The Pediatric Surgery Milestone Project

A Joint Initiative of

The Accreditation Council for Graduate Medical Education,

and

The American Board of Surgery

July 2015

The Pediatric Surgery Milestone Project

The Milestones are designed only for use in evaluation of fellows 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.

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Pediatric Surgery Milestones Chair: Ron Hirschl, MD

Working Group Advisory Group Kenneth S. Azarow, MD, FACS, FAAP Timothy P. Brigham, MDiv, PhD Mary Brandt, MD James C. Herbert, MD Laura Edgar, EdD, CAE John R. Potts III, MD J. Ted Gerstle, MD, FRCSC, FACS, FAAP Kurt Heiss, MD Whit Holcomb, MD Max R. Langham Jr., MD Grace Z. Mak, MD Mark V. Mazziotti, MD Benedict C. Nwomeh, MD David Powell, MD Peggy Simpson, EdD John Waldhausen, MD

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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.

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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 milestones demonstrated. in the higher level(s).

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v 01/2014 THE PEDIATRIC SURGERY MILESTONES: ACGME REPORT WORKSHEET

Bronchoscopy/Esophagoscopy — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Serves as first assistant for Equipment Functional knowledge Independent ability to Develops innovative operative the majority of the Limited ability to assemble adequate, but suboptimal assemble scope and technique, approach, or procedure scope and troubleshoot assembly of equipment or troubleshoot problems significant improvement in functional problems ability to troubleshoot bronchoscopy/esophagoscopy problems Consistently optimal Technique understanding and exposure Limited exposure of Adequate but suboptimal of tracheobronchial tree and tracheobronchial tree and understanding and exposure esophagus; optimal esophagus; poor utilization of tracheobronchial tree and utilization of scope of scope esophagus; adequate utilization of scope Expedient and safe Foreign body/biopsy identification of foreign Limited ability to identify Adequate but inefficient body/tumor and/or retrieval foreign body/tumor or to identification of foreign of foreign body/biopsy of retrieve foreign body/biopsy body/tumor and/or retrieval tumor tumor of foreign body/biopsy of tumor

Comments:

Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Surgery. 1 01/2014 THE PEDIATRIC SURGERY MILESTONES: ACGME REPORT WORKSHEET

Esophageal atresia/Tracheoesophageal Fistula (TEF) Repair — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Serves as first assistant for Incision Functional, but suboptimal Consistently appropriate Develops innovative the majority of the Limited ability to identify incision or port placement placement of incision or operative technique, procedure appropriate incision or port ports approach, or significant placement improvement in the established technique for Dissection esophageal atresia/TEF Limited ability to dissect TEF Adequate but suboptimal Expedient dissection, safe repair dissection of TEF isolation of TEF Fistula ligation Limited ability to Successful, but suboptimal Consistently appropriate ligate/divide fistula; concern ligation/division of fistula and ligation/division of fistula; for tracheal narrowing tracheal dissection maintained appropriate cuff of membranous trachea Anastomosis Limited ability to Occasional lapses in Consistently appropriate appropriately space and appropriate spacing and spacing of sutures, tissue place anastomotic sutures depth of anastomotic approximation, and and approximate tissue sutures, or occasional lapse in consistent bites into tissue approximation submucosa

Comments: Not yet achieved Level 1

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Inguinal hernia repair on a child less than six months of age — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Serves as first assistant for Incision Functional but suboptimal Consistently appropriate Develops innovative the majority of the Limited ability to identify placement of incision/port(s) placement of incision/port(s) operative technique, procedure appropriate incision or port approach, or significant placement improvement in established technique for inguinal hernia Exposure repair Limited ability to expose key Adequate establishment and Consistently optimizes structures maintenance of retraction exposure of inguinal but with occasional loss of anatomy; efficiently directs exposure of key structures wound retraction to Hernia sac maintain exposure dissection/ligation Limited ability to perform Successful, but suboptimal Consistently appropriate hernia sac dissection/ligation dissection/ligation of hernia dissection/ligation of hernia or vas/vessel/fallopian tube sac; vas/vessels/fallopian sac and consistently safe dissection tube preserved with minor mobilization of traumatic injury vas/vessels/fallopian tube

