The Dermatopathology Milestone Project

A Joint Initiative of

The Accreditation Council for Graduate Medical Education, The American Board of Dermatology, and The American Board of Pathology

July 2015

The Dermatopathology 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 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.

i Dermatopathology Milestones

Chair: James W. Patterson, MD Working Group Advisory Group Laura Edgar, EdD, CAE C. Bruce Alexander, MD Tammie Ferringer, MD Julia C. Iezzoni, MD Jessica Kozel, MD Rebecca Johnson, MD

Mary Stone, MD Wesley Y. Naritoku, MD, PhD Sharon Weiss, MD

ii 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 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.

iii

Additional Notes

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

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

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

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

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).

v Version 7/2014 Dermatopathology Milestones: ACGME Report Worksheet

Dermatopathologic Diagnosis – PC1

Level 1 Level 2 Level 3 Level 4 Level 5 Differentiates between Diagnoses many common Consistently diagnoses Consistently perceives Serves as a role model in normal and abnormal skin disorders; forms a common skin disorders; subtle clues in the course the teaching and practice histology; recognizes basic differential diagnosis for develops a competent of diagnosing cutaneous of dermatopathology; pathologic changes most cases differential diagnosis and diseases; often makes sought out by other health work-up plan for more correct diagnosis and care providers as a difficult or complex cases suggestions for work-up of consultant difficult cases

Comments: Not yet achieved Level 1

Ancillary Testing – PC2

Level 1 Level 2 Level 3 Level 4 Level 5 Recognizes importance of Demonstrates knowledge Usually selects cost- Consistently selects cost- Instructs others in the use ancillary studies in of relevant ancillary effective and relevant effective and relevant of cost-effective and histologic diagnosis studies in histologic ancillary studies in ancillary studies relevant ancillary studies diagnosis common disorders

Comments: Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, the American Board of Dermatology, and the American Board of Pathology. All rights reserved. The copyright owners grant third parties the right to use the Dermatopathology Milestones on a non-exclusive bases for educational purposes. 1 Version 7/2014 Dermatopathology Milestones: ACGME Report Worksheet

Histopathologic Patterns – MK1

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates knowledge Demonstrates knowledge Demonstrates knowledge Demonstrates an in-depth Teaches others the of the difference between of the types of of how clinical history and knowledge of pathogenesis and biologic inflammatory and inflammatory reaction ancillary tests help to pathogenesis and biologic behavior of cutaneous neoplastic patterns patterns and types of refine differential behavior of cutaneous disease neoplasia diagnosis disease

Comments: Not yet achieved Level 1

Immunohistochemistry – MK2

Level 1 Level 2 Level 3 Level 4 Level 5 Understands application Demonstrates knowledge Consistently identifies best Demonstrates knowledge Demonstrates knowledge and purpose of of situations in which panel of antibodies for of expected and of how to troubleshoot immunohistochemistry immunohistochemical diagnosis of cutaneous unexpected patterns of and minimize artifacts testing and has a basic stains are necessary disease immunoreactivity, understanding of tissue including artifacts processing Can select a reasonable panel of antibodies for diagnosis of cutaneous disease

Comments: Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, the American Board of Dermatology, and the American Board of Pathology. All rights reserved. The copyright owners grant third parties the right to use the Dermatopathology Milestones on a non-exclusive bases for educational purposes. 2 Version 7/2014 Dermatopathology Milestones: ACGME Report Worksheet

Health Care teams — SBP1

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the With substantial guidance, With minimal guidance, Independently plays a role Participates on an importance of the plays a role in the health plays a role in the health in the health care team institutional patient care dermatopathologist’s role care team (e.g., case care team (e.g., case (e.g., case presentation, team (e.g., risk in the health care team presentation, consultation, presentation, consultation, consultation, biopsy management committee, biopsy technique biopsy technique technique guidance) cancer committee) guidance) guidance)

Comments: Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, the American Board of Dermatology, and the American Board of Pathology. All rights reserved. The copyright owners grant third parties the right to use the Dermatopathology Milestones on a non-exclusive bases for educational purposes. 3 Version 7/2014 Dermatopathology Milestones: ACGME Report Worksheet

Patient Safety — SBP2

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the Consistently checks Trouble-shoots Independently trouble- Models patient safety importance of identity and identity and integrity of misidentified patient shoots patient safety practices integrity of the specimen specimen specimens, as needed, issues and requisition form, and with minimal supervision Writes and implements verifies the identity of the Independently obtains policies on patient safety, specimen clinical information when Follows patient safety as needed needed policies and accreditation Understands the risk requirements inherent in hand-offs Handles deviations from policies (waivers) with supervision

Performs hand-offs in an appropriate manner, according to guidelines

Comments:

Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, the American Board of Dermatology, and the American Board of Pathology. All rights reserved. The copyright owners grant third parties the right to use the Dermatopathology Milestones on a non-exclusive bases for educational purposes. 4 Version 7/2014 Dermatopathology Milestones: ACGME Report Worksheet

