Urology Milestones

The Accreditation Council for Graduate Medical Education

Implementation Date: July 2020 Second Revision: April 2020 First Revision: August 2016

©2020 Accreditation Council for Graduate Medical Education (ACGME) All rights reserved except the copyright owners grant third parties the right to use the Urology Milestones on a non-exclusive basis for educational purposes.

Urology Milestones

The Milestones are designed only for use in evaluation of residents 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 competence 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.

Urology Milestones

Work Group Gina Badaloto, MD Brian McNeil, MD Ali Dabaja, MD Amy Miller-Juve, EdD, MEd Laura Edgar, EdD, CAE Chad Ritenour, MD Serge Ginzburg, MD Mathew Sorensen, MD, MS Karim Hamawy, MD Joe Sterbis, MD Misop Han, MD Eric Wallen, MD Robert Marcovich, MD Mary Beth Westerman, MD Wesley Mayer, MD

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

American Board of Urology Review Committee for Urology Society for Academic Urologists

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 vi).

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).

Patient Care 1: Patient Evaluation

Level 1 Level 2 Level 3 Level 4 Level 5 Obtains history and Evaluates patients; orders Develops a plan to Develops a plan to Develops a clinical physical exam to form a and interprets diagnostic manage patients with manage patients with pathway for the patient assessment testing straightforward conditions complex conditions and management of patients adapts plan for with complex conditions changing clinical or identifies clinical trials situation for patients

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 2: Peri-Procedural Care

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies alterations in Accurately and reliably Independently identifies Independently identifies Proactively recognizes normal physiology gathers and reports and prioritizes tasks and prioritizes tasks potential risk factors for clinical information necessary for necessary for complications, and pertaining to common management of common management of implements measures to peri-procedural alterations peri-procedural alterations complex and/or less prevent or mitigate them, and complications and complications common peri- applying effective team procedural alterations management skills to and complications manage multiple scenarios simultaneously

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 3: Endoscopic Procedures

Level 1 Level 2 Level 3 Level 4 Level 5 Prepares patient and Independently performs Independently performs Independently performs Independently performs equipment for bedside endoscopic simple endoscopic complex endoscopic complex endoscopic endoscopic procedures procedures (e.g., procedures (e.g., simple procedures (e.g., procedures in altered (e.g., lithotomy cystoscopy with catheter transurethral resection of percutaneous anatomy (e.g., horseshoe positioning, placement over a wire) a bladder tumor (TURBT), nephrolithotomy kidney, urinary diversion, assemble endoscope) simple ureteroscopy (PCNL), complex URS, spinal malformation) (URS), small transurethral complex TURBT, large resection of the prostate TURP) (TURP))

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 4: Open Procedures

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates basic Independently performs Independently performs Independently performs Independently performs skills (e.g., positioning, bedside open procedures simple open procedures complex open uncommon complex open knot tying, suturing) (e.g., incision and (e.g., scrotal procedures, procedures (e.g., partial procedures (e.g., drainage, priapism vasectomy, cystorrhaphy, nephrectomy, prosthetic retroperitoneal lymph aspiration and irrigation, mid-urethral sling) replacement, node dissection (RPLND), circumcision, removal of cystectomy and ileal nephrectomy with caval genital wart) conduit, ureteral thrombus, reconstructive reconstruction) genital surgery)

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 5: Minimally Invasive Procedures (Laparoscopic and Robotic)

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates basic Assists during minimally Independently performs Independently performs Independently performs skills (e.g., positioning, invasive procedures (e.g., simple portions of the critical (complex) advanced minimally draping, docking and port placement, bedside procedure (e.g., bladder portions of the invasive procedures (e.g., undocking) assistant) takedown, colon procedure (e.g., hilar cystectomy, complex reflection, pelvic lymph dissection, renorrhaphy, partial nephrectomy, node dissection) anastomosis) complex reconstruction)

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 6: Office-Based Procedures

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates basic Performs simple office- Independently performs Independently performs Independently performs skills in office procedures based procedures, with simple office-based complex office-based advanced office-based (e.g., Foley catheter direct supervision (e.g., procedures, including procedures (e.g., renal procedures (e.g., stage 1 placement, drain prostate biopsy, percutaneous suprapubic ultrasound, bladder neuromodulation, removal) urodynamics tube placemen biopsy, Botox injection) minimally invasive benign interpretation, vasectomy, prostatic hyperplasia urethral stricture dilation) (BPH) procedure, penile ultrasound)

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge 1: Clinical Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Demonstrates knowledge Demonstrates knowledge Demonstrates Creates a curriculum for knowledge of anatomy of pathophysiology and of pathophysiology and comprehensive clinical medical and physiology as it treatments of simple treatments of complex knowledge, including knowledge pertains to surgical urologic conditions urologic conditions guidelines, of the full conditions considering patient spectrum of urologic factors (e.g., comorbidity, diseases, treatments, social context) and populations

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge 2: Clinical Reasoning

Level 1 Level 2 Level 3 Level 4 Level 5 Integrates patient- Provides a prioritized Independently Independently Teaches others to specific information to differential diagnosis synthesizes clinical synthesizes clinical recognize sources of generate an appropriate using supporting rationale information to inform information to inform diagnostic error working diagnosis diagnosis and therapy in diagnosis and therapy simple cases and adapts in complex cases, based on a patient’s recognizing sources of clinical course and error additional data

Comments: Not Yet Completed Level 1 Not Yet Assessable

Systems-Based Practice 1: Patient Safety and Quality Improvement

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Identifies and reports Participates in analysis of Offers strategies Actively engages and knowledge of common patient safety events patient safety events (simulated or actual) to leads teams and patient safety events and (simulated or actual) prevent patient safety processes to prevent institutional reporting events patient safety events system

Demonstrates Describes local quality Participates in local Demonstrates the skills Creates, implements, and knowledge of basic improvement initiatives quality improvement required to identify, assesses quality quality improvement (e.g., multimodal initiatives develop, implement, improvement initiatives at methodologies and analgesics, antibiotic and analyze a quality the institutional or metrics stewardship, smoking improvement project community level cessation, hospital acquired infection)