Clinical Neurophysiology Milestone Project

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The Clinical Neurophysiology Milestone Project

A Joint Initiative of

The Accreditation Council for Graduate Medical Education

and

The American Board of Psychiatry and Neurology

July 2015

The Clinical Neurophysiology 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.

Clinical Neurophysiology Milestones

Chair: Ralph Józefowicz, MD

Working Group Advisory Group Imran Ali, MD Larry Faulkner, MD Laura Edgar, EdD, CAE Eric Holmboe, MD Laurie Gutmann, MD Steven Lewis, MD* Louise King, MS Mary Lieh-Lai, MD Noor Pirzada, MD

*Acknowledgement: Special thanks to Steven Lewis, MD, who was an active member of both the Working and Advisory Groups.

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.

Patient Care milestones have a “Not Applicable” option. This option should only be used for those areas in which the fellow will receive no education/experience. For example, a fellow who is completing an EEG/NCS track with no exposure to EMG should have the EMG milestone set marked at “Not Applicable.” If the fellow has some exposure, an evaluation should be indicated. It is not expected that the fellow with limited exposure will receive a Level 4.

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 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 04/2014 Clinical Neurophysiology Milestones, ACGME Report Worksheet

History — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Obtains a relevant and Obtains a relevant and Obtains a focused history Consistently obtains a Serves as a role model to organized neurologic organized history sufficient to guide focused history sufficient other learners for focused history incorporating subtle verbal subsequent to guide subsequent history taking regarding and non-verbal cues neurophysiologic neurophysiologic neurophysiologic investigation investigation investigation

Comments: Not Applicable

Neurological Exam — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Performs a relevant Performs a relevant Performs a focused Consistently performs a Serves as a role model to neurological exam neurological exam neurological examination focused neurological other learners for incorporating some accurately incorporating sufficient to guide examination sufficient to performing a focused additional appropriate all additional appropriate subsequent guide subsequent examination regarding maneuvers maneuvers neurophysiologic neurophysiologic neurophysiologic investigation investigation investigation

Comments: Not Applicable

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

Version 04/2014 Clinical Neurophysiology Milestones, ACGME Report Worksheet

Electroencephalogram (EEG) — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Describes normal EEG Interprets common EEG Applies basic knowledge of Applies advanced Plans, supervises, and features of awake and abnormalities and creates electrical safety, filters, knowledge of electrical interprets pre-surgical sleep states a report artifacts, montages, safety, filters, artifacts, evaluation of patients with electrodes, signal analysis, montages, electrodes, epilepsy (e.g., intracranial Recognizes common EEG Recognizes normal EEG and other relevant signal analysis, and other EEG monitoring and artifacts variants technical aspects to the relevant technical aspects cortical mapping) performance and to the performance and Recognizes common EEG Recognizes uncommon interpretation of EEG interpretation of EEG patterns associated with EEG patterns associated studies studies status epilepticus with status epilepticus Utilizes appropriate Accurately interprets and Recognizes the indications technical standards for reports EEG findings in and contraindications for determining and reporting children and adults, use of activation electrocerebral inactivity including normal variants procedures (e.g., sleep in brain death and abnormal EEG deprivation, photic patterns stimulation, Interprets and reports EEG hyperventilation) findings in children and Accurately interprets and adults, including normal reports findings of Recognizes the indications variants and abnormal EEG prolonged video EEG for prolonged video EEG patterns monitoring monitoring Interprets and reports findings of prolonged video EEG monitoring

Comments:

Not Applicable

Version 04/2014 Clinical Neurophysiology Milestones, ACGME Report Worksheet

Nerve Conduction Studies (NCS) — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Applies knowledge of Performs and interprets Performs and interprets Accurately interprets and Performs and interprets peripheral nerve anatomy common motor and neuromuscular junction provides a detailed report special NCS procedures in the performance of NCS sensory NCS testing (e.g., repetitive of common and (e.g., autonomic testing) stimulation study) uncommon nerve Applies principles of Performs and interprets conduction study findings electrical safety to the late response studies (e.g., Performs and interprets in conjunction with the performance of NCS F waves, H reflexes) uncommon motor and electromyography (EMG) sensory NCS Formulates basic NCS plan Recognizes common Recognizes uncommon for specific, common anatomical variants in the Performs and interprets anatomical variants in the clinical presentations interpretation of NCS cranial nerve testing (e.g., interpretation of NCS blink reflex, facial nerve) Identifies technical Creates a report for NCS artifacts in the interpretation of NCS

Comments:

Not Applicable

Version 04/2014 Clinical Neurophysiology Milestones, ACGME Report Worksheet

EMG — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Applies knowledge of Performs and interprets Performs and interprets Recognizes uncommon Performs and interprets nerve and muscle anatomy EMG of commonly EMG of uncommonly EMG findings special EMG procedures in the performance of sampled muscles sampled muscles (e.g., single fiber EMG, EMG Accurately interprets and quantitative EMG studies) Recognizes common EMG Performs and interprets provides a detailed report Applies principles of findings EMG of cranial nerve of common and electrical safety to the innervated muscles uncommon EMG findings performance of EMG Creates a report for an in conjunction with NCS EMG study in conjunction Formulates basic EMG with NCS plan for specific, common clinical presentations

Identifies technical artifacts in the interpretation of EMG

Comments:

Not Applicable

Version 04/2014 Clinical Neurophysiology Milestones, ACGME Report Worksheet

Evoked Potential (EP)/ Intra-operative Monitoring (IOM) — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Describes normal Correlates common Applies basic knowledge of Applies detailed Interprets uncommon waveforms related to abnormalities associated technical aspects of knowledge of the technical findings of clinical commonly performed EP with EP studies in various EP/IOM studies aspects of EP/IOM studies significance during IOM studies disease states and provides guidance to and with EP studies Utilizes appropriate IOM technologists and others Correlates normal Orders and utilizes studies (SSEPs, MEP) waveforms with appropriate basic associated with the Accurately interprets associated anatomic procedures in patients surgical procedures common findings of structures and physiologic undergoing IOM (e.g., clinical significance during phenomena brainstem auditory Provides appropriate IOM, and provides timely responses, transcranial feedback to surgeons feedback to surgeons magnetic stimulation) during routine IOM independently procedures with supervision Accurately interprets common findings of clinical significance associated with EP studies

Comments: Not yet achieved Level 1

Version 04/2014 Clinical Neurophysiology Milestones, ACGME Report Worksheet

Sleep Disorders — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Obtains a relevant and Orders and utilizes Interprets Accurately interprets Interprets and reports focused history and appropriate sleep study polysomnographic clinical and polysomnography findings performs a focused and modalities (e.g., features of common sleep neurophysiological in children and adults relevant examination in a polysomnography, disorders features of common sleep patient with suspected multiple sleep latency disorders Interprets clinical and sleep disorder testing) Applies detailed neurophysiological knowledge of the technical Manages common sleep features of uncommon Applies basic knowledge of Applies basic knowledge of aspects of disorders utilizing sleep disorders common sleep disorders the technical aspects of polysomnography pharmacologic and non- to evaluation of patients polysomnography pharmacologic modalities

Comments:

Not yet achieved Level 1

Version 04/2014 Clinical Neurophysiology Milestones, ACGME Report Worksheet

Localization — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Accurately localizes lesions Demonstrates basic Demonstrates detailed Consistently demonstrates Teaches other learners to specific regions of the knowledge of knowledge of sophisticated and detailed neuroanatomy relevant to nervous system neuroanatomy and neuroanatomy and knowledge of performing and neurophysiology relevant neurophysiology relevant neuroanatomy and interpreting to performing and to performing and neurophysiology relevant neurophysiologic studies interpreting interpreting to performing and neurophysiologic studies neurophysiologic studies interpreting neurophysiologic studies

