samples, and approaches of grossing to appropriate resources assistance cases, with assistance; documents complex demonstrate optimal independently triages, cases pathology in unique samples, and documents specimens simple cases

Maintains specimen Identifies specimen Resolves specimen Independently resolves Serves as an expert for integrity to avoid sample integrity issues (e.g., integrity issues, with specimen integrity gross examination misidentification fixation, floaters, clinical- assistance issues, as needed pathologic correlation with operating room reports)

Identifies the need for Needs assistance to Handles assigned Efficiently finishes own time management handle workload workload with minimal to workload and assists no assistance others as needed

Comments: Not Yet Completed Level 1 Not Yet Rotated

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Patient Care 3: Clinical Consultation, including On-Call Interactions (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Describes the utility of a For simple consultations, For complex Manages complex Recognized as an expert consultation and lists delineates the clinical consultations, delineates consultations in providing available resources question, obtains the clinical question, independently comprehensive useful in consultation appropriate additional obtains appropriate consultations clinical information, additional clinical accesses available information, applies resources, recommends relevant resources, and next steps, and recommends next steps documents appropriately with assistance; manages with assistance simple consultations independently

Comments: Not Yet Completed Level 1 Not Yet Rotated

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Patient Care 4: Interpretation and Diagnosis (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Discusses importance of Identifies pertinent test Consistently integrates Makes accurate Is an expert diagnostician diagnoses and test results results and correlates to test results with clinical diagnoses and in patient care clinical findings to develop findings to refine interpretations of test a differential diagnosis differential and propose a results diagnosis

Identifies normal states Distinguishes normal from Identifies confounding Gives consideration to and reference ranges abnormal findings factors, artifacts, and pre- confounding factors in analytic issues formulating an interpretation(s) and diagnoses

Describes indications for Proposes appropriate Proposes and interprets Recommends further Proposes optimal common tests initial tests ancillary tests in clinical work-up using diagnostic and context diagnostic algorithms therapeutic strategies and recommends based on patterns within therapeutic options, as a population appropriate

Comments: Not Yet Completed Level 1 Not Yet Rotated

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Patient Care 5: Intra-Operative Consultation (IOC), including Frozen Section (FS) (AP)

Level 1 Level 2 Level 3 Level 4 Level 5 Describes appropriate Assesses requests for For complex cases, For complex cases, Expertly manages all IOC channels for simple IOC and plans addresses requests for independently manages communication workflow, with assistance IOC with assistance; and addresses requests regarding IOC independently assesses for IOC and manages requests for simple IOC and plans workflow

Discusses specimen- Procures tissue for Procures tissue for Supervises junior dependent variability in diagnosis and prepares diagnosis and prepares residents and advises approach to IOC quality slides on simple quality slides for complex technical staff members specimens, with specimens with in the performance of assistance assistance and IOC independently for simple specimens

Demonstrates Identifies broad diagnostic Interprets and Independently interprets understanding of utility of categories (i.e., benign communicates routine and communicates IOC versus malignant, normal IOC/FS and correlates IOC/FS and correlates versus abnormal) in with final diagnosis, with with final diagnosis in routine IOC assistance routine cases and in some complex cases

Comments: Not Yet Completed Level 1 Not Yet Rotated

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Patient Care 6: Autopsy (AP)

Level 1 Level 2 Level 3 Level 4 Level 5 Describes the value of Plans and performs all Plans and performs all Independently plans Uses advanced skills and an autopsy aspects of routine aspects of complex and performs all non-routine approaches autopsies, with assistance autopsies, with assistance aspects of complex to unique autopsies autopsies in a timely manner

Reviews clinical records Generates preliminary Independently generates Independently Uses autopsy data to and concisely presents anatomic diagnosis within final report with generates final report identify patterns that clinical data and history; accepted turnaround time clinicopathologic with clinicopathologic advance medical communicates with correlations on routine correlations on routine knowledge and improve clinical team autopsies; with and complex autopsies patient care assistance, generates final report with clinicopathologic correlations on complex autopsies

Properly identifies the Adheres to regulations Independently adheres to Instructs junior level decedent and verifies with guidance, such as regulations residents about consent and limitations legal jurisdiction, statutes regulations to extent of the autopsy regarding device reporting and communicable diseases

