Medical Toxicology Milestone Project

The Medical Toxicology Milestone Project

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

July 2015

The Medical Toxicology Milestone Project

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

Medical Toxicology Milestones

Chair: Susanne White, MD

Working Group Advisory Group Michele M. Burns, MD, MPH Timothy Brigham, MDiv, PhD Beth Baker, MD Wallace Carter, MD Laura Edgar, EdD, CAE William W. Greaves, MD, MSPH Lewis Nelson, MD Robert Johnson, MD Louis Ling, MD Earl Reisdorff, MD

Milestone Reporting

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

For each period, review and reporting will involve selecting milestone levels that best describe a fellow’s current performance and attributes. Milestones are arranged into numbered levels. Tracking from Level 1 to Level 5 is synonymous with moving from novice to expert in the subspecialty.

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

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

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

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

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

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

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Additional Notes

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

Examples are provided with some milestones. Please note that the examples are not the required element or outcome; they are provided as a way to share the intent of the element.

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

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

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 the milestones.

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

Version 12/2013 Medical Toxicology Milestones, ACGME Report Worksheet

PC1: Exposure Assessment: History and Physical

Level 1 Level 2 Level 3 Level 4 Level 5  Acquires accurate and  Acquires accurate and  Acquires accurate and  Acquires accurate and  Develops guidelines for relevant history from the relevant history from the relevant history from the relevant history from the the performance of patient and other sources patient and other sources patient and other sources patient and other sources complex exposure in an efficient manner in an efficient manner in an efficient manner in an efficient manner assessment during pediatric/adult during pediatric/adult during multiple exposure during unexplained  Performs causation acute exposure chronic exposure sources, mixed exposure, syndromes (e.g., analysis  Performs an accurate  Accurately tracks unknown exposure, or environmental illness), physical examination important changes in the withdrawal hazardous material appropriately targeted to physical examination and  Demonstrates and exposure, population the patient’s exposure ancillary testing over time, teaches how to elicit exposure (e.g., chemical history and co-existing in both the outpatient and important physical and release), or medical/surgical inpatient settings other findings for other workplace/environmental conditions members of the health exposure  Identifies pertinent care team  Routinely identifies subtle abnormalities and or unusual findings that toxidromes may influence clinical decision making

Comments:

The Milestones are a product of the Medical Toxicology Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine. 1 Version 12/2013 Medical Toxicology Milestones, ACGME Report Worksheet

PC2: Clinical Reasoning: Ordering and Interpretation of Studies and Differential Diagnosis

Level 1 Level 2 Level 3 Level 4 Level 5  Develops prioritized  Synthesizes all available  Modifies and refines  Recognizes toxicological  Uses pattern recognition differential for common data, including interview, evidence-based presentations and/or consistently to identify toxicological conditions physical examination differential diagnosis conflicting diagnostic discriminating features  Interprets appropriate findings, and preliminary based upon clinical course results that deviate from between similar patients and diagnostic testing laboratory data, to define and data, as appropriate common patterns and avoids premature closure  Recognizes abnormal test each patient’s primary  Makes appropriate clinical require more complex  Develops results toxicological problem decisions and toxicological decision-making protocols/algorithms for  Makes appropriate clinical exposure associations  Makes appropriate clinical determination of appropriate decisions based upon the based on results of decisions and toxicological diagnostic testing results of common advanced toxicological exposure associations toxicological diagnostic testing, recognizing based on ancillary testing testing limitations and risks (e.g., biomarkers,  Interprets pulmonary function tests, workplace/environmental electromyography [EMG] sample testing studies)  Prioritizes essential  Orders diagnostic testing testing based on the pre-test probability of disease and the likelihood of test results altering management  Practices cost-effective ordering of diagnostic studies

Comments:

The Milestones are a product of the Medical Toxicology Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine. 2 Version 12/2013 Medical Toxicology Milestones, ACGME Report Worksheet

PC3: Management Plan and Treatment Level 1 Level 2 Level 3 Level 4 Level 5  Recognizes toxicological  With minimal supervision,  Manages patients with  Customizes care within  Develops guidelines to situations with a need for manages patients with toxicological conditions the context of a patient’s avoid potential urgent/emergent medical common and complex that require intensive care preferences and overall complications of or surgical care toxicological disorders seen  Independently provides health status interventions and  Manages, with in the practice of both toxicological consultation  Manages rare toxicological therapies supervision, patients with inpatient and outpatient for complicated patients conditions that use common toxicological settings with straightforward specialty antidotes and disorders seen in both the  Provides appropriate poison exposures other treatments inpatient and outpatient prevention advice to patients  With assistance, provides  Manages patients in an settings and caregivers toxicological consultation occupational, clinic, or  With assistance, provides  Independently provides for complicated patients referral setting toxicological consultation toxicological consultation for with complex exposures  Independently provides for uncomplicated uncomplicated patients with  With assistance, manages toxicological consultation patients with straightforward exposures patients in an for complicated patients straightforward exposures  With assistance, provides occupational, clinic, or with complex exposures toxicological consultation for referral setting complicated patients with straightforward exposures  Uses antidotes and procedures with an understanding of indications, limitations, risks, and benefits (e.g., prevent intoxicant absorption, impact metabolism, enhance elimination)

Comments:

The Milestones are a product of the Medical Toxicology Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine. 3 Version 12/2013 Medical Toxicology Milestones, ACGME Report Worksheet

MK1: Acute and Chronic Exposure

Level 1 Level 2 Level 3 Level 4 Level 5  Understands concepts of  Understands mechanism of  Understands teratogenesis  Understands mechanism  Develops guidelines or biochemistry, physiology, toxins, pharmacokinetics, and carcinogenesis of uncommon or natural publishes personal and pharmacology and adverse drug reactions  Understands withdrawal toxins research (e.g., empirical relevant to common  Demonstrates sufficient phenomenon  Demonstrates sufficient data, systematic literature medical toxicological clinical knowledge to  Understands indications, knowledge to evaluate review) in peer-reviewed conditions diagnose and treat risks, and limitations for complex or rare journals undifferentiated and procedures, antidotes, and toxicological conditions emergent conditions other management with co-existent medical  Understands the relevant or surgical conditions pathophysiological and basic science principles that underlie uncommon or complex toxicological conditions

Comments:

The Milestones are a product of the Medical Toxicology Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine. 4 Version 12/2013 Medical Toxicology Milestones, ACGME Report Worksheet

MK2: Epidemiology and Population Exposure

Level 1 Level 2 Level 3 Level 4 Level 5  Identifies major routes of  Identifies common  Describes individual  Recommends methods of  Develops protocols to human exposure illnesses that may be factors that impact reducing adverse limit the exposure of  Identifies and recognizes caused or influenced by susceptibility to adverse environmental health populations to chemical, basic measures of disease environmental exposures health effects from effects for individuals physical, and biological frequency (e.g., incidence,  Identifies broad environmental exposures  Identifies sources and hazards prevalence, mortality) environmental factors  Identifies potential routes of environmental  Uses data to characterize  Distinguishes between that may impact the population health effects exposures to chemical, effects of exposure of a experimental and health of a community from exposure to physical, and biological local population based on observational studies  Identifies and recognizes chemical, physical, and hazards for defined comparison with other basic measures for biological hazards populations populations comparing risk (e.g., risk  Explains validity, bias,  Critically reviews and ratios, odds ratios) confounding, and effect interprets toxicologic  Describes commonly used modification; literature for commonly study designs (e.g., distinguishes between used study designs, randomized clinical trial, association and causation; identifying purpose, cohort, case-control, lists criteria for causal population, design, and cross-sectional) inference biases

Comments:

The Milestones are a product of the Medical Toxicology Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine. 5 Version 12/2013 Medical Toxicology Milestones, ACGME Report Worksheet

MK3: Laboratory and Clinical Testing

Level 1 Level 2 Level 3 Level 4 Level 5  Demonstrates knowledge  Demonstrates knowledge  Demonstrates knowledge  Identifies biomarkers of  Participates as an expert of laboratory principles of common toxicology of advanced toxicology exposure or effect in a medicolegal event using common ancillary testing, including testing, including  Demonstrates knowledge  Independently serves as a testing (e.g., glucose, limitations and appropriateness, of advanced clinical medical review officer electrocardiogram [EKG], methodology limitations, and testing (e.g., pulmonary  Develops protocols for radiographs, pulse  Identifies types of methodology function test, nerve advanced and alternative oximetry) interference and causes of  Understands levels of conduction studies, clinical testing  Identifies the differences false negative and false detection and forensic and post-mortem between assay methods positive results quantification testing) (e.g., screening,  Understands urine drug  Understands advantages confirmatory) testing principles and disadvantages of alternative testing samples (e.g., hair, saliva, meconium)  Understands medicolegal issues involving work place testing, performance enhancing drugs, and impairment

Comments:

The Milestones are a product of the Medical Toxicology Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine. 6 Version 12/2013 Medical Toxicology Milestones, ACGME Report Worksheet

SBP1: Patient Safety

Level 1 Level 2 Level 3 Level 4 Level 5  Recognizes the importance  Understands key concepts  Advocates for quality  Advocates for quality  Develops or leads a team of advocating for quality related to health care care and optimal care and optimal to evaluate medical errors care and optimal patient quality improvement individual patient care population-based care and system-based failures care systems  Recognizes potential systems systems and to improve processes  Recognizes that medical sources of system failure  Recognizes and reports  Participates in a team- and systems errors and health care in health care systems, lapses in medication based approach to system failures are a such as medication errors safety, medication evaluate medical errors significant cause of errors, and near misses and system-based morbidity failures

Comments:

The Milestones are a product of the Medical Toxicology Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine. 7 Version 12/2013 Medical Toxicology Milestones, ACGME Report Worksheet

SBP2: Clinical Application of Information Technology

Level 1 Level 2 Level 3 Level 4 Level 5  Creates a timely, accurate,  Demonstrates the use of  Demonstrates the use of  Routinely integrates data  Develops a database or and complete medical electronic databases to electronic databases and from multiple reliable recommends a system record facilitate exact systems for the reporting information redesign for improved  Recognizes the risks of ingredient/product of exposures (e.g., sources/databases into processes computer shortcuts, such identification surveillance) clinical decision making as electronic health  Uses information  Differentiates between records (EHR), on technology to locate reference sources based accurate patient care and scientific studies related on quality, accuracy, and documentation to patient health peer review problems  Recognizes the limitations of social media/open source databases

Comments:

The Milestones are a product of the Medical Toxicology Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine. 8 Version 12/2013 Medical Toxicology Milestones, ACGME Report Worksheet

PBLI1: Self-Directed Learning in Medical Toxicology

Level 1 Level 2 Level 3 Level 4 Level 5  Acknowledges gaps in  Develops learning and  Performs ongoing self-  Applies performance  Creates novel ways to personal knowledge and improvement goals based assessment to identify improvement by assess performance expertise, and frequently on feedback, with minimal areas for continued self- incorporating feedback  Applies results from self- asks for feedback external assistance improvement, and from multiple directed learning to  Understands the implements learning plans stakeholders (e.g., educating others importance of setting  Demonstrates the ability patients, members of the learning and to critically appraise health care team, third- improvement goals scientific literature and party payers) apply evidence-based  Demonstrates best clinical medicine to improve practice, including use of one’s individual evidence-based pathways performance

Comments:

The Milestones are a product of the Medical Toxicology Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine. 9 Version 12/2013 Medical Toxicology Milestones, ACGME Report Worksheet

PBLI2: Quality Improvement Project

Level 1 Level 2 Level 3 Level 4 Level 5  Identifies problems in  Begins working on a  Continues to develop a  Completes a quality  Develops and leads health care delivery quality improvement quality improvement improvement project complex quality project either as an project, employing  Displays effective improvement projects, individual or team methods to measure teamwork skills and is able to lead a root member and analyze the data cause analysis

Comments:

The Milestones are a product of the Medical Toxicology Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine. 10 Version 12/2013 Medical Toxicology Milestones, ACGME Report Worksheet

PROF1: Professional Values

Level 1 Level 2 Level 3 Level 4 Level 5  Demonstrates behavior  Demonstrates an  Recognizes how own  Develops and applies a  Develops institutional and that conveys compassion, understanding of the personal beliefs and consistent and organizational strategies honesty, genuine interest, importance of values impact medical appropriate approach to to protect and maintain and tolerance when compassion, integrity, care; consistently evaluating appropriate professional and interacting with a diverse respect, sensitivity, and manages own values and care, possible barriers, bioethical principles population of patients, responsiveness, and beliefs to optimize and strategies to families, and other exhibits these attitudes relationships and medical intervene that members of the health consistently in care consistently prioritizes the care team common/uncomplicated  Develops alternate care patient’s best interest in situations (e.g., disclosure plans when patients’ all relationships and of error) and with diverse personal decisions/beliefs situations populations preclude the use of  Effectively analyzes and commonly accepted manages ethical issues in practices complicated and challenging clinical situations (e.g., end-of- life, unexpected outcomes, suicidality)

Comments:

The Milestones are a product of the Medical Toxicology Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine. 11 Version 12/2013 Medical Toxicology Milestones, ACGME Report Worksheet

PROF2: Accountability to patients, society, profession, and self

Level 1 Level 2 Level 3 Level 4 Level 5  Demonstrates basic  Identifies basic principles  Consistently recognizes  Understands how to  Develops institutional and professional of physician wellness, limits of knowledge in identify and report organizational strategies responsibilities, such as including sleep, hygiene, uncommon and impairment in oneself or a to improve physician timely reporting for duty, and fatigue mitigation complicated clinical colleague in a professional insight into and responsiveness to  Consistently recognizes situations; develops and and confidential manner management of requests for consultation, limits of knowledge in implements plans for the  Manages medical errors professional appropriate common and frequent best possible patient care according to principles of responsibilities dress/grooming, timely clinical situations, and  Recognizes and avoids responsibility and  Trains physicians and chart completion, and asks for assistance inappropriate influences accountability in educators regarding duty hour reporting of marketing and accordance with responsibility, wellness,  Maintains patient advertising institutional policy fatigue, and physician confidentially as impairment stipulated (e.g., Health Insurance Portability and Accountability Act)  Uses social media ethically and responsibly

Comments:

The Milestones are a product of the Medical Toxicology Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine. 12 Version 12/2013 Medical Toxicology Milestones, ACGME Report Worksheet

ICS1: Patients Families and Public

Level 1 Level 2 Level 3 Level 4 Level 5  Recognizes the  Demonstrates effective  Demonstrates effective  Demonstrates effective  Demonstrates effective importance of effective communication with communication with communication with communication outside of communication with patients, families, or the patients or the public in patients and the public in the local health care patients, families, and the public in common issues related to issues related to environment, such as public across a broad situations confidential and/or highly confidential and/or highly state and federal range of socioeconomic  Provides appropriate sensitive medical sensitive medical agencies, and regional and cultural backgrounds poison prevention, information information using multiple health care systems medication safety, or  Effectively communicates communication workplace safety with vulnerable modalities counseling to patients and populations, including  Understands how to caregivers patients at risk and their develop appropriate risk families communication to the community  Able to communicate with non-medical personnel, such as police, media, risk managers, and hospital administrators

Comments:

The Milestones are a product of the Medical Toxicology Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine. 13 Version 12/2013 Medical Toxicology Milestones, ACGME Report Worksheet

ICS2: Communication with Health Care Professionals

Level 1 Level 2 Level 3 Level 4 Level 5  Recognizes the  Demonstrates effective,  Able to provide effective,  Able to work effectively  Leads change in team importance of effective, timely consultation and timely consultation and with the health care team activities to optimize timely consultation and communication with the communication with the in public health events performance communication with the health care team in health care team in (e.g., mass exposures)  Seeks leadership health care team clinical situations stressful/crisis situations  Uses flexible opportunities within  Ensures transitions of care  Develops working  Provides educational communication strategies professional organizations are accurately and relationships across support across specialties to resolve specific efficiently communicated specialties with other and to other health care challenges, such as  Ensures clear health care professionals professionals difficulties with communication and consultants and other respect among team health care professionals members

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