Pediatrics – Psychiatry – Child and Adolescent Psychiatry (Combined) Programs Must Annually Report on Each Set of Milestones

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Pediatrics – Psychiatry – Child and Adolescent Psychiatry (Combined) programs must annually report on each set of milestones. The Pediatrics Milestone Project

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

July 2017

The Pediatrics 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.

Pediatrics Milestones

Working Group Advisory Group

Chair: Carol Carraccio, MD, MA Carol Aschenbrener, MD Bradley Benson, MD Richard Behrman, MD Ann Burke, MD Timothy Brigham, MDiv, PhD Robert Englander, MD, MPH Stephen Clyman, MD Susan Guralnick, MD Eric Holmboe, MD Patricia Hicks, MD, MHPE M. Douglas Jones Jr., MD Stephen Ludwig, MD Gail McGuinness, MD Daniel Schumacher, MD Victoria Norwood, MD Jerry Vasilias, PhD Robert Perelman, MD William Raszka, MD Theodore Sectish, MD Susan Swing, PhD

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. The pediatrics milestones are designed to describe changes in observable attributes of the learner across the continuum of medical education from medical school through residency into practice. 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 reporting period, review and reporting will involve selecting the level of milestones that best describes each resident’s current performance level in relation to milestones. Milestones are arranged into levels (See the figure on page iv). Progressing from Level 1 to Level 5 is synonymous with moving from novice to expert. Selection of a level implies that the resident substantially demonstrates the milestones in that level, as well as those in lower levels.

Additional Notes

Level 3 is designed as the graduation target but does not represent a graduation requirement. Making decisions about readiness for graduation is the purview of the residency program director (See the Milestones FAQ for further discussion of this issue: “Can a resident/fellow graduate if he or she does not reach every milestone?”). Study of Milestone performance data will be required before the ACGME and its partners will be able to determine whether Level 3 milestones and milestones in lower levels are in the appropriate level within the developmental framework, and whether Milestone data are of sufficient quality to be used for high stakes decisions.

Answers to Frequently Asked Questions about the Milestones are available on the Milestones web page: http://www.acgme.org/acgmeweb/Portals/0/MilestonesFAQ.pdf.

A full report on the Pediatrics Milestone Project, including background information on each set of Milestones, is located at http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/320_PedsMilestonesProject.pdf.

iii

The figure 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 or • selecting the “Not yet Assessable” response option. This option should be used only when a resident has not yet had a learning experience in the sub-competency.

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).

iv Version 7/2017

PEDIATRICS MILESTONES

ACGME Report Worksheet

PC1. Gather essential and accurate information about the patient

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Either gathers too little Clinical experience allows Demonstrates an advanced Creates well-developed Creates robust illness information or exhaustively linkage of signs and development of pattern illness scripts that allow scripts and instance scripts gathers information following a symptoms of a current recognition that leads to essential and accurate (where the specific template regardless of the patient to those the creation of illness information to be gathered features of individual patient’s chief complaint, with encountered in previous scripts, which allow and precise diagnoses to patients are remembered each piece of information patients. Still relies information to be gathered be reached with ease and and used in future clinical gathered seeming as important primarily on analytic while simultaneously efficiency when presented reasoning) that lead to as the next. Recalls clinical reasoning through basic filtered, prioritized, and with most pediatric unconscious gathering of information in the order pathophysiology to gather synthesized into specific problems, but still relies on essential and accurate elicited, with the ability to information, but has the diagnostic considerations. analytic reasoning through information in a targeted gather, filter, prioritize, and ability to link current Data gathering is driven by basic pathophysiology to and efficient manner when connect pieces of information findings to prior clinical real-time development of a gather information when presented with all but the being limited by and encounters allows differential diagnosis early presented with complex or most complex or rare dependent upon analytic information to be filtered, in the information- uncommon problems clinical problems. These reasoning through basic prioritized, and gathering process illness and instance scripts pathophysiology alone synthesized into pertinent are robust enough to positives and negatives, as enable discrimination well as broad diagnostic among diagnoses with categories subtle distinguishing features

Comments:

Copyright © 2012 Accreditation Council for Graduate Medical Education and American Board of Pediatrics. All rights reserved. The copyright owners grant third parties the right to use the Pediatrics Milestones on a non-exclusive basis for educational purposes. 1 Version 7/2017

PC2. Organize and prioritize responsibilities to provide patient care that is safe, effective, and efficient

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Struggles to organize patient Organizes the Organizes the Organizes patient care Serves as a role model of care responsibilities, leading to simultaneous care of a few simultaneous care of many responsibilities to optimize efficiency; patient care focusing care on individual patients with efficiency; patients with efficiency; efficiency; provides care to responsibilities are patients rather than multiple occasionally prioritizes routinely prioritizes patient a large volume of patients prioritized to proactively patients; responsibilities are patient care care responsibilities to with marked efficiency; prevent interruption by prioritized as a reaction to responsibilities to proactively anticipate patient care routine aspects of patient unanticipated needs that arise anticipate future needs; future needs; additional responsibilities are care that can be (those responsibilities each additional patient or care responsibilities lead to prioritized to proactively anticipated; unavoidable presenting the most significant interruption in work leads decreases in efficiency and prevent those urgent and interruptions are crisis at the time are given the to notable decreases in ability to effectively emergent issues in patient prioritized to maximize highest priority); even small efficiency and ability to prioritize only when care that can be safe and effective interruptions in task often lead effectively prioritize; patient volume is quite anticipated; interruptions multitasking of to a prolonged or permanent permanent breaks in task large or there is a in task lead to only brief responsibilities in break in that task to attend to with interruptions are less perception of competing breaks in task in most essentially all situations the interruption, making return common, but prolonged priorities; interruptions in situations to initial task difficult or breaks in task are still task are prioritized and unlikely common only lead to prolonged breaks in task when workload or cognitive load is high

Comments:

PC3. Provide transfer of care that ensures seamless transitions

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Demonstrates variability in Uses a standard template Adapts and applies a Adapts and applies a Adapts and applies the transfer of information for the information standardized template, standard template to template without error (content, accuracy, efficiency, provided during the hand- relevant to individual increasingly complex and regardless of setting or and synthesis) from one patient off; is unable to deviate contexts, reliably and situations in a broad complexity; internalizes to the next; makes frequent from that template to reproducibly, with minimal variety of settings and the professional errors of both omission and adapt to more complex errors of omission or disciplines; ensures open responsibility aspect of commission in the hand-off situations; may have errors commission; allows ample communication, whether hand-off communication, of omission or commission, opportunity for in the receiver- or the as evidenced by formal and particularly when clinical clarification and questions; provider-of-information explicit sharing of the information is not is beginning to anticipate role, through deliberative conditions of transfer (e.g., synthesized; neither potential issues for the inquiry, including read- time and place) and anticipates nor attends to transferee backs, repeat-backs communication of those the needs of the receiver (provider), and clarifying conditions to patients, of information questions (receivers) families, and other members of the health care team

Comments:

PC4. Make informed diagnostic and therapeutic decisions that result in optimal clinical judgment

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Recalls and presents clinical Focuses on features of the Abstracts and reorganizes Reorganizes and stores Current literature does facts in the history and physical clinical presentation, elicited clinical findings in clinical information (illness not distinguish between in the order they were elicited making a unifying diagnosis memory, using semantic and instance scripts) that behaviors of proficient without filtering, elusive and leading to a qualifiers (such as paired lead to early directed and expert practitioners. reorganization, or synthesis; continual search for new opposites that are used to diagnostic hypothesis Expertise is not an demonstrates analytic diagnostic possibilities; describe clinical testing with subsequent expectation of GME reasoning through basic largely uses analytic information [e.g., acute history, physical training, as it requires pathophysiology results in a list reasoning through basic and chronic]) to compare examination, and tests deliberate practice over of all diagnoses considered pathophysiology in and contrast the diagnoses used to confirm this initial time rather than the development of diagnostic and therapeutic being considered when schema; demonstrates working diagnostic reasoning; often presenting or discussing a well-established pattern considerations, making it reorganizes clinical facts in case; shows the recognition that leads to difficult to develop a the history and physical emergence of pattern the ability to identify therapeutic plan examination to help decide recognition in diagnostic discriminating features on clarifying tests to order and therapeutic reasoning between similar patients rather than to develop and that often results in a well- and to avoid premature prioritize a differential synthesized and organized closure; Selects therapies diagnosis, often resulting assessment of the focused that are focused and based in a myriad of tests and differential diagnosis and on a unifying diagnosis, therapies and unclear management plan resulting in an effective management plans, since and efficient diagnostic there is no unifying work-up and management diagnosis plan tailored to address the individual patient

Comments:

PC5. Develop and carry out management plans

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Develops and carries out Develops and carries out Develops and carries out Develops and carries out Develops and carries out management plans based on management plans based management plans based management plans based management plans, even directives from others, either on one’s theoretical on both theoretical most often on experience; for complicated or rare from the health care knowledge and/or knowledge and some effectively and efficiently situations, based primarily organization or the supervising directives from others; can experience, especially in focuses on key information on experience that puts physician; is unable to adjust adapt plans to the managing common to arrive at a plan; theoretical knowledge into plans based on individual individual patient, but only problems; follows health incorporates patients’ context; rapidly focuses on patient differences or within the framework of care institution directives assumptions and values key information to arrive preferences; communication one’s own theoretical as a matter of habit and through bidirectional at the plan and augments about the plan is unidirectional knowledge; is unable to good practice rather than communication with little that with available from the practitioner to the focus on key information, as an externally imposed interference from personal information or seeks new patient and family so conclusions are often sanction; is able to more biases information as needed; has from arbitrary, poorly effectively and efficiently insight into one’s own prioritized, and time- focus on key information, assumptions and values limited information but still may be limited by that allow one to filter gathering; develops time and convenience; them out and focus on the management plans based begins to incorporate patient/family values in a on the framework of one’s patients’ assumptions and bidirectional conversation own assumptions and values into plans through about the management values more bidirectional plan communication

Comments:

MK1. Critically evaluate and apply current medical information and scientific evidence for patient care

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Explains basic principles of Recognizes the importance Identifies knowledge gaps Formulates answerable Teaches critical appraisal Evidence-based Medicine of using current as learning opportunities; clinical questions regularly; of topics to others; strives (EBM), but relevance is limited information to care for makes an effort to ask incorporates use of clinical for change at the by lack of clinical exposure patients and responds to answerable questions on a evidence in rounds and organizational level as external prompts to do so; regular basis and is teaches fellow learners; is dictated by best current is able to formulate becoming increasingly able quite capable with information; is able to questions with significant to do so; understands advanced searching; is able easily formulate effort and time; online varying levels of evidence to critically appraise topics answerable clinical search efficiency is and can utilize advanced and does so regularly; questions and does so with minimal; (e.g., may require search methods; is able to shares findings with others majority of patients as a multiple search strategies); critically appraise a topic to try to improve their habit; is able to effectively knows how to read and by analyzing the major abilities; practices EBM and efficiently search and interpret the literature but outcomes, however, may because of the benefit to access the literature; is requires guidance for need guidance in the patient and the desire seen by others as a role application understanding the to learn more rather than model for practicing EBM subtleties of the evidence; in response to external begins to seek and apply prompts evidence when needed, not just when assigned to do so

Comments:

SBP1. Coordinate patient care within the health care system relevant to their clinical specialty

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Performs the role of medical Begins to involve the Recognizes the Actively assists families in Current literature does decision-maker, developing patient/family in setting responsibility to assist navigating the complex not distinguish between care plans and setting goals of care goals and some of the families in navigation of health care system; has behaviors of proficient care independently; informs decisions involved in the the complex health care open communication, and expert practitioners. patient/family of the plan, but care plan; a written care system; frequently involves facilitating trust in the Expertise is not an no written care plan is plan is occasionally made patient/family in decisions patient-physician expectation of GME provided; makes referrals, and available to the at all levels of care, setting interaction; develops goals training, as it requires requests consultations and patient/family; care plan goals, and defining care and makes decisions jointly deliberate practice over testing with little or no does not address key plans; frequently makes a with the patient/family time communication with team issues; has variable written care plan available (shared-decision-making); members or consultants; is not communication with team to the patient/family and routinely makes a written involved in the transition of members and consultants to appropriately care plan available to the care between settings (e.g., regarding referrals, authorized members of the patient/family and to outpatient and inpatient, consultations, and testing; care team; care plan omits appropriately authorized pediatric and adult); shows answers patient/family few key issues; has good members of the care team; little or no recognition of questions regarding results communication with team makes a thorough care social/educational/cultural and recommendations; members and consultants; plan, addressing all key issues affecting the may inconsistently be consistently discusses issues; facilitates care patient/family involved in the transition results and through consultation, of care between settings recommendations with referral, testing, (e.g., outpatient and patient/family; is routinely monitoring, and follow-up, inpatient, pediatric and involved in the transition helping the family to adult); makes some of care between settings interpret and act on assessment of (e.g., outpatient and results/recommendations; social/educational/cultural inpatient, pediatric and coordinates seamless issues affecting the adult); considers social, transitions of care patient/family and applies educational and cultural between settings (e.g., this in interactions issues in most care outpatient and inpatient, interactions pediatric and adult; mental and dental health; education; housing; food security; family-to-family

support); builds partnerships that foster family-centered, culturally- effective care, ensuring communication and collaboration along the continuum of care

Comments:

SBP2. Advocate for quality patient care and optimal patient care systems

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Attends to medical needs of Demonstrates recognition Acts within the defined Actively participates in Identifies and acts to begin individual patient(s); wants to that an individual patient’s medical role to address an hospital-initiated quality the process of take good care of patients and issues are shared by other issue or problem that is improvement and safety improvement projects takes action for individual patients, that there are confronting a cohort of actions; demonstrates a both inside the hospital patients’ health care needs systems at play, and that patients; may enlist desire to have an impact and within one’s practice there is a need for quality colleagues to help with this beyond the hospital walls community improvement of those problem systems; acts on the observed need to assess and improve quality of care Example: Sees a child with a firearm Example: Example: Example: Example: injury and provides good care. A physician notes on The physician works with The physician attends a Upon completion of quality rounds, “We have sent colleagues to develop an hospital symposium on improvement project, the home four-to-five firearm- approach, protocol, or gun-related trauma and physician works on new injury patients and one has procedure for improving what can be done about it proposed legislation and come back with repeated care for penetrating and then arranges to speak testifies in City Council. injury. We need to do trauma injury in children on gun safety at the local something about that.” and measures the meeting of the parent- outcomes of system teachers association. changes.