Comments: Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Surgery. 3 01/2014 THE PEDIATRIC SURGERY MILESTONES: ACGME REPORT WORKSHEET Intestinal/duodenal atresia (DA) repair — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Serves as first assistant Incision/port placement Functional but suboptimal Consistently appropriate Develops innovative for the majority of the Limited ability to identify placement of incision/port(s) placement of incision/port(s) operative technique, procedure appropriate incision or port approach, or significant placement improvement in established technique for Abdominal exploration intestinal/DA repair Limited ability to perform Adequate, but suboptimal Consistently performs abdominal exploration that performance of abdominal complete, efficient, and should include evaluation for exploration that should include systematic abdominal additional abnormalities (e.g., evaluation for additional exploration that identifies atresias, malrotation) anomalies (e.g., atresias, additional abnormalities (e.g., malrotation) atresias, malrotation) Intestinal resection (atresia) Limited ability to perform Adequate, but suboptimal Consistently appropriate intestinal resection or failure to performance of intestinal understanding and consider need for resection and/or tapering/STEP performance of intestinal tapering/Serial Transverse resection and/or tapering/STEP Enteroplasty (STEP)

Anastomosis Occasional lapses in spacing Consistently appropriate Limited ability to appropriately and depth of anastomotic spacing of sutures, tissue space and place anastomotic sutures, or occasional lapse in approximation, and consistent sutures and approximate tissue tissue approximation (in DA, bites into submucosa (in DA, (in DA, often unaware of occasional lapse in awareness continually aware of Sphincter Sphincter of Oddi) of Sphincter of Oddi) of Oddi)

Comments: Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Surgery. 4 01/2014 THE PEDIATRIC SURGERY MILESTONES: ACGME REPORT WORKSHEET

Hirschsprung pull-through — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Serves as first assistant for Incision/port placement Functional but suboptimal Consistently appropriate Develops innovative the majority of the Limited ability to identify placement of incision/port(s) placement of incision/port(s) operative technique, procedure appropriate incision or port approach, or significant placement improvement in established technique for Hirschsprung Abdominal exploration pull-through Limited ability to perform Adequate, but suboptimal Consistently performs abdominal exploration or to performance of abdominal complete, efficient, and identify transition zone exploration, identification of systematic abdominal and/or perform biopsy transition zone, and/or exploration with appropriate performance of biopsy identification of transition zone and biopsy Rectal dissection/resection Limited ability to perform Adequate, but suboptimal Consistently appropriate pull-through performance of pull-through performance of pull-through

Suture placement Limited ability to Occasional lapses in spacing Consistently appropriate appropriately space and and depth of anastomotic spacing of sutures, tissue place anastomotic sutures, or sutures, or lapses in tissue approximation, and bites to approximate tissue; approximation; occasional into submucosa; consistently limited ability to orient pull- lapses in pull-through aware of pull-through through segment orientation segment orientation

Comments:

Not yet achieved Level 1

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Wilms/Neuroblastoma Resection — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Serves as first assistant for Incision/port placement (as Functional but suboptimal Consistently appropriate Develops innovative the majority of the appropriate) placement of incision/port(s) placement of incision/port(s) operative technique, procedure Limited ability to identify approach, or significant appropriate incision or port improvement in established placement technique for Wilms/neuroblastoma Abdominal exploration resection Limited ability to perform Adequate, but suboptimal Consistently performs abdominal exploration/tumor performance of abdominal complete, efficient, and exposure exploration/tumor exposure systematic abdominal exploration/tumor exposure Vascular control Limited ability to identify and Adequate, but suboptimal Consistently appropriate control vascular structures in performance of control of performance of control of either tumor, and/or to assess vascular structures in either vascular structures in either for tumor thrombus in Wilms tumor, and/or assessment for tumor, and assessment for tumor thrombus in Wilms tumor thrombus in Wilms Excision of tumor Limited ability to safely Adequate, but suboptimal Consistently appropriate manipulate tumor (e.g., ability to safely manipulate technique with tumor without rupture in Wilms) tumor (e.g., without rupture manipulation and intra- and/or to make decisions in Wilms) and/or to make operative decision-making regarding resectability decisions regarding resectability

