The Hand Surgery Milestone Project

A Joint Initiative of

The Accreditation Council for Graduate Medical Education

The American Board of Orthopaedic Surgery

The American Board of Plastic Surgery, Inc.

July 2015

The Hand Surgery Milestone Project

The Milestones are designed only for use in evaluation of fellows in the context of their participation in ACGME- accredited residency or fellowship programs. The Milestones provide a framework for the assessment of the development of the fellow in key dimensions of the elements of physician competency in a specialty or subspecialty. They neither represent the entirety of the dimensions of the six domains of physician competency, nor are they designed to be relevant in any other context.

i

Hand Surgery Milestones

Co-Chairs: Charles Day, MD, MBA and Mary McGrath, MD, MPH Working Group Advisory Group Keith Brandt, MD Tim Brigham, MDiv, PhD Mike Bednar, MD James Chang, MD Pam Derstine, PhD, MPHE Shepard R. Hurwitz, MD William Dzwierzynski, MD J. Lawrence Marsh, MD Laura Edgar, EdD, CAE R. Barrett Noone, MD Warren Hammert, DDS, MD John R. Potts III, MD W. John Kitzmiller, MD Peter Stern, MD Dawn LaPorte, MD Rod Rohrich, MD Peggy Simpson, EdD Robert Weber, MD

ii 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 each 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. These levels do not correspond with post-graduate year of education.

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.

iii 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 to institutional and program policies. For example, a fellow who performs a procedure independently must, at a minimum, be supervised through oversight.

Answers to Frequently Asked Questions about Milestones are available on the Milestones web page: http://www.acgme.org/acgmeweb/Portals/0/MilestonesFAQ.pdf.

iv 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 on the line in Selecting a response box in the middle of between levels indicates that milestones in a level implies that milestones in that lower levels have been substantially level and in lower levels have been demonstrated as well as some milestones in substantially demonstrated. the higher level(s).

v Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Acquired Conditions (Tumor, Dupuytrens, tenosynovitis, vascular, contractures) — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5  Understands soft tissue  Understands principles of  Describes treatment for  Understands the principles  Publishes research and joint pathology of diagnosis and indications Dupuytren’s and of surgical and non- findings on this topic in contractures for treatment of bone and tendinopathies (splinting, surgical management of the literature and  Understands soft tissue neoplasms (e.g., steroid injections, other complications and presents the work at pathophysiology of biopsy, imaging studies, modalities) secondary deformities national hand surgery circulatory disorders of non-invasive vascular  Understands the surgical after treatment of meetings the upper extremity testing) principles of complex acquired hand problems  Understands indications  Understands the principles procedures (e.g., surgery for and surgical principles of of evaluation of the stiff Dupuytren’s, enchondroma, routine procedures (e.g., hand sarcoma, ulnar artery surgery for ganglion, giant  Understands the diagnosis thrombosis, cell tumor, trigger finger, and evaluation of pseudoaneurysm, stiff joint) De Quervain’s, circulatory disorders of the amputations) hand, including non- invasive vascular testing and angiography  Understands the pathophysiology of other tendinopathies (e.g., lateral epicondylitis, intersection syndrome, extensor carpi ulnaris [ECU] tendonitis, subluxation)

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 1 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Acquired Conditions (Tumor, Dupuytren’s, tenosynovitis, vascular, contractures) — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5  Obtains focused history  Interprets diagnostic and  Manages work-related  Independently performs  Contributes to the practice and performs focused imaging studies injuries and return-to-work complex procedures for of hand surgery through physical examination on  Formulates a treatment issues acquired conditions (e.g., research and development patients with acquired plan and performs  Manages chronic regional surgery for sarcoma, of innovative treatments hand conditions complex procedures with pain syndromes with Dupuytren’s at proximal  Orders diagnostic and assistance (e.g., surgery for appropriate referral interphalangeal joint imaging studies melanoma, Dupuytren’s [PIPJ] and  Formulates a treatment contracture, chronic hand metacarpophalangeal plan and performs routine ischemia, hypothenar joint [MCPJ], procedures (e.g., surgery hammer, stiff hand, swan sympathectomy, for ganglion, giant cell neck) contracture requiring tumor, palmar  Recognizes complications major bone and soft tissue Dupuytren’s, trigger and enlists help release and finger, injections)  Prescribes post-operative reconstruction, major  Fabricates splints and rehabilitation vascular reconstruction, initial post-surgical including grafting) dressings  Independently manages  Manages routine post- complications operative care  Independently manages secondary deformities

