The Undersea and Hyperbaric Medicine Milestone Project

A Joint Initiative of The Accreditation Council for Graduate Medical Education and The American Board of Emergency Medicine

July 2015

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.

Undersea and Hyperbaric Medicine Milestones

Chair: Christian Tomaszewski, MD, MS, MBA

Working Group Advisory Group Alfred Bove, MD, PhD Timothy Brigham, MDiv, PhD Laura Edgar, EdD, CAE Wallace Carter, MD Alan Flower, Lt Col, USAF, MC, FS Felicia Davis, MHA Stephen Hayden, MD Anne Harvey, MD Tracey LeGros, MD, PhD Lori Lewis, EdD, RD Louis Ling, MD Earl Reisdorff, MD

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.

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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 to 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.

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

Version 02/2014 Undersea and Hyperbaric Medicine Milestones, ACGME Report Worksheet

Fitness to Dive (Divers and Attendants) – Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5  Performs a complete  Orders appropriate tests to  Interprets routine  Applies the results of  Interprets advanced history, physical, and determine fitness to dive diagnostic testing (e.g., clinical examination and diagnostic studies (e.g., neurological  Recognizes physical and pulmonary function tests, diagnostic tests to echocardiographic bubble examination psychological signs and radiographs) to determine determine fitness to dive studies) symptoms that impact fitness to dive  Completes a fitness to dive comprehensive evaluation for return to diving following a change in medical condition

Comments: Not yet achieved Level 1

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Dysbarism and Decompression Illness – Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5  Performs a history and  Performs targeted physical  Interprets clinical findings  Diagnoses and manages  Participates in injury physical examination to examination to evaluate for and diagnostic tests patients with dysbarism prevention strategies for evaluate for dysbarism dysbarism relevant to dysbarism based on current best dysbarism  Orders diagnostic  Differentiates between evidence  Acts as an undersea evaluations for pressure dysbaric and non-dysbaric medical consultant on disorders disorders diving operations  Differentiates between  Uses treatment tables and decompression sickness protocols appropriately for and barotrauma decompression illness  Stabilizes a patient and initiates treatment for dysbarism

Comments: Not yet achieved Level 1

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Hyperbaric Chamber Operations – Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5  Prepares a stable patient  Selects appropriate  Monitors patients during  Manages a critical care  Performs specialized for routine hyperbaric patients for hyperbaric hyperbaric oxygen therapy patient in the hyperbaric procedures in the oxygen therapy oxygen therapy  Treats acute complications chamber hyperbaric chamber  Diagnoses adverse effects (e.g., embolism, oxygen  Provides comprehensive and complications of toxicity, pneumothorax) of care of the routine hyperbaric oxygen therapy hyperbaric oxygen therapy hyperbaric oxygen therapy  Manages adverse effects of patient hyperbaric oxygen therapy

Comments: Not yet achieved Level 1

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Diving Medicine – Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5  Recognizes the  Elicits the appropriate  Provides consultation for  Manages diving casualties,  Develops protocols for importance of history and physical transport of ill or injured including drowning evaluation and treatment supplemental oxygen in examination from an ill or divers  Recognizes and treats of ill or injured divers the treatment of diving injured diver  Develops a plan of care for marine envenomations,  Manages personnel in illness or injuries ill or injured divers toxic ingestions, and extreme diving and  Initiates management of injuries from marine hyperbaric environments the ill or injured diver animals (e.g., caisson, tunnel, (e.g., warming, hydrating) submarines)

Comments: Not yet achieved Level 1

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Physics and Physiology of Hyperbaric and Hypobaric Exposures – Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5  Understands buoyancy as  Describes alterations in  Comprehends the  Explains the physiology of  Demonstrates mastery of applied to diving vision and acoustics under mechanism of gas entry immersion and saturation physiology and  Demonstrates knowledge water and distribution into tissue  Comprehends physiology pharmacology of mixed of oxygen under  Demonstrates knowledge  Comprehends and complications of gases normobaric conditions of gas laws decompression physiology breath-hold diving  Comprehends the  Shows familiarity with  Comprehends human  Understands human  Demonstrates application physiology of saturation units of pressure, physiology and the physiology under hypobaric of the decompression tables volume, and temperature pharmacology of oxygen conditions  Describes high pressure under hyperbaric  Describes the nervous syndrome conditions, including pharmacological and oxygen toxicity physical properties (e.g.,  Explains the mechanism of density, solubility) of gases action of hyperbaric other than oxygen oxygen