Comments: Not yet achieved Level 1

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Congenital Diaphragmatic Hernia Repair — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Serves as first Extracorporeal membrane Adequate, but suboptimal Consistently appropriate Develops innovative assistant for the oxygenation (ECMO) cannulation (if decision-making for instituting decision-making for instituting operative technique, majority of the performed) decision making ECMO and discriminating ECMO and discriminating approach, or significant procedure Limited ability to make appropriate between venovenous and between venovenous and improvement in decision for instituting ECMO and venoarterial options venoarterial options established technique discriminating between venovenous for congenital and venoarterial options Adequate, but suboptimal Consistently appropriate ability diaphragmatic hernia ability to identify and control to identify and control neck repair Cannulation neck vascular structures; vascular structures; consistent Limited ability to identify and control adequate, but suboptimal ability to safely insert cannulas cervical vascular structures; limited ability to safely insert cannulas ability to safely insert cannulas Functional but suboptimal Consistently appropriate Incision/port placement placement of incision/port(s ) placement of incision/port(s) Limited ability to identify appropriate placement of incision/port(s)

Diaphragm repair Adequate, but suboptimal Consistently demonstrates the Limited ability to safely and ability to effectively reduce appropriate ability to effectively reduce hernia contents hernia contents and/or close effectively reduce hernia and/or close diaphragmatic defect diaphragmatic defect with contents and/or close with appropriately spaced/placed appropriately spaced/placed diaphragmatic defect with sutures sutures appropriately spaced/placed sutures

Comments: Not yet achieved Level 1

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General Procedure Assessment — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Serves as first assistant for Instrument handling Adequate, but suboptimal Consistently appropriate use Develops innovative the majority of the Limited ability to choose and use and choice of and choice of instruments operative technique, procedure use instruments instruments instrumentation, operative appropriately approach, or significant improvement in established Respect for tissue technique Limited ability to handle Adequate, but suboptimal Consistently appropriate tissues carefully; moderate tissue handling; occasional handling of tissues; minimal tissue damage tissue damage tissue damage

Time and motion Frequent tentative, awkward, Efficient time and motion, Clear economy of motion unnecessary movements occasional awkward or and maximum efficiency unnecessary movements Operation flow Frequent lack of forward Some forward planning of Obviously has planned progression; frequently stops operation; reasonable course of operation and operating and seems unsure procedure progression anticipated next steps of next move

Comments: Not yet achieved Level 1

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General Patient Care Assessment — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Performs a basic physical Performs a comprehensive Provides the pre- and post- Directs the multidisciplinary Appropriately and exam and understands the physical exam, recognizes operative management of a pre- and post-operative independently counsels management and imaging associated anomalies, and complicated newborn, or management of a complex families for prenatal surgical in a newborn or child; provides the pre- and post- multiple injured child, newborn with multiple conditions performs primary operative management of an including ICU care (ventilator anomalies, or multiple assessment and initiates uncomplicated newborn or management, parenteral injured child, including ICU Directs and leads resuscitation of an injured single-system injured child, nutrition, fluids and care (ventilator multidisciplinary team in child including intensive care unit electrolytes) management, parenteral quality improvement (ICU) care (ventilator nutrition, fluids and focused on patient Diagnoses common management, parenteral Manages complex post- electrolytes) outcomes complications nutrition, fluids and operative complications electrolytes) Independently anticipates, Coordinates/leads a Recognizes normal growth, Evaluates and manages diagnoses, and proficiently multidisciplinary team in development, and Manages common post- variances from expected manages interventions and providing comprehensive expected outcome after operative complications outcomes in the late post- complications, and care of the child treatment operative course in the appropriately involves the transitioning to adulthood Recognizes variances in outpatient setting multidisciplinary team growth, development, and expected outcome after Independently provides treatment comprehensive long-term care in the outpatient setting

Comments:

Not yet achieved Level 1

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Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Through discussion in Through discussion in didactic Through discussion in Through discussion in Demonstrates expertise didactic and clinical settings, and clinical settings, this didactic and clinical didactic and clinical in specific area(s) of this fellow demonstrates fellow demonstrates settings, this fellow settings, this fellow pediatric surgery, and/or thorough knowledge of the thorough knowledge of the demonstrates thorough demonstrates thorough contributes substantially basic pediatric surgery topics intermediate pediatric knowledge of the advanced knowledge of the complex to the literature below: surgery topics below: pediatric surgery topics pediatric surgery topics below: below: . Appendicitis . Branchial cleft . Inguinal hernia cyst/sinus/remnant . DA . Anorectal . Intussusception . Gastroesophageal reflux . ECMO malformation . Malrotation . Gastroschisis . Hirschsprung disease . Biliary atresia . Pyloric stenosis . Lung physiology . Intestinal atresia . Choledochal cyst . Thoracic/abdominal . Omphalocele . Neuroblastoma . Congenital trauma . Ovarian/adnexal diseases . Wilms tumor diaphragmatic hernia . Undescended testis . Cystic pulmonary airway malformation . Esophageal atresia with or without TEF

Comments: Not yet achieved Level 1

Demonstration of knowledge of topics can be evaluated through tools such as: 1) PedScore modules; 2) multiple choice questions; and 3) discussion of open-ended questions with faculty members.

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General Knowledge Assessment — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates knowledge of Demonstrates knowledge of Demonstrates knowledge of Demonstrates knowledge of Demonstrates significant embryology, anatomy, and embryology, anatomy, and embryology, anatomy, and embryology, anatomy, and command of the literature, physiology of basic topics physiology of intermediate physiology of advanced topics physiology of complex topics including novel therapeutic topics interventions and Discusses initial diagnostic Discusses initial diagnostic Discusses initial diagnostic outcomes and treatment Discusses initial diagnostic and treatment and treatment recommendations for basic and treatment recommendations for recommendations for topics, including those that recommendations for advanced topics, including complex topics, including require urgent management intermediate topics, including those that require urgent those that require urgent those that require urgent management management Discusses potential management complications and their Discusses potential Discusses potential management, as well as Discusses potential complications and their complications and their expected outcomes for complications and their management, as well as management, as well as basic topics management, as well as expected outcomes for expected outcomes for expected outcomes for advanced topics complex topics intermediate topics

Comments: Not yet achieved Level 1

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Healthcare Delivery and Cost – Systems Based Practice

Level 1 Level 2 Level 3 Level 4 Level 5 Understands cost Articulates risk-benefit Incorporates cost Leads efforts to reduce costs Develops or institutes a cost implications of clinical analysis, including cost to considerations into clinical by reducing variations in efficient clinical pathway decisions patient decisions care which reduces cost of patient care Understands how to Incorporates risk Understands the principles of Understands the concept of appropriately utilize mid- management in pediatric insurance coverage and work relative value units Advocates on a national or level and other health care surgery access to care for children (RVUs) and physician regional level for health care providers to optimize the compensation policy delivery of care to children (inpatient, outpatient, on call, rounding)

Comments:

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Patient Safety — Systems-based Practice

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates an Recognizes medical errors Suggests improvements to Leads multidisciplinary Participates as an advocate understanding of the as systemic events and reduce medical errors efforts to improve patient on a regional or national importance of patient facilitates reporting in a safety at the division and/or level for pediatric patient safety and the occurrence blame-free environment Anticipates potentially hospital level safety of medical errors in dangerous situations and pediatric surgery patients Anticipates the inherent risk intervenes Designs evidence-based of medical errors as a result clinical pathway to Participates in an effective of inadequate patient hand- decrease medical errors patient hand-off and off and surgical time-out surgical time-out process

Comments: Not yet achieved Level 1

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Systems-based Documentation — Systems-based Practice

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates commitment Accurately and promptly Effectively uses medical Effectively uses medical Works with the electronic to maintaining medical documents daily patient care record system to synthesize record system to answer a medical record professional records within the institutional complex patient information clinical research question or team to solve problems in documentation system complete a quality the medical record system improvement project

Comments: Not yet achieved Level 1

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Evidence-based Medicine — Practice-based Learning and Improvement