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 2 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Arthritis — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5  Understands the  Understands the  Understands indications  Understands indications  Publishes research findings pathophysiology of pathophysiology and and surgical treatment and surgical treatment on this topic in the degenerative arthritis of medical management of options for osteoarthritis options for rheumatoid literature the hand rheumatoid arthritis  Understands the arthritis  Understands the  Understands the indications, principles, and  Understands surgical pathophysiology of post- pathophysiology and anatomy of wrist treatment options for other traumatic arthritis of the medical management of arthroscopy inflammatory arthritides hand gout, pseudogout, and  Understands the materials  Understands surgical  Describes the anatomy of other inflammatory principles of synthetic treatment options for the small joints of the arthritides implants, such as silicone, advanced carpal instability hand and wrist  Understands the titanium, pyrocarbon (scapholunate advanced  Understands indications pathophysiology of  Understands the collapse [SLAC], scaphoid for diagnostic joint degenerative arthritis of pathophysiology of carpal nonunion advanced imaging and laboratory the wrist instability collapse [SNAC]) studies  Understands the  Understands post-  Understands principles of  Understands the pathophysiology of post- operative rehabilitation post-operative biomechanical principles traumatic arthritis of the principles for arthritis rehabilitation for of joint motion wrist rheumatoid arthritis (RA)  Understands the non-  Understands the long-term operative treatment of performance of implants arthritis

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 3 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Arthritis — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5  Obtains focused history  Obtains focused history  Performs diagnostic wrist  Performs therapeutic wrist  Performs total wrist and performs focused and performs focused arthroscopy arthroscopy arthroplasty physical examination of physical examination of  Performs small joint  Manages complications of  Performs distal radioulnar patient with patient with rheumatoid fusions in the hand implant arthroplasty joint [DRUJ] reconstruction osteoarthritis of hand arthritis  Performs salvage  Performs limited carpal and/or wrist  Obtains focused history procedures (proximal row fusions (e.g., mid-carpal  Obtains focused history and performs focused carpectomy [PRC], total fusion) and performs focused physical examination of wrist fusion)  Performs small joint physical examination of patient with ulnar-sided  Performs rheumatoid arthroplasty, including patient with post- wrist pain synovectomies (joint and implant with or without traumatic arthritis of  Performs thumb tendon) soft tissue balancing hand and/or wrist carpometacarpal joint  Prescribes non- (CMC) arthroplasty operative management of osteoarthritis and post-traumatic arthritis  Performs joint aspiration and injection

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 4 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Congenital — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 - Advanced  Understands the  Understands the  Understands non-operative  Understands adverse  Demonstrates embryology of the upper classifications of upper treatment for congenital surgical sequelae following understanding of limb extremity congenital conditions (e.g., splinting hand reconstruction (e.g., diagnosis and indications  Recognizes routine differences (e.g., for radial longitudinal web creep, joint instability, for treatment for congenital hand polydactyly, syndactyly, deficiency or tendon imbalance, growth complex congenital hand differences (syndactyly, transverse and camptodactyly) arrest ) differences (e.g., mirror polydactyly, longitudinal longitudinal deficiencies)  Understands the principles  Demonstrates hand, microvascular toe deficiencies)  Demonstrates knowledge of the surgical treatment of understanding of treatment transfer) of associated medical common congenital hand for symbrachydactyly/  Publishes research conditions differences polysyndactyly (e.g., Poland findings on this topic in (thrombocytopenia  Develops surgical treatment syndrome) the literature absent radius, Fanconi’s plan for thumb hypoplasia  Understands the principles anemia, vertebral (e.g., first web space of distraction lengthening anomalies, anal atresia, deepening, opponensplasty cardiovascular anomalies, and ulnar collateral tracheoesophageal fistula, ligament [UCL] renal and/or radial reconstruction) anomalies, limb defects  Develops treatment plan for [VACTERAL]) pollicization, including timing and post-operative management

