The Otolaryngology - Head and Neck Surgery Milestone Project

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

October 2013 The Otolaryngology - Head and Neck Surgery 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.

Otolaryngology - Head and Neck Surgery Milestones

Chair: Terry Tsue, MD, FACS Working Group Advisory Group Nasir I. Bhatti, MD Timothy Brigham, MDiv, PhD Anthony E. Brissett, MD, FACS Brian Burkey, MD Brian Burkey, MD Sukgi S. Choi, MD Laura Edgar, EdD, CAE Michael Cunningham, MD, FACS Pamela Derstine, PhD, MHPE Ellen S. Deutsch, MD Noel Jabbour, MD Marvin P. Fried, MD, FACS Abraham Jacob, MD Sonya Malekzadeh, MD Michael M. Johns III, MD Bradley Marple, MD Eric Kezirian, MD Anna H. Messner, MD Daniel J. Kirse, MD Robert Miller, MD Joseph Walter Kutz, MD Michael G. Stewart, MD Anna H. Messner, MD Randal S. Weber, MD, FACS Liana Puscas, MD, MHS Matthew Ryan, MD Ivan Wayne, MD

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 moves from entry into residency through graduation. In the initial years of implementation, the Review Committee will examine milestone performance data for each program’s residents as one element in the Next Accreditation System (NAS) to determine whether residents overall are progressing.

For each period, review and reporting will involve selecting milestone levels that best describe a resident’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. These levels do not correspond with post-graduate year of education.

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

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, consistently including the majority of milestones targeted for residency.

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.

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 residency program director. Study of milestone performance data will be required before the ACGME and its partners will be able to determine whether milestones in the first four levels appropriately represent the developmental framework, and whether milestone data are of sufficient quality to be used for high-stakes decisions.

Some milestone descriptions include statements about performing independently. These activities must occur in conformity to ACGME supervision guidelines, as well as institutional and program policies. For example, a resident 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.

4 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 that resident’s performance in relation to the milestones.

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

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Salivary Disease — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 • Obtains basic history and • Obtains focused history and • Interprets appropriate lab, • Accurately tumor node • Performs ultrasound guided physical physical, including pathologic, and radiologic metastasis (TNM) stages a FNA of salivary gland mass • Understands normal comprehensive head and studies specific patient • Teaches pathophysiology salivary gland function neck exam, neck and cranial • Describes an accurate • Makes correct diagnosis • Performs extended • Knows treatment of nerve exam; orders differential diagnosis of a from clinical, radiologic, and dissection of parotid bed sialadenitis appropriate labs, fine- salivary gland mass; able to pathologic information; neoplasm with preservation • Knows how to scrub; needle aspiration (FNA), clinically distinguish knows histopathologic of neurovascular (NV) performs surgical time and radiologic studies neoplastic from non- findings of common structures as appropriate; out; maintains sterile field • Understands factors neoplastic etiologies neoplastic processes teaches procedure precipitating inflammatory • Discusses appropriate • Formulates appropriate • Treats complex salivary disease therapeutic options and treatment plan for a specific complications • Discusses treatment understands implications of salivary gland cancer patient modality options in general those options based on primary site, terms (including adjuvant • Performs procedure with disease stage, and patient treatment) assistance; identifies factors • Performs intra-operative neurovascular structures • Completes procedure with patient prep; raises skin • Recognizes common oversight flaps in appropriate plane; complications; obtains • Recognizes and is able to able to aesthetically close appropriate consultations treat and/or develop wound for patient management treatment plan for common • Lists some potential complications complications

