The Colon and Rectal Surgery Milestone Project

A Joint Initiative of The Accreditation Council for Graduate Medical Education and The American Board of Colon and Rectal Surgery

June 2013

Examples included

The Colon and Rectal Surgery Milestone Project

The milestones are designed only for use in evaluation of resident physicians in the context of their participation in ACGME-accredited residency or fellowship programs. The milestones provide a framework for the assessment of the development of the resident physician in key dimensions of the elements of physician competency in a specialty or subspecialty. They neither represent the entirety of the dimensions of the six domains of physician competency, nor are they designed to be relevant in any other context.

Colon and Rectal Surgery Milestones

Chair: Charles B. Whitlow, MD

Working Group Advisory Group Glenn Ault, MD Elisa H. Birnbaum, MD Jennifer Beaty, MD Timothy Brigham, MDiv, PhD Bertram T. Chinn, MD Bruce Orkin, MD Pamela Derstine, PhD, MPHE John Potts, MD Laura Edgar, EdD, CAE David Schoetz Jr., MD Karin M. Hardiman, MD Eric G. Weiss, MD Gerald Isenberg, MD Jan Rakinic, MD Anthony Senagore, MD

Milestone Reporting

This document presents milestones designed for programs to use in semi-annual review of resident performance and reporting to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced. They are descriptors and targets for resident performance as a resident moves from entry into residency through graduation. In the initial years of implementation, the Review Committee will examine milestone performance data for each program’s residents as one element in the Next Accreditation System (NAS) to determine whether residents overall are progressing.

For each period, review and reporting will involve selecting milestone levels that best describe a resident’s current performance and attributes. Milestones are arranged into numbered levels. Tracking from Level 1 to Level 5 is synonymous with moving from novice to expert. These levels do not correspond with post-graduate year of education.

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

Level 1: The resident demonstrates milestones expected of an incoming resident.

Level 2: The resident is advancing and demonstrates additional milestones, but is not yet performing at a mid-residency level.

Level 3: The resident continues to advance and demonstrate additional milestones, consistently including the majority of milestones targeted for residency.

Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target.

Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level.

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Additional Notes

Level 4 is designed as the graduation target and does not represent a graduation requirement. Making decisions about readiness for graduation is the purview of the residency program director. Study of milestone performance data will be required before the ACGME and its partners will be able to determine whether milestones in the first four levels appropriately represent the developmental framework, and whether milestone data are of sufficient quality to be used for high-stakes decisions.

Examples are provided with some milestones. Please note that the examples are not the required element or outcome; they are provided as a way to share the intent of the element. Two documents are available – one with examples, and one without.

Some milestone descriptions include statements about performing independently. These activities must conform to ACGME supervision guidelines, as well as institutional and program policies. For example, a resident who performs a procedure independently must, at a minimum, be supervised through oversight.

To aid in scoring the milestones, assessment tools are available on the Association of Program Directors for Colon and Rectal Surgery website (http://www.apdcrs.org/global_assessment.htm). These assessment tools are not required.

Answers to Frequently Asked Questions about the NAS and milestones are available on the ACGME’s NAS microsite: http://www.acgme- nas.org/assets/pdf/NASFAQs.pdf.

The diagram below presents an example set of milestones for one sub-competency in the same format as the milestone report worksheet. For each reporting period, a resident’s performance on the milestones for each sub-competency will be indicated by selecting the level of milestones that best describes that resident’s performance in relation to the milestones.

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

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet

Benign Perianal and Anal Disease Processes — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 • Lists some components • Discusses some • Demonstrates knowledge • Integrates anatomy, • Discusses new theories of anatomy, physiology, components of anatomy, of physiology, anatomy, physiology, pathogenesis, of physiologic pathogenesis, and physiology, pathogenesis, pathogenesis, and and histopathology disturbance and disease histopathology and histopathology histopathology • Distinguishes and justifies pathogenesis • Lists some processes that • Discusses some processes • Demonstrates urgent vs. elective • Discusses investigational require urgent that require urgent understanding of approaches for initial options for disease management management processes requiring urgent treatment; distinguishes treatment and • Lists some general • Discusses mechanism of management and justifies appropriate prevention elective treatment action for some initial • Demonstrates resuscitation preparatory • Discusses investigational recommendations elective treatment understanding of initial to urgent management options for disease • Lists some treatment recommendations elective treatment • Distinguishes and justifies treatment and options for disease • Discusses some recommendations and non-operative vs. prevention progression or recurrence treatment options for their limitations operative approaches for • Discusses investigational disease progression or • Demonstrates knowledge initial elective treatment options for decreasing recurrence of treatment options for • Distinguishes and justifies risks associated with disease progression or treatment options for management of disease Example: recurrence disease progression or progression or The resident discusses some recurrence, including the recurrence processes that require Example: associated risks, in the urgent management. The resident demonstrates context of previous understanding of processes treatment attempts The resident is able to requiring urgent discuss some anorectal management. Example: disease processes that The resident distinguishes require urgent The resident is able to and justifies urgent vs. management, but explain the pathophysiology elective approaches for initial differential diagnosis is of anorectal processes that treatment; he or she incomplete. require urgent management, distinguishes and justifies such as abscess; however, he appropriate resuscitation for or she cannot articulate the preparatory to urgent rationale for bedside abscess management. drainage vs. resuscitation prior to operative drainage. The resident correctly identifies and distinguishes

Copyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Colon and Rectal Surgery. All rights reserved. The copyright owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 1

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet appropriate elective abscess drainage, such as when some spontaneous drainage has occurred, when bedside drainage can be done in appropriate patients, and when patients with specific comorbid factors, such as immunocompromise or diabetes, that require resuscitation prior to operative intervention.