Comments: Not yet achieved Level 1

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Fitness to Dive – Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5  Acknowledges that diving  Understands the physical  Cites recreational diving  Describes commercial  Defines international is a physical activity with requirements for diving standards diving standards diving standards various standards for  Demonstrates knowledge  Comprehends the  Knows the implications of  Demonstrates knowledge different classifications of of the effect of the diving implications of acute and disabilities on diving of technical diving divers environment on organ chronic medical conditions,  Demonstrates knowledge  Recognizes that medical systems including medications, on of waivers for diving and conditions or medications  Explains contraindications diving hyperbaric chamber affect fitness to dive to diving  Lists the criteria for return attendants  Understands the medical to diving requirements for hyperbaric chamber attendants

Comments: Not yet achieved Level 1

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Indications for Hyperbaric Oxygen Therapy – Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5  Is aware of hyperbaric  Describes approved  Explains approved  Describes other indications  Researches and develops oxygen therapy for routine indications (e.g., emergent indications (e.g., for hyperbaric oxygen emerging indications for specific disorders selected wounds, decompression illness, therapy or demonstrates hyperbaric oxygen therapy irradiated tissue) for trauma, toxic exposure, knowledge of  Develops new hyperbaric hyperbaric oxygen therapy infections) for hyperbaric investigational indications oxygen therapy protocols  Aware of different oxygen therapy for hyperbaric oxygen treatment protocols based  Comprehends relative therapy on condition contraindications,  Explains evidence that  Comprehends absolute complications, and adverse supports hyperbaric oxygen contraindications to effects of hyperbaric therapy guidelines hyperbaric oxygen therapy oxygen therapy  Discusses appropriate utilization reviews

Comments: Not yet achieved Level 1

The Milestones are a product of the Undersea and Hyperbaric Medicine Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine. 7 Version 02/2014 Undersea and Hyperbaric Medicine Milestones, ACGME Report Worksheet

Dysbarism and Decompression Illness – Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5  Is aware of environments  Recognizes differences  Differentiates between  Demonstrates  Investigates the that relate to dysbarism between decompression decompression illness and comprehensive knowledge prevention and treatment and barotrauma-related non-decompression of decompression illness of dysbarism disorders disorders (e.g., decompression  Understands implications sickness, barotrauma, gas of altitude on dysbarism embolism)  Understands the long-term effects of diving

Comments: Not yet achieved Level 1

Hyperbaric Chamber Operations – Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5  Recognizes the hazards of  Differentiates between  Demonstrates working  Demonstrates knowledge  Participates in developing the hyperbaric the types of chambers knowledge of emergency of the national standards new standards and environment  Identifies equipment and procedures and regulations for safe regulations items prohibited in a  Assesses the safety of operation of hyperbaric  Independently supervises hyperbaric chamber equipment and devices chambers or operates a hyperbaric used in hyperbaric  Explains the use of critical chamber chambers care equipment and devices in the hyperbaric environment

Comments: Not yet achieved Level 1

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Diving Medicine – Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5  Recognizes basic diving  Lists the differences  Demonstrates knowledge  Explains risks and benefits  Demonstrates systems and equipment between various types of of diving support of diving support comprehensive knowledge  Recognizes the effects of diving (e.g., surface equipment (e.g., scuba, re- equipment of systems and procedures altitude on diving decompression diving, breather, mixed gas)  Understands systems and for saturation diving saturation diving, bounce  Cites protocols for flying procedures for saturation  Modifies diving tables for diving, breath hold diving) after diving diving diving at altitude  Comprehends the thermal  Demonstrates knowledge  Comprehends effects of  Understands how to effects of diving of hazardous marine life diving at altitude manage a pressurized  Cites quality standards for caisson or tunnel breathing gases operation

Comments: Not yet achieved Level 1

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Patient Safety – Systems-based Practice

Level 1 Level 2 Level 3 Level 4 Level 5  Recognizes the  Understands key concepts  Advocates for optimal  Understands and directs  Acts as a safety officer for importance of advocating related to health care individual patient care in department protocols for a hyperbaric chamber for quality care and quality improvement the hyperbaric chamber patient safety in the facility optimal patient care  Recognizes potential environment hyperbaric chamber  Participates in the systems sources of system failure  Recognizes and reports  Advocates for quality care development of national  Acknowledges that in health care systems, lapses in medication safety, and supports an standards for safety in the medical errors and health such as medication errors medication errors, and near environment of safety hyperbaric chamber care system failures are a misses  Participates in a team- environment significant cause of based approach to  Leads a team to evaluate morbidity evaluate medical errors medical errors and and system-based failures system-based failures and improve processes and systems

Comments: Not yet achieved Level 1

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Level 1 Level 2 Level 3 Level 4 Level 5  Identifies the members  Recognizes need for  Coordinates  Coordinates system  Creates appropriate use and roles of the participation in a multidisciplinary care of the resources and transitions criteria for hyperbaric hyperbaric team multidisciplinary care hyperbaric patient of care for a complicated therapy team  Practices cost-effective hyperbaric patient  Participates in national  Understands principles of hyperbaric care  Effectively manages the decision-making for hyperbaric-related  Understands the role of hyperbaric team coding and procedure coding utilization review  Engages in utilization reimbursement of review hyperbaric therapy