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Aerodigestive Tract Lesions (ADT) — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 • Obtains basic history and • Obtains focused history and • Orders appropriate labs, • Interprets appropriate lab, • Performs flexible physical physical, including functional, and radiologic functional, and radiologic fiberoptic laryngoscopy • Demonstrates limited comprehensive aerodigestive studies; performs flexible studies with manipulation with understanding of normal tract and cranial nerve clinic and rigid endoscopic • Makes correct diagnosis oversight laryngeal function exam with recognition of evaluation from clinical, radiologic, • Teaches pathophysiology • Demonstrates limited normal anatomy and obvious • Knows differential diagnosis and pathologic • Teaches management of knowledge of treatment abnormalities of vocal cord lesion; able to information; knows complex aerodigestive options • Understands normal clinically distinguish histopathologic findings of tract (ADT) lesions laryngeal and esophageal neoplastic from non- common neoplastic • Performs function; understands factors neoplastic etiologies processes microlaryngoscopy in the precipitating inflammatory • Discusses appropriate • Formulates appropriate difficult to expose patient laryngeal disease therapeutic options and treatment plan for a with complete exposure of • Discusses treatment modality understands implications of specific vocal cord lesion the anterior commissure options in general terms each patient based on lesion and • Performs esophagoscopy • Positions patient properly for • Able to consistently visualize patient factors with complex intervention laryngoscopy, and sometimes the larynx during • Performs efficiently in the difficult able to visualize the larynx laryngoscopy and perform microlaryngoscopy to expose patient • Positions patient properly for binocular microlaryngoscopy consistently with complete • Treats complex esophagoscopy, and • Performs esophagoscopy exposure of the anterior complications sometimes able to visualize with biopsy in patients with commissure the esophagus favorable anatomy • Recognizes and is able to • Lists some potential • Recognizes common treat and/or develop complications (e.g., identifies complications; obtains treatment plan for and appropriately treats local appropriate consultations common complications injury from endoscopic for patient management instruments)

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Sleep Disordered Breathing (SDB) — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 • Obtains general history • Recognizes signs and • Performs detailed • Interprets examination • Teaches focused history and performs basic symptoms of SDB and the examination with and advanced diagnostic and physical exam physical exam differences between evaluation of upper airway testing • Recognizes interaction children and adults; orders anatomy and interprets • Demonstrates thorough between SDB and other appropriate routine lab, basic diagnostic testing understanding of sleep disorders in radiologic, and sleep • Demonstrates moderate spectrum of sleep children and adults studies understanding of spectrum disorders in children and • Identifies indications and • Demonstrates basic of sleep disorders in adults risks of non-surgical understanding of spectrum children and adults • Able to list and prioritize treatment plans for sleep of sleep disorders in • Demonstrates deepening treatment options for the disorders other than SDB, children and adults understanding of medical patient with SDB in and disorders of initiating • Demonstrates beginning treatments, role of complicated patient and maintaining sleep understanding of surveillance, and alternate populations • Teaches T&A and treatment measures therapies • Performs T&A and palatopharyngoplasty • Performs tonsillectomy • Performs palatopharyngoplasty on and/or adenoidectomy palatopharyngoplasty on complex patients (T&A) on typical pediatric typical patient • Recognizes and is able to or adult patient • Lists rare complications; treat and/or develop • Lists common potential recognizes common treatment plan for complications complications and is able common and uncommon to initiate treatment in the complications in the typical patient complex patient

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Facial Trauma — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 • Obtains history and • Recognizes symptoms of • Obtains focused history and • Interprets appropriate lab • Develops appropriate performs basic physical mandible and facial performs focused exam, and radiologic studies; treatment plan for exam fractures; able to quickly including airway evaluation identifies and orders panfacial fracture patient • Demonstrates basic assess airway, breathing, and survey for other head necessary adjunctive • Performs revision/infected knowledge of normal and circulation (ABC's) and and neck injuries; orders studies (i.e., angiography) mandibular fracture ORIF facial skeleton and need for urgent intervention appropriate routine lab and • Accurately diagnoses • Treats complex relationships • Localizes zones of the radiologic studies location and extent of complications • Demonstrates limited traumatically involved facial • Identifies common facial specific facial trauma knowledge of treatment skeleton (i.e., frontal, orbital, skeleton fracture patterns • Develops appropriate options midface, and mandible) • Discusses appropriate treatment plan and • Knows how to scrub; using detailed familiarity therapeutic options for performs ORIF for a facial Performs surgical time with normal facial boney and major facial fracture fracture patient with out soft tissue anatomy types/patterns combined mandible and • Demonstrates limited • Discusses treatment • Facile at placing maxillary- midface fracture familiarity with modality options in general mandibular fixation (MMF) • Performs uncomplicated complications terms; demonstrates limited and establishing baseline mandibular ORIF knowledge of potential patient occlusion; able to • Recognizes and is able to indications for operative perform surgical treat common open reduction and internal approaches (location and complications fixation (ORIF) of the extent) to visualize spectrum of facial fractures fractures and provide • Demonstrates beginning adequate exposure for ORIF ability to apply maxillo- • Recognizes common mandibular fixation complications; makes hardware and to perform appropriate consultations intraoral and external for patient management incisions • Lists some potential complications

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Version 10/2013 Otolaryngology - Head and Neck Surgery Milestones, ACGME Report Worksheet

