Family Medicine Milestones

The Accreditation Council for Graduate Medical Education

Second Revision: October 2019 First Revision: October 2015

©2019 Accreditation Council for Graduate Medical Education (ACGME) All rights reserved except the copyright owners grant third parties the right to use the Family Medicine Milestones on a non-exclusive basis for educational purposes.

Family Medicine Milestones

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.

Family Medicine Milestones

Work Group Tanya Anim, MD, FAAFP Grant Hoekzema, MD David Araujo, MD Gary Knepp, DO Roxanne Cech, MD Sara Martin, MD Deborah Clements, MD Brad Miller, DO Andrew Crow, DO Saroj Misra, DO, FACOFP Rob Danoff, DO, MS, FACOFP, FAAFP Catherine Pipas, MD, MPH Laura Edgar, EdD, CAE Stacy Potts, MD, MEd Adam Froyum Roise, MD, MPH, FAAFP Martin Quan, MD Timothy Graham, MD Christopher Robles, DO Alysia Herzog, MD

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

American Association of Colleges of Osteopathic Medicine Association of American Medical Colleges American Board of Family Medicine American College of Osteopathic Family Physicians Association of Family Medicine Residency Directors Assembly of Osteopathic Graduate Medical Educators Committee on Osteopathic Recognition and Development Review Committee for Family Medicine

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).

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 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.

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).

Patient Care 1: Care of the Acutely Ill Patient

Level 1 Level 2 Level 3 Level 4 Level 5 Generates differential Prioritizes the differential Promptly recognizes Mobilizes the Efficiently manages and diagnosis for acute diagnosis for acute urgent and emergent multidisciplinary team to coordinates the care of presentations presentations situations and coordinates manage care for multiple patients with a appropriate diagnostic simultaneous patient range of severity, strategies visits including life-threatening conditions

Recognizes role of Develops management Implements management Independently Directs the use of clinical protocols and plans for patients with plans for patients with coordinates care for resources to manage a guidelines in acute common acute conditions complex acute conditions, acutely ill patients with complex patient care situations including stabilizing complex comorbidities environment or situation acutely ill patients

Recognizes that acute Identifies the interplay Incorporates psychosocial Modifies management Implements strategies to conditions have an between psychosocial factors into management plans for acute illness address the psychosocial impact beyond the factors and acute illness plans of acute illness for based on complex impacts of acute illness immediate disease patients and caregivers psychosocial factors on populations process and patient preferences

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 2: Care of Patients with Chronic Illness

Level 1 Level 2 Level 3 Level 4 Level 5 Recognizes that Identifies variability in Determines the potential Balances the competing common conditions may presentation and impact of comorbidities on needs of patients’ be chronic (e.g., anxiety, progression of chronic disease progression comorbidities high blood pressure) conditions

Formulates a basic Identifies and accesses Synthesizes a patient- Applies experience with Leads multidisciplinary management plan that appropriate clinical centered management patients while initiatives to manage addresses a chronic guidelines to develop and plan that acknowledges incorporating evidence- patient populations with illness implement plans for the relationship between based medicine in the chronic conditions and management of chronic comorbidities and disease management of patients comorbidities conditions progression with chronic conditions

Recognizes that chronic Identifies the impact of Develops collaborative Facilitates efforts at Initiates supplemental conditions have an chronic conditions on goals of care and self-management of strategies (e.g., leads impact beyond the individual patients and the engages the patient in chronic conditions, patient and family disease process others involved in their self-management of including engagement advisory councils, care chronic conditions of family and community community health, resources practice innovation) to improve the care of patients with chronic conditions

Comments:

Not Yet Completed Level 1 Not Yet Assessable

Patient Care 3: Health Promotion and Wellness

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies screening and Reconciles competing Identifies barriers and Incorporates screening Participates in guideline prevention guidelines by prevention guidelines to alternatives to preventive and prevention development or various organizations develop a plan for an health tests, with the goal guidelines in patient implementation across a individual patient, and of shared decision making care outside of system of care or considers how these designated wellness community guidelines apply to the visits patient population

Identifies opportunities to Recommends Implements plans to Implements Partners with the maintain and promote management plans to maintain and promote comprehensive plans to community to promote wellness in patients maintain and promote health, including maintain and promote health health addressing barriers health, incorporating pertinent psychosocial factors and other determinants of health

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 4: Ongoing Care of Patients with Undifferentiated Signs, Symptoms, or Health Concerns

Level 1 Level 2 Level 3 Level 4 Level 5 Acknowledges the Accepts uncertainty and Facilitates patients’ Coordinates Coordinates expanded value of continuity in maintains continuity understanding of their collaborative treatment initiatives to facilitate caring for patients with while managing patients expected course and plans for patients with care of patients with undifferentiated illness with undifferentiated events that require undifferentiated illness undifferentiated illness illness physician notification