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 5 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Congenital — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5  Obtains history and  Obtains focused history  Performs excision of  Designs incision and  Performs complex performs basic physical and performs focused polydactylous digit without performs procedures for procedures (e.g., examination physical examination need for joint congenital conditions pollicization, macrodactyly  Provides basic post-  Interprets imaging studies reconstruction (e.g., excision and debulking) operative management  Recognizes surgical  Performs uncomplicated reconstruction of Wassel 2- and splinting indications congenital reconstructions 6 thumb, syndactyly  Prescribes appropriate non- (e.g., simple syndactyly release, 4 flap Z-plasty and operative management, repair with skin flaps and reconstruction of ulnar splinting grafts, constriction band collateral ligament for  Identifies potential post- release) hypoplastic thumb, operative complications  Develops treatment plans osteotomies)  Performs congenital trigger for complex syndactyly, thumb release including nail fold and osseous reconstruction

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 6 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Nerve — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5  Understands peripheral  Understands brachial  Understands the  Understands the  Publishes research nerve anatomy plexus anatomy pathophysiology and principles of nerve findings on this topic in  Understands classification  Understands and can treatment of chronic pain transfer the literature of nerve injuries interpret electrodiagnostic syndromes  Describes the treatment  Understands the evaluations  Understands the principles for brachial principles of sensory and  Understands the pathophysiology of thoracic plexus injuries motor examination pathophysiology and outlet syndrome  Understands treatment  Understands the treatment of neuromas  Understands the principles options for secondary or physiology of nerve of sensory reeducation and recurrent nerve repair, grafting, and desensitization compression regeneration  Understands and can  Describes treatment  Understands physiology interpret imaging and options for peripheral of nerve compression electrodiagnosis of brachial nerve palsies and plexus disorders tetraplegia  Describes treatment options for upper extremity spasticity (e.g., due to stroke, cerebral palsy, or traumatic brain injury)  Understands rehabilitation after nerve and tendon transfers

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 7 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Nerve — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5  Obtains focused history  Obtains focused history  Performs major peripheral  Performs nerve grafting  Performs brachial plexus and performs focused and performs focused nerve repair  Performs late reconstruction physical examination for physical examination for  Treats recurrent neuroma reconstruction of  Performs nerve transfers peripheral nerve injury the brachial plexus operatively and non- peripheral nerve injuries  Performs chemo  Obtains focused history  Performs digital nerve operatively (e.g., tendon transfer, joint denervation injections and performs focused repair  Treats recurrent or stabilization) for spastic conditions physical examination for  Treats primary neuroma secondary nerve  Manages complications of  Performs functional peripheral nerve operatively and non- compression nerve surgery (e.g., muscle transfers compression operatively performs neurolysis)  Performs carpal tunnel  Surgically treats ulnar release nerve compression at wrist and elbow

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 8 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Trauma: Bone, Joint — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5  Understands the  Understands the basic  Demonstrates knowledge of  Understands, analyzes and  Publishes research pathomechanics of biomechanics of the upper current literature regarding evaluates controversies findings on this topic in common extremity fracture/dislocation within field (e.g. fixation the literature fractures/dislocations and  Demonstrates knowledge of classifications and therapeutic techniques, fracture soft tissue injuries the pathologic anatomy of alternatives pattern)  Describes the anatomy hand fractures, dislocations,  Understands the natural  Understands the principles and function of the upper and ligamentous injuries history of distal radius of prosthetics and extremity  Understands the indications fractures secondary rehabilitation  Understands the principles for advanced imaging  Understands the implications  Understands the risks and of splinting and casting  Understands surgical of forearm and elbow injuries consequences of early  Understands basic imaging approaches and fixation  Understands the biomechanics physeal closure principles and techniques techniques for hand of different implant choices  Understands the biology fractures/dislocations  Understand the advantages of osseous and  Demonstrates knowledge of and disadvantages of different ligamentous healing associated hand injury fixation techniques  Describes the effects of patterns (e.g., median nerve  Understands the principles of medical comorbidities on injury and/or scapholunate post-operative hand therapy fracture healing (e.g., ligament (SL) injury with regimens Vitamin D deficiency, distal radius fractures)  Understands the indications osteoporosis, smoking)  Recognizes surgical for autologous bone grafting  Understands the Salter- indications (e.g., median and bone substitutes Harris fracture nerve dysfunction,  Understands the etiology, classification instability, articular step management, and functional off/gap) limitations of non-union,  Understands principles of malunion, and chronic remodeling in the pediatric subluxation hand and forearm  Understands the sequelae and management of pediatric hand and forearm injuries