Comments:

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet

Benign Perianal and Anal Disease Processes — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 • Lists some common • Discusses epidemiology of • Demonstrates knowledge • Assesses specific history • Understands and diagnoses common diagnoses of common diagnoses; details in formulation of discusses current • Lists some options for • Articulates options for demonstrates some differential diagnosis; controversies in disease problems requiring urgent intervention and knowledge of specialty independently performs incidence and prevalence urgent intervention some component steps examination exam for diagnosis • Demonstrates • Lists some options for • Articulates options for • Recognizes situations confirmation proficiency as a teaching the elective treatment elective treatment and requiring urgent • Independently identifies assistant in the • Lists common some component steps intervention; with need for urgent component steps of complications of • Articulates variances in assistance, directs intervention; proficiently urgent intervention operative procedures progress after treatment appropriate resuscitation directs appropriate • Understands and implementation and and completes indicated resuscitation and selects discusses current investigational options intervention and completes indicated controversies in therapy; • With assistance, selects and intervention demonstrates proficiency Example: directs or performs initial • Independently selects and as a teaching assistant in The resident articulates elective treatment, directs or performs initial the component steps of options for urgent operative or non-operative elective treatment, elective operative intervention and some • Recognizes disease operative or non-operative, management component steps. progression, treatment including discussion with • Reviews and assesses failure, and complications, patient regarding risk- practice results and uses The resident articulates a few and implements benefit analysis the information to operative options in patients management • Anticipates, diagnoses, and effectively modify who present with severe proficiently manages disease practice perianal pain as well as some Example: progression, treatment component steps of The resident recognizes failure, or complications in a procedures, but knowledge situations requiring urgent timely manner of the operative process is intervention; with assistance, incomplete due to an he or she directs appropriate Example: incomplete knowledge of the resuscitation and completes The resident independently likely causative processes of indicated intervention. identifies the need for urgent this presentation. intervention, proficiently The resident recognizes the directs appropriate possibility of suppurative resuscitation, and selects and disease as the causative completes the indicated process and understands that intervention.

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet this would require operative drainage, but his or her The resident independently understanding of other obtains the appropriate potential causative processes historical details, performs the and appropriate laboratory appropriate exam to determine assessment and resuscitation the possibility of suppurative requires assistance; the disease, correctly identifies risk resident’s knowledge of factors for systemic appropriate anesthetic in this complication of anorectal situation is incomplete; the suppuration, and directs resident requires assistance to appropriate laboratory studies prepare for and perform the for assessment, then directs operative examination and resuscitation as indicated; the properly indicate operative resident correctly determines intervention. when resuscitation is adequate to proceed to the operating room; having requested appropriate form of anesthetic management, the resident independently prepares for and performs the operative examination and correct avenue of drainage of suppuration, or other indicated operative intervention if suppuration is not the causative process.

Comments:

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet Colonic Neoplasia — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 • Lists some components • Discusses some • Demonstrates knowledge of • Integrates anatomy, • Discusses investigational of anatomy, components of anatomy, anatomy, pathogenesis, pathogenesis, tumor markers and pathogenesis, pathogenesis, histopathology, genetics, and histopathology, genetics, other staging modalities histopathology, histopathology, genetics, staging for colon cancer and and staging for colon • Discusses investigational genetics, and staging for and staging for colon polyps and polyposis cancer and polyps and chemotherapeutic colon cancer and polyps cancer and polyps and syndromes polyposis syndromes options and polyposis polyposis syndromes • Demonstrates understanding • Distinguishes and justifies • Discusses investigational syndromes • Discusses mechanism of of treatment protocols and use of specific neo- modalities for post- • Lists common agents in action for some complications adjuvant agents and treatment surveillance neoadjuvant and neoadjuvant and adjuvant • Demonstrates understanding protocols for stage-based • Discusses controversial adjuvant therapy therapies of stage-based post- therapy and complications or emerging modalities • Lists modalities for post • Discusses guidelines for treatment surveillance • Justifies post-treatment for management of treatment surveillance post-treatment surveillance • Demonstrates understanding surveillance strategies recurrent disease • Lists common sites and • Recognizes and discusses of therapeutic options for based upon timing and • Discusses advanced relative risks of risk factors for recurrence recurrence patterns of local and genetic and treatment recurrence • Discusses post- • Demonstrates understanding distant recurrence concepts for polyposis • Lists surveillance polypectomy surveillance of polyp surveillance • Distinguishes and justifies syndromes schedule for patients schedule schedule palliative vs. curative with polyps • Discusses polyposis • Demonstrates understanding management of recurrence Example: • Lists polyposis syndrome treatment plan, of polyposis syndrome • Justifies timing and The resident can explain syndromes and knows timing, and type of treatment plan, timing, and procedure type for various the genetic basis of colon some differences procedures specific procedures polyposis syndromes cancer, as well as between them appropriate markers and Example: Example: Example: how this affects treatment Example: The resident articulates basic The resident can explain the The resident can clearly options. For polyposis The resident knows basic attributes of colon cancer and treatment approach based on explain multiple treatment patients, he or she can TNM stages, but not details polyposis syndromes, different stages for colon cancer modalities, including different discuss treatment of within each stage, (i.e., including treatment and and polyposis, and knows timing folfox/folfiri, when to use recurrent polyps in pouch does not know the surveillance, but is unsure of of surveillance and rationale. Avastin etc.; he or she knows and surveillance of difference between T1 and the exact plan and current how to manage a patient with duodenum. T2, but knows the T stage is guidelines. polyposis and rectal cancer. referring to tumor depth).