Rhinosinusitis — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 • Obtains basic sinonasal • Obtains focused history • Performs nasal endoscopy • Identifies nasal endoscopic • Teaches nasal endoscopy symptom history and and physical, including and recognizes basic pathologic findings in the • Recognizes and diagnoses performs basic head and detailed sinonasal sinonasal pathology; previously operated the possible uncommon neck exam symptom inventory demonstrates basic patient; facile with etiologies of chronic • Recognizes symptoms • Explains the diagnostic understanding of interpretation/use of bacterial sinusitis that indicate sinonasal distinction between viral appropriate laboratory, appropriate laboratory, refractory to standard pathology upper respiratory pathologic, and radiologic pathologic and radiologic therapy • Demonstrates minimal infections (URI) and acute diagnostic studies diagnostic studies • Provides treatment of knowledge of treatment bacterial sinusitis • Provides a differential • Distinguishes the recurrent/extensive options • Discusses treatment diagnosis that includes the pathophysiologic and frontal sinus disease • Performs surgical time modality options in general most common spectrum of clinical presentations of • Performs revision and out; familiar with pre-op terms; prescribes medical bacterial sinusitis disease the various subtypes of advanced endoscopic documentation therapy for simple processes chronic rhinosinusitis sinus surgery requirements (e.g., common conditions (i.e., • Discusses appropriate • Formulates appropriate • Treats complex consent, history and viral URI, acute bacterial therapeutic options for treatment plan for patient complications physical, imaging) Knows rhinosinusitis [ABRS]) chronic rhinosinusitis (CRS) with acute exacerbations how to scrub • Performs intra-operative and chronic rhinosinusitis of CRS or recurrent • Lists some complications patient nasal decongestion with nasal polyps (CRSNP) polypoid disease; tailors of rhinosinusitis and local injections under • Performs endoscopic sinus medical therapy to endoscopic guidance; able surgery (ESS) procedure patient's symptoms level to apply/register with guidance; recognizes and disease presentation stereotactic surgical endoscopic surgical • Completes ESS procedure guidance system landmarks with oversight • Lists some potential • Recognizes common • Recognizes and is able to complications of sinus complications; appropriate treat and/or develop surgery management for common treatment plan for complications significant complications

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Nasal Deformity — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 • Obtains basic history and • Obtains focused history and • Performs limited dynamic • Performs comprehensive • Performs analysis in performs basic head and physical nasal function analysis and dynamic nasal function revision/post-surgical neck exam • Demonstrates anterior rhinoscopy analysis; identifies setting • Demonstrates minimal understanding of normal • Differentiates between aesthetic/cosmetic • Formulates appropriate knowledge of treatment nasal physiology variable and fixed nasal abnormalities; correlates treatment plan for patient options • Discusses treatment obstruction contributors examination findings with requiring revision surgery • Performs surgical time out; modality options in general • Discusses appropriate underlying structural • Performs revision knows how to scrub terms; prescribes medical therapeutic options for etiologies rhinoplasty, including • therapy for simple common common nasal deformities • Identifies specific harvest and placement of condition • Plans and performs components of nasal graft material • Prepares patient intra- incisions that would be pathophysiology in • Performs revision septal operatively needed for both intranasal functional obstruction surgery, including • Plans, performs, and closes and external rhinoplasty; • Formulates appropriate correction of complex incisions that would be cognizant of landmarks that treatment plan for patient septal abnormalities needed for adequate mark important with fixed and/or dynamic • Treats complex exposure; able to intra- neurovascular structures nasal obstruction complications operatively prepare patient • Elevates septal mucosal • Resects or augments bony (i.e., pack nose with flaps adequately to address or cartilaginous framework, decongestant pledgets, identified structural places and secure grafting inject nose with local abnormalities material, and performs anesthetic) • Recognizes common osteotomies • Demonstrates limited complications • Resects, recontours, and knowledge of potential corrects septal complications abnormalities • Recognizes and is able to treat and/or develop treatment plan for common complications

