Cytopathology Milestones

The Accreditation Council for Graduate Medical Education

Implementation Date: July 1, 2021 Second Revision: November 2020 First Revision: May 2014

©2020 Accreditation Council for Graduate Medical Education (ACGME) All rights reserved except the copyright owners grant third parties the right to use the Cytopathology Milestones on a non-exclusive basis for educational purposes.

Cytopathology Milestones

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.

Cytopathology Milestones Work Group

Scott Anderson, MD Kathryn Dyhdalo, MD Laura Edgar, EdD, CAE Kate Hatlak, MSEd Evita Henderson-Jackson, MD Wesley Y. Naritoku, MD, PhD Ritu Nayar, MD Matthew Rosenbaum, MD Frida Rosenblum, MD

The ACGME would like to thank the following organizations for their continued support in the development of the Milestones: American Board of Pathology

American Society of Cytopathology

Review Committee for Pathology

Understanding Milestone Levels and Reporting

This document presents the Milestones, which programs use in a semi-annual review of fellow performance, and then report to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME Competencies organized in a developmental framework. The narrative descriptions are targets for resident/fellow performance throughout their educational program.

Milestones are arranged into levels. Tracking from Level 1 to Level 5 is synonymous with moving from novice to expert fellow in the specialty or subspecialty. For each reporting period, the Clinical Competency Committee will review the completed evaluations to select the milestone levels that best describe each learner’s current performance, abilities, and attributes for each subcompetency.

These levels do not correspond with post-graduate year of education. Depending on previous experience, a junior fellow may achieve higher levels early in his/her educational program just as a senior fellow may be at a lower level later in his/her educational program. There is no predetermined timing for a resident to attain any particular level. Fellows may also regress in achievement of their milestones. This may happen for many reasons, such as over scoring in a previous review, a disjointed experience in a particular procedure, or a significant act by the fellow.

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

Additional Notes

Level 4 is designed as a graduation goal but does not represent a graduation requirement. Making decisions about readiness for graduation and unsupervised practice is the purview of the program director. Furthermore, Milestones 2.0 include revisions and changes that preclude using Milestones as a sole assessment in high-stakes decisions (i.e., determination of eligibility for certification or credentialing). Level 5 is designed to represent an expert fellow whose achievements in a subcompetency are greater than the expectation. Milestones are primarily designed for formative, developmental purposes to support continuous quality improvement for individual learners, education programs, and the specialty. The ACGME and its partners will continue to evaluate and perform research on the Milestones to assess their impact and value.

Some milestone descriptions include statements about performing independently or without assistance. These activities must occur in conformity to ACGME supervision guidelines as described in the Program Requirements, 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.

A Supplemental Guide is also available to provide the intent of each subcompetency, examples for each level, assessment methods or tools, and other available resources. The Supplemental Guide, like examples contained within the Milestones, is designed only to assist the program director and Clinical Competency Committee, and is not meant to demonstrate any required element or outcome and is not all inclusive.

Additional resources are available in the Milestones section of the ACGME website. Follow the links under “What We Do” at www.acgme.org.

The diagram below presents an example set of milestones for one subcompetency in the same format as the ACGME Report Worksheet. For each reporting period, a fellow’s performance on the milestones for each subcompetency 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 Selecting a response box on the line in middle of a level implies that between levels indicates that milestones milestones in that level and in lower in lower levels have been substantially levels have been substantially demonstrated as well as some demonstrated. milestones in the higher level(s).