Comments: Not Yet Completed Level 1 Not Yet Rotated

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Medical Knowledge 1: Diagnostic Knowledge (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates basic Applies anatomic, cellular, Applies advanced Integrates advanced Recognized as an expert medical knowledge of and molecular knowledge knowledge of anatomic, knowledge of anatomic, in the integration of anatomy, cellular, and to identify pathologic cellular, and molecular cellular, and molecular anatomic, cellular, and molecular systems processes pathology to common pathology to common molecular pathology diagnoses and uncommon knowledge to disease diagnoses Demonstrates Identifies abnormal knowledge of normal histology and cell biology histology and cell biology

Comments: Not Yet Completed Level 1 Not Yet Rotated

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Medical Knowledge 2: Clinical Reasoning (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates a basic Demonstrates clinical Synthesizes information Independently Demonstrates intuitive framework for clinical reasoning to determine to inform clinical synthesizes information approach to clinical reasoning relevant information reasoning, with to inform clinical reasoning for complex assistance reasoning in complex cases cases

Identifies appropriate Selects relevant Seeks and integrates Independently seeks resources to inform resources based on evidence-based out, analyzes, and clinical reasoning scenario to inform information to inform applies relevant original decisions diagnostic decision research to diagnostic making in complex cases, decision making in with assistance complex clinical cases

Comments: Not Yet Completed Level 1 Not Yet Rotated

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Systems-Based Practice 1: Patient Safety and Quality Improvement (QI) (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Identifies system factors Participates in analysis of Conducts analysis of Actively engages teams knowledge of common that lead to patient safety patient safety events patient safety events and processes to modify patient safety events events (simulated or actual) and offers error systems to prevent prevention strategies patient safety events (simulated or actual)

Demonstrates Reports patient safety Participates in disclosure Discloses patient safety Role models or mentors knowledge of how to events through of patient safety events to events to clinicians others in the disclosure of report patient safety institutional reporting clinicians and/or patients and/or patients and patient safety events events systems (simulated or and families, as families, as appropriate actual) appropriate (simulated or (simulated or actual) actual)

Demonstrates Describes departmental Participates in Demonstrates the skills Creates, implements, and knowledge of basic QI and institutional QI departmental and required to identify, assesses QI initiatives at methodologies and initiatives institutional QI initiatives develop, implement, the institutional or metrics and analyze a QI community level project

Comments: Not Yet Completed Level 1

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Systems-Based Practice 2: Systems Navigation for Patient-Centered Care (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Coordinates care of Coordinates care of Models effective Analyses the process of knowledge of case patients in routine cases patients in complex cases coordination of patient- care coordination and coordination effectively using effectively using centered care among leads in the design and interprofessional teams interprofessional teams different disciplines and implementation of specialties improvements

Identifies key elements Performs safe and Performs safe and Models and advocates Improves quality of for safe and effective effective transitions of effective transitions of for safe and effective transitions of care within transitions of care and care/hand-offs in routine care/hand-offs in complex transitions of care/hand- and across health care hand-offs situations situations offs within and across delivery systems to health care delivery optimize patient outcomes systems

Demonstrates Identifies pathology’s role Identifies opportunities for Recommends and/or Leads innovations and knowledge of population in population and pathology to participate in participates in changing advocates for populations and community health community health needs community and and adapting practice to and communities with needs and disparities and inequities for their population health provide for the needs of health care inequities local population communities and populations

Comments: Not Yet Completed Level 1

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Systems-Based Practice 3: Physician Role in Health Care System (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies key Describes how Discusses how individual Manages various Advocates for or leads components of the components of a complex practice affects the components of the systems change that complex health care health care system are broader system (e.g., test complex health care enhances high-value, system (e.g., hospital, inter-related, and how this utilization, turnaround system to provide efficient, and effective skilled nursing facility, impacts patient care time) efficient and effective patient care and transition finance, personnel, patient care and of care technology) transition of care

Describes basic health Documents testing detail Engages with clinicians Practices and Participates in health payment systems (e.g., and explains the impact of and/or patients in shared- advocates for cost policy advocacy activities government, private, documentation on billing decision making, such as effective patient care public, uninsured care) and reimbursement use of preauthorization for with consideration of the and practice models complex testing limitations of each patient’s payment model