Develops a differential Prioritizes cost-effective Uses multidisciplinary Contributes to the diagnosis for patients diagnostic testing and resources to assist development of medical with undifferentiated consultations that will patients with knowledge around illness change the undifferentiated illness undifferentiated illness management of to deliver health care undifferentiated illness more efficiently

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 5: Management of Procedural Care

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies the breadth of Identifies patients for Demonstrates confidence Identifies and acquires Identifies procedures procedures that family whom a procedure is and motor skills while the skills to needed in future practice physicians perform indicated and who is performing procedures, independently perform and pursues equipped to perform it including addressing procedures in the supplemental training to complications current practice independently perform environment

Recognizes family Counsels patients about Performs independent Collaborates with physicians’ role in expectations for common risk and appropriateness procedural colleagues referring patients for procedures performed by assessment based on to match patients with appropriate procedural family physicians and patient-centered priorities appropriate procedures, care consultants for procedures performed including declining by consultants support for procedures that are not in the patient’s best interest

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge 1: Demonstrates Medical Knowledge of Sufficient Breadth and Depth to Practice Family Medicine

Level 1 Level 2 Level 3 Level 4 Level 5 Describes the Applies knowledge of Demonstrates knowledge Integrates clinical Expands the knowledge pathophysiology and pathophysiology with of complex experience and base of family medicine treatments of patients intellectual curiosity for pathophysiology and the comprehensive through dissemination of with common conditions treatment of patients with comprehensive knowledge in the original research common conditions management of patients management of patients across the lifespan across the lifespan

Describes how behaviors Identifies behavioral Engages in learning Demonstrates impact patient health strategies to improve behavioral strategies to comprehensive health address patient care knowledge of behavioral needs strategies and resources to address patient’s needs

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge 2: Critical Thinking and Decision Making

Level 1 Level 2 Level 3 Level 4 Level 5 Incorporates key Develops an analytic, Develops a prioritized Synthesizes Engages in deliberate elements of a patient prioritized differential differential diagnosis for information to reach practice and coaches story into an accurate diagnosis for common complex presentations high probability others to minimize clinical depiction of their presentations diagnoses with reasoning errors presentation continuous re-appraisal to minimize clinical Describes common Identifies types of clinical Demonstrates a reasoning errors causes of clinical reasoning errors within structured approach to reasoning error patient care, with personally identify clinical guidance reasoning errors

Interprets results of Interprets complex Synthesizes complex Anticipates and Pursues knowledge of common diagnostic diagnostic diagnostic information accounts for errors and new and emerging testing information accurately to reach high biases when diagnostic tests probability diagnoses interpreting diagnostic tests

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 skills Designs, implements, and knowledge of basic improvement initiatives quality improvement required to identify, assesses quality quality improvement (e.g., community initiatives develop, implement, improvement initiatives at methodologies and vaccination rate, infection and analyze a quality the institutional or metrics rate, smoking cessation) 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 Role models effective Analyses 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 team of the interprofessional specialties improvements members team member

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

Demonstrates Identifies specific Uses local resources Participates in changing Leads innovations and knowledge of population population and effectively to meet the and adapting practice to advocates for populations and community health community health needs needs of a patient provide for the needs of and communities with needs and disparities and inequities in their population and specific populations health care inequities local population community

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 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., complex health care enhances high-value, system (e.g., hospital, interrelated, and how this length of stay, system to provide efficient, and effective skilled nursing facility, impacts patient care readmission rates, clinical efficient and effective patient care and transition finance, personnel, efficiency) patient care and of care technology) transition of care

Describes basic health Delivers care with Engages with patients in Advocates for patient Participates in health payment systems, consideration of each shared decision making, care needs (e.g., policy advocacy activities (including government, patient’s payment model informed by each community resources, private, public, uninsured (e.g., insurance type) patient’s payment models patient assistance care) and practice resources) models

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

Comments: Not Yet Completed Level 1

Systems-Based Practice 4: Advocacy

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies that advocating Identifies that advocating Describes how Accesses advocacy Develops a relationship for patient populations is for family medicine is a stakeholders influence tools and other with stakeholders that a professional professional responsibility and are affected by health resources needed to advances or prevents a responsibility policy at the local, state, achieve (or prevent a policy change that and federal level deleterious) policy improves individual or change community health

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, categorize, and questions and elicits best available evidence, applies evidence even critically appraise and analyze clinical evidence patient preferences and integrated with patient in the face of apply evidence for values in order to guide preference, to the care of uncertainty and complex patients; and/or evidence-based care complex patients conflicting evidence to collaboratively develops guide care, tailored to evidence-based decision- the individual patient making tools

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 Intermittently seeks Consistently seeks Leads performance personal and to performance data additional performance performance data with review processes professional (feedback and other data with adaptability and adaptability and humility development by input) in order to inform humility establishing goals goals

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

Acknowledges there are Designs and implements Independently creates Uses performance data Facilitates the design and always opportunities for a learning plan, with and implements a to measure the implementing learning self-improvement prompting learning plan effectiveness of the plans for others learning plan and when necessary, improves it

Comments: Not Yet Completed Level 1

Professionalism 1: Professional Behavior and Ethical Principles

Level 1 Level 2 Level 3 Level 4 Level 5 Describes professional Demonstrates professional Demonstrates professional Recognizes situations Mentors others in behavior and potential behavior in routine behavior in complex or that may trigger professional behavior triggers for personal situations stressful situations professionalism lapses lapses in professionalism and intervenes to prevent lapses in self and others

Takes responsibility for Describes when and how Recognizes need to seek Recognizes and uses Identifies and seeks to personal lapses in to report professionalism help in managing and appropriate resources for address system-level professionalism lapses in self and others resolving complex managing and resolving factors that induce or professionalism lapses dilemmas as needed exacerbate ethical problems and professionalism lapses or impede their resolution Demonstrates knowledge Analyzes straightforward Analyzes complex of ethical principles situations using ethical situations using ethical principles principles

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 failure to complete tasks responsibilities in a timely responsibilities in a timely and responsibilities, manner with appropriate manner with appropriate identifies potential attention to detail in attention to detail in contributing factors, and routine situations complex or stressful Recognizes and describes strategies for situations addresses situations ensuring timely task that may impact others’ Takes ownership of completion in the future ability to complete tasks system outcomes and responsibilities in a timely manner Responds promptly to Recognizes situations Proactively implements requests or reminders to that may impact own strategies to ensure that complete tasks and ability to complete tasks the needs of patients, responsibilities and responsibilities in a teams, and systems are timely manner met

Comments: Not Yet Completed Level 1

Professionalism 3: Self-Awareness and Help-Seeking Behaviors

Level 1 Level 2 Level 3 Level 4 Level 5 Recognizes status of Independently recognizes Proposes a plan to Independently develops Addresses system personal and status of personal and optimize personal and a plan to optimize barriers to maintain professional well-being, professional well-being professional well-being, personal and personal and professional with assistance with guidance professional well-being well-being

Recognizes limits in the Independently recognizes Proposes a plan to Independently develops Mentors others to knowledge/skills of self, limits in the remediate or improve a plan to remediate or enhance knowledge/skills with assistance knowledge/skills of self limits in the improve limits in the of self or team and team and knowledge/skills of self or knowledge/skills of self demonstrates appropriate team, with guidance or team help-seeking behaviors

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 Maintains therapeutic Mentors others in nonverbal behavior to relationship in relationship relationships, with situational awareness and demonstrate respect, straightforward in challenging patient attention to critical self-reflection to establish rapport while encounters using active encounters patient/family concerns consistently develop communicating one’s listening and clear and context, regardless positive therapeutic own role within the language of complexity relationships health care system

Recognizes easily Identifies complex When prompted, reflects Independently Leads or develops identified barriers to barriers to effective on personal biases while recognizes personal initiatives to identify and effective communication communication (e.g., attempting to minimize biases while attempting address bias (e.g., language, health literacy, cultural) communication barriers to proactively minimize disability) communication barriers

Identifies the need to Organizes and initiates Sensitively and Independently uses Role models shared individualize communication, sets the compassionately delivers shared decision making decision making in communication agenda, clarifies medical information, to align patient/family patient/family strategies expectations, and verifies managing patient/family values, goals, and communication including understanding values, goals, preferences with those with a high degree preferences, uncertainty, treatment options to of uncertainty/conflict and conflict make a personalized care plan

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 Respectfully Clearly and concisely Checks understanding of Coordinates Role models flexible requests/receives a requests/responds to a consult recommendations recommendations from communication strategies consultation consultation (received or provided) different members of that value input from all the health care team to health care team optimize patient care, members, resolving resolving conflict when conflict when needed needed

Uses language that Communicates Communicates concerns Communicates Facilitates regular health values all members of information effectively and provides feedback to feedback and care team-based the health care team with all health care team peers and learners constructive criticism to feedback in complex members supervising individuals 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 Accurately and timely Demonstrates organized Uses patient record to Demonstrates efficiency Optimizes and improves records information in diagnostic and communicate updated in documenting patient functionality of the the patient record therapeutic reasoning and concise information in encounters and electronic medical record through notes in the an organized format updating record within their system patient record

Learns institutional policy Appropriately uses Appropriately selects Manages the volume Guides departmental or and safeguards patient documentation shortcuts; direct (e.g., telephone, in- and extent of written institutional personal health records required data in person) and indirect (e.g., and verbal communication around information formats and timeframes progress notes, text communication that are policies and procedures specified by institutional messages) forms of required for practice policy communication based on context and policy

Communicates through Respectfully Uses appropriate Initiates difficult Facilitates dialogue appropriate channels as communicates concerns channels to offer clear conversations with regarding systems issues required by institutional about the system and constructive appropriate among larger community policy (e.g., patient suggestions for system stakeholders to improve stakeholders (residency safety reports, cell improvement while the system institution, health care phone/pager usage) acknowledging system system, field) limitations

Comments: Not Yet Completed Level 1