Level 1 Level 2 Level 3 Level 4 Level 5 Incorporates evidence- Understands the quality and Synthesizes a clinical plan Demonstrates utilization of Formulates an outcomes- based guidelines into limitations of available from multiple sources of evidence derived from a based quality improvement clinical decisions literature and data evidence database or registry in project to answer a clinical changing his or her practice question pattern

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 Takes responsibility for Committed to self- Is self-reflective about own Analyzes and interprets own Displays a commitment to actions and acknowledges improvement; responds well academic, professional, and experience, and uses the lifelong learning (e.g., errors to feedback personal needs, strengths, literature to alter practice routinely surveys literature, and limitations pattern engages in continuing Directs the discussion at medical education [CME] morbidity and mortality activities, actively publishes) conference with an understanding of the severity of the complication presented (e.g., selects cases to be presented, performs appropriate literature search)

Comments: Not yet achieved Level 1

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Integrity — Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates an Thinks like a professional by Acts like a professional who Leads as a professional by Mentors others in areas of understanding of the basic demonstrating behavioral recognizes limitations, managing him- or herself professionalism cognitive and ethical and social components of accepts feedback, and is and his or her team and components of professionalism effective at managing patients Mentors and teaches professionalism difficult clinical situations integrity, altruism, Demonstrates compassion Serves as a role model for individual responsibility, Demonstrates and empathy for patients; Demonstrates integrity, honesty, integrity, and and professionalism fundamental aspects of his or her work is noted for altruism, and individual professionalism; patient medical professionalism, integrity, responsibility, responsibility to the needs supersede self- Understands the ethical including confidentiality, commitment, and reliability patient, family, and team interest implications of respect for patient choice, under most circumstances under all circumstances; incorporating new surgical citizenship (e.g., medical serves as an advocate for skills and techniques into record completeness, quality patient care practice timeliness, arrives on time for work, etc.), and individual responsibility to the team

Comments: Not yet achieved Level 1

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Recognition of Limits — Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5 Overestimates ability; Recognizes when Is self-aware of limitations; Never takes on tasks Mentors and educates rarely asks for help when uncomfortable with tasks; anticipates situations that beyond own ability; reliably others in discovering and needed asks for, and waits for help may be beyond his or her asks for help when needed acknowledging their ability, and plans strengths and limitations Organizes multidisciplinary accordingly teams to optimize patient care

Comments: Not yet achieved Level 1

Behavior and Respect — Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5 Few complaints related No complaints related to Consistently compassionate Serves as a role model for Mentors others in behavior to behavior behavior; rarely displays and respectful of patients, respect and compassion which is respectful and lapses in compassion and families, and other health towards patients, families, compassionate to patients, respectfulness even in care workers even in and other health care families, and other health difficult, stressful, and difficult, stressful, and workers care workers highly demanding situations highly demanding situations

Comments: Not yet achieved Level 1

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Leadership — Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates an Organizes people and Demonstrates leadership Demonstrates advanced Models to and teaches understanding of his or leads the pediatric surgery skills in adverse skills in leading a broad, others to be leaders, and her role on team; works team environments; multidisciplinary team and develops the talents of effectively with others on demonstrates best practices in managing the needs of others the team for managing one’s team the team members; motivates the team to high performance

Comments: Not yet achieved Level 1

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Collaborator — Interpersonal and Communication Skills

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates an Communicates effectively Resolves disagreements Negotiates and manages Is viewed as an exemplary understanding of the with attending staff with other health care conflict among care communicator, problem importance of effective members, peers, and other providers in a professional providers solver, and ambassador for communication with other health care providers, manner the pediatric surgery service Communicates effectively providers including during transfer to in the children’s hospital other services and in times of crisis multidisciplinary rounds

Comments: Not yet achieved Level 1

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Patient- and Family-centered Care — Interpersonal and Communication Skills

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates an Communicates effectively Demonstrates effective Customizes emotionally Serves on local, regional, or understanding of the value with patients and families in communication with difficult and ethically difficult national committees of patient- and family- the inpatient and outpatient families information, such as addressing ethical or centered care settings, including in palliative care discussions advocacy issues obtaining informed consent Demonstrates sensitivity in Uses translation services caring for culturally diverse patients appropriately

Comments: Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Surgery. 21