Patient Care 1: Reporting

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies the key Generates a timely report Generates a timely report Independently Independently generates elements of a report and for a simple case, with with or without ancillary generates timely and signs out a demonstrates assistance, using current testing for a complex integrated reports for cytopathology report understanding of timely reporting/ classification case, with assistance; complex cases reporting systems independently generates reports for a simple case

Generates an Generates an amended/addended amended/addended report that includes report and documents updated information, with communication with the assistance clinical team, as appropriate

Identifies the importance Identifies implications of Generates a report that Independently of a complete pathology the diagnosis in the report includes the language of generates a report that report for optimal patient and makes simple uncertainty, as includes the language care recommendations appropriate, with of uncertainty and assistance complex recommendations

Comments: Not Yet Completed Level 1 Not Yet Rotated

Patient Care 2: Consultation

Level 1 Level 2 Level 3 Level 4 Level 5 Describes the use of a For simple consultations, For complex Manages complex Demonstrates expertise in consultation and refers delineates the clinical consultations, delineates consultations providing comprehensive to useful resources question, obtains the clinical question, independently consultations additional information, obtains additional accesses available information, applies resources, recommends relevant resources, and next steps, and recommends next steps documents with with assistance; manages assistance simple consultations independently

Comments: Not Yet Completed Level 1 Not Yet Rotated

Patient Care 3: Performance of Fine Needle Aspirations

Level 1 Level 2 Level 3 Level 4 Level 5 Recognizes indications Performs a simple fine Independently performs a Independently performs Teaches/consults in the for fine needle needle aspiration with simple fine needle a complex fine needle performance of fine aspirations; properly appropriate patient aspiration; performs a aspiration needle aspirations identifies patient and consent and time-out with complex fine needle describes the anatomy of assistance (actual or aspiration with assistance the area simulated)

Describes potential Describes potential Manages adverse patient Independently manages adverse patient events of adverse events for events, with assistance adverse patient events various superficial fine specific clinical scenarios (actual or simulated) (actual or simulated) needle aspiration procedures

Comments: Not Yet Completed Level 1 Not Yet Rotated

Patient Care 4: Adequacy (Rapid On-Site Evaluation [ROSE]) and Triage

Level 1 Level 2 Level 3 Level 4 Level 5 Describes adequacy Provides appropriate Independently provides Independently provides Teaches/consults in criteria for different assessment of adequacy appropriate assessment appropriate assessment assessment of adequacy specimen types interpretations and of adequacy and communicates interpretations communicates results, interpretations and results for simple and with assistance communicates results for complex cases simple cases

Describes options for Suggests appropriate Independently triages Independently triages Teaches/consults in specimen triage specimen triage simple cases simple and complex specimen triage cases

Comments: Not Yet Completed Level 1 Not Yet Rotated

Patient Care 5: Fine Needle Aspiration Slide and Core Biopsy Touch Preparations

Level 1 Level 2 Level 3 Level 4 Level 5 Describes methods and Prepares a touch/smear Independently prepares Independently prepares Teaches/consults on importance of fine and stains a slide for a touch/smear and stains touch/smear and stains techniques for touch needle aspiration, simple specimen slides for a simple slides for a complex preparations, smearing, smears, touch (simulated or actual) specimen specimen and staining preparations, and staining techniques

Comments: Not Yet Completed Level 1 Not Yet Rotated

Patient Care 6: Cytopreparatory Techniques

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Performs cytopreparatory Independently performs Independently Provides consultation and knowledge of techniques, with multiple cytopreparatory troubleshoots technical support to supervisory cytopreparatory assistance (actual or techniques; troubleshoots issues cytotechnologist on techniques simulated) technical issues with technical issues assistance

Comments: Not Yet Completed Level 1 Not Yet Rotated

Medical Knowledge 1: Diagnosis

Level 1 Level 2 Level 3 Level 4 Level 5 Correctly describes Provides differential Independently diagnoses Independently cytomorphology diagnosis; locates and simple cytologic cases diagnoses simple and categorizes cells as complex cytologic cases normal, reactive, or neoplastic

Describes applicable Suggests ancillary studies Independently orders and Independently orders Teaches other ancillary studies interprets ancillary studies and interprets ancillary experienced learners in simple cases studies in simple and about cytopathology complex cases including how to select and interpret ancillary studies

Comments: Not Yet Completed Level 1 Not Yet Rotated

Medical Knowledge 2: Clinical Reasoning

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates a basic Demonstrates clinical Synthesizes information Independently Demonstrates intuitive framework for clinical reasoning to determine to inform clinical synthesizes information approach to clinical reasoning relevant information reasoning, with to inform clinical reasoning for complex assistance reasoning in complex cases cases

Identifies appropriate Selects relevant Seeks and integrates Independently seeks resources to inform resources based on evidence-based out, analyzes, and clinical reasoning scenario to inform information to inform applies relevant original decisions diagnostic decision research to diagnostic making in complex cases, decision making in with assistance complex clinical cases

Comments: Not Yet Completed Level 1 Not Yet Rotated

Systems-Based Practice 1: Patient Safety and Quality Improvement (QI)

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Identifies system factors Participates in analysis of Conducts analysis of Actively engages teams knowledge of common that lead to patient safety patient safety events patient safety events and processes to modify patient safety events events (simulated or actual) and offers error systems to prevent prevention strategies patient safety events (simulated or actual)

Demonstrates Reports patient safety Participates in disclosure Discloses patient safety Role models or mentors knowledge of how to events through of patient safety events to events to clinicians others in the disclosure of report patient safety institutional reporting clinicians and/or patients and/or patients and patient safety events events systems (simulated or and families, as families, as appropriate actual) appropriate (simulated or (simulated or actual) actual)

Demonstrates Describes departmental Participates in Demonstrates the skills Creates, implements, and knowledge of basic QI and institutional QI departmental and required to identify, assesses QI initiatives at methodologies and initiatives institutional QI initiatives develop, implement, the institutional or metrics and analyze a QI community level project

Comments: Not Yet Completed Level 1

Systems-Based Practice 2: Systems Navigation for Patient-Centered Care

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Coordinates care of Coordinates care of Models effective Analyzes the process of knowledge of case patients in routine cases patients in complex cases coordination of patient- care coordination and coordination effectively using effectively using centered care among leads in the design and interprofessional teams interprofessional teams different disciplines and implementation of specialties improvements

Identifies key elements Performs safe and Performs safe and Models and advocates Improves quality of for safe and effective effective transitions of effective transitions of for safe and effective transitions of care within transitions of care and care/hand-offs in routine care/hand-offs in complex transitions of care/hand- and across health care hand-offs situations situations offs within and across delivery systems to health care delivery optimize patient outcomes systems

Demonstrates Identifies pathology’s role Identifies opportunities for Recommends and/or Leads innovations and knowledge of population in population and pathology to participate in participates in changing advocates for populations and community health community health needs community and and adapting practice to and communities with needs and disparities and inequities for the local population health provide for the needs of health care inequities population communities and populations

Comments: Not Yet Completed Level 1

Systems-Based Practice 3: Physician Role in Health Care System

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies key Describes how Discusses how individual Manages various Advocates for or leads components of the components of a complex practice affects the components of the systems change that complex health care health care system are broader system (e.g., test complex health care enhances high-value, system (e.g., hospital, interrelated, and how this use, turnaround time) system to provide efficient, and effective skilled nursing facility, impacts patient care efficient and effective patient care and finance, personnel, patient care and transitions of care technology) transitions of care

Describes basic health Documents testing detail Engages with clinicians Practices and Participates in health payment systems (e.g., and explains the impact of and/or patients in shared advocates for cost policy advocacy activities government, private, documentation on billing decision making, such as effective patient care public, uninsured care) and reimbursement use of preauthorization for with consideration of the and practice models complex testing limitations of each patient’s payment model

Comments: Not Yet Completed Level 1

Systems-Based Practice 4: Accreditation, Compliance, and Quality

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Demonstrates knowledge Identifies the differences Participates in an Serves as a resource for knowledge that of the components of between accreditation internal or external accreditation at the laboratories must be laboratory accreditation and regulatory laboratory inspection regional or national level accredited and regulatory compliance; discusses compliance (Clinical the process for achieving Laboratory Improvement accreditation and Amendments and others), maintaining regulatory either through training or compliance experience

Discusses the need for Interprets quality data and Demonstrates knowledge Reviews the quality Creates and follows a quality control and charts and trends, of the components of a management plan to comprehensive quality proficiency testing including proficiency laboratory quality identify areas for management plan testing results, with management plan improvement assistance

Discusses implications of Performs analysis and Formulates a response proficiency testing failures review of proficiency for proficiency testing testing failures and failures recommends a course of action, with oversight

Comments: Not Yet Completed Level 1

Systems-Based Practice 5: Utilization

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies general Explains rationale for Identifies opportunities to Initiates efforts to Completes a utilization pathology work practices optimizing utilization optimize utilization optimize utilization review and implements and workflow (e.g., pathology resources change histology, immunohistochemistry stains, chemical tests)

Comments: Not Yet Completed Level 1 Not Yet Rotated

Practice-Based Learning and Improvement 1: Evidence-Based Practice and Scholarship

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates how to Identifies and applies the Identifies and applies the Critically appraises and Teaches others to access and select best available evidence to best available evidence to applies evidence to critically appraise and applicable evidence guide diagnostic work-up guide diagnostic work-up guide care, even in the apply evidence for of simple cases of complex cases face of conflicting data complex cases; and/or participates in the development of guidelines

Is aware of the need for Develops knowledge of Applies knowledge of the Proactively and Suggests improvements patient privacy, the basic principles of basic principles of consistently applies to research regulations autonomy, and consent research (e.g., research such as knowledge of the basic and/or substantially as applied to clinical demographics, informed consent and principles of research contributes to the primary research Institutional Review research protocols to such as informed literature through basic, Board, human subjects), clinical practice, with consent and research translational, or clinical including how research is supervision protocols to clinical research evaluated, explained to practice patients, and applied to patient care

Comments: Not Yet Completed Level 1

Practice-Based Learning and Improvement 2: Reflective Practice and Commitment to Personal Growth

Level 1 Level 2 Level 3 Level 4 Level 5 Accepts responsibility for Demonstrates openness Seeks performance data Actively and Models seeking personal and to receiving performance and feedback with consistently seeks performance data and professional data and feedback in humility performance data and accepting feedback with development by order to inform goals feedback with humility humility establishing goals

Identifies the gap(s) Analyzes and reflects on Institutes behavioral Critically evaluates the Coaches others reflective between expectations the factors which change(s) to narrow the effectiveness of practice and actual performance contribute to gap(s) gap(s) between behavioral changes in between expectations and expectations and actual narrowing the gap(s) actual performance performance between expectations and actual performance

Actively seeks Designs and implements Independently creates Uses performance data Facilitates the design and opportunities to improve a learning plan, with and implements a to measure the implementing learning assistance learning plan effectiveness of the plans for others learning plan and improves it when necessary

Comments: Not Yet Completed Level 1

Professionalism 1: Professional Behavior and Ethical Principles

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Analyzes straightforward Recognizes the need and Independently resolves Identifies and seeks to knowledge of the ethical situations using ethical uses appropriate and manages complex address system-level principles underlying principles resources to seek help in ethical situations factors that induce or informed consent, managing and resolving exacerbate ethical surrogate decision complex ethical situations problems or impede their making, advance resolution directives, confidentiality, error disclosure, stewardship of limited resources, and related topics

Describes when and how Demonstrates insight into Demonstrates Recognizes situations Coaches others when to appropriately report professional behavior in professional behavior in that may trigger their behavior fails to professionalism lapses, routine situations; takes complex or stressful professionalism lapses meet professional including strategies for responsibility for one’s situations and intervenes to expectations addressing common own professionalism prevent lapses in self barriers; identifies and lapses and others describes potential triggers for professionalism lapses

Comments: Not Yet Completed Level 1

Professionalism 2: Accountability and Conscientiousness

Level 1 Level 2 Level 3 Level 4 Level 5 Responds promptly to Takes appropriate Recognizes situations Anticipates and Takes ownership of instructions, requests, or ownership and performs that may impact own intervenes in situations system outcomes reminders to complete tasks and responsibilities ability to complete tasks that may impact others’ tasks and responsibilities in a timely manner with and responsibilities in a ability to complete tasks attention to detail timely manner and and responsibilities in a Designs new strategies to describes the impact on timely manner ensure that the needs of team patients, teams, and systems are met

Comments: Not Yet Completed Level 1

Professionalism 3: Self-Awareness and Help-Seeking

Level 1 Level 2 Level 3 Level 4 Level 5 Recognizes limitations in Independently recognizes Proposes and implements Independently develops Serves as a resource or the knowledge/skills/ limitations in the a plan to remediate or and implements a plan consultant for developing behaviors of self or knowledge/skills/ improve the knowledge/ to remediate or improve a plan to remediate or team, with assistance behaviors of self or team skills/behaviors of self or the knowledge/skills/ improve the knowledge/ and seeks help when team, with assistance behaviors of self or skills/behaviors needed team

Recognizes status of Independently recognizes Proposes and implements Independently develops Coaches others when personal and status of personal and a plan to optimize and implements a plan responses or limitations in professional well-being, professional well-being personal and professional to optimize personal knowledge/skills do not with assistance and seeks help when well-being, with and professional well- meet professional needed assistance being expectations

Comments: Not Yet Completed Level 1

This subcompetency is not intended to evaluate a fellow’s well-being. Rather, the intent is to ensure that each fellow has the fundamental knowledge of factors that affect well-being, the mechanisms by which those factors affect well-being, and available resources and tools to improve well-being.

Interpersonal and Communication Skills 1: Patient and Family-Centered Communication

Level 1 Level 2 Level 3 Level 4 Level 5 Uses language and Establishes a relationship Sensitively and Independently, Mentors others in the nonverbal behavior to in straightforward compassionately delivers sensitively, and sensitive and demonstrate respect and encounters using active medical information, with compassionately compassionate delivery of establish rapport listening and clear assistance delivers medical medical information language information and acknowledges uncertainty and conflict

Identifies common Identifies complex When prompted, reflects Independently Models self-awareness barriers to effective barriers to effective on personal biases while recognizes personal while teaching a communication (e.g., communication (e.g., attempting to minimize biases while attempting contextual approach to language, disability) health literacy, cultural) communication barriers to proactively minimize minimize communication while accurately communication barriers barriers communicating one’s own role within the health care system

Comments: Not Yet Completed Level 1

Interpersonal and Communication Skills 2: Interprofessional and Team Communication

Level 1 Level 2 Level 3 Level 4 Level 5 Uses language that Communicates Uses active listening to Coordinates Models flexible values all members of information effectively adapt communication recommendations from communication strategies the health care team with all health care team style to fit team needs different members of that value input from all members the health care team to health care team optimize patient care members, resolving conflict when needed

Describes the utility of Solicits feedback on Integrates feedback from Communicates Facilitates regular health constructive feedback performance as a team members to improve feedback and care team-based member of the health communication constructive criticism to feedback in complex care team superiors situations

Comments: Not Yet Completed Level 1

Interpersonal and Communication Skills 3: Communication within Health Care Systems

Level 1 Level 2 Level 3 Level 4 Level 5 Safeguards patient Appropriately selects Communicates while Independently Guides departmental or personal health forms of communication ensuring security of communicates while institutional information by based on context and personal health ensuring security of communication around communicating through urgency of the situation information, with guidance personal health policies and procedures appropriate means as information regarding the security of required by institutional personal health policy (e.g., patient information safety reports, cell phone/pager usage)

Identifies institutional Respectfully Uses institutional Initiates conversations Facilitates dialogue and departmental communicates concerns structure to effectively on difficult subjects with regarding systems issues structure for about the system communicate clear and appropriate among larger community communication of issues constructive suggestions stakeholders to improve stakeholders (e.g., to improve the system the system institution, health care system, field)

Comments: Not Yet Completed Level 1