Neurological Surgery Milestones

The Accreditation Council for Graduate Medical Education

Second Revision: March 2018 First Revision: July 2013

The Milestones are designed only for use in evaluation of residents in the context of their participation in ACGME-accredited residency programs. The Milestones provide a framework for the assessment of the development of the resident 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.

Neurological Surgery Milestones

Chair: Nathan R. Selden, MD, PhD

Work Group Aviva Abosch, MD Robert E. Harbaugh, MD Nicholas Bambakidis, MD Griff Harsh, MD Nicholas Barbaro, MD Carl Heilman, MD Frederick A. Boop, MD Nickalus R. Khan, MD Charles Branch, MD Jack Knightly, MD Richard W. Byrne, MD Doug Kondziolka, MD Ennio Antonio Chiocca, MD Timothy B. Mapstone, MD E. Sander Connolly Jr., MD Harry Rosenbluth, MBA Laura Edgar, EdD, CAE Oren Sagher, MD Steven L. Giannotta, MD Warren Selman, MD Michael Haglund, MD Shelly Timmons, MD Stanley Hamstra, PhD Greg Zipfel, MD

Understanding Milestone Levels and Reporting

This document presents the Milestones, which programs use in a semi-annual review of resident 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 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 resident 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 resident may achieve higher levels early in his/her educational program just as a senior resident 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. Residents 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 resident. Selection of a level implies the resident substantially demonstrates the milestones in that level, as well as those in lower levels (see the diagram on page iv).

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 resident/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.

Examples are provided for some milestones within this document. Please note: 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 ACGME supervision guidelines as described in the Program Requirements, as well as to institutional and program policies. For example, a resident 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.

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

iii

Below is an example Set of Milestones for one sub-competency in the same format as the ACGME Report Worksheet. For each reporting period, a resident’s performance within each sub-competency will be indicated by selecting the level that best describes that resident’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).

Version 2 Neurological Surgery Milestones, ACGME Report Worksheet

Patient Care 1: Brain Tumor

Level 1 Level 2 Level 3 Level 4 Level 5 Performs a history and Explains the risks and Formulates a diagnostic Adapts standard Leads discussion at an physical examination in benefits of craniotomy for and treatment plan for a treatment plans and interdisciplinary tumor patients with a brain brain tumor patient with a brain or techniques to special board tumor spinal cord tumor circumstances (e.g., recurrence, bone marrow suppression)

Places an external Assists with routine Performs routine Performs complex Performs advanced ventricular drain; assists craniotomy for brain tumor craniotomy for brain craniotomy for brain craniotomy for brain tumor with set-up, opening, and tumor; assists with tumor; assists with closing for brain tumor complex craniotomy for advanced craniotomy craniotomies brain tumor for brain tumor

Provides routine peri- Recognizes and initiates Manages routine Manages complex Utilizes patient outcome operative care for brain work-up of routine complications and complications data for quality tumor patients complications (e.g., air recognizes complex improvement or the embolism, CSF fistula, complications (e.g., development of adjunctive hematoma) refractory cerebral therapy protocols edema, major vascular injury)

Comments: Not Yet Completed Level 1 Not Yet Rotated

©2018 by The Accreditation Council for Graduate Medical Education and The American Board of Neurological Surgery. All rights reserved except the copyright owners grant third parties the right to use the Neurological Surgery Milestones on a non-exclusive basis for educational purposes. 1 Version 2 Neurological Surgery Milestones, ACGME Report Worksheet

Patient Care 2: Surgical Treatment of Epilepsy and Movement Disorders

Level 1 Level 2 Level 3 Level 4 Level 5 Performs a history and Explains the risks and Formulates a diagnostic Adapts standard Leads discussion at an physical examination in benefits of functional and treatment plan for a treatment plans and interdisciplinary epilepsy patients with epilepsy or neurosurgical procedures patient with epilepsy or a techniques to special center patient movement disorders movement disorder circumstances (e.g., management conference Parkinson’s plus, multifocal epilepsy)

Performs stereotactic Assists with routine Performs routine Performs complex Performs advanced frame placement or functional neurosurgical functional neurosurgical functional neurosurgical functional neurosurgical frameless navigation procedures procedures; assists with procedures; assists with procedures, including registration; assists with complex functional advanced functional interpretation of set-up, opening, and neurosurgical procedures neurosurgical electrophysiological data closing for functional procedures neurosurgical procedures