Comments:

SBP3. Work in inter-professional teams to enhance patient safety and improve patient care quality

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Seeks answers and responds to Is beginning to have an Aware of the unique Same as Level 3, but an Current literature does authority from only intra- understanding of the other contributions (knowledge, individual at this stage not distinguish between professional colleagues; does professionals on the team, skills, and attitudes) of understands the broader behaviors of proficient not recognize other members especially their unique other health care connectivity of the and expert practitioners. of the interdisciplinary team as knowledge base, and is professionals, and seeks professions and their Expertise is not an being important or making open to their input, their input for appropriate complementary nature; expectation of GME significant contributions to the however, still acquiesces to issues, and as a result, is an recognizes that quality training, as it requires team; tends to dismiss input physician authorities to excellent team player patient care only occurs in deliberate practice over from other professionals aside resolve conflict and the context of the inter- time from other physicians provide answers in the professional team; serves face of ambiguity; is not as a role model for others dismissive of other health in interdisciplinary work care professionals, but is and is an excellent team unlikely to seek out those leader individuals when confronted with ambiguous situations

Comments:

PBLI1. Identify strengths, deficiencies, and limits in one’s knowledge and expertise

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

The learner acknowledges Assessment of Prompts for understanding Prompted by anticipation Prompted by a self- external assessments, but performance is seen as specifics of level of or contemplation of directed goal of improving understanding of his being able to do or not do performance are internal potential clinical problems, the professional self, the performance is superficial and the task at hand without and may be identified in the learner self-identifies practitioner anticipates limited to the overall grade or appreciation for how well response to uncertainty, gaps in KSA through hypothetical clinical bottom line; has little it is done and whether discomfort, or tension in reflection that assesses scenarios that build on understanding of how the there is a need to improve completing clinical duties; current KSA versus current experience and performance measure relates the outcome evidence of this stage is understanding of systematically addresses in a meaningful way to his demonstrated by active underlying basic science or identified gaps to enhance specific level of Knowledge, questioning and pathophysiologic principles the level of KSA; elaborate Skills and Attitudes (KSA) application of knowledge to generate new questions questioning occurs to in developing a rationale about limitations or further explore gaps and for care plans or in mastery of KSA; evidence strengths teaching activities of this stage can be determined by the advanced nature and level of questioning or resource seeking

Example: Example: Example: Example: Example: During a semiannual review, a The learner seeks external Learner requests In caring for a patient with In caring for a patient, a learner is unable to describe in assessment of performance elaboration, clarification, an illness not previously practitioner becomes any specific terms how he has as ability “to do” or “not or expansion on patient- encountered, this aware of a gap in KSA, and performed when asked to do so able to do” with little care related task. “Why practitioner says, “I have in response (with or by his mentor. In response, the understanding of what the would we use this experience taking care of without consultation from mentor reviews and interprets assessment means. “Are antibiotic for this patients with this acute a mentor) seeks to the learner’s evaluations and these orders written condition?” or “The patient illness but have never had understand more about the then asks the learner to reflect correctly?” “Did I do that has underlying condition x. a patient with this acute identified KSA gap. A PICO- on the discussion. The learner correctly?” Seeks feedback Does that alter therapy y illness who also had this formatted question (P = repeats the language used and approval on whether KSA for this patient?” or “I think particular underlying Patient, I = Intervention, C recites the overall score/grade were “right” or “wrong.” we should order study w condition and wonder if = Comparison, O =

without interpretation of Does not seek “How?” or for this patient, since the chronic condition might Outcome) is constructed, further meaning or inference “Why?” as part of request sometimes this disease alter his clinical course?” followed by a process of regarding the reported for feedback to assist presents with underlying identification of learning performance assessment identification of KSA. condition z.” needed.

Comments:

PBLI2. Identify and perform appropriate learning activities to guide personal and professional development

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Sets learning activities based Well-defined goals are Learning resources are Consideration of choice of Seeking resources to learn on readily available curricular mapped to appropriate sought based on analysis activities is based on is undertaken with high materials, irrespective of learning activities and of learning needs instructional methods that efficiency and learning style, preferences, resources based on assessment and are known to be effective effectiveness, with open appropriateness of activity, or assigned curriculum; constructed goals, and in the development of the and flexible inclusion of any outcome measures assignment may be part of with consideration of the relevant knowledge the influences from a teacher-constructed nature of the learning content, application of that outside sources (including curriculum, or part of a content and method knowledge, and regulatory and oversight prescribed curriculum development of skills or groups); fruitful pathways offered by others, or behaviors; learning takes and resources for learning sought by the learner in place through collaborative are readily shared with response to a performance interface with experts in peers and self-assessment gap which learning activities of learning drives further sought are ones that allow resource seeking for constant course correction and interactive sharing of alternative perspectives and differing lenses Example: Example: Example: Example: Example: The learner seeks to After realizing a need to better A learner reads cases Having failed at intubation A learner is planning an expand the types of devices understand what medications assigned for primary care in the delivery room, the advocacy workshop for discussed in the workshop should be used in the in advance of coming to a learner goes back to the parents of children with and looks to the work management of a clinic patient scheduled clinic session simulation lab to receive complex medical needs to published by the Institute with moderate asthma, the where a discussion of the further training on improve their skills with of Medicine Committee on learner asks a peer who is cases is to take place. intubation with the managing medical devices. Safe Medical Devices for working with him in clinic Others have not read the manikin (and does not In the process of preparing Children.11 He decides to rather than pursuing the case, and after the session simply reread the Neonatal for this workshop, he pursue resources (experts references suggested by his the resident is left Resuscitation Protocol10). discovers that there is an in the field) to see if it clinic preceptor. wondering about the case in-service for parents of would be possible to learn and its relevance to overall hospitalized patients in how to provide the

learning. The case is part of how to care for devices and instructional materials, a core curriculum with participates in this learning plans, and workshops to learning goals and activity. Through this in- parents throughout the objectives. Later, in clinic a service, he identifies state. patient presents with a written resources, models problem similar to last useful for demonstrations, week’s case discussion, and and video-recorded the learner is able to go illustrations of anticipated back to that case to glean complications with device further information on how use. He chooses to conduct to manage the patient. a practice rehearsal with some families in the inpatient setting, with course correction from the hospital’s nurse-educator.

Comments:

PBLI3. Systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Unable to gain insight from Able to gain insight from Able to gain insight for Able to use both individual In addition to encounters due to a lack of reflection on individual improvement encounters and population demonstrating continuous reflection on practice; does not patient encounters, but opportunities from data to drive improvement improvement activities and understand the principles of potential improvements reflection on both using improvement appropriately utilizing quality improvement are limited by a lack of individual patients and methodology; analyzes quality improvement methodology or change systematic improvement populations; grasps one’s own data on a methodologies, thinks and management; is defensive strategies and team improvement continuous basis, without acts systemically to try to when faced with data on approach; is dependent methodologies enough to reliance on external forces, use one’s own successes to performance improvement upon external prompts to apply to populations; is still to prioritize improvement benefit other practices, opportunities within one’s define improvement reliant on external efforts, and uses that systems, or populations; is practice opportunities at the prompts to inform and analysis in an iterative open to analysis that at population level prioritize improvement process for improvement; times requires course opportunities at the is able to lead a team in correction to optimize population level improvement improvement

Comments:

PBLI4. Incorporate formative evaluation feedback into daily practice

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Has difficulty in considering Is dependent on external Understands others’ points Internal sources of Demonstrates professional others’ points of view when sources of feedback for of view and changes feedback allow for insight maturity and deep these differ from his or her improvement; is beginning behavior to improve into limitations and emotional commitment own, leading to defensiveness to acknowledge other specific deficiencies that engagement in self- that lead to deliberate and inability to receive points of view, but are noted by others (e.g., regulation; improves daily practice and result in the feedback and/or avoidance of reinterprets feedback in a understands that the practice based on both habits of continuous feedback; demonstrates a way that serves his or her perceptions of others are external formative reflection, self-regulation, limited incorporation of own need for praise or important even when feedback and internal and internal feedback and formative feedback into daily consequence avoidance, those perceptions are insights (e.g., is able to that lead to continuous practice rather than informing a different from his or her point out what went well improvement beyond a personal quest for own, (such as when a and what did not go well in focus solely on deficiencies improvement; little to no nurse interprets a a given encounter, and behavioral change occurs response as abrupt when it makes positive changes in in response to feedback was not intended to be) behavior as a result) (e.g., listens to feedback causing the learner to but takes away only those examine what prompted messages he or she wants this perception) to hear)

Comments:

PROF1. Demonstrate humanism, compassion, integrity, and respect for others; based on the characteristics of an empathetic practitioner

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Interacts with patients and Demonstrates compassion Demonstrates consistent Goes beyond responding Proactively advocates on families in a way that is for patients in selected understanding of patient to expressed needs of behalf of individual detached and not sensitive to situations (e.g., tragic and family expressed patients and families; is patients, families, and the human needs of the patient circumstances, such as needs and a desire to meet altruistic and anticipates groups of children in need and family unexpected death), but has those needs on a regular the human needs of a pattern of conduct that basis; is responsive in patients and families and demonstrates a lack of demonstrating kindness works to meet those needs sensitivity to many of the and compassion as part of her skills in daily needs of others practice

Comments:

PROF2. Professionalization: A sense of duty and accountability to patients, society, and the profession

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Appears to be interested in Appreciates the role in Demonstrates Internalizes and accepts Extends professional role learning pediatrics but not fully providing care and being a understanding and full responsibility of the beyond the care of engaged and involved as a professional, at times has appreciation of the professional role and patients and sees self as a professional, which results in difficulty in seeing self as a professional role and the develops fluency with professional who is an observational or passive role professional, which may gravity of being the patient care and contributing to something result in not taking “doctor” by becoming fully professional relationships larger (e.g., a community, a appropriate primary engaged in patient care in caring for a broad range specialty, or the medical responsibility activities; has a sense of of patients and team profession) duty; has rare lapses into members behaviors that do not reflect a professional self-view

Comments:

PROF3. Professional Conduct: High standards of ethical behavior which includes maintaining appropriate professional boundaries

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Demonstrates repeated lapses Demonstrates lapses in Conducts interactions In Demonstrates an in-depth Role models professional in professional conduct professional conduct under nearly all circumstances understanding of conduct; interactions with wherein responsibility to conditions of stress or with a professional professionalism that allows patients, families, and patients, peers, and/or the fatigue, that lead others to mindset, sense of duty, her to help other team peers demonstrates high program are not met. These engage in reminding about and accountability; members and colleagues ethical standards across lapses may be due to an and, enforcing professional demonstrates conduct that with issues of settings and apparent lack of insight about behaviors as well as illustrates insight into her professionalism; circumstances; utilizes the professional role and resolving conflicts; there own behavior, as well as demonstrates self- excellent emotional expected behaviors or other may be some insight into likely triggers for reflection to identify and intelligence about human conditions or causes (e.g., behavior, but an inability professionalism lapses, and voice insights to prevent behavior and insight into depression, substance use, to modify behavior when is able to use this lapses in conduct as part of self, to promote and poor health) placed in stressful information to remain her duty to help others engage in professional situations professional behavior as well as to prevent lapses in others and self

Comments:

PROF4. Self-awareness of one’s own knowledge, skill, and emotional limitations that leads to appropriate help-seeking behaviors

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Demonstrates limited insight Expresses concern that Recognizes limitations, but Recognizes limitations and Demonstrates the into limitations in knowledge, limitations may be seen as has the perception that has matured to the stage personal drive to learn and skills or attitudes which results weaknesses that will autonomy is a key element where a personal value improve results in the in the learner not seeking help negatively impact of one’s identity as a system of help-seeking for habit of engaging in help- when needed, sometimes evaluations; this results in physician, and the need to the sake of the patient seeking behaviors and resulting in unintended help-seeking behaviors, emulate this behavior to supersedes any perceived explicitly role modeling consequences typically only in response belong to the profession value of physician and encouraging these to external prompts rather may interfere with internal autonomy, resulting in behaviors in others than internal drive drive to engage in appropriate requests for appropriate help-seeking help when needed behavior

Comments:

PROF5. Trustworthiness that makes colleagues feel secure when one is responsible for the care of patients

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Demonstrates gaps or is Demonstrates gaps in KSA, Demonstrates inadequate Demonstrates competent Demonstrates competent unaware of significant but does not always voice level of KSA for the level of level of KSA for the level of level of KSA for the level of knowledge, skills or attitudes awareness of or seek help clinical responsibility, with clinical responsibility and clinical responsibility and (KSA) gaps; demonstrates when confronted with realistic insight into limits assumes full responsibility assumes full responsibility lapses in data-gathering or in limitations; demonstrates with responsive help for all aspects of patient for all aspects of patient follow-through of assigned lapses in follow-up or seeking; data-gathering is care, anticipating problems care, anticipating problems tasks; may misrepresent data follow-through with tasks, complete with and demonstrating and demonstrating (for a number of reasons) or despite awareness of the consideration of vigilance in all aspects of vigilance in all aspects of omit important data, leaving importance of these tasks; anticipated patient care management; pursues management; pursues others uncertain as to the follow-through may be needs, and careful answers to questions, and answers to questions, and nature of the learner’s limited due to consideration of high-risk communications include communications include truthfulness or awareness of inconsistency or yielding to conditions first and open, transparent open, transparent the importance of attention to barriers; when such foremost; little prompting expression of uncertainty expression of uncertainty detail and accuracy (overt lack barriers are experienced, is required for follow-up and limits of knowledge and limits of knowledge; of truth-telling is assessed in no escalation occurs (such uncertainty brings about another professionalism as notifying others or rigorous search for competency) pursuing alternative answers and conscientious solutions) and ongoing review of information; may seek the help of a consultant in addition to primary source literature

Example: * Example: Example: Example: Example: A learner calls his supervisor at On hand-over of patients Presentation of a patient An individual possesses the This is the practitioner who home to present a patient that from the day team to the consultation is done in a KSA to lead the team on leaves no stone unturned. he admitted. Key laboratory night team, several tasks comprehensive manner, rounds, asking for Colleagues are confident results are missing in the are identified as needing without the need for pertinent data not when handing-off a patient presentation and the supervisor follow-up or completion prompting. Questions presented by other team that the patient will receive requests that the learner seek during the next shift. The posed by the learner allow members (assertive exemplary care. In fact, this critical information and following day, when the the consultant to inquiry). Constant review when there is a complex report back. Several hours later service is handed back over appreciate the learner’s and vigilance of patient patient, colleagues are

on rounds, the learner is again to the original learner, understanding of the status uncovers relieved when this questioned about the several of these tasks were disease process and the unexplained findings on practitioner is on-call laboratory values, and reports either incomplete or not learners’ awareness of laboratory or physical because he typically invests that the results are normal, but completed as specified in gaps in his knowledge. examination. Findings are much time and energy in is unable to locate those results the sign-out. When Careful attention to detail reported to supervisors as searching for needed in his paperwork. questioned about these and accuracy are evident in change with un-identified answers and meticulously D-2, C-1, T-2 tasks, the night-float the history and physical meaning (and potential reports back on all individual indicated that examination that is concern). KSA-4, D-4, T-4 important developments. things were busy, he presented. The next day, KSA-4, D-4, C-4, T-4 forgot, or gives another the service is busy and the KSA= Knowledge, skills & excuse indicating an learner needs reminding to attitudes awareness of the re-check the send-out labs. D= Discernment expectation but failure to KSA-3, D-3, C-3 C= Conscientiousness complete the tasks. KSA-3, T= Truth telling D-2, C-3 Number refers to performance level (1-5)

Comments:

PROF6. Recognize that ambiguity is part of clinical medicine and to recognize the need for and to utilize appropriate resources in dealing with uncertainty