Comments: Not yet achieved Level 1

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Self-directed Learning – Practice-based Learning and Improvement

Level 1 Level 2 Level 3 Level 4 Level 5  Acknowledges gaps in  Develops learning and  Performs ongoing self-  Engages in performance  Creates novel ways to personal knowledge and improvement goals based assessment and improvement by assess performance frequently asks for on feedback implements individual incorporating feedback  Applies results from self- feedback  Utilizes online data learning plans from multiple directed learning to  Understands the resources appropriately  Critically appraises stakeholders (e.g., educating others importance of setting scientific literature and patients, members of the  Completes scholarly learning and applies evidence-based health care team, third- activity (e.g., scientific improvement goals medicine principles for self- party payors) presentation, publication, improvement as a clinician  Demonstrates best research)  Participates in a quality clinical practice, including improvement project use of evidence-based pathways

Comments:

Not yet achieved Level 1

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Professional Values – Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5  Demonstrates behavior  Engages in patient-  Consistently manages own  Develops and applies a  Develops institutional that conveys caring, centered care, including values and beliefs to consistent approach to and organizational honesty, genuine demonstrating optimize relationships and evaluating appropriate strategies to protect interest, and tolerance compassion, integrity, medical care care and maintain when interacting with a respect, sensitivity, and  Engages in shared decision  Evaluates possible professional and diverse population of responsiveness making to develop barriers to care, and bioethical principles patients, families, and  Consistently recognizes alternate care plans when creates strategies that other members of the ethical issues in practice, patients’ personal consistently prioritize the health care team including conflicts of decisions/beliefs preclude patient’s best interests interest the use of commonly  Effectively analyzes and accepted practices manages ethical issues in challenging clinical situations (e.g., end-of- life, unexpected outcomes)

Comments: Not yet achieved Level 1

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Level 1 Level 2 Level 3 Level 4 Level 5  Demonstrates basic  Identifies basic principles  Consistently recognizes  Understands how to  Develops institutional professional of physician wellness, limits of knowledge in identify and confidentially and organizational responsibilities, such as including sleep, hygiene, uncommon and report impairment in self strategies for physician timely reporting for and fatigue mitigation complicated clinical or a colleague professional duty, responsiveness to  Consistently recognizes situations; develops and  Manages medical errors responsibilities consultation requests, limits of knowledge in implements plans for the consistent with principles  Trains physicians and appropriate common and frequent best possible patient care of responsibility and educators regarding dress/grooming, timely clinical situations, and  Recognizes and avoids accountability in responsibility, wellness, chart completion, and asks for assistance inappropriate influences accordance with fatigue, and physician duty hour reporting of marketing and institutional policy impairment  Maintains patient advertising  Serves as a role model for confidentially other physicians and  Uses social media health care providers ethically and responsibly

Comments: Not yet achieved Level 1

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Patients, Families, and Public – Interpersonal and Communication Skills

Level 1 Level 2 Level 3 Level 4 Level 5  Recognizes the  Demonstrates effective  Educates patients and the  Communicates with  Consults on undersea and importance of effective communication with public regarding issues patients and families hyperbaric issues outside communication with patients, families, and the related to diving and regarding confidential of the local health care patients, families, and public hyperbaric medicine medical information environment, such as the public across a broad  Engages in shared decision  Effectively communicates  Educates the public with regional and range of socioeconomic making when obtaining with vulnerable regarding environmental national health care and cultural informed consent populations, including risks (e.g., safe diving agencies backgrounds patients at risk and their practices, toxic gas families exposure)

Comments: Not yet achieved Level 1

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Communication with Health Care Professionals – Interpersonal Communication Skills

Level 1 Level 2 Level 3 Level 4 Level 5  Recognizes the  Demonstrates effective,  Provides effective, timely  Adapts communication  Seeks leadership importance of effective, timely consultation and consultation and strategies to resolve opportunities within timely consultation and communication with the communication with the challenges with professional communication with the health care team in health care team in consultants and other organizations health care team clinical situations stressful/crisis situations health care professionals  Delivers presentations  Ensures transitions of care  Develops working  Provides education to the  Provides undersea and advocating for undersea are accurately and relationships across health care team hyperbaric education to and hyperbaric medicine efficiently communicated specialties with other  Participates in peer other specialties within to regional or national  Ensures clear health care professionals review own institution audiences communication and respect among health care team members

Comments: Not yet achieved Level 1