Provides routine peri- Recognizes and initiates Manages routine Manages complex Utilizes patient outcome operative care for work-up of routine complications and complications data for quality movement disorder and complications (e.g., recognizes complex improvement; designs epilepsy patients seizures, device infection) complications (e.g., status care pathways for epilepticus, dystonia) epilepsy or movement disorder patients

Comments:

©2018 by The Accreditation Council for Graduate Medical Education and The American Board of Neurological Surgery. All rights reserved except the copyright owners grant third parties the right to use the Neurological Surgery Milestones on a non-exclusive basis for educational purposes. 2 Version 2 Neurological Surgery Milestones, ACGME Report Worksheet

Patient Care 3: Pain and Peripheral Nerve Disorders

Level 1 Level 2 Level 3 Level 4 Level 5 Performs a history and Explains the risks and Formulates a diagnostic Adapts standard Leads discussion at an physical examination in benefits of chronic pain and treatment plan for treatment plans and interdisciplinary case patients with chronic pain and peripheral nerve patients with chronic pain techniques to special conference or specialty or a peripheral nerve procedures or peripheral nerve circumstances (e.g., clinic for chronic pain or disorder disorders cancer pain, peripheral nerve disorder deafferentation pain) patients

Interrogates and Assists with routine Performs routine chronic Performs complex Performs advanced programs implanted chronic pain and pain and peripheral nerve chronic pain and chronic pain and devices; assists with set- peripheral nerve procedures; assists with peripheral nerve peripheral nerve up, opening, and closing procedures complex chronic pain and procedures; assists with procedures for chronic pain and peripheral nerve advanced chronic pain peripheral nerve procedures and peripheral nerve procedures procedures

Provides routine peri- Recognizes and initiates Manages routine Manages complex Utilizes patient outcome operative care for work-up of routine complications and complications data for quality chronic pain or complications (e.g., recognizes complex improvement; designs peripheral nerve disorder implanted device failure or complications (e.g., care pathways for chronic patients infection) intrathecal drug overdose pain or peripheral nerve or withdrawal) disorder patients

Comments:

©2018 by The Accreditation Council for Graduate Medical Education and The American Board of Neurological Surgery. All rights reserved except the copyright owners grant third parties the right to use the Neurological Surgery Milestones on a non-exclusive basis for educational purposes. 3 Version 2 Neurological Surgery Milestones, ACGME Report Worksheet

Patient Care 4: Spinal Neurological Surgery

Level 1 Level 2 Level 3 Level 4 Level 5 Performs a history and Explains the risks and Formulates a diagnostic Adapts standard Leads discussion at an physical examination in benefits of spinal surgery and treatment plan for a treatment plans and interdisciplinary spine patients with patient with degenerative, techniques to special case conference or degenerative, traumatic, traumatic, or neoplastic circumstances (e.g., specialty clinic or neoplastic spinal spinal disorders spinal deformity, post- disorders irradiated spine, or infection)

Implements spinal Assists with routine spinal Performs routine spinal Performs complex Performs advanced spinal bracing or traction; surgery procedures surgery procedures; spinal surgery surgery and assists with set-up, assists with complex procedures; assists with reconstructive procedures opening, and closing for spinal surgery procedures advanced spinal surgery spinal surgery and reconstructive procedures procedures

Provides routine peri- Recognizes and initiates Manages routine Manages complex Utilizes patient outcome operative care for spinal work-up of routine complications and complications and registry data for surgery patients complications (e.g., pain, recognizes complex quality improvement and surgical site infection) complications (e.g., treatment selection myelopathy, cerebrospinal fluid (CSF) leak, instrument failure/malposition)

Comments:

©2018 by The Accreditation Council for Graduate Medical Education and The American Board of Neurological Surgery. All rights reserved except the copyright owners grant third parties the right to use the Neurological Surgery Milestones on a non-exclusive basis for educational purposes. 4 Version 2 Neurological Surgery Milestones, ACGME Report Worksheet

Patient Care 5: Vascular Neurological Surgery

Level 1 Level 2 Level 3 Level 4 Level 5 Performs a history and Explains the risks and Formulates a diagnostic Adapts standard Leads discussion at an physical examination in benefits of vascular and treatment plan for a treatment plans and interdisciplinary vascular patients with ischemic or neurosurgical and patient with ischemic or techniques to special neurosurgical and hemorrhagic stroke or endovascular procedures hemorrhagic stroke or circumstances (e.g., endovascular surgery vascular neurosurgical vascular neurosurgical vasculitis, ischemic case conference or disorders disorders heart disease) specialty clinic

Manages and obtains Assists with routine Performs routine vascular Performs complex Performs advanced CSF samples from vascular neurosurgical neurosurgical and vascular neurosurgical vascular neurosurgical external ventricular and endovascular endovascular procedures; and endovascular and endovascular drains; assists with set- procedures assists with complex procedures; assists with procedures up, opening, and closing vascular neurosurgical advanced vascular for vascular and endovascular neurosurgical and neurosurgical and procedures endovascular endovascular procedures procedures

Provides routine peri- Recognizes and initiates Manages routine Manages complex Utilizes patient outcome operative care for work-up of routine complications and complications data for quality vascular neurosurgical complications (e.g., recognizes complex improvement; designs and endovascular seizure, hydrocephalus) complications (e.g., care pathways for patients cerebral vasospasm, vascular neurosurgical herniation syndrome, and endovascular patients intra-operative aneurysm rupture)

Comments:

©2018 by The Accreditation Council for Graduate Medical Education and The American Board of Neurological Surgery. All rights reserved except the copyright owners grant third parties the right to use the Neurological Surgery Milestones on a non-exclusive basis for educational purposes. 5 Version 2 Neurological Surgery Milestones, ACGME Report Worksheet

Patient Care 6: Pediatric Neurological Surgery

Level 1 Level 2 Level 3 Level 4 Level 5 Performs an age- Explains the risks and Formulates a diagnostic Adapts standard Leads discussion at an appropriate history and benefits of pediatric and treatment plan for a treatment plans and interdisciplinary pediatric physical examination neurosurgical procedures; pediatric patient; techniques to special case conference or with developmental adapts diagnoses to age- determines prognosis in circumstances (e.g., specialty clinic; counsels assessment, including related variations severe brain injury and/or very young children and expectant parents for non-accidental diagnoses brain death in infants) regarding fetal anomalies trauma infants and children

Performs CSF shunt tap Assists with routine Performs routine pediatric Performs complex Performs advanced and valve programming; pediatric neurosurgical neurosurgical procedures; pediatric neurosurgical pediatric neurosurgical assists with set-up, procedures assists with complex procedures; assists with procedures opening, and closing for pediatric neurosurgical advanced pediatric pediatric neurosurgical procedures neurosurgical procedures procedures

Provides routine peri- Recognizes and initiates Manages routine Manages complex Utilizes patient outcome operative care for work-up of routine complications and complications data for quality pediatric neurosurgical complications, including in recognizes complex improvement; designs patients pre-verbal children (e.g., complications (e.g., care pathways for CSF shunt failure, hematoma, CSF leak) pediatric neurosurgical seizure) patients

Comments:

©2018 by The Accreditation Council for Graduate Medical Education and The American Board of Neurological Surgery. All rights reserved except the copyright owners grant third parties the right to use the Neurological Surgery Milestones on a non-exclusive basis for educational purposes. 6 Version 2 Neurological Surgery Milestones, ACGME Report Worksheet

Patient Care 7: Traumatic Brain Injury (TBI)

Level 1 Level 2 Level 3 Level 4 Level 5 Performs a history and Explains risks and Selects patients for Adapts standard Leads discussion at physical examination in benefits of trauma operative intervention; treatment plans to interdisciplinary trauma patients with severe TBI neurosurgical procedures; prioritizes the special circumstances unit rounds and/or and assigns a Glasgow evaluates patients with management of injuries in (e.g., medical co- conference Coma Scale score multiple trauma patients with multiple morbidity, trauma coagulopathy)

Places an intracranial Assists with routine Performs routine Performs complex Performs advanced pressure (ICP) monitor; procedures for patients procedures for patients procedures for patients procedures for patients assists with set-up, with TBI with TBI; assists with with TBI; assists with with TBI opening, and closing for complex procedures for advanced procedures neurotrauma procedures patients with TBI for patients with TBI

Provides routine peri- Recognizes and initiates Manages routine Manages complex Utilizes patient outcome operative care for work-up of routine complications and complications data for quality patients with TBI complications (e.g., sinus recognizes complex improvement; designs injury, air embolus) complications (e.g., care pathways for cerebral herniation neurotrauma patients syndrome, persistent CSF fistula)

Comments:

©2018 by The Accreditation Council for Graduate Medical Education and The American Board of Neurological Surgery. All rights reserved except the copyright owners grant third parties the right to use the Neurological Surgery Milestones on a non-exclusive basis for educational purposes. 7 Version 2 Neurological Surgery Milestones, ACGME Report Worksheet

Patient Care 8: Critical Care

Level 1 Level 2 Level 3 Level 4 Level 5 Performs a history and Manages transient Manages refractory Diagnoses and initiates Leads a multidisciplinary physical examination in intracranial hypertension intracranial hypertension management of acute neurocritical care team critically-ill patients (e.g., hyperosmolar (e.g., cerebral perfusion respiratory distress agents, CSF drainage) pressure directed therapy, syndrome advanced monitoring, decompressive craniectomy)

Inserts arterial and Assists with routine Performs routine and Performs complex and Performs advanced central venous catheters neurocritical care unit assists with complex assists with advanced neurocritical care unit procedures; manages neurocritical care unit neurocritical care unit procedures; performs airway and performs procedures; manages procedures; manages or bronchoscopy endotracheal intubation difficult and emergency initiates management of airways surgical airways

Manages neurocritical Recognizes and initiates Manages routine systemic Manages metabolic and Manages complex care unit admissions and work-up of routine complications and nutritional support for critically-ill patients (e.g., discharges systemic complications prioritizes simultaneous critically-ill patients septic shock, organ (e.g., pneumonia, critical clinical events failure); designs care infection, pulmonary pathways for critically-ill embolus, cardiac patients dysrhythmia, myocardial infarction)

Comments:

©2018 by The Accreditation Council for Graduate Medical Education and The American Board of Neurological Surgery. All rights reserved except the copyright owners grant third parties the right to use the Neurological Surgery Milestones on a non-exclusive basis for educational purposes. 8 Version 2 Neurological Surgery Milestones, ACGME Report Worksheet

Medical Knowledge 1: Information Gathering and Interpretation

Level 1 Level 2 Level 3 Level 4 Level 5 Correlates normal Correlates pathological Identifies anatomical and Interprets unusual Effectively teaches neuroanatomy and neuroanatomy and temporal patterns of variations in patterns of anatomic-pathological physiology with function physiology with function disease occurrence disease occurrence correlation

Gathers, interprets, and Describes indications for Prioritizes, orders, and Prioritizes, orders, and Utilizes complex reports basic diagnostic standard diagnostic interprets diagnostic tests interprets complex diagnostic approaches in test results (e.g., testing appropriate to clinical diagnostic studies (e.g., novel situations serology, chest urgency and complexity SPECT, cerebral radiograph, brain and perfusion, MR spine CT) tractography)

Comments:

©2018 by The Accreditation Council for Graduate Medical Education and The American Board of Neurological Surgery. All rights reserved except the copyright owners grant third parties the right to use the Neurological Surgery Milestones on a non-exclusive basis for educational purposes. 9 Version 2 Neurological Surgery Milestones, ACGME Report Worksheet

Medical Knowledge 2: Critical Thinking for Diagnosis and Therapy

Level 1 Level 2 Level 3 Level 4 Level 5 Lists a differential Provides a Provides a focused Interprets anomalous Studies and reports diagnosis for common comprehensive differential differential diagnosis presentations and rare challenging diagnostic clinical presentations diagnosis for a wide range based on individual disorders presentations of clinical presentations patient presentation

Lists therapeutic options Explains advantages and Justifies optimal Adapts therapeutic Creates new or modifies for common clinical drawbacks of standard therapeutic option based choice to anomalous or existing therapeutic presentations therapeutic options on individual patient rare patient options presentation presentations

Comments:

©2018 by The Accreditation Council for Graduate Medical Education and The American Board of Neurological Surgery. All rights reserved except the copyright owners grant third parties the right to use the Neurological Surgery Milestones on a non-exclusive basis for educational purposes. 10 Version 2 Neurological Surgery Milestones, ACGME Report Worksheet

Systems-Based Practice 1: Patient Safety

Level 1 Level 2 Level 3 Level 4 Level 5 Describes principles of Recognizes and reports Discloses patient safety Analyzes patient safety Actively engages teams in patient safety; performs patient safety events; events; supervises hand- events and offers error process and system safe and effective hand- performs safe and offs and transitions of prevention strategies; modification to prevent offs and transitions of effective hand-offs and care advocates for safe and patient safety events; care in routine clinical transitions of care in effective transitions of improves care transition situations complex clinical situations care within and across practices within and health care systems across health care systems