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Demonstrates state of being Expresses recognition of Anticipates and focuses on Anticipates that Acknowledges and overwhelmed and unsure uncertainty and the uncertainty, looking for uncertainty at the time of manages personal level of when faced with uncertainty or tension/pressure from not resolution by seeking diagnostic deliberation will risk aversion or risk-taking ambiguity; communications knowing or knowing with additional information; be likely; uses such tendencies; seeks to with patients/families and limited control of informs the patient of the uncertainty or ambiguity as understand patient/family development of therapeutic outcomes; explains more optimal outcome(s), a prompt/motivation to goals for health and their plan are approached in a situation to the patient in framed by physician goals; seek information or capacity to achieve those limited and authoritarian framework most familiar does not manage overall understanding of unknown goals,; engages in manner;; patient/family to the physician, rather balance of patient/family (to self or world); balances discussion with high numeracy (understanding of than framing it with terms, uncertainty with quality of delivery of diagnosis with sensitivity towards health probability/risk) is presumed; graphics, or analogies life, need for hope, and hope, information, and literacy and numeracy, seeks only self or self-available familiar to the patient; ability to adhere to exploration of individual emphasizing patient/family resources to manage response seeks rules and statistics therapeutic plan; focuses patient goals; works control of choices; openly to this uncertainty, resulting in and feels compelled to on own risk management through concepts of risk and comfortably discusses a response characterized by transfer all information to position for a given versus hope using strategies and outcomes their (individual) preexisting the patient immediately, problem and does not conceptual framework that anticipated with the state of risk aversion or risk regardless of patient suggest that more or less includes cost (e.g., patient/family, taking; does not regard patient readiness, patient goals, risk taking (different from suffering, lifestyle changes, emphasizing that all plans need for hope; feels compelled and patient ability to physician’s position) could financial) versus benefit, are subject to the to make sure that patients manage information be chosen; still seeks framed by patient health imperfect knowledge and understand full potential for patient/parent recitation care goals; expresses state of uncertainty; negative outcome of uncertainty/morbidity openness to patient ongoing information (defensive/protective of as proof that position and patient sharing through changes as physician) patient/family understands uncertainty about his or knowledge and patient the uncertainty; her position and response health status evolve; unresolved balance of remains flexible and physician/patient committed to engagement expectations with with the patient/family physician expectations throughout the patient’s taking precedence illness, serving as a

resource to gather information; constant revisiting of knowledge, uncertainty, and developed plans is balanced with acceptance of what is unknown; transparent communication of limits of treatment plan outcomes

Comments:

ICS1. Communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Uses standard medical Uses the medical interview Uses the interview to Uses communication to Connects with patients and interview template to prompt to establish rapport and effectively establish establish and maintain a families in an authentic all questions; does not vary the focus on information rapport; is able to mitigate therapeutic alliance; sees manner that fosters a approach based on a patient’s exchange relevant to a physical, cultural, beyond stereotypes and trusting and loyal unique physical, cultural, patient’s or family’s psychological, and social works to tailor relationship; effectively socioeconomic, or situational primary concerns; barriers in most situations; communication to the educates patients, families, needs; may feel intimidated or identifies physical, cultural, verbal and non-verbal individual; a wealth of and the public as part of all uncomfortable asking personal psychological, and social communication skills experience has led to communication; intuitively questions of patients barriers to communication, promote trust, respect, development of scripts for handles the gamut of but often has difficulty and understanding; the gamut of difficult difficult communication managing them; begins to develops scripts to communication scenarios; scenarios with grace and use non-judgmental approach most difficult is able to adjust scripts ad humility questioning scripts in communication scenarios hoc for specific encounters response to sensitive situations

Comments:

ICS2. Demonstrate the insight and understanding into emotion and human response to emotion that allows one to appropriately develop and manage human interactions

Not yet Assessable Level 1 Level 2 Level 3 Level 4 Level 5

Does not accurately anticipate Begins to use past Anticipates, reads, and Perceives, understands, Intuitively perceives, or read others’ emotions in experiences to anticipate reacts to emotions in real uses, and manages understands, uses, and verbal and non-verbal and read (in real time) the time with appropriate and emotions in a broad range manages emotions to communication; is unaware of emotional responses in professional behavior in of medical communication improve the health and one’s own emotional and himself and others across a nearly all typical medical scenarios and learns from well-being of others and to behavioral cues and may limited range of medical communication scenarios, new or unexpected foster therapeutic transmit emotions in communication scenarios, including those evoking emotional experiences; relationships in any and all communication (e.g., anxiety, but does not yet have the very strong emotions; uses effectively manages own situations; is seen as an exuberance, anger) that can ability or insight to these abilities to gain and emotions appropriately in authentic role model of precipitate unintended moderate behavior to maintain therapeutic all situations; effectively humanism in medicine emotional responses in others; effectively manage the alliances with others and consistently uses does not effectively manage emotions; strong emotions emotions to gain and strong emotions in oneself or in oneself and others may maintain therapeutic others still become overwhelming alliances with others; is perceived as a humanistic provider

Comments:

The Psychiatry Milestone Project

A Joint Initiative of

The Accreditation Council for Graduate Medical Education

and

The American Board of Psychiatry and Neurology

July 2015

The Psychiatry 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.

Psychiatry Milestone Group

Christopher R. Thomas MD, Chair

Working Group Advisory Group

Sheldon Benjamin, MD Timothy Brigham, MDiv, PhD Adrienne L. Bentman, MD Carol A. Bernstein, MD Robert Boland , MD Beth Ann Brooks, MD

Deborah S. Cowley, MD Larry R. Faulkner, MD

Jeffrey Hunt, MD, MS Deborah Hales, MD George A. Keepers, MD Victor I. Reus, MD Louise King, MS Richard F. Summers, MD Gail H. Manos, MD Donald E. Rosen, MD

Kathy M. Sanders, MD Mark E. Servis, MD Kallie Shaw, MD Susan Swing, PhD Alik Widge, MD, PhD

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 progresses from entry into residency through graduation. In the initial years of implementation, the Review Committee will examine aggregate milestone performance data for each program’s residents as one element in the Next Accreditation System to determine whether residents overall are progressing. Thus, aggregate resident performance will be an additional measure of a program’s ability to educate its residents.

Program directors have the responsibility of ensuring that residents’ progress on all 22 psychiatry subcompetencies (as identified in the top row of each milestone table) is documented every six months through the Clinical Competency Committee (CCC) review process. The CCC’s decisions should be guided by information gathered through formal and informal assessments of residents during the prior six-month period. The ACGME does not expect formal, written evaluations of all milestones (each numbered item within a subcompetency table) every six months. For example, formal evaluations, documented observed encounters in inpatient and outpatient settings, and multisource evaluation should focus on those subcompetencies and milestones that are central to the resident’s development during that time period.

Progress through the Milestones will vary from resident to resident, depending on a variety of factors, including prior experience, education, and capacity to learn. Residents learn and demonstrate some skills in episodic or concentrated time periods (e.g., formal presentations, participation in quality improvement project, child/adolescent rotation scheduling, etc.). Milestones relevant to these activities can be evaluated at those times. The ACGME does not expect that resident progress will be linear in all areas or that programs organize their curricula to correspond year by year to the Psychiatry Milestones. All milestone threads (as indicated by the letter in each milestone reference number, the “A” in PC1, 1.1/A ) should be formally evaluated and discussed by the CCC on at least two occasions during a resident’s educational program.

Thread names, preceded by their indicator letters, are listed in the top row of each milestone table. Each thread describes a type of activity, behavior, skill, or knowledge, and typically consists of two-to-four milestones at different levels. For example, the “B” thread for PC1, named “collateral information gathering and use,” consists of the set of progressively more advanced and comprehensive behaviors identified as 1.2/B, 2.3/B, 3.3/B, 4.2/B, 4.3/B and 5.2/A,B. The thread identifies the unit of observation and evaluation. For, PC1, thread “B,” faculty members would observe a resident’s evaluation of a patient to see whether he or she demonstrates the

iii

collateral information gathering and use behaviors described in that milestone. Threads do not always have milestones at each level 1-5; some threads may consist of only one milestone (see the diagram on page vi).

For each six-month reporting period, review and reporting will involve selecting the level of milestones that best describes a resident’s current performance level. Milestones are arranged into numbered levels. These levels do not correspond with post- graduate year of education.

Selection of a level for a subcompetency implies that the resident substantially demonstrates the milestones in that level, as well as those in lower levels (see the diagram on page vi). A general interpretation of levels for psychiatry is below:

Has not Achieved Level 1: The resident does not demonstrate the milestones expected of an incoming resident.

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; the resident demonstrates the majority of milestones targeted for residency in this sub-competency.

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.

*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 (See the Milestones FAQ for further discussion of this issue: “Can a resident/fellow graduate if he or she does not reach every milestone?”). Study of Milestone performance data will be required before the ACGME and its partners will be able to determine whether Level 4 milestones and milestones in lower levels are in the appropriate level within the developmental framework, and whether Milestone data are of sufficient quality to be used for high stakes decisions.

Selecting the Appropriate Milestone Level for your Residents: The Role of Supervision

Faculty supervisors, especially those overseeing clinical care, will directly assess many milestones. The CCC assessment is based on evaluations completed by these clinical supervisors along with other assessments, including performance on tests and evaluations from other sources. The process of Milestone assignment assumes that all residents are supervised in their clinical work, as outlined in the ACGME’s supervision levels and requirements. For the purposes of evaluating a resident’s progress in achieving Patient Care and Medical Knowledge Milestones, though, it is important that the evaluator(s) determine what the resident knows and can do, separate from the skills and knowledge of his or her supervisor.

Implicit in milestone level evaluation of Patient Care (PC) and Medical Knowledge (MK) is the assumption that during the normal course of patient care activities and supervision, the evaluating faculty member and resident participate in a clinical discussion of the patient's care. During these reviews the resident should be prompted to present his or her clinical thinking and decisions regarding the patient. This may include evidence for a prioritized differential diagnosis, a diagnostic workup, or initiation, maintenance, or modification of the treatment plan, etc. In offering his or her independent ideas, the resident demonstrates his or her capacity for clinical reasoning and its application to patient care in real-time.

As residents progress, their knowledge and skills should grow, allowing them to assume more responsibility and handle cases of greater complexity. They are afforded greater autonomy - within the bounds of the ACGME supervisory guidelines - in caring for patients. At Levels 1 and 2 of the Milestones, a resident's knowledge and independent clinical reasoning will meet the needs of patients with lower acuity, complexity, and level of risk, whereas, at Level 4, residents are expected to independently demonstrate knowledge and reasoning skills in caring for patients of higher acuity, complexity, and risk. Thus, one would expect residents achieving Level 4 milestones to be senior residents at an oversight level of supervision. In general, one would not expect beginning or junior residents to achieve Level 4 milestones. At all levels, it is important that residents ask for, listen to, and process the advice they receive from supervisors, consult the literature, and incorporate this supervisory input and evidence into their thinking.

Additional Notes Please note that most milestone sets include explanatory footnotes for selected concepts. These appear at the bottom of each milestone table. The footnotes are essential tools in milestone evaluation.

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 the resident’s performance in relation to those milestones or  selecting the “Has not Achieved Level 1” response option

Competency Domain

Thread for: “Development as a Subcompetency Thread Names teacher” (all milestones with “A”)

Milestone

PSYCHIATRY MILESTONES ACGME Report Worksheet

PC1. Psychiatric Evaluation A: General interview skills B: Collateral information gathering and use C: Safety assessment D: Use of clinician's emotional response Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Obtains general 2.1/A Acquires efficient, 3.1/A Consistently obtains 4.1/A Routinely identifies 5.1/A Serves as a role medical and psychiatric accurate, and relevant history complete, accurate, and subtle and unusual findings model for gathering history and completes a customized to the patient’s relevant history subtle and reliable mental status examination complaints information from the 3.2/A Performs efficient patient 2.2/A Performs a targeted interview and examination examination, including with flexibility appropriate neurological examination, to the clinical setting and relevant to the patient’s workload demands 5.2/A, B Teaches and complaints supervises other learners in clinical 1.2/B Obtains relevant 2.3/B Obtains information that 3.3/B Selects laboratory 4.2/B Follows clues to evaluation collateral information from is sensitive and not readily and diagnostic tests identify relevant historical secondary sources offered by the patient appropriate to the clinical findings in complex clinical presentation situations and unfamiliar circumstances 3.4/B Uses hypothesis- driven information gathering techniques2

1.3/C Screens for patient 2.4/C Assesses patient safety, safety, including suicidal including suicidal and and homicidal ideation homicidal ideation

2.5/D Recognizes that the 4.3/D Begins to use the clinician’s emotional responses clinician's emotional have diagnostic value1 responses to the patient as a diagnostic tool

The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology. 1 11/15/2013

Comments:

Footnotes: 1This milestone refers to the use of the resident’s own emotional response to the patient’s presentation as a source of information to generate ideas about the patient’s own inner emotional state, both conscious and unconsious. 2This milestone focuses on the efficient and deductive conduct of the interview in accordance with diagnostic hypotheses to refine the differential diagnosis.

PC2. Psychiatric Formulation and Differential Diagnosis1 A: Organizes and summarizes findings and generates differential diagnosis B: Identifies contributing factors and contextual features and creates a formulation Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Organizes and accurately 2.1/A Identifies patterns 3.1/A Develops a full 4.1/A Incorporates subtle, summarizes, reports, and and recognizes differential diagnosis while unusual, or conflicting presents to colleagues phenomenology from the avoiding premature findings into hypotheses information obtained from the patient's presentation to closure and formulations patient evaluation generate a diagnostic hypotheses 1.2/A Develops a working diagnosis based on the patient 2.2/A Develops a basic evaluation differential diagnosis for common syndromes and patient presentations

2.3/B Describes patients’ 3.2/B Organizes 4.2/B Efficiently synthesizes 5.1/B Serves as a role symptoms and problems, formulation around all information into a model of efficient and precipitating stressors or comprehensive models of concise but comprehensive accurate formulation events, predisposing life phenomenology that take formulation events or stressors, etiology into account 2 5.2/B Teaches perpetuating and formulation to advanced protective factors, and learners prognosis

Comments:

Footnotes: 1A psychiatric formulation is a theoretically-based conceptualization of the patient’s mental disorder(s). It provides an organized summary of those individual factors thought to contribute to the patient’s unique psychopathology. This includes elements of possible etiology, as well as those that modify or influence presentation, such as risk and protective factors. It is therefore distinct from a differential diagnosis that lists the possible diagnoses for a patient, or an assessment that summarizes the patient’s signs and symptoms, as it seeks to understand the underlying mechanisms of the patient’s unique problems by proposing a hypothesis as to the causes of mental disorders. 2Models of formulation include those based on either major theoretical systems of the etiology of mental disorders, such as behavioral, biological, cognitive, cultural, psychological, psychoanalytic, sociological, or traumatic, or comprehensive frameworks of understanding, such as bio-psycho-social or predisposing, precipitating, perpetuating, and prognostic outlines. Models of formulation set forth a hypothesis about the unique features of a patient’s illness that can serve to guide further evaluation or develop individualized treatment plans.