Comments: Not yet achieved Level 1

Planning Neurophysiologic Testing — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Knows the indications for Knows the indications for Plans basic Plans detailed Guides other learners in ordering neurophysiologic ordering specific subtypes neurophysiologic testing neurophysiologic testing planning neurophysiologic testing of neurophysiologic relevant to the underlying relevant to the underlying testing relevant to the testing (e.g., single fiber disorder disorder underlying disorder EMG, multiple sleep latency test, inpatient video EEG monitoring)

Comments:

Not yet achieved Level 1

Version 04/2014 Clinical Neurophysiology Milestones, ACGME Report Worksheet

Neuromuscular Disorders — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates knowledge Demonstrates knowledge Demonstrates basic Demonstrates detailed Engages in scholarly of common patterns of of uncommon patterns of knowledge of knowledge of activity related to neuromuscular disorders neuromuscular disorders neurophysiologic findings neurophysiologic findings neurophysiologic findings in common and in common and in neuromuscular uncommon uncommon disorders neuromuscular disorders neuromuscular disorders

Comments:

Not yet achieved Level 1

Epilepsy — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates knowledge Demonstrates knowledge Demonstrates basic Demonstrates detailed Engages in scholarly of common types of of uncommon types of knowledge of clinical and knowledge of clinical and activity related to clinical seizures and epilepsy, seizures and epilepsy, EEG findings in common EEG findings in common and EEG findings in including epilepsy including epilepsy and uncommon seizures and uncommon seizures seizures and epilepsy syndromes syndromes and epilepsy and epilepsy

Comments: Not yet achieved Level 1

Version 04/2014 Clinical Neurophysiology Milestones, ACGME Report Worksheet

Sleep Disorders — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Describes normal Recognizes the indications Describes Recognizes clinical and Interprets and reports neurophysiologic features for use of different sleep polysomnographic neurophysiological polysomnography findings of sleep stages study modalities (e.g., features of sleep disorders features of common sleep in children and adults polysomnography, disorders Recognizes clinical multiple sleep latency Demonstrates knowledge Recognizes clinical and features of common sleep testing) of the technical aspects of neurophysiological disorders polysomnography features of uncommon sleep disorders

Comments:

Not yet achieved Level 1

Version 04/2014 Clinical Neurophysiology Milestones, ACGME Report Worksheet

EP/ IOM — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Describes fundamental Describes common Demonstrates basic Demonstrates detailed Describes uncommon neurophysiologic abnormalities associated knowledge of technical knowledge of the technical findings of clinical principles of sensory and with EP studies in various aspects of EP/IOM studies aspects of EP/IOM studies significance during IOM motor EP studies disease states and with EP studies Describes common Describes common Describes indications and Describes basic indications for IOM and findings of clinical limitations of EP studies procedures utilized in IOM appropriate studies significance during IOM (e.g., brainstem auditory associated with the responses, transcranial surgical procedures Describes common magnetic stimulation) findings of clinical significance associated with EP studies

Comments: Not yet achieved Level 1

Systems thinking, including cost- and risk-effective practice — Systems-based Practice

Level 1 Level 2 Level 3 Level 4 Level 5 Describes basic cost and Describes cost- and risk- Makes clinical decisions Incorporates available Engages in scholarly risk implications of care benefit ratios in patient that balance cost- and risk- quality measures in activity regarding cost- care benefit ratios patient care and risk-effective practice in clinical neurophysiology

Comments:

Version 04/2014 Clinical Neurophysiology Milestones, ACGME Report Worksheet

Work in inter-professional teams to enhance patient safety — Systems-based Practice

Level 1 Level 2 Level 3 Level 4 Level 5 Describes team members’ Identifies and reports Describes potential Participates in a team- Engages in scholarly roles in maintaining errors and near-misses sources of system failure based approach to medical activity regarding error patient safety in clinical care such as error analysis analysis and patient safety minor, major, and sentinel in clinical neurophysiology events