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Chronic Ear — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 • Performs general history • Obtains pertinent • Performs reliable • Accurately interprets • Interprets less and physical otologic history and otomicroscopic exam; orders appropriate diagnostic commonly utilized • Knows some common performs hand-held appropriate audiometry, studies; understands the diagnostic tests symptoms of ear otoscopy; differentiates laboratory, and radiologic indications for operative • Manages chronic otitis infections middle ear/mastoid studies intervention; recognizes media in an only hearing • Demonstrates limited disease from otitis • Clinically differentiates otitis acute complications in the ear knowledge of chronic externa; performs cranial media (OM), otitis externa setting of COM • Performs canal wall ear disease nerve exam (OE), necrotizing OE, chronic • Understands mechanisms down mastoidectomy • Demonstrates little • Identifies Eustachian otitis media (COM), underlying the skillfully; able to knowledge of tube (ET) dysfunction and mastoiditis, and development of proficiently perform medical/surgical the normal and abnormal cholesteatoma intratemporal and facial recess approach treatments for ear physiologic contributors • Recognizes clinical failure of intracranial complications • Treats major post- disease • Prescribes appropriate medical management; of chronic ear disease surgical complications • Knows how to scrub; systemic and/or topical describes surgical risks, • Formulates appropriate performs surgical time antibiotic therapy for benefits, and alternatives; treatment plan for care of out; maintains sterile chronic otitis media; understands concept of a patient with field understands basics of recidivism and understands complications of chronic post-operative wound need for long-term ear disease care surveillance plan • Removes granulation tissue • Positions, preps, and • Performs ear canal incisions and/or cholesteatoma from drapes patient; able to and elevates tympanomeatal the middle ear/mastoid; inject local anesthetic; flap; performs cortical skeletonizes vertical makes post-auricular mastoidectomy and segment of the facial incision; able to identifies antrum/horizontal nerve; performs aesthetically close wound semicircular canal; tympanoplasty and/or • Lists potential skeletonizes posterior canal ossiculoplasty complications of ear wall • Recognizes major surgery • Able to manage routine post- complications operative complications

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Pediatric Otitis Media — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 • Performs basic history • Performs focused clinical • Performs pneumatic • Skilled pneumatic • Skilled pneumatic and physical examination examination and is able to otoscopy and accurately otoscopist in children of all otoscopist in syndromic • Understands concept of correctly diagnose acute diagnose acute OM, OM ages; recognizes children OM and OE OM, OM with effusion, and with effusion, and OE; complications of acute • Places tympanostomy tube • Participates in surgical OE some of the time; knows knows when additional OM, OM with effusion, and safely in patients with time out when to order basic imaging is required for OE difficult anatomy audiometric testing diagnosis • Diagnoses intra- and • Describes the etiologic • Accurately diagnoses extracranial complications organisms most commonly patients along the OM of ear infections associated with OM and OE; natural history spectrum • Treats complications of ear understands the and identifies ramifications infections predisposing factors of treated/untreated OM • Places tympanostomy tube associated with each type of • Recognizes treatment safely in all patients with ear infection failures/refractoriness and easy anatomy and in some • Appropriately prescribes indications for surgical patients with difficult topical and/or oral intervention anatomy antibiotics for ear • Identifies tympanic • Recognizes and is able to infections; demonstrates membrane and external treat and/or develop familiarity with auditory canal (EAC) treatment plan for effectiveness/ landmark and structures; common complications ineffectiveness of non- able to consistently antibiotic medications and perform appropriate alternative treatments myringotomy • Inserts ear speculum and • Recognizes common safely cleans cerumen from complications; obtains ear canal appropriate consultations • Lists potential complications for patient management

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Upper Aerodigestive Tract (UADT) Malignancy — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 • Demonstrates basic • Demonstrates moderate • Demonstrates proficient • Correlates anatomic • Gives lectures on anatomy understanding of UADT knowledge of UADT and knowledge of normal knowledge with disease • Articulates treatment and neck anatomy neck anatomy; teaches anatomy; teaches anatomy physical examination (PEx) protocol specifics for • Knows normal UADT anatomy to medical to junior residents in the OR and radiologic findings primary chemoradiation function (mastication, students in the operating • Knows major risk factors for • Understands molecular basis therapy deglutition, respiration, room (OR) UADT cancer according to for UADT cancer; knows and phonation) • Knows abnormal UADT type of cancer benign and malignant • Obtains basic history and physiologic function and • Knows most common differential diagnoses of physical locoregional disease progression routes common site presentations manifestations; knows for UADT malignancy • Knows staging system for tobacco is correlated with • Interprets appropriate lab, most common UADT cancers, UADT cancer pathologic, and radiologic and can accurately stage • Knows most common studies using available clinical and disease state presentations • Understands concepts of radiologic data for UADT malignancies neo-adjuvant, primary, and • Understands the prognostic • Performs focused history adjuvant treatments; indicators of tumor and physical, including describes options for pathology, including clinic laryngoscopy; securing the difficult airway molecular markers understands appropriate in the OR • Describes treatment options labs, FNA, and radiologic based on primary site, studies for workup disease stage, and patient • Describes basic treatment factors algorithm for UADT malignancies