PC3. Treatment Planning and Management A: Creates treatment plan B: Manages patient crises, recognizing need for supervision when indicated C: Monitors and revises treatment when indicated Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Identifies potential 2.1/A Sets treatment goals 3.1/A Incorporates 4.1/A Devises individualized 5.1/A Supervises treatment options in collaboration with the manual-based treatment1 treatment plan for complex treatment planning of patient when appropriate presentations other learners and multidisciplinary 2.2/A Incorporates a clinical 3.2/A Applies an 4.2/A Integrates multiple providers practice guideline or understanding of modalities and providers in treatment algorithm when psychiatric, neurologic, comprehensive approach3 5.2/A Integrates available and medical co-morbidities emerging neurobiological to treatment selection2 and genetic knowledge 2.3/A Recognizes co-morbid into treatment plan4 conditions and side effects’ 3.3/A Links treatment to impact on treatment formulation

1.2/B Recognizes patient in 2.4/B Manages patient 3.4/B Recognizes need for crisis or acute presentation crises with supervision consultation and supervision for complicated or refractory cases

1.3/C Recognizes patient 2.5/C Monitors treatment 3.5/C Re-evaluates and 4.3/C Appropriately readiness for treatment adherence and response revises treatment modifies treatment approach based on new techniques and flexibly information and or applies practice guidelines response to treatment to fit patient need

Comments:

Footnotes: 1Manual-based treatment is any psychotherapy that relies on written instructions for the therapist on the steps and conduct of treatment, often including specific indications, techniques, goals, and objectives. Manual-based treatments are frequently theory-driven and evidence-based. Examples of manual-based treatments include Interpersonal Psychotherapy, Dialectical-Behavioral Therapy, and many Cognitive-Behavioral Therapies. 2Examples might include psychopharmacology in the presence of neurodegenerative disorders, traumatic brain injury, critical medical illness, and cancer treatment, as well as understanding the family, systems, and multidisciplinary team efforts for the best outcome for treatment. 3Understanding and use of an array of modalities and providers may include consideration of complementary and alternative medicine, occupational therapy, and

physical therapy. 4Examples may include cytochrome genetics, ethnic differences, and family counseling, etc.

PC4. Psychotherapy Refers to 1) the practice and delivery of psychotherapies, including psychodynamic1, cognitive-behavioral2, and supportive therapies3; 2) exposure to couples, family, and group therapies; and 3) integrating psychotherapy with psychopharmacology A: Empathy and process B: Boundaries C: The alliance and provision of psychotherapies D: Seeking and providing psychotherapy supervision Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Accurately identifies 2.1/A Identifies and reflects 3.1/A Identifies and reflects 4.1/A Links feelings, patient emotions, the core feeling and key the core feeling, key issue, behavior, recurrent/central particularly sadness, anger, issue for the patient during and what the issue means to themes/schemas, and their and fear4 a session the patient meaning to the patient as they shift within and across sessions

1.2/B Maintains appropriate 2.2/B Maintains appropriate 3.2/B Recognizes and avoids 4.2/B Anticipates and professional boundaries professional boundaries in potential boundary appropriately manages psychotherapeutic violations potential boundary relationships while being crossings and avoids responsive to the patient5 boundary violations

1.3/C Demonstrates a 2.3/C Establishes and 3.3/C Establishes and 4.3/C Provides different 5.1/C Provides professional interest and maintains a therapeutic maintains a therapeutic modalities of psychotherapy psychotherapies to curiosity in a patient’s story alliance with patients with alliance with, and provides (including supportive patients with very uncomplicated problems6 psychotherapies (at least therapy and at least one of complicated and/or supportive, psychodynamic, psychodynamic or cognitive refractory 2.4/C Utilizes elements of and cognitive-behavioral) to, behavioral therapies) to disorders/problems supportive therapy in patients with uncomplicated patients with moderately treatment of patients problems complicated problems 5.2/C Personalizes treatment based on 3.4/C Manages the 4.4/C Selects a awareness of one’s own emotional content of, and psychotherapeutic modality skill sets, strengths, and feelings aroused during, and tailors the selected limitations sessions psychotherapy to the patient on the basis of an 3.5/C Integrates the selected appropriate case psychotherapy with other formulation treatment modalities and other treatment providers 7 4.5/C Successfully guides

the patient through the different phases of psychotherapy, including termination

4.6/C, D Recognizes, seeks appropriate consultation 3.6/D Balances autonomy about, and manages 5.3/D Provides with needs for consultation treatment impasses psychotherapy and supervision supervision to others

Comments:

Footnotes: 1Psychodynamic therapy includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to understand the concepts of resistance/defenses, transference/countertransference. 2Cognitive-behavioral therapy includes the capacity to generate a case formulation, to demonstrate techniques of intervention, including behavior change, skills acquisition, and to address cognitive distortions. 3Supportive therapy includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to strengthen the patient’s adaptive defenses, resilience, and social supports. 4This thread (A), consisting of the first items in Levels 1-4, regarding the development of empathy across residency, is adapted from the American Association of Directors of Psychiatric Residency Training (AADPRT) Psychotherapy Workgroup’s document “Benchmarks for Psychotherapy Training.” 5This refers to the ability to maintain professional boundaries in psychotherapy without being aloof or overly detached. 6Examples of uncomplicated problems are major depression or panic disorder without co-morbidity. 7At this level, the resident is expected to be able to integrate both psychotherapy and psychopharmacology in combined treatment of a patient, to deliver psychotherapy or psychopharmacology in collaboration with another provider who is doing the other treatment (shared treatment), and to be able to anticipate, discuss, and manage issues that result from a patient’s receiving other treatments (e.g., family, couples, or group therapy; psychopharmacology) at the same time as individual psychotherapy.

PC5. Somatic Therapies Somatic therapies including psychopharmacology, electroconvulsive therapy (ECT), and emerging neuromodulation therapies A: Using psychopharmacologic agents in treatment B: Education of patient about medications C: Monitoring of patient response to treatment and adjusting accordingly D: Other somatic treatments Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Lists commonly used 2.1/A Appropriately 3.1/A Manages 4.1/A Titrates dosage and psychopharmacologic agents prescribes1 commonly used pharmacokinetic and manages side effects of and their indications to psychopharmacologic agents pharmacodynamic drug multiple medications target specific psychiatric interactions when using symptoms (e.g., depression, multiple medications psychosis) concurrently

1.2/B Reviews with the 2.2/B Incorporates basic 5.1/B Explains less patient/family general knowledge of proposed common somatic indications, dosing mechanisms of action and treatment choices to parameters, and common metabolism of commonly patients/families in terms side effects for commonly prescribed of proposed mechanisms prescribed psychopharmacologic agents of action psychopharmacologic agents in treatment selection, and explains rationale to patients/families

2.3/C Obtains basic physical 3.2/C Monitors relevant 4.2/C Appropriately selects 5.2/C Integrates emerging exam and lab studies lab studies throughout evidence-based somatic studies of somatic necessary to initiate treatment, and treatment options treatments into clinical treatment with commonly incorporates emerging (including second and third practice prescribed medications physical and laboratory line agents and other findings into somatic somatic treatments2) for treatment strategy patients whose symptoms are partially responsive or 3.3/C Uses augmentation not responsive to treatment strategies, with supervision, when primary pharmacological interventions are only partially successful1

2.4/D Seeks consultation and The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology. 8 11/15/2013

supervision regarding potential referral for ECT

Comments:

Footnotes: 1This includes: (a) selection of agent, dose, and titration, based on psychiatric diagnoses, target symptoms, and specifics of patient’s history; (b) discussion of potential risks and benefits with patients (and family members, where appropriate); (c) decision regarding whether or not to prescribe a medication (or medication versus other type of treatment). 2Examples of other somatic therapies include neuromodulation, biofeedback, and phototherapy.

MK1. Development through the life cycle (including the impact of psychopathology on the trajectory of development and development on the expression of psychopathology) A: Knowledge of human development B: Knowledge of pathological and environmental influences on development C: Incorporation of developmental concepts in understanding Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Describes the basic 2.1/A Describes neural 3.1/A Explains 5.1/A Incorporates new stages of normal physical, development across the life developmental tasks and neuroscientific social, and cognitive cycle2 transitions throughout the knowledge into his or her development through the life life cycle, utilizing multiple understanding of cycle1 2.2/A Recognizes deviation conceptual models3 development from normal development, including arrests and regressions at a basic level

2.3/B Describes the effects 3.2/B Describes the 4.1/B Describes the of emotional and sexual influence of psychosocial influence of acquisition and abuse on the development factors (gender, ethnic, loss of specific capacities in of personality and cultural, economic), the expression of psychiatric disorders in general medical, and psychopathology across the infancy, childhood, neurological illness on life cycle adolescence, and personality development adulthood at a basic level 4.2/B Gives examples of gene-environment interaction influences on development and psychopathology4

2.43.2/C Utilizes De 3.3/C Utilizes appropriate developmental concepts in conceptual models of case formulation development in case formulation

Comments:

Footnotes: 1Includes knowledge of motoric, linguistic, and cognitive development at the level required to pass the United States Medical Licensing Examination (USMLE) Step 2, and also knowledge of developmental milestones in infancy through senescence, such as language acquisition, Piagetian cognitive development, and social and emotional development, such as the emergence of stranger wariness in infancy and the theme of independence versus dependence in adolescence. The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology. 10 11/15/2013

2Knowledge of fetal, childhood, adolescent, and early adult brain development, including abnormal brain development caused by genetic disorders (Tay-Sachs), environmental toxins, malnutrition, social deprivation, and other factors. 3Using the theoretical models proposed by psychodynamic, cognitive, and behavioral theorists. 4An example is bipolar disorder with genetic diathesis + environmental stress leading to manic behavior.

MK2. Psychopathology1 Includes knowledge of diagnostic criteria, epidemiology, pathophysiology, course of illness, co-morbidities, and differential diagnosis of psychiatric disorders, including substance use disorders and presentation of psychiatric disorders across the life cycle and in diverse patient populations (e.g., different cultures, families, genders, sexual orientation, ethnicity, etc.) A: Knowledge to identify and treat psychiatric conditions B: Knowledge to assess risk and determine level of care C: Knowledge at the interface of psychiatry and the rest of medicine Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Identifies the major 2.1/A Demonstrates 3.1/A Demonstrates 4.1/A Demonstrates psychiatric diagnostic system sufficient knowledge to sufficient knowledge to sufficient knowledge to (DSM) identify and treat common identify and treat most identify and treat atypical psychiatric conditions in psychiatric conditions and complex psychiatric adults in inpatient and throughout the life cycle conditions throughout the emergency settings (e.g., and in a variety of settings2 life cycle and in a range of depression, mania, acute settings (inpatient, psychosis) outpatient, emergency, 3 consultation liaison)

1.2/B Lists major risk and 2.2/B Demonstrates 3.2/B Displays knowledge 4.2/B Displays knowledge 5.1/B Displays knowledge protective factors for danger to knowledge of, and ability of, and the ability to weigh, sufficient to determine the sufficient to teach self and others to weigh risks and risk and protective factors appropriate level of care for assessment of risks and protective factors for, for, danger to self and/or patients expressing, or who the appropriate level of danger to self and/or others across the life cycle, may represent, danger to care for patients who others in emergency and as well as the ability to self and/or others, across may represent a danger inpatient settings determine the need for the life cycle and in a full to self and/or others acute psychiatric range of treatment settings hospitalization

1.3/C Gives examples of 2.3/C Shows sufficient 3.3/C Shows sufficient 4.3/C Shows knowledge 5.2/C Shows sufficient interactions between medical knowledge to perform an knowledge to identify and sufficient to identify and knowledge to identify and and psychiatric symptoms and initial medical and treat common psychiatric treat a wide range of treat uncommon disorders neurological evaluation in manifestations of medical psychiatric conditions in psychiatric conditions in psychiatric inpatients illness (e.g., delirium, patients with medical patients with medical depression, steroid- disorders disorders 2.4/C Demonstrates induced syndromes) sufficient knowledge to 4.4/C Demonstrates 5.3/C Demonstrates identify common medical 3.4/C Demonstrates sufficient knowledge to sufficient knowledge to conditions (e.g., sufficient knowledge to systematically screen for, detect and ensure hypothyroidism, include relevant medical evaluate, and diagnose appropriate treatment of

hyperlipidemia, diabetes) and neurological conditions common medical conditions uncommon medical in psychiatric patients in the differential diagnoses in psychiatric patients, and conditions in patients of psychiatric patients to ensure appropriate with psychiatric disorders further evaluation and treatment of these conditions in collaboration with other medical providers

Comments:

Footnotes: 1This milestone focuses on knowledge needed for patient care. Thus, knowledge of psychopathology can be assessed through multiple choice knowledge examinations (e.g., the Psychiatry Resident In-Training Examination (PRITE)), and/or through evaluations of the application of knowledge of psychopathology to patient care, such as standardized patients or case vignettes, clinical skills evaluations, and knowledge evidenced during clinical rotations and the routine, supervised care of patients during residency. 2This level includes identification and treatment of a wider array of conditions, across the life cycle (including childhood, adolescent, adult, and geriatric conditions), and in a variety of settings (e.g., outpatient, consultation liaison, subspecialty settings). 3“Atypical” and “complex” psychiatric conditions refer to unusual presentations of common disorders, co-occurring disorders in patients with multiple co-morbid conditions, and diagnostically challenging clinical presentations.