Comments:

Self-directed learning — Practice-based Learning and Improvement  Identify strengths, deficiencies, and limits in one’s knowledge and expertise  Set learning and improvement goals  Identify and perform appropriate learning activities  Use information technology to optimize learning Level 1 Level 2 Level 3 Level 4 Level 5 Acknowledges gaps in Incorporates feedback Develops an appropriate Completes an appropriate Engages in scholarly knowledge and expertise learning plan based upon learning plan based upon activity regarding practice- in clinical neurophysiology clinical experience clinical experience based learning and improvement in clinical neurophysiology

Comments:

Version 04/2014 Clinical Neurophysiology Milestones, ACGME Report Worksheet

Locate, appraise, and assimilate evidence from scientific studies related to the patient’s health problems – Practice-based Learning and Improvement Level 1 Level 2 Level 3 Level 4 Level 5 Uses information Uses scholarly articles and Critically evaluates Incorporates appropriate Engages in scholarly technology to search and guidelines to answer scientific literature evidence-based activity regarding access relevant medical patient care issues information into patient evidence-based medicine information care in clinical neurophysiology

Understands the limits of evidence-based medicine in patient care

Comments:

Version 04/2014 Clinical Neurophysiology Milestones, ACGME Report Worksheet

Compassion, integrity, accountability, and respect for self and others — Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates compassion, Describes effects of sleep Demonstrates Mentors others in the Engages in scholarly sensitivity, and deprivation and substance compassionate practice of compassionate practice of activity regarding responsiveness to patients abuse on performance medicine, even in context medicine, even in context professionalism in clinical and families of disagreement with of disagreement with neurophysiology Demonstrates appropriate patient beliefs patient beliefs Demonstrates non- steps to address discriminatory behavior in impairment in self Incorporates patients’ Mentors others in all interactions, including sociocultural needs and sensitivity and diverse and vulnerable beliefs into patient care responsiveness to diverse populations and vulnerable populations Demonstrates appropriate Consistently demonstrates steps to address Advocates for quality professional behavior, impairment in colleagues patient care including dress and timeliness

Comments:

Version 04/2014 Clinical Neurophysiology Milestones, ACGME Report Worksheet

Knowledge about, respect for, and adherence to the ethical principles relevant to the practice of medicine, remembering in particular that responsiveness to patients that supersedes self-interest is an essential aspect of medical practice — Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5 Describes basic ethical Determines presence of Analyzes and manages Analyzes and manages Demonstrates leadership principles ethical issues in practice ethical issues in ethical issues in complex and mentorship in straightforward clinical clinical situations applying ethical principles situations in clinical neurophysiology settings

Comments:

Relationship development, teamwork, and managing conflict — Interpersonal and Communication Skills

Level 1 Level 2 Level 3 Level 4 Level 5 Develops a positive Manages simple patient- Manages conflict in Manages conflict across Engages in scholarly relationship with patients /family-related conflicts complex situations specialties and systems of activity regarding in uncomplicated care teamwork and conflict situations Engages patients in shared Uses easy-to-understand management decision making language in all phases of Leads team-based patient Actively participates in communication care activities team-based care

Comments:

Version 04/2014 Clinical Neurophysiology Milestones, ACGME Report Worksheet

Information sharing, gathering, and technology — Interpersonal and Communication Skills

Level 1 Level 2 Level 3 Level 4 Level 5 Completes documentation Educates patients about Effectively communicates Effectively and ethically Develops patient in a timely fashion their diseases and the results of a neurologic uses all forms of education materials management, including consultation in a timely communication regarding clinical risks and benefits of manner neurophysiology treatment options Mentors colleagues in Effectively gathers timely, accurate, and Engages in scholarly Completes all information from efficient documentation activity regarding documentation accurately, collateral sources when interpersonal including use of electronic necessary communication in clinical health records (EHR), to neurophysiology promote patient safety Demonstrates synthesis, formulation, and thought process in documentation

Comments: