Ophthalmology Milestones the Accreditation Council for Graduate Medical Education

Ophthalmology Milestones The Accreditation Council for Graduate Medical Education

Second Revision: January 2020 First Revision: December 2015

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

Version 2 Ophthalmology, ACGME Report Worksheet

Ophthalmology Milestones

The Milestones are designed only for use in evaluation of resident’s 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.

Version 2 Ophthalmology, ACGME Report Worksheet

Ophthalmology Milestones

Work Group Pratap Challa, MD, MS Mark Juzych, MD, MHSA Jillian Chong, MD Shahzad Mian, MD Susan Culican, MD, PhD Nicholas Sala, DO Laura Edgar, EdD, CAE Bhavna Sheth, MD Matthew Fitzgerald, DrPH Misha Syed, MD Douglas Fredrick, MD

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

Version 2 Ophthalmology, ACGME Report Worksheet

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 vi).

Version 2 Ophthalmology, ACGME Report Worksheet

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. Level 5 is designed to represent an expert resident 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.

Version 2 Ophthalmology, ACGME Report Worksheet

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 resident’s performance on the milestones for each sub-competency will be indicated by selecting the level of milestones 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 Ophthalmology, ACGME Report Worksheet

Patient Care 1: Data Acquisition – Basic Ophthalmology Exam and Testing

Level 1 Level 2 Level 3 Level 4 Level 5 Acquires relevant Performs problem- Identifies subtle or Orders and interprets Demonstrates expertise in problem-focused history, focused exam with uncommon examination advanced diagnostic advanced diagnostic tests including outside medical appropriate techniques findings of common tests and imaging and imaging records (e.g., gonioscopy and disorders and procedures according to scleral depression), typical or common evidence-based consistently identifies findings of rarer medicine (i.e., when common abnormalities on disorders and when not to order examination; may identify testing) subtle findings

Performs and documents Orders, performs, and Interprets unusual a comprehensive interprets basic testing findings on routine ophthalmic examination; (e.g., visual field testing, testing, identifies artifacts; distinguishes between Optical Coherence recognizes indications for normal and abnormal Tomography, B-scan) advanced diagnostic tests findings and imaging procedures (e.g., specular microscopy, electroretinography)

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 2: Hospital-Based Consultation

Level 1 Level 2 Level 3 Level 4 Level 5 Acquires relevant Triages consult requests Manages consultations Manages consultations Oversees the consultation problem-focused history, (including coordination of (including coordination process and manages including outside medical care) requiring surgical of care) requiring interdisciplinary systems records intervention, including surgical intervention, issues affecting patient procedural options and including procedural care Performs inpatient Performs a complete timing; requests options and timing; consultation, with direct examination ophthalmic subspecialty requests ophthalmic supervision advice, with indirect subspecialty input, with supervision oversight

Recognizes ophthalmic Manages ophthalmic Manages ophthalmic emergencies and initiates emergencies with non- emergencies with non- non-surgical treatment surgical and surgical surgical and surgical plan, with indirect treatment, with indirect treatment, with supervision supervision oversight

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 3: Office-Based Procedures

Level 1 Level 2 Level 3 Level 4 Level 5 Describes essential Administers anesthesia Administers anesthesia Administers Incorporates recent components of care and performs and performs anesthesia and advancements in related to office-based procedure, with direct procedure, with indirect performs procedure, technologies or procedures (e.g., supervision supervision with oversight techniques informed consent, indications and Recognizes and Manages intra- and post- Manages intra- and contraindications, manages intra- and operative complications, post-operative anesthesia, sterile post-operative with indirect supervision complications, with procedure prep) complications, with oversight direct supervision

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 4: Cataract Surgery – Technical Skill

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies visually Assesses patients for Assesses patients for Assesses patients who Assesses patients for significant cataract routine cataract surgery complex cataract surgery are candidates for intraocular lenses refractive intraocular complications requiring a lenses to correct more complex astigmatism and/or intervention provide near correction

Demonstrates ability to Performs elements of Performs routine cataract Performs cataract Performs lens surgery for scrub, prep and drape cataract surgery in the surgery in the OR surgery requiring patients with patient for surgery; hands-on surgical skills complex technical complications requiring a performs basic suturing laboratory and in the maneuvers (e.g., pupil more complex skills operating room (OR) expander, capsular intervention (e.g., sutured tension ring) intraocular lenses)

Manages common post- Manages common intra- Manages complex intra- Manages rare and operative complications and post-operative and post-operative complex intra- and post- (e.g., post-op pain, high complications (e.g., complications (e.g., operative complications intraocular pressure) posterior capsule rupture, endophthalmitis) (e.g., aqueous wound leak) misdirection, suprachoroidal hemorrhage)

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 5: Extraocular Surgery (Plastics, Strabismus)

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies patients for Develops a pre-operative Develops a pre- Assess patients and routine extraocular plan for routine operative plan for develops a pre-operative surgery extraocular surgery complex extraocular plan for complex/ surgery multidisciplinary extraocular surgery (e.g., nerve sheath decompression, vessel sparing strabismus)

Demonstrates ability to Performs simple Performs routine Performs complex Performs complex scrub, prep and drape extraocular surgery (e.g., extraocular surgery (e.g., extraocular surgery extraocular surgery patient for surgery; simple lid laceration complex lid laceration (e.g., vertical performs basic suturing repair, nasolacrimal duct repair, horizontal strabismus), with skills probing) strabismus, ptosis) assistance

Identifies common post- Manages common post- Manages intra- and post- Manages complex intra- operative complications operative complications operative complications and post-operative (e.g., post-op pain, (e.g., bleeding, complications (e.g., bleeding) perforation) infection, retrobulbar hemorrhage)

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 6: Intraocular Surgery (Cornea, Retina, Glaucoma)

Level 1 Level 2 Level 3 Level 4 Level 5 Assesses patients for Assesses patients for Assesses patients for Assess patients requiring routine intraocular surgery complex intraocular multispecialty surgery from multiple surgery intraocular surgeries disciplines (e.g., plastic surgery, facial trauma)

Demonstrates ability to Performs routine Assists in subspecialty Performs routine Performs complex scrub, prep and drape intraocular surgery in the intraocular surgery intraocular surgery intraocular surgery patient for surgery; hands-on surgical skills performs basic suturing laboratory skills

Manages common post- Manages common intra- Manages complex intra- Manages rare and operative complications operative complications and post-operative complex intra- and post- (e.g., post-op pain, high (e.g., flat chamber, wound complications (e.g., re- operative complications intraocular pressure) leak, hyphema) bubble graft, blebitis) (e.g., tube erosion, proliferative vitreoretinopathy)

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge 1: Pathophysiology

Level 1 Level 2 Level 3 Level 4 Level 5 Articulates knowledge of Demonstrates basic Demonstrates advanced Demonstrates Contributes new pathophysiology and knowledge of knowledge of advanced knowledge of knowledge for clinical findings for pathophysiology and pathophysiology and pathophysiology and pathophysiology and ophthalmic conditions clinical findings for clinical findings for clinical findings for clinical findings for routinely managed by common ophthalmic commonly encountered uncommon ophthalmic ophthalmic conditions non-ophthalmologists conditions routinely ophthalmic conditions; conditions (e.g., publication, managed by demonstrates basic curriculum development) ophthalmologists knowledge of pathophysiology and clinical findings for uncommon conditions

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge 2: Differential Diagnosis

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies resources to Generates Generates refined Generates probabilistic Recognizes, self-reflects, generate a focused comprehensive differential based on differential diagnosis in and shares experiences differential differential diagnosis patient symptoms, history patients with multiple to educate others on based on patient and examination findings, ocular and medical factors that contributed to symptoms and history; distinguishing between comorbidities; modifies missed diagnosis or faulty documents and presents common and uncommon likely differential with clinical reasoning (e.g., differential in oral conditions new information from publication, curriculum presentation clearly and additional testing development) concisely

Generates a basic Describes diagnostic tests Selects additional Articulates the rationale differential diagnosis to aid in the differential diagnostic testing to for ordering diagnostic based on patient diagnosis distinguish between testing in hierarchical symptoms and history conditions on the fashion based upon differential probabilistic differential

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge 3: Therapeutic Interventions

Level 1 Level 2 Level 3 Level 4 Level 5 Describes basic Explains relevant Identifies and describes Describes and Participates in the concepts of ophthalmic pathophysiology and lists side effects of medical articulates the rationale development and pathophysiology and indications and therapies and ways to for using emerging dissemination of novel pharmacology contraindications for minimize potential alternative medical therapies or interventions planned medical therapy complications therapies

Describes basic Explains indications, Identifies and describes Describes and ophthalmic anatomy and contraindications, and causes of complications articulates the rationale categories of procedural relevant steps required for and alternatives for for using novel interventions procedural intervention routine procedural alternative procedural (e.g., anesthesia, interventions interventions technique, instruments)

Comments: Not Yet Completed Level 1 Not Yet Assessable

Systems-Based Practice 1: Patient Safety and Quality Improvement

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 patients and others in the disclosure of report patient safety institutional reporting patients and families families (simulated or patient safety events events systems (simulated or (simulated or actual) actual) actual)

Demonstrates Describes local quality Participates in local Demonstrates the skills Creates, implements, and knowledge of basic improvement initiatives quality improvement required to identify, assesses quality quality improvement (e.g., eye protection for initiatives develop, implement, improvement initiatives at methodologies and high risk activities, and analyze a quality the institutional or metrics diabetic eye screening) improvement project community level

Comments: Not Yet Completed Level 1

Systems-based Practice 2: System Navigation for Patient-Centered Care

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Coordinates care of Coordinates care of Teaches effective Analyzes the process of knowledge of care patients in routine clinical patients in complex coordination of patient- care coordination and coordination situations effectively using clinical situations centered care among leads in the design and the roles of the effectively using the roles different disciplines and implementation of interprofessional teams of their interprofessional specialties to junior improvements teams members of the team

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

Demonstrates Demonstrates knowledge Identifies specific local Uses local resources Participates in changing knowledge of the role of of local population and health needs and effectively to meet the and adapting practice to the physician in community health needs disparities related to needs of a patient provide for the needs of addressing community and disparities ophthalmic care population and specific populations health needs and community disparities

Comments: Not Yet Completed Level 1

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

Level 1 Level 2 Level 3 Level 4 Level 5 Describes basic health Describes how different Optimizes patient care Advocates for patient Participates in health care systems and system types require the given available resources care needs beyond policy advocacy activities access models (e.g., physician to deliver care patients’ available government, private, effectively with available resources (e.g., public, uninsured care) resources community resources, patient assistance resources, telehealth)

Demonstrates use of Identifies the Describes knowledge Demonstrates Analyzes individual electronic medical record documentation required domains for effective administrative practice patterns and for billing and coding transition to practice (e.g., knowledge needed for professional requirements compliance information technology, transition to practice in preparation for practice legal, billing and coding) (e.g., contract negotiations, malpractice insurance, government regulation, compliance)

Comments: Not Yet Completed Level 1

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

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates how to Articulates clinical Locates and applies the Critically appraises and Coaches others to access and use available questions and elicits best available evidence, applies evidence even critically appraise and evidence, and patient preferences and integrated with patient in the face of apply evidence for incorporate patient values in order to guide preference, to the care of uncertainty and complex patients; and/or preferences and values evidence-based care complex patients conflicting evidence to participates in the in order to take care of a guide care, tailored to development of patient routine patient the individual patient care guidelines

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 Uses performance data Facilitates the design and personal and to performance data and accepts it with to measure the implementing learning professional (feedback and other responsibility and effectiveness of the plans for others development by input) in order to inform equipoise; demonstrates learning plan and when establishing goals; goals; designs and implementation of a necessary, improves it actively seeks implements a learning learning plan opportunities to improve plan, with guidance

Identifies the factors Analyzes and reflects on Analyzes, reflects on, and Challenges Coaches others on which contribute to the factors which institutes behavioral assumptions and reflective practice gap(s) between contribute to gap(s) change(s) to narrow the considers alternatives in expectations and actual between expectations and gap(s) between narrowing the gap(s) performance actual performance expectations and actual between expectations performance and actual performance

Comments: Not Yet Completed Level 1

Professionalism 1: Professional Behavior and Ethical Principles

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies and describes Demonstrates insight into Demonstrates Recognizes situations Coaches others when potential triggers for professional behavior in professional behavior in that may trigger their behavior fails to professionalism lapses routine situations complex or stressful professionalism lapses meet professional situations and intervenes to expectations prevent lapses in self and others