MK3. Clinical Neuroscience1 Includes knowledge of neurology, neuropsychiatry, neurodiagnostic testing, and relevant neuroscience and their application in clinical settings A: Neurodiagnostic testing B: Neuropsychological testing C: Neuropsychiatric co-morbidity D: Neurobiology E: Applied neuroscience Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Knows commonly 2.1/A Knows indications for 3.1/A Recognizes the 4.1/A Explains the significance 5.1/A Integrates recent available neuroimaging and structural neuroimaging significance of abnormal of routine neuroimaging, neurodiagnostic research neurophysiologic diagnostic (cranial computed findings in routine neurophysiological, and into understanding of modalities and how to order tomography [CT] and neurodiagnostic test6 neuropsychological testing psychopathology them magnetic resonance reports in psychiatric abnormalities to patients imaging [MRI]) and patients neurophysiological testing 4.2/A Knows clinical indications (electroencephalography and limitations of functional [EEG], evoked potentials, neuroimaging7 sleep studies)

1.2/B Knows how to order 2.2/B Describes common 3.2/B Knows indications 5.2/B Flexibly applies neuropsychological testing neuropsychological tests for specific knowledge of and their indications2 neuropsychological tests neuropsychological and understands meaning findings to the differential of common abnormal diagnoses of complex findings patients

2.3/C Describes psychiatric 4.3/C Describes psychiatric co- disorders co-morbid with morbidities of less common common neurologic neurologic disorders8 and less disorders3 and neurological common neurologic co- disorders frequently seen in morbidities of psychiatric psychiatric patients4 disorders9

3.3/D Describes 4.4/D Explains neurobiological 5.3/D Explains neurobiological and hypotheses and genetic risks of neurobiological genetic hypotheses of common psychiatric disorders hypotheses and genetic common psychiatric to patients risks of less common disorders and their psychiatric disorders11 to limitations patients

5.4/D Integrates knowledge of neurobiology into advocacy for psychiatric patient care and stigma reduction12

2.4/E Identifies the brain 4.5/E Demonstrates sufficient areas thought to be knowledge to incorporate important in social and leading neuroscientific emotional behavior5 hypotheses of emotions and social behaviors10 into case formulation

Comments:

Footnotes: 1This milestone focuses on knowledge needed for patient care. Thus, knowledge of clinical neuroscience can be assessed through multiple choice knowledge examination (e.g., PRITE), and/or through evaluations of the application of knowledge of clinical neuroscience to patient care, such as standardized patients or case vignettes, clinical skills evaluations, and knowledge evidenced during clinical rotations and the routine, supervised care of patients during residency. 2Common neuropsychological tests include the Montreal Cognitive Assessment (or Mini Mental State Examination), Wechsler Adult Intelligence Scale (or Halstead- Reitan battery), Wechsler Memory Scale, Wide Range Achievement Test, Wisconsin Card Sorting Test, Clock Drawing Test. 3Examples include psychosis, mood disorders, personality changes, and cognitive impairments seen in common neurological disorders. 4These include drug-induced and idiopathic extrapyramidal syndromes, neuropathies, traumatic brain injury (TBI), vascular lesions, dementias, and encephalopathies. 5Areas might include dorsolateral prefrontal cortex, anterior cingulate, amygdala, hippocampus, etc. 6These include structural imaging and electrophysiologic testing. 7For example, positron emission tomography (PET)/single-photon emission computed tomography (SPECT) in the diagnosis of Alzheimer’s disease (supportive but non- diagnostic); functional magnetic resonance imaging (fMRI) is not yet reimbursable for clinical use. 8Examples include: mood disorder due to neurological condition, manic type, in right hemisphere or orbitofrontal strokes/tumors; depression in peri-basal ganglionic infarcts; manic behavior in limbic encephalitis. 9Examples include: neuroleptic malignant syndrome; lethal catatonia; “Parkinson plus” syndromes (e.g., multisystem atrophy, dementia with Lewy bodies, etc). 10Social behaviors might include attachment, empathy, attraction, reward/addiction, aggression, appetites, etc. 11Examples include : Obsessive-Compulsive Disorder (OCD); eating disorders ; Gilles de la Tourette syndrome. 12Uses neurobiologic hypotheses of psychiatric disorders to advocate for health coverage, treatment availability, etc.

MK4. Psychotherapy Refers to knowledge regarding: 1) individual psychotherapies, including but not limited to psychodynamic1, cognitive-behavioral2, and supportive therapies3; 2) couples, family, and group therapies; and, 3) integrating psychotherapy and psychopharmacology A: Knowledge of psychotherapy: theories B: Knowledge of psychotherapy: practice C: Knowledge of psychotherapy: evidence base Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Identifies psycho- 2.1/A Describes the basic 3.1/A Describes 4.1/A Describes proposed 5.1/A Incorporates new dynamic, cognitive-behavioral, principles of each of the differences among the mechanisms of therapeutic theoretical developments and supportive therapies as three core individual three core individual change into knowledge base major psychotherapeutic psychotherapy modalities4 therapies modalities 2.2/A Discusses common 3.2/A Describes the factors across historical and conceptual psychotherapies5 development of psychotherapeutic 5.2/A, B Demonstrates paradigms sufficient knowledge of psychotherapy to teach 2.3/B Lists the basic 3.3/B Describes the basic others effectively indications, techniques of the three contraindications, benefits, core individual therapies and risks of supportive, psychodynamic and 3.4/B Describes the basic cognitive behavioral principles, indications, psychotherapies contraindications, benefits, and risks of couples, group, and family therapies

3.5/C Summarizes the 4.2/C Discusses the evidence base for each of evidence base for the three core individual combining different therapies psychotherapies and psychopharmacology

4.3/C Critically appraises the evidence for efficacy of psychotherapies

Comments:

Footnotes: 1This includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to understand the concepts of resistance/defenses, and transference/countertransference. 2This includes the capacity to generate a case formulation, and to demonstrate techniques of intervention, including behavior change, skills acquisition, and addressing cognitive distortions. 3This includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to strengthen the patient’s adaptive defenses, resilience, and social supports. 4Throughout this subcompetency, the three “core” or “major” individual psychotherapies refer to supportive, psychodynamic, and cognitive-behavioral therapy. 5Common factors refer to elements that different psychotherapeutic modalities have in common, and that are considered central to the efficacy of psychotherapy. These include accurate empathy, therapeutic alliance, and appropriate professional boundaries.

MK5. Somatic Therapies Medical Knowledge of somatic therapies, including psychopharmacology, ECT, and emerging somatic therapies, such as transcranial magnetic stimulation (TMS) and vagnus nerve stimulation (VNS) A: Knowledge of indications, metabolism and mechanism of action for medications B: Knowledge of ECT and other emerging somatic treatments C: Knowledge of lab studies and measures in monitoring treatment Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Describes general 2.1/A Describes 3.1/A Demonstrates an 4.1/A Describes the 5.1/A Integrates indications and common side hypothesized mechanisms understanding of evidence supporting the use emerging studies of effects for commonly of action and metabolism pharmacokinetic and of multiple medications in somatic treatments into prescribed for commonly prescribed pharmacodynamic drug certain treatment situations knowledge base psychopharmacologic agents psychopharmacologic interactions (e.g., polypharmacy and agents augmentation) 5.2/A Effectively teaches 3.2/A Demonstrates an at a post-graduate level 2.2/A Describes indications understanding of evidence-based or best for second- and third-line psychotropic selection somatic treatment pharmacologic agents based on current practice practices guidelines or treatment 2.3/A Describes less algorithms for common frequent but potentially psychiatric disorders serious/dangerous adverse effects for commonly prescribed psychopharmacological agents

2.4/A Describes expected time course of response for commonly prescribed classes of psychotropic agents

1.2/B Describes indications for 2.5/B Describes length and 3.3/B Describes specific ECT frequency of ECT techniques in ECT treatments, as well as relative contraindications 3.4/B Lists emerging neuro-modulation therapies1

2.6/C Describes the physical 4.2/ C Integrates knowledge The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology. 18 11/15/2013

and lab studies necessary of the titration and side to initiate treatment with effect management of commonly prescribed multiple medications, medications monitoring the appropriate lab studies, and how emerging physical and laboratory findings impact somatic treatments

Comments:

Footnotes: 1Examples of neuromodulation techniques include TMS and variations, VNS, Deep Brain Stimulation, etc.

MK6. Practice of Psychiatry A: Ethics B: Regulatory compliance C: Professional development and frameworks Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Lists common ethical 2.1/A Lists and discusses 3.1/A Discusses conflict of issues in psychiatry sources of professional interest and management standards of ethical practice

2.2/A Lists situations that mandate reporting or breach of confidentiality

1.2/B Recognizes and describes 3.2/B Describes applicable 4.1/B Describes the 5.1/B Describes institutional policies and regulations for billing and existence of state and international variations procedures1 reimbursement regional variations regarding practice, regarding practice, involuntary treatment, involuntary treatment, and health regulations health regulations, and psychiatric forensic evaluation

1.3/C Lists ACGME 2.3/C Describes how to 4.2/C Describes 5.2/C Proposes advocacy Competencies keep current on regulatory professional advocacy2 activities, policy and practice management development, or scholarly issues 4.3/C Describes how to seek contributions related to out and integrate new professional standards information on the practice of psychiatry

Comments:

Footnotes: 1“Institutional policies and procedures” refers to those related to the practice of medicine and psychiatry at the specific institution where the resident is credentialed. These include a Code of Conduct (addressing gifts, etc.) and privacy policies (related to HIPAA, etc.), but not patient safety policies. These are usually covered during an orientation to the institution and program. 2 Advocacy includes efforts to promote the wellbeing and interests of patients and their families, the mental health care system, and the profession of psychiatry. While advocacy can include work on behalf of specific individuals, it is usually focused on broader system issues, such as access to mental health care services or public

awareness of mental health issues. The focus on larger societal problems typically involves work with policy makers (state and federal legislators) and peer or professional organizations (American Psychiatry Association (APA), National Alliance on Mental Illness (NAMI), etc.).

SBP1. Patient Safety and the Health care Team A: Medical errors and improvement activities B: Communication and patient safety C: Regulatory and educational activities related to patient safety Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Differentiates among 2.1/A Describes the 3.1/A Describes systems 4.1/A Participates in formal 5.1/A Leads medical errors, near misses, common system causes for and procedures that analysis (e.g., root-cause multidisciplinary teams and sentinel events errors promote patient safety analysis, failure mode (e.g., human factors effects analysis) of medical engineers1, social errors and sentinel events scientists) to address patient safety issues

1.2/B Recognizes failure in 2.2/B Consistently uses teamwork and communication structured communication 5.2/A, C Provides as leading cause of preventable tools to prevent adverse consultation to patient harm events (e.g., checklists, safe organizations to improve hand-off procedures, personal and patient briefings) safety

1.3/C Follows institutional 2.3/C Actively participates 4.2/C Develops content for safety policies, including in conferences focusing on and facilitates a patient reporting of problematic systems-based errors in safety presentation or behaviors and processes, patient care conference focusing on errors, and near misses systems-based errors in patient care (i.e., a morbidity and mortality [M&M] conference)

Comments:

Footnotes: 1 Human Factors Engineering (HFE) is a framework for efficient and constructive thinking which includes methods and tools to help health care teams perform patient safety analyses (see: Gosbee J, Human factors engineering and patient safety, Quality and Safety in Health Care, 2002;11:352–354).

SBP2. Resource Management (may include diagnostics, medications, level of care, other treatment providers, access to community assistance) A: Costs of care and resource management Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Recognizes need for 2.1/A Recognizes disparities 3.2/A Coordinates patient 4.1/A Practices cost- 5.1/A Designs efficient and equitable use of in health care at individual access to community and effective, high-value clinical measurement tools to resources and community levels system resources care1, using evidence-based monitor and provide tools and information feedback to 2.2/A Knows the relative technologies to support providers/teams on cost of care (e.g., decision making resource consumption to medication costs, facilitate improvement diagnostic costs, level of 4.2/A Balances the best care costs, procedure costs) interests of the patient with 5.2/A Advocates for the availability of resources improved access to and additional resources within systems of care

Comments:

Footnotes: 1 Examples include: avoids higher-cost, newer antipsychotics when older formulations are adequate; recommends levels of care that are matched to clinical need and available in the community.

SBP3. Community-Based Care A: Community-based programs B: Self-help groups C: Prevention D: Recovery and rehabilitation Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Gives examples of 2.1/A Coordinates care with 5.1/A Participates in the community mental health community mental health administration of systems of care agencies, including with community-based case managers treatment programs

5.2/A Participates in creating new community- based programs

1.2/B Gives examples of self- 2.2/B Recognizes role and 3.1/B Incorporates 4.1/B Routinely uses self- help groups (Alcoholics explains importance of self- disorder-specific support help groups, community Anonymous [AA], Narcotics help groups and community and advocacy groups in resources, and social Anonymous [NA]), other resource groups clinical care networks in treatment3 community resources (church, (e.g., disorder-specific school) and social networks support and advocacy (e.g., family, friends, groups) acquaintances)

2.3/C Describes individual 3.2/C Describes prevention 4.2/C Employs prevention and population risk factors measures: universal, and risk reduction for mental illness selective and indicated1 strategies in clinical care

3.3/D Describes 4.3/D Appropriately refers 5.3/D Practices effectively rehabilitation programs to rehabilitation and in a rehabilitation and/or (vocational, brain injury, recovery programs recovery-based program etc.) and the recovery model2 4.4/D Uses principles of evidence-based practice and patient centered care in management of chronically ill patients

Comments:

Footnotes: 1Universal prevention strategies are designed to reach the entire population; selective prevention are designed for a targeted subgroup of the general population; and indicated prevention intervention targets individuals. 2The Substance Abuse and Mental Health Services Administration (SAMHSA) has a working definition for the recovery model applied to mental health and addictions. This definition acknowledges that recovery is a process of change for an individual consumer to improve health and wellness, live a self-directed life, and strive and reach his or her full potential. The guiding principles that inform a recovery model of care include hope, person-driven, holistic, peer supports, social networks, culturally-based, trauma-informed, strength-based, responsibility, and respect (see: http://www.samhsa.gov/newsroom/advisories/1112223420.aspx). 3These community resources include supports and services from both the peer and professional workforces.

SBP4. Consultation to non-psychiatric medical providers and non-medical systems (e.g., military, schools, businesses, forensic ) A: Distinguishes care provider roles related to consultation B: Provides care as a consultant and collaborator C: Specific consultative activities Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Describes the 2.1/A Describes differences difference between in providing consultation for consultant and primary the system or team versus treatment provider the individual patient

2.2/B Provides consultation 4.1/B Provides integrated 5.1/B Provides psychiatric to other medical services care for psychiatric patients consultations to larger through collaboration with systems other physicians1 5.2/B Leads a consultation team

2.3/C Clarifies the 3.1/C Assists primary 4.2/C Manages complicated consultation question treatment care team in and challenging identifying unrecognized consultation requests 2.4/C Conducts and reports a clinical care issues basic decisional capacity evaluation 3.2/C Identifies system issues in clinical care and provides recommendations

3.3/C Discusses methods for integrating mental health and medical care in treatment planning

Comments:

Footnotes: 1 Provides communication back to the primary care physicians in the outpatient setting, including collaborative and co-located settings such as a medical home.

PBLI1. Development and execution of lifelong learning through constant self-evaluation, including critical evaluation of research and clinical evidence A: Self-Assessment and self-Improvement B: Evidence in the clinical workflow Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Uses feedback from 2.1/A Regularly seeks and 3.1/A Demonstrates a 4.1/A Demonstrates teachers, colleagues, and incorporates feedback to balanced and accurate self- improvement in clinical patients to assess own level of improve performance assessment of competence, practice based on continual knowledge and expertise using clinical outcomes to self-assessment and 2.2/A Identifies self- identify areas for continued evidence-based information 1.2/A Recognizes limits of one’s directed learning goals and improvement knowledge and skills and seeks periodically reviews them 4.2/A Identifies and meets supervision with supervisory guidance self-directed learning goals with little external guidance

4.3/A, B Demonstrates use 5.1/A, B Sustains practice of a system or process for of self-assessment and keeping up with relevant keeping up with relevant 1.3/B Describes and ranks 2.3/B Formulates a 3.2/B Selects an changes in medicine2 changes in medicine, and levels of clinical evidence1 searchable question from a appropriate, evidence- makes informed, clinical question2 based information tool1 to 4.4/B Independently evidence-based clinical meet self-identified searches for and decisions learning goals discriminates evidence relevant to clinical practice 5.2/B Teaches others 3.3/B Critically appraises problems techniques to efficiently different types of research, incorporate evidence including randomized gathering into clinical controlled trials (RCTs), workflow systematic reviews, meta- analyses, and practice 5.3/B Independently guidelines teaches appraisal of clinical evidence

Comments:

Footnotes: 1Examples include: practice guidelines; PubMed Clinical Queries; Cochrane, DARE, or other evidence-based reviews; Up-to-Date, etc. 2Examples include: a performance-in-practice (PIP) module as included in the American Board of Psychiatry and Neurology (ABPN) Maintenance of Certification (MOC) process; or regular and structured readings of specific evidence sources.

PBLI2. Formal practice-based quality improvement based on established and accepted methodologies1 A: Specific quality improvement project B: Quality improvement didactic knowledge Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Recognizes potential 2.1/A Narrows problems 3.1/A Involves appropriate 4.1/A Substantially 5.1/A Independently gaps in quality of care and within own clinical service(s) stakeholders in design of a contributes to a supervised proposes and leads system-level inefficiencies2 to a specific and achievable QI project4 project to address specific projects to enhance aim for a quality quality deficit within own patient care improvement (QI) project clinical service(s), and measures relevant 5.2/A Uses advanced outcomes quality measurement and “dashboard” tools

1.2/B Discusses with 2.2/B Outlines factors and 3.2/B Lists common 4.2/B Describes basic 5.3/B Describes core supervisors possible quality causal chains contributing to responses of teams and methods for concepts of advanced QI gaps and problems with quality gaps within own individuals to changes in implementation and methodologies and psychiatric care delivery institution and practice3 clinical operations and evaluation of clinical QI business processes6 describes strategies for projects5 managing same

Comments:

Footnotes: 1Many of these requirements would be satisfied by active participation in an individual or group project within the residency program, department, or institution. Active participation, at a minimum, should include observation and participation through a full feedback cycle (e.g., one Plan-Do-Study-Act loop). Some didactic material or assigned readings may be helpful to supplement the case-based learning. Resources for didactics include the Institute for Health Care Improvement Open School (http://www.ihi.org/offerings/IHIOpenSchool/), World Health Organization Patient Safety Curriculum (http://www.who.int/patientsafety/education /curriculum/download/en/index.html), and Department of Veterans Affairs Patient Safety Curriculum (http://www.patientsafety.va.gov/curriculum/index.html). 2 Examples include: problems with transfer of information during sign-out or patient movement between care areas; difficulty in moving needed resources to a patient’s location; prescribing practices that markedly deviate from guidelines. 3 Chooses an inefficient/ineffective practice or recent adverse outcome, identifies some factors contributing to the status quo, and displays some sense of which factors are amenable to intervention. 4 Examples include, for a project involving a standard order protocol on an inpatient unit: meets with nurse managers and ancillary clinical staff members and learns about their needs/constraints before designing intervention; recognizes fear of change as a common characteristic in clinical environments and provides staff members space/time to adequately process and modify proposals. At this stage, requires supervision/guidance in such efforts. 5 This might include variations on the Plan-Do-Study-Act theme (i.e., stating an understanding that an effective project should include a target population and intervention, an outcome measure, and some form of iterative refinement). 6 Can state some core philosophical concepts of Lean Production, the Six-Sigma/Total Quality Management methods, or other emerging management philosophies, and gives examples of how these could apply in health care.

PBLI3. Teaching A: Development as a teacher B: Observable teaching skills Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Recognizes role of 2.1/A Assumes a role in the 3.1/A Participates in 4.1/A Gives formal didactic 5.1/A Educates broader physician as teacher clinical teaching of early learners activities designed to presentation to groups professional community develop and improve (e.g., grand rounds, case and/or public (e.g., teaching skills conference, journal club) presents at regional or national meeting)

2.2/B Communicates goals and 3.2/B Organizes content 4.2/B Effectively uses 5.2/B Organizes and objectives for instruction of and methods for individual feedback on teaching to develops curriculum early learners instruction for early improve teaching methods materials learners and approaches 2.3/B Evaluates and provides feedback to early learners

Comments:

PROF1.1 Compassion, integrity, respect for others, sensitivity to diverse patient populations2, 3, adherence to ethical principles A: Compassion, reflection, sensitivity to diversity B: Ethics Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Demonstrates behaviors 2.1/A Demonstrates 3.1/A Elicits beliefs, values, 4.1/A Develops a mutually 5.1/A Serves as a role that convey caring, honesty, capacity for self-reflection, and diverse practices of agreeable care plan in the model and teacher of genuine interest, and respect empathy, and curiosity patients and their families, context of conflicting compassion, integrity, for patients and their families about and openness to and understands their physician and patient respect for others, and different beliefs and points potential impact on and/or family values and sensitivity to diverse 1.2/A Recognizes that patient of view, and respect for patient care beliefs patient populations diversity affects patient care diversity 3.2/A Routinely displays 4.2/A Discusses own 2.2/A Provides examples of sensitivity to diversity in cultural background and the importance of attention psychiatric evaluation and beliefs and the ways in to diversity in psychiatric treatment which these affect evaluation and treatment interactions with patients

1.3/B Displays familiarity with 2.3/B Recognizes ethical 3.3/B Recognizes ethical 5.2/B Leads resident case some basic ethical principles conflicts in practice and issues in practice and is discussions regarding (e.g., confidentiality, informed seeks supervision to able to discuss, analyze, ethical issues consent, professional manage them and manage these in boundaries) common clinical situations 5.3/B Adapts to evolving ethical standards (i.e. can manage conflicting ethical standards and values and can apply these to practice)

5.4/B Systematically analyzes and manages ethical issues in complicated and challenging clinical situations

Comments:

Footnotes: 1The two Professionalism subcompetencies (PROF1 and PROF2) reflect the following overall values: Residents must demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles. Residents must develop and acquire a professional identity consistent with values of oneself, the specialty, and the practice of medicine. Residents are expected to demonstrate compassion, integrity, and respect for others; sensitivity to diverse populations; responsibility for patient care that supersedes self-interest; and accountability to patients, society, and the profession. 2Diversity refers to unique aspects of each individual patient, including gender, age, socioeconomic status, culture, race, religion, disabilities, and sexual orientation. 3For milestones regarding health disparities, please see SBP2.

PROF2. Accountability to self, patients, colleagues, and the profession A: Fatigue management and work balance B: Professional behavior and participation in professional community C: Ownership of patient care Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Understands the need 2.1/A Notifies team and 3.1/A Identifies and manages 4.1/A Knows how to take 5.1/A Develops physician for sleep, and the impact of enlists back-up when situations in which steps to address wellness programs or fatigue on work fatigued or ill, so as to maintaining personal impairment in self and in interventions ensure good patient care emotional, physical, and colleagues 1.2/A Lists ways to manage mental health is challenged, fatigue, and seeks back-up as and seeks assistance when 4.2/A Prioritizes and needed to ensure good needed balances conflicting patient care interests of self, family, and 3.2/A Recognizes the tension others to optimize medical between the needs of care and practice of personal/family life and profession2 professional responsibilities, and its effect on medical care

1.3/B Exhibits core 2.2/B Follows institutional 3.3/B Recognizes the 4.3/B Prepares for obtaining 5.2/B Develops professional behaviors1 policies for physician importance of participating in and maintaining board organizational policies, conduct one’s professional community certification programs, or curricula for 1.4/B Displays openness to physician professionalism feedback 5.3/B Participates in the professional community (e.g., professional societies, patient advocacy groups, community service organizations)

1.5/C Introduces self as 2.3/C Accepts the role of 3.4/C Is recognized by self, 4.4/C Displays increasing 5.4/C Serves as a role patient’s physician the patient’s physician and patient, patient’s family, and autonomy and leadership in model in demonstrating takes responsibility (under medical staff members as the taking responsibility for responsibility for ensuring supervision) for ensuring patient’s primary psychiatric ensuring that patients that patients receive the that the patient receives provider receive the best possible best possible care the best possible care care

Comments:

Footnotes: 1Professional behavior refers to the global comportment of the resident in carrying out clinical and professional responsibilities. This includes: a. timeliness (e.g., reports for duty, answers pages, and completes work assignments on time); b. maintaining professional appearance and attire; c. being reliable, responsible, and trustworthy (e.g., knows and fulfills assignments without needing reminders); d. being respectful and courteous (e.g., listens to the ideas of others, is not hostile or disruptive, maintains measured emotional responses and equanimity despite stressful circumstances); e. maintaining professional boundaries; and, f. understanding that the role of a physician involves professionalism and consistency of one’s behaviors, both on and off duty. These descriptors and examples are not intended to represent all elements of professional behavior. 2Residents are expected to demonstrate responsibility for patient care that supersedes self-interest. It is important that residents recognize the inherent conflicts and competing values involved in balancing dedication to patient care with attention to the interests of their own well-being and responsibilities to their families and others. Balancing these interests while maintaining an overriding commitment to patient care requires, for example, ensuring excellent transitions of care, sign-out, and continuity of care for each patient during times that the resident is not present to provide direct care for the patient.

ICS1. Relationship development and conflict management with patients, families, colleagues, and members of the health care team A: Relationship with patients B: Conflict management C: Team-based care Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Cultivates positive 2.1/A Develops a therapeutic 3.1/A Develops 4.1/A Sustains therapeutic 5.1/A Sustains relationships with patients, relationship with patients in therapeutic relationships and working relationships relationships across families, and team members uncomplicated situations in complicated situations during complex and systems of care and with challenging situations, patients during long-term 2.2/A Develops working including transitions of care follow-up relationships across specialties and systems of 5.2/A, B Develops care in uncomplicated models/approaches to situations managing difficult communications 1.2/B Recognizes 2.3/B Negotiates and 3.2/B Sustains working communication conflicts in manages simple relationships in the face of 5.3/B, C Manages work relationships patient/family-related conflict treatment team conflicts conflicts as team leader

1.3/C Identifies team-based 2.4/C Actively participates in 3.3/C Facilitates team- 4.2/C Leads a 5.4/C Leads and care as preferred treatment team-based care; supports based activities in clinical multidisciplinary care team facilitates meetings approach, and collaborates as activities of other team and/or non-clinical within the a member of the team members, and situations (including on organization/system communicates their value to committees) the patient and family

Comments:

ICS2. Information sharing and record keeping A: Accurate and effective communication with health care team B: Effective communications with patients C: Maintaining professional boundaries in communication D: Knowledge of factors which compromise communication Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 1.1/A Ensures transitions of 5.1/A Models care are accurately continuous documented, and optimizes improvement in record communication across 2.1/A, B Organizes both written 3.1/ A, B Uses easy-to- 4.1/A, B Demonstrates keeping systems and continuums of and oral information to be shared understand language in all effective verbal care with patient, family, team, and phases of communication, communication with others including working with patients, families, 1.2/A Ensures that the interpreters colleagues, and other written record (electronic health care providers medical record [EMR], that is appropriate, personal health records efficient, concise, and [PHR]/patient portal, hand- pertinent offs, discharge summaries, etc.) are accurate and timely, 4.2/A, B Demonstrates with attention to preventing written communication confusion and error, with patients, families, consistent with institutional colleagues, and other policies health care providers that is appropriate, 1.3/B Engages in active 2.2/B Consistently demonstrates 3.2/B Consistently engages efficient, concise, and listening, “teach back,” and communication strategies to patients and families in pertinent other strategies to ensure ensure patient and family shared decision making patient and family understanding understanding 2.3/B Demonstrates appropriate face-to-face interaction while using EMR

1.4/C Maintains appropriate 2.4/C Understands issues raised by 4.3/C Uses discretion 5.2/C Participates in the boundaries in sharing the use of social media by patients and judgment in the development of changes information by electronic and providers inclusion of sensitive in rules, policies, and communication patient material in the procedures related to medical record technology

4.4/C Uses discretion and judgment in electronic communication with patients, families, and colleagues

2.5/D Lists factors that affect 3.3/D Gives examples of information sharing (e.g., intended situations in which audience, purpose, need to know) communication can be compromised (e.g., 2.6/D Lists effects of computer use perceptual impairment, on accuracy of information cultural differences, gathering and recording and transference, limitations of potential disruption of the electronic media) physician/patient/family relationship

Comments:

The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology. 36

The Child & Adolescent Psychiatry Milestone Project

A Joint Initiative of

The Accreditation Council for Graduate Medical Education

and

The American Board of Psychiatry and Neurology

July 2015

The Child and Adolescent Psychiatry 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 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 content.

Child and Adolescent Psychiatry Milestone Group

Psychiatry Subspecialty Milestones Chair: Christopher R. Thomas, MD

Working Group Chair: Jeffrey Hunt, MD Sandra M. DeJong, MD Laura Edgar, EdD, CAE Howard Liu, MD Cynthia Santos, MD

Advisory Group Chair: George A. Keepers, MD

Larry R. Faulkner, MD Paramjit T. Joshi, MD Christopher K. Varley, MD

Milestone Reporting

This document presents Milestones designed for programs to use in semi-annual review of 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 each 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. These levels do not correspond with post-graduate year of education.

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.

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.

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.

Definitions used in this document: Systems – includes schools, courts, community based organizations (advocacy, community mental health), governmental agencies (e.g. child protective agencies), health care (primary care, etc.). Families – includes parents, foster parents, legal guardians Developmental domains – includes social/emotional, cognitive, behavioral, gross motor, fine motor, speech and language development

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

5 Version 9/2014 Child and Adolescent Psychiatry Milestones: ACGME Report Worksheet

PC1 — Psychiatric Evaluation

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 For adolescents, 2.1 For adolescents, obtains 3.1 Evaluates the structure and 4.1 Acquires efficient, 5.1 Incorporates acquires accurate information that is sensitive and functioning of the family, including accurate, thorough and therapeutic interventions history and mental not readily offered by the patient strengths, vulnerabilities, and relevant history for as part of the evaluation status examination cultural factors, as they pertain to preschool, school-age, and patients and families findings, customized to 2.2 Considers the structure and the child adolescent patients, the patient’s complaints functioning of the family, including customized to each patient’s 5.2 Utilizes creative use of strengths, vulnerabilities, and 3.2 Assesses development across complaints evaluation techniques, 1.2 Assesses patient cultural factors, as they pertain to all domains both verbal and non- safety, including suicidal the child 4.2 Modifies interview verbal and homicidal ideation, 3.3 For school-age and adolescent approach to assess patients and considers the 2.3 Conducts assessment that patients, obtains information that at different developmental 5.3 Serves as a role model potential for trauma, includes observation of child’s is sensitive and not readily offered levels, including use of non- for gathering subtle and abuse, aggression, and interaction with caretakers by the patient verbal techniques and play reliable information from high-risk behaviors the patient 2.4 Conducts basic assessment of 3.4 Selects and uses appropriate 4.3 Effectively assesses 1.3 Demonstrates a the child’s development diagnostic tests (screening development, including 5.4 Independently teaches respectful manner with instruments, rating scales, atypical development and supervises other children and adolescents 2.5 Selects laboratory and psychoeducational testing) (intellectual disability, etc.) learners in clinical and their families diagnostic tests (medical work-up) appropriate to the clinical evaluation appropriate to the clinical presentation 4.4 Collects information from 1.4 Seeks supervision presentation the pertinent systems appropriately 3.5 Regularly uses the clinician's 2.6 Uses hypothesis-driven emotional responses to the patient 4.5 Assesses the family in a information-gathering techniques and family as a diagnostic tool sophisticated and culturally- sensitive manner 2.7 Begins to use the clinician's 3.6 Demonstrates ability to shift emotional responses to the patient focus when verbal and non-verbal and family as a diagnostic tool information is conflicting