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Hearing Loss — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 • Demonstrates limited • Demonstrates proficient • Demonstrates proficient • Understands congenital • Demonstrates knowledge knowledge of temporal knowledge of temporal knowledge of normal variations of temporal of central auditory bone and bone and temporal bone and bone and pathways cochleovestibular cochleovestibular gross cochleovestibular cochleovestibular anatomy anatomy anatomy/embryology histopathology • Generates differential • Demonstrates limited • Understands normal • Generates differential diagnosis for hearing loss understanding of the middle ear mechanics diagnosis for hearing loss in children, and identifies physiology of hearing and cochlear physiology in adult patients uncommon causes of • Demonstrates limited • Understands the natural • Understands the natural hearing loss in adults understanding of the history of presbycusis history of adult onset • Understands the natural natural history of hearing and noise-induced hearing loss history of pediatric hearing loss hearing loss • Recognizes an abnormal loss and uncommon • Recognizes normal ear ear exam/audiogram; causes of adult-onset exam and normal orders appropriate hearing loss audiometry; able to routine audiometric, • Considers unusual causes identify basic hearing loss laboratory, and imaging for hearing loss and classifications on an tests for work-up orders/interprets audiogram; demonstrates • Demonstrates appropriate advanced limited knowledge of comprehensive audiometric, laboratory, options for diagnostic awareness of aural and imaging studies work-up of hearing loss rehabilitation options, • Describes indications/ • Demonstrates awareness including surgical contraindications and of non-surgical aural management of hearing complications of the rehabilitation options; loss surgical aural understands importance rehabilitation techniques; of hearing surveillance tailors aural rehabilitation to patient-specific needs

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Dysphagia-Dysphonia — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 • Demonstrates limited • Understands basic • Demonstrates mid-level • Demonstrates thorough • Teaches pathophysiology understanding of anatomy and physiology understanding of anatomy knowledge of anatomy and aerodigestive functional of voice and swallowing and physiology of voice and physiology of voice and anatomy • Demonstrates basic swallowing swallowing • Demonstrates limited understanding of • Demonstrates mid-level • Demonstrates comprehensive understanding of common voice and understanding of common understanding of most voice and common voice and swallowing disorders voice and swallowing swallowing disorders, including swallowing disorders • Understands age-related disorders voice and swallowing • Demonstrates limited changes to voice and • Demonstrates knowledge manifestations of systemic knowledge of disease swallowing of disease progression and diseases (i.e., autoimmune progression and sequelae • Obtains focused history sequelae of untreated disorders, sarcoid, of untreated voice and and physical, including voice and swallowing neuromuscular disorders) swallowing disorders clinic laryngoscopy; able disorders • Articulates comprehensive • Obtains basic history and to list appropriate • Interprets appropriate lab, understanding of risk factors and physical diagnostic modalities for pathologic, and radiologic timeframe for malignant • Demonstrates minimal work-up of voice and studies transformation of premalignant understanding of swallowing disorders • Demonstrates mid-level conditions (laryngopharyngeal treatment options and • Demonstrates beginning understanding of reflux disease [LPRD], Barrett's, rationales, and understanding of treatment options and Dysplasia/Leukoplakia, recurrent risks/benefits of each treatment options and rationales, and respiratory papillomatosis [RRP]) treatment option rationales, and risks/benefits of each • Correlates laboratory and risks/benefits of each treatment option radiologic work-up with clinical treatment option diagnosis • Demonstrates understanding of treatment options and rationales, risks/benefits of each treatment option, and surveillance algorithms for malignant disease

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Inhalant Allergy — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 • Demonstrates familiarity • Demonstrates basic • Demonstrates knowledge • Demonstrates thorough • Demonstrates advanced with basic nasal anatomy understanding of of histopathology of understanding of anatomic understanding of allergy and normal respiratory derangements in nasal allergic rhinitis and impact of allergic diagnostic testing mucosa histology anatomy and mucosal anatomic factors affecting inflammation on the nasal • Is facile with multiple • Demonstrates familiarity inflammation the nasal airway airway methods of with normal functions of • Knows pathophysiology • Knows pathophysiology • Distinguishes immunotherapy nasal mucosa and nasal of allergic rhinitis (AR) of non-allergic rhinitis presentations of allergic cavities • Describes comorbidities • Describes the natural and non-allergic rhinitis • Demonstrates limited in AR history and components patients; demonstrates knowledge of allergy • Demonstrates familiarity of severity in allergic knowledge of cellular and work-up with clinical presentations disease molecular features of of allergic disease • Demonstrates knowledge inhalant allergy • Prescribes basic medical of testing methods in • Describes systems for AR treatment for AR allergic disease subtype and severity (e.g., • Prescribes advanced seasonal vs. perennial, medical treatment for intermittent vs. persistent, allergic disease etc.) and incorporates knowledge of severity and natural history into patient management • Combines clinical features and test results to correctly diagnose allergic disease • Demonstrates a working knowledge of immunotherapy for allergic disease

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Patient Safety — Systems-based Practice

Level 1 Level 2 Level 3 Level 4 Level 5 • Understands the need • Participates in the use of • Consistently uses tools • Advocates for quality • Educates other services for formal patient safety tools to prevent adverse to prevent adverse patient care and optimal re patient safety issues measures (e.g., surgical events (e.g., checklists events (e.g., checklists patient care systems in otolaryngology head time out) and briefings) and briefings) • Analyzes M&M findings and neck surgery OHNS • Understands and uses • Identifies potential and provides feedback chain of command to patient safety issues to improve patient develop and implement (patient positioning in safety patient care plans OR, aspiration risk) and (junior to senior resident means to prevent those to attending) problems • Presents at morbidity and mortality (M&M) conference (organizes data and identification of some pertinent patient safety issues)

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Resource Utilization — Systems-based Practice

Level 1 Level 2 Level 3 Level 4 Level 5 • Uses resources (social • Actively functions as • Incorporates cost issues • Practices cost-effective • Designs measurement work, patient care part of an inter- into care decisions care (e.g., managing tools to monitor and manager) to coordinate disciplinary team to care • Contributes to length of stay, operative provide feedback to patient care for patients leadership of the efficiency) providers/teams on • Aware of socio- interdisciplinary care • Leads interdisciplinary resource consumption economic issues in team team in patient care to facilitate patient care and takes • Uses technology and improvement those into consideration other hospital/clinic when developing patient resources in patient care care plans

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The ability to investigate and evaluate the care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning — Practice-based Learning and Improvement

Level 1 Level 2 Level 3 Level 4 Level 5 • Is aware of one’s own • Continually seeks and • Demonstrates • Demonstrates consistent • Is competent at level of knowledge and incorporates feedback improvement in clinical behavior of performing meta- uses feedback from to improve performance thought and action incorporating evidence- analyses to answer teachers, colleagues, • Develops a learning plan based on continual self- based information in complex patient care and patients and uses published assessment common practice areas questions • Identifies learning review articles and • Selects an appropriate • Organizes educational • is a sophisticated user of resources guidelines evidence-based activities at the program learning resources information tool to level answer specific questions

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Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5 • Demonstrates behavior • Is aware of ethical issues • Recognizes ethical issues • Analyzes and manages • Helps lead institutional that conveys caring, in patient care, including in practice and is able to ethical issues in and organizational ethics honesty, and genuine issues of autonomy, discuss, analyze, and complicated and programs interest in patients and end-of-life care and manage common ethical challenging situations families research ethics situations • Develops a mutually • Exhibits professional • Recognizes individual • Displays sensitivity and agreeable care plan in behavior (e.g., reliability, limits in clinical responsiveness toward the context of conflicting industry, integrity, and situations and asks for all patient populations physician and patient confidentiality) assistance when needed values and beliefs • Maintains respect for • Understands and patient confidentiality manages the issues related to fatigue and sleep deprivation • Completes paperwork, administrative tasks and assignments in a timely manner

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Interpersonal Communication Skills

Level 1 Level 2 Level 3 Level 4 Level 5 • Develops a positive • Effectively • Sustains effective • Develops working • Develops relationship with communicates during relationships with relationships across models/approaches to patients and transitions of care services requesting specialties and systems managing difficult understands patients’ • Communicates with OHNS consultation of care communications and families’ patients and families, • Works effectively as a • Organizes and facilitates • Coaches others to perspectives taking into account the member of a health care family/health care team improve communication • Utilizes interpreters as socioeconomic and team conferences skills needed cultural backgrounds of • Uses multiple forms of these individuals communication (e.g., e- • Ensures that the medical mail, patient portal, record is timely, social media) ethically accurate, and complete and with respect for patient privacy

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