Describes when and how Takes responsibility for Recognizes need to seek Recognizes and uses Identifies and seeks to to appropriately report own professionalism help in managing and appropriate resources address system-level professionalism lapses, lapses resolving complex ethical for managing and factors that induce or including strategies for situations resolving ethical exacerbate ethical addressing common dilemmas as needed problems or impede their barriers (e.g., ethics resolution consultations, literature Demonstrates Analyzes straightforward Analyzes complex review, risk knowledge of the ethical situations using ethical situations using ethical management/legal principles underlying principles principles consultation) informed consent, surrogate decision making, advance directives, confidentiality, error disclosure, stewardship of limited resources, and related topics

Comments: Not Yet Completed Level 1

Professionalism 2: Accountability/Conscientiousness

Level 1 Level 2 Level 3 Level 4 Level 5 Takes responsibility for Performs tasks and Performs tasks and Recognizes situations Takes ownership of failure to complete tasks responsibilities in a timely responsibilities in a timely that may impact others’ system outcomes, and responsibilities, manner with attention to manner with attention to ability to complete tasks attempts to implement identifies potential detail in routine situations detail in complex or and responsibilities in a changes at a systems contributing factors, and stressful situations timely manner level in order to advance describes strategies for the goals of professional ensuring timely task accountability completion in the future

Responds promptly to Recognizes situations Recognizes detrimental Proactively implements requests or reminders to that may impact own consequences when strategies to ensure that complete tasks and ability to complete tasks tasks and responsibilities the needs of patients, responsibilities and responsibilities in a are not completed in a teams, and systems are timely manner timely manner (e.g., team met members, compliance)

Comments: Not Yet Completed Level 1

Professionalism 3: Self-Awareness and Help-Seeking

Level 1 Level 2 Level 3 Level 4 Level 5 Recognizes status of Independently recognizes With assistance, Independently develops personal and status of personal and proposes a plan to a plan to optimize professional well-being, professional well-being optimize personal and personal and Coaches others when with assistance professional well-being professional well-being emotional responses or limitations in Recognizes limits in the Independently recognizes With assistance, Independently develops knowledge/skills do not knowledge/skills of self limits in the knowledge/ proposes a plan to a plan to improve the meet professional and/or team, with skills of self and/or team; improve knowledge/skills knowledge/skills of self expectations assistance demonstrates appropriate of self and/or team and/or team help-seeking behaviors for self or others

Comments: Not Yet Completed Level 1

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 therapeutic Establishes a therapeutic Easily establishes Mentors others in nonverbal behavior to relationship in relationship therapeutic situational awareness and demonstrate respect and straightforward in challenging patient relationships, with critical self-reflection to establish rapport encounters using active encounters (e.g., breaking attention to consistently develop listening and clear bad news) patient/family concerns positive therapeutic language and context, regardless relationships of complexity

Identifies barriers to Addresses barriers to When prompted, reflects Role models self- effective communication effective communication on personal biases while awareness to minimize (e.g., health literacy, attempting to minimize communication barriers language, disability, communication barriers cultural) while accurately communicating 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 Communicates concerns Role models flexible values all members of information effectively to the team and learners communication the health care team and uses active listening strategies that value with all health care team input from all health members care team members, resolving conflict when needed

Accepts feedback on Solicits feedback on Provides feedback and Provides feedback and Facilitates regular health performance from all performance as a constructive criticism to constructive criticism to care team-based members of the health member of the health peers and learners superiors feedback in complex care team (e.g., nurses, care team situations staff members, peers)

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 Accurately records Demonstrates organized Communicates clearly Provides feedback to information in the diagnostic and and concisely, including improve others’ written medical record therapeutic reasoning anticipatory guidance, in communication through notes in the the medical record medical record

Aware of the role of Appropriately selects Avoids creating or Provides feedback and Facilitates dialogue communication in patient forms of communication propagating errors in the constructive criticism regarding systems issues safety and privacy; (e.g., telephone versus medical record through regarding compliance among larger community safeguards patient text) to promote patient accurate use of with patient privacy and stakeholders (institution, personal health safety and privacy documentation tools safety health care system, field) information

Aware of responsibility to Identifies appropriate Uses appropriate Offers clear and Guides departmental or report system channels to communicate channels to communicate constructive institutional deficiencies system deficiencies system deficiencies suggestions to address communication around system deficiencies policies and procedures

Comments: Not Yet Completed Level 1