Evidence-based Practice — PBLI1

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the With substantial guidance, With minimal guidance, Independently performs Contributes to the importance of evidence- critically reviews the critically reviews the critical reviews of the evidence-based utilization based practice literature literature literature of the literature

Comments: Not yet achieved Level 1

Process Improvement and Patient Safety — PBLI2

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates awareness Consistently demonstrates Assists with practice Able to develop and lead a Participates in an of common sources of work habits that minimize change based on an process improvement institutional quality error in laboratory error; consistently and identified error or exercise (e.g., root-cause improvement team processes and transitions promptly communicates systematic problem (e.g., analysis, work-flow in care discrepancies to post-analytic, pre-analytic, analysis) appropriate team laboratory or members and acts to interpretative) resolve them

Comments: Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, the American Board of Dermatology, and the American Board of Pathology. All rights reserved. The copyright owners grant third parties the right to use the Dermatopathology Milestones on a non-exclusive bases for educational purposes. 5 Version 7/2014 Dermatopathology Milestones: ACGME Report Worksheet

Accountability, Honesty, and Integrity — PROF1

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the Dependably completes Anticipates team needs Anticipates team needs Exemplifies effective importance of completing assigned tasks in a timely and steps in to assist as and takes a leadership role management of multiple assigned tasks on time manner; assists team needed to independently competing tasks, with members when requested; implement solutions reliable follow up; is Behaves honestly and respects assigned Demonstrates honesty source of understand the concepts schedules with all members of the Is viewed by members of support/guidance to other of ethical behavior; seeks health care team the health care team as a members of the health counsel when ethical Acknowledges personal role model in accepting care team questions arise near misses and errors, Identifies, communicates, personal responsibility, and putting the needs of and corrects errors and in always putting the patients first; engages in needs of the patient above ethical behavior Recognizes conflict of his/her own interests interest in the ethical ordering of ancillary Practices ethical ordering testing of ancillary testing

Comments: Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, the American Board of Dermatology, and the American Board of Pathology. All rights reserved. The copyright owners grant third parties the right to use the Dermatopathology Milestones on a non-exclusive bases for educational purposes. 6 Version 7/2014 Dermatopathology Milestones: ACGME Report Worksheet

Giving and Receiving Feedback — PROF2

Level 1 Level 2 Level 3 Level 4 Level 5 Receives feedback Accepts feedback Provides constructive Exemplifies giving and Models giving and constructively constructively and feedback receiving constructive receiving constructive modifies practice in feedback; encourages and feedback; encourages and response to feedback actively seeks feedback to actively seeks feedback to improve performance improve performance

Comments: Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, the American Board of Dermatology, and the American Board of Pathology. All rights reserved. The copyright owners grant third parties the right to use the Dermatopathology Milestones on a non-exclusive bases for educational purposes. 7 Version 7/2014 Dermatopathology Milestones: ACGME Report Worksheet

Personnel Management and Conflict Management — ICS1

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the challenge With substantial guidance, With minimal guidance, Demonstrates the ability Develops job descriptions in managing clinical, manages clinical, clerical, manages clinical, clerical, to independently manage and competency clerical, and laboratory and laboratory personnel and laboratory personnel clinical, clerical, and assessments for clinical, personnel (e.g., laboratory personnel clerical, and laboratory competency assessment, With substantial guidance, With minimal guidance, personnel performance evaluation) manages conflicts and manages conflicts and Independently manages complaints complaints conflicts and complaints Teaches concepts of Understands the emotional intelligence and importance of conflict Understands the Understands the Fosters a collegial and team building management importance of personal importance of a collegial respectful atmosphere emotional awareness and and respectful atmosphere among all team members empathy and their impact among all team members on team members

Comments: Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, the American Board of Dermatology, and the American Board of Pathology. All rights reserved. The copyright owners grant third parties the right to use the Dermatopathology Milestones on a non-exclusive bases for educational purposes. 8 Version 7/2014 Dermatopathology Milestones: ACGME Report Worksheet

Diagnostic Reporting — ICS2

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the With substantial guidance, With minimal guidance, Effectively communicates Serves as a role model for importance of timely and provides timely and provides timely and complex, difficult, or effective and professional effective communication effective communication effective communication challenging information communication to health of diagnosis, and their of diagnosis of diagnosis (e.g., errors, adverse care providers impact on patients events) With substantial guidance, Recognizes when direct Understands that the produces a clear and communication is required Designs a clear and written report is a form of understandable written with the clinician effective written report communication that must report be clear and With minimal guidance, Teaches synoptic reporting understandable to the Knows when synoptic produces a clear and to junior learners treating clinician reporting is required understandable written report Becomes familiar with synoptic reports Completes a synoptic report accurately

Comments: Not yet achieved Level 1