Comments: Not yet achieved Level 1

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PC2 — Psychiatric Formulation and Differential Diagnosis1

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Organizes and accurately 2.1 Develops comprehensive 3.1 Describes how 4.1 Efficiently synthesizes all 5.1 Formulates a case summarizes, reports, and differential diagnosis for development influences the information into a concise but based on different presents information from common syndromes, presentation of comprehensive formulation conceptual models the patient, family, and synthesizing data from the psychopathology collateral sources to patient, family, and 4.2 Incorporates subtle, 5.2 Expands the colleagues collateral sources 3.2 Develops a comprehensive unusual, or conflicting reports differential diagnosis to differential diagnosis while into hypotheses and include subtle or rare 1.2 Develops a working 2.2 Describes patients’ avoiding premature closure formulations, including presentations or diagnosis based on patient symptoms and problems, developmental, family, and disorders evaluation precipitating stressors or 3.3 Organizes formulation in a systems factors events, predisposing life systematic manner that 5.3 Serves as a role events or stressors, follows a conceptual model2 4.3 Includes the interaction model of efficient and perpetuating and protective between contributing factors in accurate formulation factors, and prognosis the diagnostic formulation 5.4 Teaches formulation to advanced learners

Comments: Not yet achieved Level 1

Footnotes: 1A psychiatric formulation is a theoretically-based conceptualization of the patient’s mental disorder(s). It provides an organized summary of those individual factors thought to contribute to the patient’s unique psychopathology. This includes elements of possible etiology, as well as those that modify or influence presentation, such as risk and protective factors. It is therefore distinct from a differential diagnosis that lists the possible diagnoses for a patient, or an assessment that summarizes the patient’s signs and symptoms, as it seeks to understand the underlying mechanisms of the patient’s unique problems by proposing a hypothesis as to the causes of mental disorders. 2Models of formulation include those based on either major theoretical systems of the etiology of mental disorders (such as behavioral, biological, cognitive, cultural, psychological, psychoanalytic, sociological, or traumatic), or comprehensive frameworks of understanding (such as bio-psycho-social or predisposing, precipitating, perpetuating, protective, and prognostic outlines). Models of formulation set forth a hypothesis about the unique features of a patient’s illness that can serve to guide further evaluation or develop individualized treatment plans.

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PC3 — Treatment Planning and Management

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Sets treatment goals in 2.1 Incorporates a clinical 3.1 Applies an understanding 4.1 Devises individualized, 5.1 Supervises treatment collaboration with the practice guideline or of psychiatric, neurologic, and developmentally-sensitive, planning of other learners patient and family treatment algorithm when medical co-morbidities to and systems-informed and multidisciplinary available treatment selection treatment plans for complex providers 1.2 Manages patient crises presentations and safety concerns with 2.2 Links treatment to 3.2 Applies an understanding 5.2 Integrates emerging supervision formulation of family strengths and 4.2 Integrates multiple neurobiological and genetic vulnerabilities in the modalities and systems, as knowledge into treatment 1.3 Monitors treatment 2.3 Recognizes need for treatment plan and its appropriate, with a plan adherence and response consultation and supervision implementation comprehensive approach for complicated or 5.3 Demonstrates ability to refractory cases 4.3 Integrates mobilize appropriate neurobiological and genetic systems of care to optimize 2.4 Re-evaluates and revises knowledge into treatment patient outcomes treatment approach based plan on new information and or response to treatment 4.4 Appropriately modifies treatment techniques and flexibly applies practice guidelines to fit patient needs

Comments: Not yet achieved Level 1

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PC4 — Psychotherapy

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 For all child and 2.1 Recognizes that overt 3.1 Establishes and maintains a 4.1 For all child and adolescent age groups, 5.1 Creatively adolescent age affect and behavior may therapeutic alliance with, and demonstrates capacity to listen and observe integrates different groups, approaches mask underlying feelings provides psychotherapies to, and use information obtained this way in therapy modalities the therapeutic patients with uncomplicated psychotherapy tailored to the encounter with 2.2 Selects and implements problems individual patient curiosity and a psychotherapeutic 4.2 Substantially manages the and family empathy, and modality based on an 3.2 Uses verbal and non-verbal structure/frame of psychotherapy with substantially appropriate formulation strategies to access internal patient and/or family 5.2 Provides recognizes and starts processes of the patient psychotherapies to to manage own 2.3 Discusses the structure/ 4.3 Anticipates and appropriately manages patients with very anxiety frame of psychotherapy, 3.3 Links feelings, behavior, potential boundary crossings and avoids complicated and/or including the limits of recurrent/central boundary violations refractory 1.2 Begins to identify confidentiality, with patient themes/schemas, and their disorders/problems patient emotions and family meaning to the patient as they 4.4 Consistently uses developmentally- across the shift within and across sessions appropriate psychotherapeutic techniques, 5.3 Personalizes developmental 2.4 Maintains including non-verbal strategies treatment based on spectrum developmentally- 3.4 Successfully guides the patient awareness of one’s appropriate professional and family through the different 4.5 Provides different modalities of own skill set, 1.3 Able to use non- boundaries in phases of psychotherapy in a psychotherapy (including family or supportive strengths, and verbal techniques to psychotherapeutic developmentally-appropriate way therapy and at least one psychodynamic or limitations start to build an relationships while being cognitive behavioral therapy) to patients with alliance with children responsive to the patient 3.5 Balances autonomy with need moderately complicated problems 5.4 Provides and adolescents and family for consultation and supervision psychotherapy 4.6 Recognizes and manages treatment supervision to others 1.4 Establishes 2.5 Establishes and 3.6 Integrates the selected impasses appropriate maintains a therapeutic psychotherapy with other professional alliance with both patients treatment modalities and other 4.7 Appropriately manages own feelings boundaries and avoids and families treatment providers elicited by work with patients and families boundary violations

Comments: Not yet achieved Level 1

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PC5 — Somatic Therapies, including Psychopharmacology and Other Somatic Treatments

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 With supervision, 2.1 Discusses medication use 3.1 Independently applies 4.1 Appropriately titrates dosage 5.1 Integrates selects and prescribes with children in a appropriate judgment about and prevents and manages side emerging studies of commonly used developmentally-appropriate off-label use of somatic effects, including when patients somatic treatments psychopharmacologic manner treatments are on multiple medications into clinical practice agents targeting specific child and adolescent 2.2 Applies appropriate judgment 3.2 Manages 4.2 Appropriately selects 5.2 Skillfully psychiatric disorders about off-label use of somatic pharmacokinetic and evidence-based somatic demonstrates treatments with supervision pharmacodynamic drug treatment options and safely management of 1.2 Engages in an interactions when using manages patients when the complex patients using informed 2.3 Describes contraindications multiple medications evidence base is limited multimodal somatic consent/assent process and adverse effects of commonly concurrently treatments with family and patient, prescribed medications 4.3 Follows practice guidelines including general 3.3 Appropriately selects for management of multiple indications, dosing 2.4 Titrates medication dosage evidence-based somatic medications, and if deviating parameters, and and prevents or manages side treatment options and from guidelines, provides common side effects for effects with a single medication incorporates evidence into appropriate rationale commonly prescribed psychoeducation of patient medications 2.5 Incorporates basic knowledge and family 4.4 Engages in a fully-informed of mechanisms of action and consent/assent process with 1.3 Obtains basic metabolism across development 3.4 With supervision, uses families and patients, including physical exam and lab in treatment selection evidenced-based off-label use, specific studies necessary to augmentation strategies contraindications, level of initiate treatment with 2.6 Monitors and responds to when primary evidence, etc. commonly prescribed relevant lab studies throughout pharmacological medications treatment interventions are only 4.5 Recognizes limitations of partially successful psychopharmacological treatment

Comments: Not yet achieved Level 1

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MK1 — Development in Infancy, Childhood, and Adolescence, Including the Impact of Psychopathology on the Trajectory of Development and Development on the Expression of Psychopathology

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Describes the basic 2.1 Demonstrates basic 3.1 Explains developmental 4.1 Describes in detail the 5.1 Teaches or develops stages of normal physical, knowledge of the major tasks and transitions stages of normal physical, curricula on the stages of social, and cognitive developmental theories throughout the life cycle, social/emotional, speech normal physical (gross development from infancy across all developmental utilizing multiple conceptual and language, sexual, motor, fine motor, sensory to young adulthood domains models gender identity, and integration), cognitive development from social/emotional, speech 2.2 Describes the effects of 3.2 Gives examples of gene- infancy to young adulthood and language, sexual, trauma, neglect, and early environment interaction gender identity, and adverse events on influences on development and 4.2 Describes how cognitive development from development psychopathology developmental capacities infancy to young adulthood and limitations influence the 2.3 Recognizes deviation 3.3 Describes the influence of differing presentation of 5.2 Incorporates new from normal development, psychosocial factors (gender, psychopathology from neuroscientific knowledge including arrests and ethnic, cultural, economic), infancy to young adulthood into his/her understanding regressions medical conditions, perinatal of development factors, and neurological illness 4.3 Describes the impact of 2.4 Utilizes developmental on development cultural factors on concepts in case development formulation 3.4 Describes interaction between family organization 4.4 Interprets the impact of 2.5 Describes family and development and major life events in the development developmental stages of all context of the patient’s family members developmental stage 3.4 Describe the

Comments: Not yet achieved Level 1

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MK2 — Psychopathology and Wellness, including Knowledge of Diagnostic Criteria, Epidemiology, Risk and Protective Factors, Pathophysiology, Course of Illness, Co-morbidities, and Differential Diagnosis of Psychiatric Disorders

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Lists common 2.1 Demonstrates sufficient 3.1 Demonstrates sufficient 4.1 Demonstrates sufficient 5.1 Displays knowledge Diagnostic and Statistical knowledge to identify and knowledge to identify and treat knowledge to identify and sufficient to teach risk Manual of Mental treat common psychiatric most psychiatric conditions treat complex psychiatric assessment Disorders, Fifth Edition conditions in youth in a from infancy to young conditions from infancy (DSM-5) diagnoses that variety of settings adulthood and in a variety of through young adulthood and 5.2 Demonstrates a begin in infancy, settings in a range of settings sophisticated understanding childhood, and 2.2 Demonstrates sufficient of current controversies in adolescence knowledge to identify co- 3.2 Displays knowledge to 4.2 Demonstrates the diagnosis morbid medical conditions conduct a risk assessment and knowledge of the appropriate 1.2 Lists major risk and in psychiatric patients determine the appropriate level of care for patients at 5.3 Shows sufficient protective factors for level of care for older children risk of harm to self or others knowledge to identify and danger to self and others 2.3 Identifies factors that and adolescents from infancy to young treat uncommon psychiatric and abuse/neglect contribute to wellness adulthood and in a full range conditions in patients with 3.3 Shows sufficient knowledge of treatment settings medical disorders 1.3 Gives examples of to identify and treat common interactions between psychiatric manifestations of 4.3 Shows knowledge medical and psychiatric medical illness sufficient to identify and treat symptoms and disorders a wide range of psychiatric 3.4 Demonstrates sufficient conditions in patients with 1.4 Lists examples of knowledge to include relevant medical disorders interactions between medical and neurological psychiatric symptoms and conditions in the differential psychosocial stressors diagnoses of psychiatric patients

Comments: Not yet achieved Level 1

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MK3 — Clinical Neuroscience and Genetics, including Knowledge of Neurology, Neuropsychiatry, Neurodiagnostic Testing, and Relevant Neuroscience and their Application in Clinical Settings

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Demonstrates 2.1 Demonstrates 3.1 Describes neural 4.1 Explains the significance of 5.1 Integrates recent knowledge of commonly knowledge of general development from infancy routine neuroimaging, neurodiagnostic research available neuroimaging indications for structural to young adulthood neurophysiological, into understanding of and neurophysiologic neuroimaging, magnetic neuropsychological testing, and psychopathology diagnostic modalities and resonance imaging [MRI]), 3.2 Recognizes the genetic abnormalities to patients how to order them and neurophysiological significance of abnormal and families 5.2 Flexibly applies testing findings in routine knowledge of 1.2 Lists common factors neurodiagnostic test 4.2 Demonstrates knowledge of neuropsychological in neural development 2.2 Describes common reports in psychiatric clinical indications and limitations of findings to the differential that may impact the neuropsychological tests patients functional neuroimaging diagnoses of complex overall development and and their indications patients the presentation of 3.3 Demonstrates 4.3 Explains neurobiological psychiatric symptoms 2.3 Describes psychiatric knowledge of indications hypotheses and genetic risks of 5.3 Explains disorders co-morbid with for specific common psychiatric disorders to neurobiological common neurologic neuropsychological tests patients hypotheses and genetic disorders and neurological and understands meaning risks of less common disorders frequently seen in of common abnormal 4.4 Describes psychiatric co- psychiatric disorders to psychiatric patients findings morbidities of less common patients neurologic and genetic disorders and 2.4 Identifies the brain areas 3.4 Describes less common neurologic co- 5.4 Integrates knowledge thought to be important in neurobiological and genetic morbidities of psychiatric disorders of neurobiology into social and emotional hypotheses of common advocacy for psychiatric behavior psychiatric disorders and 4.5 Demonstrates sufficient patient care, prevention, their limitations knowledge to incorporate pertinent and stigma reduction neuroscientific and genetic hypotheses of emotions and social behaviors into case formulation

Comments: Not yet achieved Level 1

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MK4 — Psychotherapy: Refers to knowledge regarding: 1) individual psychotherapies, including psychodynamic1, IPT, cognitive-behavioral2, and supportive therapies3; 2) family and group therapies; 3) dyadic therapies (PCIT, etc.); and 4) integrating psychotherapy and psychopharmacology

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Identifies psycho- 2.1 Describes the basic 3.1 Describes the basic 4.1 Describes proposed 5.1 Incorporates new dynamic, cognitive- principles of each of the techniques of the core mechanisms of therapeutic theoretical developments behavioral, family, dyadic, psychotherapy modalities4 psychotherapy modalities4 change into knowledge base and supportive therapies as major psychotherapeutic 2.2 Discusses common 3.2 Summarizes the evidence 4.2 Discusses the evidence 5.2 Demonstrates sufficient modalities in relationship factors across psychotherapy base for the core base for combining different knowledge of psychotherapy to child and adolescent modalities5 psychotherapy modalities4 psychotherapies and to teach and supervise patients psychopharmacology others effectively 2.3 Lists the basic indications, 1.2 Recognizes the core contraindications, benefits, 4.3 Critically appraises the differences in therapeutic and risks of each of the evidence for efficacy of the approaches when working psychotherapy modalities, core psychotherapies with children vs. adults including whether to use individual vs. family-based approaches

Comments: Not yet achieved Level 1

Footnotes: 1This includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to understand the concepts of resistance/defenses, and transference/countertransference. 2This includes the capacity to generate a case formulation, and to demonstrate techniques of intervention, including behavior change, skills acquisition, and addressing cognitive distortions. 3This includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to strengthen the patient’s adaptive defenses, resilience, and social supports. 4Throughout this subcompetency, the three “major” or “core” individual psychotherapies refer to supportive, psychodynamic, and cognitive-behavioral therapies. 5“Common factors” refers to elements that different psychotherapeutic modalities have in common and that are considered central to the efficacy of psychotherapy. These include accurate empathy, therapeutic alliance, and appropriate professional boundaries.

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MK5 — Somatic Therapies: Medical Knowledge of Somatic Therapies, including Psychopharmacology, ECT, and Emerging Somatic Therapies, such as Transcranial Magnetic Stimulation (TMS) and Vagal Nerve Stimulation (VNS)

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Describes general 2.1 Describes hypothesized 3.1 Demonstrates an 4.1 Describes the 5.1 Integrates emerging indications and common mechanisms of action and understanding of developmental strengths and limitations studies of somatic side effects for commonly metabolism for commonly impacts on pharmacokinetics and of the evidence treatments into prescribed prescribed pharmacodynamic drug supporting the use of knowledge base psychopharmacologic psychopharmacologic interactions medications and other agents for children and agents somatic therapies in 5.2 Effectively teaches adolescents 3.2 Demonstrates an certain treatment evidence-based or best 2.2 Describes less frequent, understanding of the potential situations in children and somatic treatment 1.2 Accesses practice but potentially serious, impact of medication on adolescents practices parameters and other adverse effects for development appropriate resources to commonly prescribed 4.2 When deviating from answer questions about psychopharmacological 3.3 Demonstrates an practice guidelines, somatic treatments agents understanding of psychotropic demonstrates knowledge selection based on current of the potential risks and 2.3 Describes practical practice guidelines or treatment appropriate management issues for initiation or algorithms for common for children and maintenance of medications psychiatric disorders in children adolescents for children and adolescents and adolescents

2.4 Describes the physical 3.4 Describes indications for and lab studies necessary to second- and third-line initiate treatment with pharmacologic agents commonly prescribed medications 3.5 Lists indications, evidence- base, and how to implement non- medication somatic treatments

Comments: Not yet achieved Level 1

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MK6 — Practice of Psychiatry

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Lists common ethical 2.1 Demonstrates 3.1 Discusses potential 4.1 Understands that there 5.1 Describes evolving issues issues in child and knowledge of the regulatory conflicts of interest related to are state and regional regarding practice, adolescent psychiatry compliance requirements of having multiple professional differences regarding involuntary treatment, and his/her own jurisdiction roles practice, involuntary health regulations 1.2 Recognizes and (e.g., mandatory reporting, treatment, health describes institutional age of consent, etc.) 3.2 Discusses potential regulations, and psychiatric 5.2 Proposes advocacy policies and procedures conflicting interests and forensic evaluation activities, policy 2.2 Lists and discusses obligations of the patient, development, or scholarly sources of professional family, and systems of care 4.2 Describes ways to contributions related to standards of ethical practice advocate for patients and professional standards 3.3 Describes applicable the profession 2.3 Describes how to keep regulations for billing and current on regulatory and reimbursement 4.3 Describes how to seek practice management issues out and integrate new 3.4 Demonstrates familiarity information on the practice 2.4 Demonstrates with the American Academy of child and adolescent knowledge of telehealth as a of Child and Adolescent psychiatry modality of care Psychiatry (AACAP) Code of Ethics

3.5 Demonstrates knowledge of educational laws

Comments: Not yet achieved Level 1

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SBP1 — Patient Safety and the Health Care Team

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Describes the common 2.1 Describes systems and 3.1 Recognizes special patient 4.1 Participates in a team- 5.1 Leads multidisciplinary system causes for errors procedures that promote or family circumstances that based approach to medical teams (e.g., human factors patient safety will affect discharge planning error or root-cause analysis, engineers, social scientists) 1.2 Follows institutional including quality to address patient safety safety policies, including 2.2 Effectively and regularly 3.2 Negotiates patient- improvement projects issues reporting of problematic utilizes all appropriate forms centered care among multiple behaviors and processes, of communication to ensure care providers and systems 4.2 Takes a leadership role 5.2 Provides consultation to errors, and near misses safe transitions of care and in ensuring safe transitions organizations to improve optimize communication of care and optimizing the health care team and 1.3 Actively participates in across systems and the communication across patient safety conferences focusing on continuum of care systems and the continuum systems-based errors in of care patient care 2.3 Follows regulatory requirements related to 4.3 Participates in a patient prescribing practices safety presentation or a critical case conference focusing on systems-based errors in patient care

Comments: Not yet achieved Level 1

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SBP2 — Resource Management

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Recognizes disparities in 2.1 Coordinates, or oversees 3.1 Balances the best interests 4.1 Practices cost-effective, 5.1 Designs measurement health care access at the coordination of, patient of the patient and family with high-value clinical care, tools to monitor and individual and community access to community and the availability of resources using evidence-based tools provide feedback to levels system resources and information providers/teams on 3.2 Uses available resources technologies to support resource consumption to 1.2 Knows the relative costs 2.2 Is aware of health care (e.g., Electronic Medical decision making facilitate improvement funding and regulations Record [EMR]) to improve of care and reimbursement related to organization of patient safety and quality 5.2 Advocates for improved health care services access to and additional resources within systems of care

Comments: Not yet achieved Level 1

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SBP3 — Community-based Care

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Understands the local 2.1 Understands cultural 3.1 Participates in planning 4.1 Demonstrates capacity 5.1 Participates in the health care delivery systems and community differences care with community mental to provide medical- administration of and other community in use of systems health agencies, schools, and psychiatric leadership to community-based organizations, including community organizations health care facilities treatment programs advocacy groups 2.2 Recognizes role and explains importance of self- 3.2 Incorporates self-help 4.2 Assists families in 5.2 Participates in creating help groups and community groups, community resources, coordinating long-term new community-based resource groups (e.g., and social networks in treatment and care of programs family-based and disorder- treatment and clinical care patients in a community specific support and setting advocacy groups)

2.3 Identifies community- based systems of care for the chronically mentally ill and disabled

Comments: Not yet achieved Level 1

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SBP4 — Consultation to and Integration with Non-psychiatric Medical Providers and Non-medical Systems (e.g., primary care providers, schools, community-based agencies, forensics)

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Describes various 2.1 Provides basic 3.1 Describes consultative 4.1 Skillfully provides 5.1 Designs novel ways to consultative approaches consultation to non- frames across a variety of consultation to non- improve mental health care and the basic consultative psychiatric medical community-based systems psychiatric medical delivery to other systems frame providers providers, including in 3.2 Identifies systems issues complex cases 5.2 Leads a consultation 2.2 Discusses methods for and provides basic team integrating mental health recommendations for change 4.2 Provides integrated care and medical care in in the settings where for psychiatric patients and 5.3 Supervises junior treatment planning consultation occurs families through learners in consultation to collaboration with other systems physicians and other health care providers at community-based sites

4.3 Skillfully provides consultation to a variety of community-based systems (e.g., schools, courts)

Comments Not yet achieved Level 1

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PBLI1 — Development and Execution of Lifelong Learning through Constant Self-evaluation, including Critical Evaluation of Research and Clinical Evidence

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Regularly seeks and 2.1 Demonstrates a 3.1 Critically appraises 4.1 Identifies and meets 5.1 Teaches others incorporates feedback to balanced and accurate self- different types of research, self-directed learning goals techniques to efficiently improve performance assessment of competence, including randomized with little external guidance incorporate evidence using clinical outcomes to controlled trials (RCTs), gathering into clinical 1.2 Identifies self-directed identify areas for continued systematic reviews, meta- 4.2 Demonstrates use of a workflow learning goals and improvement analyses, and practice system or process for periodically reviews them guidelines keeping up with relevant 5.2 Contributes to the with supervisory guidance 2.2 Selects an appropriate, changes in medicine knowledge base and evidence-based information 3.2 Demonstrates disseminates new 1.3 Formulates a searchable tool to meet self-identified improvement in clinical 4.3 Sustains a practice of information through peer- question from a clinical learning goals practice based on continual self-assessment and keeping reviewed publication and practice problem [see 3.3] self-assessment and evidence- up with relevant changes in other scholarly activity and conducts a basic online based information medicine, and applies the search to answer it evidence appropriately to 3.3 Independently searches practice for and discriminates among evidence relevant to clinical practice problems

Comments: Not yet achieved Level 1

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PBLI2 — Teaching

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Assumes a role in the 2.1 Participates in activities 3.1 Teaches groups and 4.1 Develops and gives 5.1 Educates broader clinical teaching of early designed to develop and individuals in clinical settings specialty- and subspecialty- professional community learners improve teaching skills specific presentations to and/or public (e.g., presents 3.2 Teaches in formal didactic groups at regional or national 1.2 Communicates goals and 2.2 Provides feedback to presentations to groups (e.g., meeting) objectives for instruction of early and advanced-level grand rounds, departmental 4.2 Effectively uses feedback early learners learners case conference) on teaching to improve 5.2 Organizes, develops, and teaching methods and delivers curricular materials 2.3 Describes basic 3.3 Participates in and approaches principles of adult learning contributes to educational program review (e.g., resident 4.3 Implements basic retreat, annual program principles of adult learning evaluation, education in his/her teaching committees)

Comments: Not yet achieved Level 1

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PROF1 — Compassion, Integrity, Respect for Others, Sensitivity to Diverse Patient Populations, Adherence to Ethical Principles

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Demonstrates respect 2.1 Elicits beliefs, values, 3.1 Discusses, in educational 4.1 Adapts clinical approach 5.1 Leads educational for trainees and other and diverse cultural settings, his/her own cultural to meet the needs of diverse activities and case members of the treatment practices of patients and background and beliefs and patients and populations discussions regarding ethical team their families, and the ways in which these affect issues specific to child understands their potential interactions with patients 4.2 Incorporates ethical psychiatry 1.2 Demonstrates capacity impact on patient care issues into case discussion for self-reflection, empathy, 3.2 Recognizes ethical and clinical care 5.2 Serves as a role model curiosity about patient and 2.2 Routinely displays conflicts in child psychiatry and teacher of compassion, family, and openness to sensitivity to diversity in practice and seeks supervision 4.3 Recognizes and skillfully integrity, respect for others, different beliefs and points psychiatric evaluation and to manage them manages ethical conflicts in and sensitivity to diverse of view treatment child psychiatry practice and patient populations seeks consultation 1.3 Provides examples of 2.3 Recognizes ethical issues appropriately 5.3 Identifies emerging the importance of attention in practice and is able to ethical issues within to diversity in psychiatric discuss, analyze, and 4.4 Develops a mutually subspecialty practice, and evaluation and treatment manage them in common agreeable care plan in the can discuss opposing clinical situations context of conflicting viewpoints 1.4 Recognizes basic ethical physician and patient conflicts in practice and and/or family values and seeks supervision to manage beliefs them

Comments: Not yet achieved Level 1

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PROF2 — Accountability to Self, Patients, Colleagues, and the Profession

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Follows procedures for 2.1 Identifies and manages 3.1 Knows appropriate steps 4.1 Appropriately prioritizes 5.1 Demonstrates coverage for clinical and situations in which for addressing impairment in and balances conflicting leadership in covering non-clinical responsibilities maintaining personal self and colleagues interests of patient, family, professional duties for emotional, physical, and self, co-workers, and others to colleagues when 1.2 Follows institutional mental health is challenged, 3.2 Prepares for obtaining optimize clinical care and the appropriate policies for physician and seeks assistance when and maintaining board work environment conduct and responsibility needed certification 5.2 Participates in physician 4.2 Participates in the wellness programs or 1.3 Accepts the role as the 2.2 Describes the importance 3.3 Covers professional professional community (e.g., interventions and patient’s physician and of participating in one’s duties for colleagues when house officer association, organizations that address takes responsibility (under professional community appropriate professional societies, patient physician wellness supervision) for ensuring advocacy groups, community that the patient receives 2.3 Is recognized by self, service organizations) 5.3 Develops the best possible care patient, patient’s family, and professionalism policies, medical staff members as an 4.3 When relevant, takes programs, or curricula for 1.4 Demonstrates ability to active member of the clinical appropriate steps in child psychiatry accept professional team addressing impairment in self feedback from supervisors and colleagues 2.4 Displays increasing autonomy and leadership in 4.4 Applies ethical principles taking primary responsibility to practice based on AACAP’s for patient care Code of Ethics

Comments: Not yet achieved Level 1

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ICS1 — Relationship Development and Conflict Management with Patients and Families, Colleagues, Members of the Health Care team, and Other Systems

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Develops therapeutic 2.1 Develops working 3.1 Develops therapeutic 4.1 Skillfully manages 5.1 Develops relationship with patients relationships across relationships with patients therapeutic and working models/approaches to and their families in specialties and systems in and families in complicated relationships during managing difficult uncomplicated situations uncomplicated situations situations complex and challenging communications situations, including 1.2 Describes and respects 2.2 Manages simple 3.2 Sustains working transitions of care 5.2 Effectively mentors cultural and linguistic patient/family-related relationships with co-workers other health care providers diversity in communicating conflicts in the face of conflict 4.2. Sustains relationships in leadership, with people of different across systems of care and communication skills, and backgrounds 2.3 Actively participates in 3.3 Takes a leadership role in a with patients and families conflict management and supports activities of multidisciplinary care team during long-term follow-up 1.3 Recognizes team-based care 5.3 Leads and facilitates communication conflicts in 3.4 Recognizes differing 4.3 Takes a leadership role meetings within the work relationships philosophies within and in managing team conflicts organization/system between different disciplines in care provision 4.4 Effectively leads multidisciplinary patient care and family meetings

Comments: Not yet achieved Level 1

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ICS2 — Information Sharing and Record Keeping

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Ensures transitions of 2.1 Uses developmentally- 3.1 Demonstrates written 4.1 Demonstrates skillful 5.1 Participates in the care are optimally appropriate language in all communication with patients, communication that is development of changes in communicated across phases of communication families, colleagues, and other appropriate, efficient, rules, policies, and systems and continuums of with patients health care providers that is concise, and pertinent with procedures related to care appropriate, efficient, concise, patients and families, technology 2.2 Communicates with and pertinent colleagues, and co-workers 1.2 Sufficiently documents families at an appropriate 5.2 Engages in scholarly clinical encounters in the level of sophistication 3.2 Appropriately balances 4.2 Recruits appropriate activity regarding effective medical record in an patient confidentiality and the assistance from external communication and accurate and timely way 2.3 Consistently family’s right to know sources when cultural documentation consistent with institutional demonstrates information differences create barriers policies communication strategies to patient care to ensure patient and family 3.3 Appropriately balances 1.3 Effectively understanding patient confidentiality and 4.3 Thoroughly and communicates information communication with the efficiently documents with patients and families in treatment team patient encounters and uses clinical encounters discretion and judgment in 3.4 Consistently engages the inclusion of sensitive 1.4 Maintains appropriate patients and families in shared patient material in the boundaries in sharing decision making medical record information by electronic communication and in the 3.5 Demonstrates appropriate 4.4 Uses discretion and use of social media face-to-face interaction while judgment in electronic using EMR communication with patients, families, and colleagues

Comments: Not yet achieved Level 1