Comments:

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet Colonic Neoplasia (polyps, colon cancer, polyposis) — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 • Lists some imaging • Discusses strategies for • Formulates an • Assesses imaging • Understands and options for imaging, but has limited appropriate imaging information and justifies a discusses current tumour/node/metastases understanding of strategy and interprets TNM-based treatment controversies regarding (TNM) staging interpretation of results results strategy image-based treatment • Lists some of the surgical • Articulates surgical • With assistance, selects • Independently selects and strategies options for management options and some and completes the completes component • Demonstrates proficiency and treatment; knows component steps for component steps for steps for partial as a teaching assistant different procedures for partial colectomy, total partial colectomy, TAC, colectomy, TAC, TPC, partial colectomy, TAC, polyps, cancer, and abdominal colectomy TPC, restorative restorative proctectomy, TPC, restorative polyposis (TAC), total proctectomy, and and laparoscopic and open proctectomy, and • Lists common proctocolectomy (TPC), laparoscopic and open techniques laparoscopic and open complications and restorative proctectomy, techniques • Anticipates, diagnoses, techniques management of those and laparoscopic and open • Implements and proficiently manages • Reviews and assesses complications techniques management of complications in a timely practice results, and uses • Lists modalities of post- • Recognizes variances from complications manner the information to treatment surveillance the normal post-operative • Understands post- • Directs post-treatment effectively modify practice for polyps, cancer, and course and begins treatment surveillance surveillance strategies • Understands and polyposis syndromes investigation strategies vary by stage • Implements curative vs. discusses current • Lists potential evaluation • Discusses modalities for • Discusses treatment of palliative intervention for controversies regarding and treatment of post-treatment recurrence and potential recurrence surveillance recurrence surveillance complications • Understands and • Discusses evaluation of Example: discusses evolving Example: recurrence Example: The resident directs post- management of recurrent The resident lists modalities The resident understands treatment surveillance disease of post-treatment Example: that post-treatment strategies. surveillance. The resident discusses surveillance strategies vary modalities for post- by stage. For an N1 or N2 patient, the treatment surveillance. resident directs the three- The resident discusses the month clinical exam, carcino- The resident articulates rationale for timing and embryonic antigen (CEA); at individual components of relative strengths and one year he or she directs post-treatment modalities, weaknesses of tests based colonoscopy and computed but is unable to articulate a upon stage-specific risks for tomography (CT) of pelvis coherent evidence-based recurrence, but the patient- and chest x-ray; schema is plan of recurrence. specific plan is incomplete. evidence-based; he or she

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet then recognizes the signs and symptoms of a leak; following the patient’s discharge, he or she appropriately recommends timing for clinical evaluation and imaging surveillance.

Comments:

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet

Crohn’s Disease — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 • Lists some components • Discusses some • Demonstrates knowledge • Integrates anatomical • Discusses investigational of anatomical components of anatomical of anatomical distribution, distribution, pathogenesis, genetic markers, distribution, distribution, pathogenesis, pathogenesis, histopathology, inflammatory mediators, pathogenesis, histopathology, histopathology, immunology, genetics, and and imaging modalities histopathology, immunology, genetics, and immunology, genetics, and diagnostic information • Discusses controversial immunology, genetics, diagnostic information diagnostic information • Distinguishes and justifies or emerging modalities and diagnostic • Discusses mechanisms of • Demonstrates use of specific immune- for surgical therapy information action for drug therapy understanding of suppressive and anti- • Lists common agents for • Discusses indications for appropriate use and inflammatory therapy medical therapy surgical intervention monitoring of drug • Justifies appropriate • Lists common surgical therapy timing and selection of options Example: • Demonstrates surgical intervention The resident discusses understanding of Examples: obstruction, fistula appropriate timing and Examples: The resident discusses that formation, abscess, or failure selection of surgical The potential role of NOD2 the chronic inflammatory of medical treatment as intervention mutation as a risk factor in process of Crohn’s produces indications for surgery. Crohn’s is discussed. The full thickness inflammation Example: resident defines both top- throughout the The resident articulates the down (tumor necrosis factor gastrointestinal (GI) tract. need for both image-guided [TNF] agents early) and He or she defines the classic and endoscopic assessment bottom-up (5- aminosalicylic association of linear ulcers, to monitor therapy and guide acid [ASA] then steroids then skip lesions, and granulomas prognosis. immunosuppressives) (non- caseating) on the treatment options. pathology and characteristic Assessment of treatment endoscopic findings. efficacy using the Crohn Disease Activity Index (CDAI) is clearly articulated.

Comments:

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet Crohn’s Disease — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 • Displays limited • Discusses strategies for • Formulates an appropriate • Assesses symptom scoring, • Understands and understanding of imaging and medical scoring, imaging, and imaging, and endoscopic discusses current appropriate symptom therapy based on endoscopic strategy and information to develop controversies scoring, imaging, and symptom scoring or interprets results treatment strategy regarding imaging and endoscopic options for disease activity • With assistance selects and • Independently selects and emerging medical disease evaluation • Articulates medical completes component completes component steps treatment modalities • List some of the medical (corticosteroids, steps for fistula for fistula management, lap • Demonstrates and surgical options for immunosuppression, 5 management, lap and open and open segmental bowel proficiency as a management and ASA) and surgical (fistula segmental bowel resection, resection, strictureplasty, and teaching assistant for treatment management, lap and strictureplasty, and TPC/Ileostomy fistula management, • Lists common open segmental bowel TPC/Ileostomy • Anticipates, diagnoses, and lap and open complications of resection, strictureplasty, • Recognizes and implements proficiently manages segmental bowel disease, medical, and TPC/Ileostomy) options management of complications in a timely resection, surgical treatment • Recognizes disease complications manner strictureplasty, and • List modalities for progression and • Understands and discusses • Directs post-surgical TPC/Ileostomy disease monitoring and variances from normal post-treatment and management for surveillance • Reviews and assesses prophylaxis post-operative course surveillance strategies and prophylaxis practice results and and begins investigations uses the information to Example: • Recognizes strategies for Example: Example: effectively modify The resident is aware that disease monitoring and The resident requires The resident is able to practice there is a CDAI but is prophylaxis assistance to manage a independently direct the unfamiliar with the Crohn’s Disease-associated management of specifics; he or she is Example: enterocutaneous fistula, enterocutaneous fistula unaware of imaging The resident is able to including imaging, control of secondary to Crohn’s Disease, modalities other than CT. discuss the use of steroids, sepsis, assessment for disease including imaging, control of 5-ASA, and metronidazole, remote from the fistula, sepsis, assess for disease remote but is unaware of anti-TNF nutritional support, medical from the fistula, nutritional options. treatment, and timing to support, medical treatment, and surgery. timing to surgery.