Comments: Not Yet Completed Level 1

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Systems-Based Practice 4: Informatics (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates familiarity Understands laboratory Discusses the role of the Applies knowledge of Participates in operational with basic technical specific software, key pathologist in laboratory informatics skills as and strategy meetings, concepts of hardware, technical concepts and initiatives based on needed in laboratory troubleshooting with operating systems, interfaces, workflow, integrative pathology initiatives (e.g., data information technology databases, and software barcode application, informatics and management and staff members; able to for general purpose automation systems bioinformatics (e.g., security, computational utilize medical informatics applications (enterprise systems laboratory information statistics, information in the direction and architecture) system implementation governance) operation of the and configuration, QI laboratory initiatives)

Comments: Not Yet Completed Level 1

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Systems-Based Practice 5: Accreditation, Compliance, and Quality (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Demonstrates knowledge Identifies the differences Participates in an Serves as a resource for knowledge that of the components of between accreditation internal or external accreditation at the laboratories must be laboratory accreditation and regulatory laboratory inspection regional or national level accredited and regulatory compliance; discusses compliance (Clinical the process for achieving Laboratory Improvement accreditation and Amendments and others), maintaining regulatory either through training or compliance experience

Discusses the need for Interprets quality data and Demonstrates knowledge Reviews the quality Creates and follows a quality control and charts and trends, of the components of a management plan to comprehensive quality proficiency testing including proficiency laboratory quality identify areas for management plan testing results, with management plan improvement assistance

Discusses implications of Performs analysis and Formulates a response proficiency testing failures review of proficiency for proficiency testing testing failures and failures recommends a course of action, with oversight

Comments: Not Yet Completed Level 1

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Practice-Based Learning and Improvement 1: Evidence-Based Practice and Scholarship (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates how to Identifies and applies the Identifies and applies the Critically appraises and Teaches others to access and select best available evidence to best available evidence to applies evidence to critically appraise and applicable evidence guide diagnostic workup guide diagnostic work-up guide care, even in the apply evidence for of simple cases of complex cases face of conflicting data complex cases; and/or participates in the development of guidelines

Aware of the need for Develops knowledge of Applies knowledge of the Proactively and Suggest improvements to patient privacy, the basic principles of basic principles of consistently applies research regulations autonomy, and consent research (demographics, research such as knowledge of the basic and/or substantially as applied to clinical Institutional Review informed consent and principles of research contributes to the primary research Board, human subjects), research protocols to such as informed literature through basic, including how research is clinical practice, with consent and research translational, or clinical evaluated, explained to assistance protocols to clinical research patients, and applied to practice patient care

Comments: Not Yet Completed Level 1

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Practice-Based Learning and Improvement 2: Reflective Practice and Commitment to Personal Growth (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Accepts responsibility for Demonstrates openness Seeks performance data Actively and Models seeking personal and to receiving performance and feedback with consistently seeks performance data with professional data and feedback in humility performance data and humility development by order to inform goals feedback with humility establishing goals

Identifies the gap(s) Analyzes and reflects on Institutes behavioral Critically evaluates the Teaches others reflective between expectations the factors which change(s) to narrow the effectiveness of practice and actual performance contribute to gap(s) gap(s) between behavioral changes in between expectations and expectations and actual narrowing the gap(s) actual performance performance between expectations and actual performance

Actively seeks Designs and implements Independently creates Uses performance data Facilitates the design and opportunities to improve a learning plan, with and implements a to measure the implementing learning assistance learning plan effectiveness of the plans for others learning plan and improves it when necessary

Comments: Not Yet Completed Level 1

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Professionalism 1: Professional Behavior and Ethical Principles (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Analyzes straightforward Recognizes the need and Independently resolves Identifies and seeks to knowledge of the ethical situations using ethical uses appropriate and manages complex address system-level principles underlying principles resources to seek help in ethical situations factors that induce or informed consent, managing and resolving exacerbate ethical surrogate decision complex ethical situations problems or impede their making, advance resolution directives, confidentiality, error disclosure, stewardship of limited resources, and related topics

Describes when and how Demonstrates insight into Demonstrates Recognizes situations Coaches others when to appropriately report professional behavior in professional behavior in that may trigger their behavior fails to professionalism lapses, routine situations; takes complex or stressful professionalism lapses meet professional including strategies for responsibility for own situations and intervenes to expectations addressing common professionalism lapses prevent lapses in self barriers; identifies and and others describes potential triggers for professionalism lapses

Comments: Not Yet Completed Level 1

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Professionalism 2: Accountability and Conscientiousness (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Responds promptly to Takes appropriate Recognizes situations Anticipates and Takes ownership of instructions, requests, or ownership and performs that may impact own intervenes in situations system outcomes reminders to complete tasks and responsibilities ability to complete tasks that may impact others’ tasks and responsibilities in a timely manner with and responsibilities in a ability to complete tasks attention to detail timely manner and and responsibilities in a describes the impact on timely manner team Designs new strategies to ensure that the needs of patients, teams, and systems are met

Comments: Not Yet Completed Level 1

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Professionalism 3: Self-Awareness and Help-Seeking (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Recognizes limitations in Independently recognizes Proposes and implements Independently develops Serves as a resource or the knowledge/skills/ limitations in the a plan to remediate or and implements a plan consultant for developing behaviors of self or knowledge/skills/ improve the knowledge/ to remediate or improve a plan to remediate or team, with assistance behaviors of self or team skills/behaviors of self or the knowledge/skills/ improve the knowledge/ and seeks help when team, with assistance behaviors of self or skills/behaviors needed team

Recognizes status of Independently recognizes Proposes and implements Independently develops Coaches others when personal and status of personal and a plan to optimize and implements a plan responses or limitations in professional well-being, professional well-being personal and professional to optimize personal knowledge/skills do not with assistance and seeks help when well-being, with and professional well- meet professional needed assistance being expectations

Comments: Not Yet Completed Level 1

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Interpersonal and Communication Skills 1: Patient and Family-Centered Communication (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Uses language and Establishes a relationship Establishes a relationship Easily establishes Mentors others in nonverbal behavior to in straightforward in challenging patient relationships, with situational awareness and demonstrate respect and encounters using active encounters, as attention to critical self-reflection to establish rapport listening and clear appropriate patient/family concerns consistently develop language and context, regardless positive therapeutic of complexity relationships

Identifies common Identifies complex When prompted, reflects Independently Models self-awareness barriers to effective barriers to effective on personal biases while recognizes personal while teaching a communication (e.g., communication (e.g., attempting to minimize biases while attempting contextual approach to language, disability) health literacy, cultural) communication barriers to proactively minimize minimize communication while accurately communication barriers barriers communicating own role within the health care system

Identifies the need to Organizes and initiates Sensitively and Independently, Models shared decision adjust communication communication with compassionately delivers sensitively, and making in patient/family strategies based on patient/family by medical information, compassionately communication including assessment of introducing stakeholders, elicits patient/family delivers medical those with a high degree patient/family setting the agenda, values, goals and information, elicits of uncertainty/conflict expectations and clarifying expectations preferences, and patient/family values, understanding of their and verifying acknowledges uncertainty goals and preferences, health status and understanding of the and conflict, with and acknowledges treatment options clinical situation guidance uncertainty and conflict

Comments: Not Yet Completed Level 1

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Interpersonal and Communication Skills 2: Interprofessional and Team Communication (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Uses language that Communicates Uses active listening to Coordinates Models flexible values all members of information effectively adapt communication recommendations from communication strategies the health care team with all health care team style to fit team needs different members of that value input from all members the health care team to health care team optimize patient care members, resolving conflict when needed

Describes the utility of Solicits feedback on Integrates feedback from Communicates Facilitates regular health constructive feedback performance as a team members to improve feedback and care team-based member of the health communication constructive criticism to feedback in complex care team superiors situations

Comments: Not Yet Completed Level 1

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Interpersonal and Communication Skills 3: Communication within Health Care Systems (AP/CP)

Level 1 Level 2 Level 3 Level 4 Level 5 Safeguards patient Appropriately selects Communicates while Independently Guides departmental or personal health forms of communication ensuring security of communicates while institutional information by based on context and personal health ensuring security of communication around communicating through urgency of the situation information, with guidance personal health policies and procedures appropriate means as information regarding the security of required by institutional personal health policy (e.g., patient information safety reports, cell phone/pager usage)

Identifies institutional Respectfully Uses institutional Initiates conversations Facilitates dialogue and departmental communicates concerns structure to effectively on difficult subjects with regarding systems issues structure for about the system communicate clear and appropriate among larger community communication of issues constructive suggestions stakeholders to improve stakeholders (institution, to improve the system the system health care system, field)

Comments: Not Yet Completed Level 1