Comments:

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet Large Bowel Obstruction — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 • Lists some components • Discusses some • Demonstrates knowledge • Integrates symptoms, • Discusses investigational of etiology, anatomic components of etiology, of etiology, anatomic exams, lab, imaging, and diagnostic modalities distribution, anatomic distribution, distribution, endoscopic findings to • Discusses investigational pathophysiology, and pathophysiology, and pathophysiology, and develop an appropriate diagnostic modalities clinical staging (when clinical staging (when clinical staging (when differential diagnosis • Discusses controversial or appropriate) appropriate) appropriate) • Distinguishes and justifies emerging modalities for • Lists common diagnostic • Discusses appropriate • Demonstrates knowledge appropriate use of treatment or palliation modalities diagnostic imaging and of appropriate diagnostic diagnostic imaging and • Discusses post-treatment • Lists endoscopic or endoscopic modalities imaging and endoscopic endoscopic modalities controversies and surgical modalities for • Discusses endoscopic or modalities • Distinguishes and justifies emerging strategies for treatment surgical modalities for • Demonstrates knowledge appropriate endoscopic definitive therapy, • Limited understanding of treatment or palliation for endoscopic or surgical or surgical modalities for adjuvant therapy, or need for post-treatment • Recognizes the need for modalities for treatment treatment or palliation surveillance definitive therapy, post-treatment definitive or palliation • Appropriately justifies adjuvant therapy, or therapy, adjuvant therapy, • Demonstrates knowledge post-treatment strategies Example: surveillance dependent or surveillance dependent and understanding of for definitive therapy, The resident discusses upon histo-pathology upon histo-pathology some post-treatment adjuvant therapy, or controversial or emerging strategies for definitive surveillance dependent modalities for treatment or Example: Example: therapy, adjuvant therapy, upon histo-pathology palliation. The resident lists endoscopic The resident discusses or surveillance dependent or surgical modalities for endoscopic or surgical upon histo-pathology Example: The resident is able to treatment. modalities for treatment or The resident distinguishes appropriately discuss the palliation. Example: and justifies appropriate role of resection vs. repeated The resident is able list The resident demonstrates endoscopic or surgical palliative endoscopic endoscopic decompression The resident is able to discuss knowledge for endoscopic or modalities for treatment or decompression for and surgical resection for the roles of surgery and surgical modalities for palliation. chronic/recurrent sigmoid treatment in cases of endoscopy for treatment in treatment or palliation. volvulus. sigmoid volvulus. cases of sigmoid volvulus. The resident is able to The resident is able to articulate and recognize: articulate indications and surgical indications and contra-indications for surgery contra-indications for or endoscopic sigmoid volvulus; determine decompression if sigmoid appropriate procedures to volvulus is present. be performed (e.g., primary anastomosis vs resection

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet and diversion); whether ischemia or peritoneal inflammation is present; or if endoscopic decompression is more appropriate in the absence of these findings.

Comments:

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet Large Bowel Obstruction — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 • Displays limited • Discusses strategies for • Formulates an appropriate • Appropriately assesses • Understands and understanding of clinical clinical- and image-guided assessment based on clinical presentation, discusses current or image-based therapy with limited imaging and clinical staging, and imaging, and controversies in presentation understanding of results evaluation and discusses justifies appropriate assessment and therapy • Lists some medical, and benign/malignant options for therapy therapy • Demonstrates image-guided, or surgical etiologies • With assistance selects • Independently selects and proficiency as a teaching options for management • Articulates some and completes component completes component assistant in the and treatment component steps for steps for definitive, steps for definitive, component steps • Lists common definitive, staged, or staged, or palliative staged, or palliative definitive, staged, or complications and their palliative treatment using treatment using treatment using palliative treatment management endoscopic, minimally endoscopic, MIS, and endoscopic, MIS, and using endoscopic, MIS, • Limited understanding of invasive surgery (MIS), and traditional surgical traditional surgical and traditional surgical need for post-treatment traditional surgical approaches approaches approaches strategies for definitive approaches • Recognizes and • Anticipates, diagnoses, • Reviews and assesses therapy, adjuvant • Recognizes variances in implements management and proficiently manages practice results and uses therapy, or surveillance medical, interventional, for failure of non- treatment failure or the information to dependent upon histo- and surgical recovery, and operative therapy or surgical complications in a effectively modify pathology begins investigation surgical complications timely manner practice • Recognizes need for post- • Demonstrates knowledge • Appropriately directs post- • Discusses controversies Example: treatment strategies for and understanding of treatment strategies for and emerging theories The resident displays a definitive therapy, some components of post- definitive therapy, regarding post- limited understanding of adjuvant therapy, or treatment strategies for adjuvant therapy, or treatment strategies for clinical or image-based surveillance dependent definitive therapy, surveillance dependent definitive therapy, presentation. upon histo-pathology adjuvant therapy, or upon histo-pathology adjuvant therapy, or surveillance dependent surveillance The resident is able to Example: upon histo-pathology Examples: identify colonic distension, The resident discusses The resident appropriately Example: but is unable to determine strategies for clinical and Examples: assesses clinical The resident understands the need for urgent vs. image-guided therapy with a The resident formulates an presentation, staging, and and discusses current emergent intervention and limited understanding of appropriate assessment imaging and justifies the controversies in assessment studies to distinguish a results and benign/malignant based on imaging and clinical appropriate therapy. and therapy. complete vs. incomplete etiologies. evaluation and discusses obstruction. options for therapy. The resident is able to The resident is able to The resident is able to appropriately determine if identify Stage IV Colo-Rectal determine the need for The resident is able to the obstruction is complete cancer and discuss the roles

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet urgent vs. emergent formulate an opinion if the or resulting in compromised of systemic therapy with intervention, discuss the role obstruction is due to an bowel necessitating surgery subsequent re-staging, for CT scan, and contrast acute inflammatory process based upon clinical exam, stenting followed by studies and endoscopy to (e.g., diverticulitis or Crohn’s) labs and imaging. systemic therapy, or identify the degree of or a chronic stricture from resection/diversion obstruction and features benign or malignant The resident is able to followed by systemic suggesting cancer, processes. determine if the obstruction therapy. diverticulitis, inflammatory is incomplete and chronic, bowel disease (IBD), ischemia The resident is able to discuss and whether a stent should or, extrinsic process as an the need for intervention be placed as a bridge to a etiology. utilizing resection with or single stage resection. without diversion, colonic stent placement, or medical therapy.

Comments:

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet

Rectal Cancer — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 • Lists some components • Discusses some • Demonstrates knowledge • Integrates anatomy, • Discusses investigational of anatomy, components of anatomy, of anatomy, pathogenesis, pathogenesis, tumor markers and other pathogenesis, pathogenesis, histopathology, genetics, histopathology, genetics, staging modalities histopathology, genetics, histopathology, genetics, and staging and staging • Discusses investigational and staging and staging • Demonstrates • Distinguishes and justifies chemotherapeutic and • Lists common agents in • Discusses mechanism of understanding of use of specific neo- radiation options neo-adjuvant and action for some neo- treatment protocols and adjuvant and adjuvant • Discusses investigational adjuvant therapy adjuvant and adjuvant complications agents and protocols for modalities for post- • Lists modalities for post- therapies • Demonstrates stage-based therapy and treatment surveillance treatment surveillance • Discusses guidelines for understanding of stage- complications • Discusses controversial • Lists common sites and post-treatment based post-treatment • Justifies post-treatment or emerging modalities relative risks of surveillance surveillance surveillance strategies for management of recurrence • Recognizes and discusses • Demonstrates based upon timing and recurrent disease risk factors for recurrence understanding of patterns of local and therapeutic options for distant recurrence recurrence • Distinguishes and justifies palliative vs. curative management of recurrence

Comments:

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet

Rectal Cancer — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 • Lists some imaging • Discusses strategies for • Formulates appropriate • Assesses imaging • Understands and options for TNM staging imaging, but has limited imaging strategy and information and justifies a discusses current • Lists some surgical understanding of interprets result TNM-based treatment controversies regarding options for management interpretation of results • With assistance, selects strategy image-based treatment and treatment • Articulates surgical and completes the • Independently selects and strategies • Lists common options and some component steps for TAE, completes component • Demonstrates complications and component steps for TME, restorative steps for TAE, TME, proficiency as a teaching management of those transanal excision (TAE), proctectomy, and APR restorative proctectomy, assistant for TAE, TME, complications TME, restorative • Implements management and APR restorative proctectomy, • Lists modalities of post- proctectomy, and anterior of complications • Anticipates, diagnoses, and APR treatment surveillance perineal resection (APR) • Understands that post- and proficiently manages • Reviews and assesses • Lists potential evaluation • Recognizes variances from treatment surveillance complications in a timely practice results, and uses and treatment of the normal post-operative strategies vary by stage manner information to effectively recurrence course and begins • Discusses treatment of • Directs post-treatment modify practice investigation recurrence and potential surveillance strategies • Understands and Example: • Discusses modalities for complications • Implements curative vs. discusses current The resident lists modalities post-treatment palliative intervention for controversies regarding of post-treatment surveillance Example: recurrence surveillance surveillance. • Discusses evaluation of The resident understands • Understands and recurrence that post-treatment Examples: discusses evolving surveillance strategies vary The resident directs post- management of Example: by stage. treatment surveillance recurrent disease The resident discusses strategies. modalities for post- The resident discusses treatment surveillance. rationale for timing and For an N1 or N2 patient, the relative strengths and resident directs a three- The resident articulates weaknesses of tests based month clinical exam, CEA; at individual components of upon stage-specific risks for one year, the resident directs post-treatment modalities, recurrence, but the patient- colonoscopy and CT of pelvis but is unable to articulate a specific plan is incomplete. and chest x-ray; schema is coherent evidence-based evidence-based. plan. The resident discusses the components of a digital rectal

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet exam that describes the nature of the lesion; recommends an endorectal ultrasound (ERUS), and when presented with a T3N1 M0 lesion recommends neoadjuvant chemo-radiation; understands the treatment protocol requires five weeks for completion, followed by a nine-week rest period; re- evaluates the patient and recognizes that a lesion at 4cm distal margin is appropriately managed by colon-anal total mesorectal excision (TME); the resident then recognizes the signs and symptoms of an leak; following the patient’s discharge, the resident appropriately recommends timing for clinical evaluation and imaging surveillance.

Comments:

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet

Rectal Prolapse — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 • Lists some components • Discusses some • Demonstrates knowledge • Integrates anatomy and • Proposes investigational of anatomy and components of anatomy of anatomy and physiology of rectal research in anatomic or physiology of rectal and physiology of rectal physiology of rectal prolapse physiologic disturbances prolapse prolapse prolapse • Integrates results of • Discusses new • Lists some imaging • Discusses strategies for • Demonstrates imaging and physiologic investigational modalities options (defecography, imaging and physiology understanding of testing and correlates for rectal prolapse air contrast barium but has limited ability to appropriate imaging and appropriately with • Discusses current enema) and physiologic interpret results physiologic evaluation anatomical and controversies in studies (anorectal • Discusses rationale for • Demonstrates knowledge physiological treatment options manometry [ARM], transabdominal versus of success rates for abnormalities electromyographic perineal techniques for treatment options, and • Justifies appropriate [EMG], Pudendal Nerve rectal prolapse surgical management of treatment interventions Terminal Motor Latency anterior compartment for rectal and general [PNTML], Colon Transit Example: prolapse pelvic organ prolapse Studies) useful in The resident discusses evaluating rectal prolapse surgical management but Example: Example: • Lists options for has a limited ability to The resident demonstrates The resident discusses risks treatment of rectal discuss non-operative knowledge of repair types, and benefits of abdominal vs prolapse management. but requires direction for perineal repair based on co- selection of repair in morbidities and examination Example: individual patients. of individual patients. The resident has Incomplete knowledge of the pathophysiology of rectal prolapse as opposed to other anorectal conditions.

Comments:

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet

Rectal Prolapse — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 • Lists some imaging • Discusses strategies for • Formulates an appropriate • Assesses history and • Reviews and assesses the options (defecography imaging and physiology investigative work-up after physical, imaging, and frequency of time std x-rays vs. MRI) and but has limited ability to conducting appropriate physiologic data, and physiology studies would physiologic studies (ARM, interpret results history and physical justifies treatment change surgical decisions EMG, PNTML, Colon • Discusses key steps of • With assistance, performs strategy in personal practice Transit Studies) useful in abdominal rectopexy and key steps of rectopexy, • Independently performs • Demonstrates evaluation of rectal resection/rectopexy resection/rectopexy, and transabdominal and proficiency as a teaching prolapse (laparoscopic vs. open); perineal repair; discusses perineal repair of rectal assistant for repair of • Lists options for discusses key steps of newer modalities for prolapse; discusses newer rectal prolapse and pelvic treatment of rectal perineal repair of rectal rectal prolapse ventral rectopexy organ prolapse prolapse prolapse • With assistance, performs • Independently performs • Discusses current • Lists common • Discusses rationale for key steps of surgery for surgery for rectal controversies regarding complications associated rectopexy vs. resection rectal prolapse repair prolapse; appropriately repairs with pelvic prolapse rectopexy • Recognizes and involves multidisciplinary • Reviews outcome data surgeries • Recognizes disease implements management team for repairs of collected and uses this progression and variances of complications associated pelvic organ data to change practice from normal post- prolapse operative course and Example: • Anticipates, diagnoses, begins investigations The resident is able to reduce and proficiently manages the rectal prolapse when complications in a timely Example: appropriate, and perform the manner The resident distinguishes definitive repair of the rectal prolapse from other prolapse with guidance. Example: conditions, such as acute The resident Independently hemorrhoidal disease. performs a definitive repair of rectal prolapse.

Comments:

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet

Rectovaginal (RV) Fistula — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 • Lists some components • Discusses some • Demonstrates knowledge • Integrates classification • Discusses of classification schemes, components of of classification schemes, schemes, pathogenesis, investigational pathogenesis, and classification schemes, pathogenesis, and and diagnostic approaches of diagnostic information pathogenesis, and diagnostic information information pathogenesis and • Lists common surgical diagnostic information • Demonstrates • Justifies appropriate diagnosis options • Discusses options for understanding of timing and selection of • Discusses controversial surgical intervention appropriate timing and surgical intervention, or emerging modalities Examples: selection of surgical including benefits of one for surgical therapy and The resident articulates that Examples: intervention therapy over another approaches to recurrent classification schemes exist The resident articulates and including RV fistula which include size, location, classification schemes by Examples: recurrence rates and etiology. He or she may size, location, and etiology. The resident has sound articulate other Based on evaluation, the knowledge of how to classify Examples: classifications such as high resident is able, with RV fistulas, but requires some The resident correctly or low. The resident direction from an attending, assistance from an attending classifies the RV fistula generally categorizes to integrate diagnostic to integrate clinical and based on history and treatment into conservative, information and diagnostic information diagnostic information local repairs, or complex appropriately classify RV available to appropriately obtained. He or she repairs. fistula. Based on classify the fistula. The integrates this clinical classification, the resident, resident can articulate various information into an with direction from an options for surgical appropriate classification. attending, can discuss some intervention, but requires Based on that classification, of the pros and cons of assistance from an attending the resident correctly surgical options based on to select the appropriate chooses an appropriate class of RV fistula. intervention based on the surgical intervention classification and underlying (conservative; or local etiology. repair, which may include sealants, advancement flaps, excision, layered closure, etc. vs. complex repair with tissue interposition). While choosing the surgical intervention, the resident

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet can articulate recurrence rates, and when more than one option exists for treatment, demonstrates the ability to discuss the advantages and disadvantages of one treatment over another.

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Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet

Rectovaginal Fistula — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 • Displays limited • Discusses strategies for • Formulates appropriate • Assesses symptoms, • Understands and understanding of imaging and examination assessment based on imaging, and examination discusses current appropriate examination, of patients based on imaging and examination to develop an appropriate controversies regarding imaging, and evaluation presenting symptoms results treatment strategy imaging treatment options for disease • Articulates surgical fistula • With assistance, selects • Independently selects and modalities evaluation management options and completes completes component • Demonstrates proficiency • List some surgical options (sealants, advancement component steps of steps for fistula as a teaching assistant for for management and flaps layered closure, fistula management management fistula management treatment muscle interpositions) • Recognizes and • Anticipates, diagnoses, • Reviews and assesses • Lists common • Recognizes variances from implements management and proficiently manages practice results and uses complications of surgical normal post-operative of complications complications in a timely the information to treatment course and begins manner effectively modify practice investigations Example: Examples: The resident conducts a Example: The resident has a limited Examples: targeted examination and The resident is able to assess ability to establish an Based on the presenting evaluation strategy. This the patient without guidance, evaluation strategy, which symptoms, the resident evaluation leads to an taking into account possibly may include proctoscopy, articulates an evaluation appropriate diagnosis and underlying disease conditions colposcopy, and use of strategy, including assessment of the that may affect evaluation methylene blue tampon assessment of local tissues presenting problem. and treatment strategies. test, vaginography, barium and selecting an appropriate enema, or magnetic test to initiate evaluation. Based on the evaluation, a Based on the assessment resonance imaging (MRI). surgical treatment plan is during the examination and This evaluation also includes Based on the evaluation developed and the resident evaluation, the resident assessment of local tissues. findings and underlying is able to articulate selects an appropriate disease process that may components of how the treatment strategy and is The resident is able to list exist, the resident can operation is conducted, but able to conduct the repair some of the repair articulate a potential is unable to conduct the without significant assistance techniques, which may treatment plan based on the operation without guiding from the attending physician. include fibrin sealants, options available. The assistance. advancement flaps, excision resident still may struggle The resident anticipates of fistula and layered with the ability to choose a Post-operatively, the potential complications and closure, perineal- strategy, but is aware of the resident recognizes is able to recognize early proctectomy, and tissue various surgical options. complications, and with onset of symptoms of those

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet interposition. guidance initiates evaluation complications; the resident Post-operatively, the resident and treatment of initiates evaluation and The resident is able to list recognizes symptoms that complications. treatment of the same in a some of the reasons for may indicate a failure of the timely fashion. failure of repair which may repair has occurred, or other be linked to underlying post-operation complication, disease such as IBD or and initiates evaluation of radiation injury. the same, based on presenting symptoms.

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Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet Anatomy and Physiology — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 • Lists some important • Discusses important • Completely describes • Assesses history and physical, • Reviews and assesses muscular components of muscular components of important muscular imaging, and physiologic data the frequency of time the pelvic floor and the the pelvic floor and the components of the pelvic floor and justifies treatment physiology studies innervation innervation and the innervation strategy would change surgical • Lists major arterial • Discusses major arterial • With assistance, can • Independently and decisions in personal supply, venous, and supply, venous, and demonstrate knowledge of the proficiently demonstrates practice lymphatic drainage for lymphatic drainage for surgical approaches to the knowledge of the anatomy • Demonstrates the colorectum and the colorectum and major arterial supply, venous, demonstrate the surgical proficiency as a small bowel small bowel and lymphatic drainage for the approaches to the major teaching assistant for • Lists major hormonal • Discusses the major colorectum and small bowel arterial supply, venous, and the evaluation of and chemical hormonal and chemical • Defines the appropriate lymphatic drainage for the functional bowel neurotransmitters neurotransmitters evaluation of major hormonal colorectum and small bowel disorders and altered involved in the control of involved in the control and chemical • Independently interprets the intestinal physiology intestinal motility and of intestinal motility and neurotransmitters involved in physiologic diagnostic studies • Discusses current secretion/absorption secretion/absorption the control of intestinal • Anticipates, diagnoses, and controversies the • Lists common functional • Discusses common motility and proficiently manages the assessment of bowel disorders investigational strategies secretion/absorption (disease assessment and evaluation of functional bowel for common functional specific) anorectal physiology disorders Example: bowel disorders but has • With help, can formulate • Reviews outcome data The resident is unable to limited ability to strategies for evaluation of Example: collected and uses this differentiate operatively interpret results common functional bowel The resident independently data to change practice between the internal and disorders, but requires demonstrates the surgical external sphincter and their Example: guidance to interpret approaches to the major arterial Example: functions. The resident is able to supply, venous, and lymphatic The resident conceives of differentiate operatively Example: drainage for the colorectum and and conducts investigative between the internal and With assistance, the resident small bowel related to specific studies such as neo- external sphincter with demonstrates the surgical procedures. sphincter. guidance and discuss some approaches to the major arterial difference in function. supply, venous, and lymphatic drainage for the colorectum and small bowel related to specific procedures.

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Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet Pelvic Floor Disorders — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 • Lists some components • Discusses some • Demonstrates knowledge of • Integrates anatomy and • Proposes of anatomy and components of anatomy anatomy and physiology of physiology of pelvic floor investigational physiology of pelvic floor and physiology of pelvic pelvic floor disorders disorders research in anatomic disorders floor disorders • Demonstrates understanding • Integrates results of imaging or physiologic • Lists some imaging • Discusses strategies for of appropriate imaging and and physiologic testing and disturbances options (e.g., transanal imaging and physiology physiologic evaluation correlates appropriately • Discusses new ultrasound, MRI, but has limited ability to • Demonstrates knowledge of with anatomical and investigational proctography)and interpret results success rates for treatment physiological abnormalities modalities for pelvic physiologic studies (e.g., • Discusses rationale for options • Justifies appropriate floor disorders ARM, EMG, PNTML, biofeedback, surgical treatment interventions • Discusses current Colon Transit Studies) interventions, and Example: controversies in useful in evaluating medical management The resident demonstrates Example: treatment options pelvic floor disorders knowledge of success rates for The resident justifies • Lists options for Example: treatment options for fecal appropriate treatment treatment of fecal The resident discusses incontinence. interventions for fecal incontinence and pelvic rationale for biofeedback, incontinence. outlet obstruction surgical interventions, and The resident discusses relative medical management of strengths and weaknesses of The resident synthesizes a Example: fecal incontinence. each intervention. The resident treatment plan based on The resident lists options discusses fecal incontinence history and physical and for fecal incontinence (e.g., The resident articulates scales (Cleveland Clinic Fecal investigational studies, such as Stool bulking agents, individual components of Incontinence Score, Fecal stool bulking agents, constipating agents, treatment modalities, and Incontinence Quality of Life biofeedback therapy followed injectables, biofeedback discusses how each [FIQOL], Fecal Incontinence by a sphincteroplasty or sacral therapy, sphincteroplasty, improves fecal Severity Index [FISI]), and nerve stimulator for severe sacral nerve stimulator, incontinence. anticipated improvement from incontinence in patient with Secca procedure, artificial interventions, but is unable to significant sphincter injury. sphincter, fecal diversion.) appropriately articulate a The resident appropriately patient-specific plan. accounts for patients’ medical co-morbidities when proposing interventions.

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Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet

Pelvic Floor Disorders — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 • Lists some imaging • Discusses strategies for • Formulates an appropriate • Assesses history and • Reviews and assesses the options (e.g., transanal imaging and physiology investigative work-up after physical, imaging, and frequency physiology ultrasound, MRI, but has limited ability to conducting appropriate physiologic data and studies change surgical proctography)and interpret results history and physical justifies treatment decisions in personal physiologic studies (e.g., • Discusses key steps of • With assistance, performs strategy practice ARM, EMG, PNTML, sphincteroplasty and key steps of • Independently performs • Demonstrates Colon Transit Studies) rationale for biofeedback, sphincteroplasty; sphincteroplasty; acquires proficiency as a teaching useful in evaluation of surgical interventions, and discusses newer skills for sacral nerve assistant for fecal incontinence and medical management modalities for fecal stimulation (SNS) and sphincteroplasty constipation • Discusses rationale for incontinence other modalities as they • Discusses current • Lists options for biofeedback, surgical • With assistance, performs becomes available controversies regarding treatment of interventions, and medical key steps of surgery for • Independently performs biologic mesh in these incontinence management rectal prolapse, rectocele, surgery for rectal repairs • Lists options for • Recognizes disease and enterocele prolapse, rectocele, and • Reviews outcome data treatment of outlet progression and variances • Recognizes and enterocele, or collected and uses this obstruction from normal post- implements management appropriately involves data to change practice • Lists common operative course and of complications multidisciplinary team for complications associated begins investigations repairs Example: with pelvic floor surgeries Example: • Anticipates, diagnoses, Reviews and assesses the Example: The resident formulates an and proficiently manages frequency physiology Example: The resident discusses appropriate investigative complications in a timely studies change surgical The resident lists some strategies for imaging and work-up after conducting manner decisions in personal imaging options and physiology, but has a limited appropriate history and practice. physiologic studies useful in ability to interpret results. physical. Example: evaluation of fecal The resident assesses history incontinence and The resident articulates how The resident discusses and physical, imaging, and constipation. dynamic proctography can be relative strengths and physiologic data, and justifies used to diagnose outlet weaknesses of investigational a treatment strategy. The resident lists imaging obstruction, but is unable to modalities correlating with options, including transanal interpret the imaging. history and physical. The resident appropriately ultrasound, MRI, and reads colon transit time, proctography. The resident discusses the The resident appropriately correctly assesses role of ultrasound to proposes transanal deficiencies in dietary The resident lists physiology diagnose sphincter defect, ultrasound with ARM and history, appropriately

Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet studies, including ARM, but is unable to accurately PNTML to work up a patient interprets paradoxical motion EMG, PNTML, and Colon read transanal ultrasound with fecal incontinence with on EMG, and interprets Transit Studies. independently. an elevated Cleveland Clinic failure to relax the pelvic Fecal Incontinence score, floor on dynamic proctogram with thin perineal body and in a patient with chronic decreased resting and constipation. squeezing sphincter tone on examination. The resident appropriately recommends trial of biofeedback therapy and bowel program, understanding that subtotal colectomy without correcting outlet obstruction leads to a poor outcome.

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Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet

Systems-based Practice — • Utilizes/accesses outside resources • Demonstrates awareness of and accommodation to circumstances affecting patient care, including the patient’s financial resources and other factors that can affect health care delivery and quality • Understands the basics of patient safety and clinical risk management, with emphasis on avoidance of medical errors • Uses technology and external resources to accomplish safe and effective health care delivery Level 1 Level 2 Level 3 Level 4 Level 5 • Rarely demonstrates • Occasionally • Consistently • Consistently demonstrates • Is a leader in the area of proficiency in systems- demonstrates proficiency demonstrates proficiency proficiency in systems- systems-based practice; based practice in systems-based practice in systems-based practice based practice in most advice is frequently sought in in common clinical clinical situations relating to difficult situations situations

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Professionalism — • Exhibits ethical and responsible behavior, including respect, compassion, honesty, and integrity, in all aspects of practice and scholarly activity • Accountable to patients, society and the profession and acknowledges errors • Maintains responsibility for his or her own emotional, physical, and mental health, including fatigue awareness and avoidance, and commitment to lifelong learning and self-assessment • Demonstrates sensitivity to diverse patient, staff, and support personnel populations • Considers needs of patients, families, and colleagues • Demonstrates a high standard of ethical behavior and a commitment to continuity of care Level 1 Level 2 Level 3 Level 4 Level 5 • Rarely demonstrates • Occasionally demonstrates • Consistently demonstrates • Consistently demonstrates • Is a leader in the area of professional behaviors professional behaviors and professional behaviors and professional behaviors and professionalism; advice and attitudes expected of attitudes expected of a attitudes expected of a attitudes expected of a is frequently sought in a colon rectal surgery colon rectal surgery colon rectal surgery colon rectal surgery relating to difficult resident resident resident in common resident in most clinical situations situations situations

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Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet

Interpersonal and Communication Skills — • Provides team-based care and develops productive relationships with patients, peers, staff members, and interdisciplinary care team members • Ensures that patients understand their condition(s) and treatments, encourages questions from patients, and provides explanations appropriate to patient needs • Educates and counsels patients, families, and colleagues when appropriate • Identifies and accommodates special communication needs of vulnerable populations (e.g. children, elderly, patients with complex biomedical, psychosocial conditions; persons with disabilities; immigrant and refugee populations; veterans; prisoners; LGBT [lesbians, gay, bisexual, transgender] patients; etc.) • Uses technology and information sharing modalities to facilitate communication Level 1 Level 2 Level 3 Level 4 Level 5 • Rarely demonstrates • Occasionally demonstrates • Consistently demonstrates • Consistently • Is a leader in the area of proficiency in proficiency in proficiency in interpersonal demonstrates proficiency interpersonal and interpersonal and interpersonal and and communication skills in in interpersonal and communication skills; communication skills communication skills common clinical situations communication skills in advice is frequently most clinical situations sought in relating to difficult situations

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Version 06/13 Colon and Rectal Surgery Milestones, ACGME Report Worksheet

Practice-based Learning and Improvement — • Self-evaluates performance • Incorporates feedback • Identifies strengths, deficiencies, and limits in self knowledge and expertise • Sets learning and improvement goals in a manner that fosters productive self-directed learning • Actively participates in quality improvement project(s) • Locates, appraises, and assimilates evidence from scientific studies pertinent to patients • Uses technology to enhance patient care and self-improvement • Evaluates and analyzes patient care outcomes • Utilizes an evidence-based approach to patient care Level 1 Level 2 Level 3 Level 4 Level 5 • Rarely demonstrates • Occasionally demonstrates • Regularly demonstrates • Consistently • Is a leader in the area of proficiency in practice- proficiency in practice- proficiency in practice- demonstrates proficiency practice-based learning; based learning based learning based learning in practice-based learning advice is frequently sought in relating to difficult situations

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