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 9 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Trauma: Bone, Joint — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5  Orders and interprets basic  Orders and interprets  Performs surgical reduction  Performs arthroscopic  Performs complex imaging studies advanced imaging (e.g., and fixation of simple intra- diagnosis and debridement for arthroscopic/minimally  Performs simple closed computed tomography [CT] articular fractures (e.g., no traumatic injuries of the wrist invasive fixation techniques reduction and splinting of for comminuted articular more than two articular  Treats DRUJ dislocation and/or (e.g., arthroscopic scaphoid pediatric and adult fractures) fragments) triangular fibrocartilage internal fixation) fractures/dislocations  Recognizes stable/unstable  Independently formulates a complex (TFCC) injury  Performs revision surgery  Provides basic post- fractures/dislocations treatment plan for patients  Performs reduction and for complex nonunions and operative management (including CMC) with comorbidities and/or fixation of complex hand and dislocations (e.g., displaced and rehabilitation  Independently formulates a mangled extremity wrist fractures and dislocations scaphoid with avascular  Obtains a focused history treatment plan for simple  Surgically treats CMC (e.g., comminuted intra- necrosis [AVN]) and performs a focused fracture dislocations fracture dislocations articular fractures, intra-  Performs physeal bar physical examination of  Performs surgical fixation of  Performs reduction and articular PIP injuries, perilunate excision bone and joint traumatic simple extra-articular repair of ligamentous injuries, scapholunate ligament injuries fractures/dislocations injuries (MCP and PIP joints) injuries)  Develops a treatment plan  Performs surgical exposure  Performs reduction and pin  Surgically treats complex for associated soft tissue for fracture fixation of pediatric complications (e.g., those injuries  Manages open distal phalanx phalangeal neck fractures requiring osteotomy, revision physeal injuries fixation, bone grafting,  Manages simple nonunion surgery surgeries, complications (e.g., hardware replacement ) infections, acute  Performs operative reduction compression neuropathy, and fixation of displaced compartment syndrome) scaphoid fracture  Modifies and adjusts post- operative plan when indicated  Provides surgical management of physeal growth arrest (e.g., wedge osteotomy, epiphysiodesis)

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 10 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Soft Tissue Trauma, Infections — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5  Manages acute and  Understands the use of  Understands the  Understands the timing and  Understands the chronic infections of the biologic and negative physiology of ischemic sequencing of treatment of physiology and indications hand pressure dressings reperfusion mutilating soft tissue for allotransplantation  Understands biology and  Understands anatomy and  Understands indications injuries (crush, ischemic, risk factors for primary physiology of grafts and for amputation vs. salvage burn, gunshot wound) wound healing flaps (e.g., random, fascial, of amputated parts  Understand the potential  Understands indications axial, microvascular flaps)  Understands options for causes, monitoring, and for imaging of soft tissue  Understands the physiology soft tissue reconstruction treatment of the ischemic conditions of thermal injury of the hand, including failing flap or replanted  Understands physiology  Understands the burn care part and presentation of presentation and natural  Understands options for  Understands indications compartment syndrome history of septic arthritis post-traumatic thumb and selection of local,  Understands the signs and and osteomyelitis reconstruction at different regional, and distant flaps symptoms of infections  Recognizes and levels (interphalangeal for hand reconstruction (e.g., purulent flexor understands treatment of [IP], MP, CMC) tenosynovitis, deep space non-bacterial hand  Understands conditions infections, necrotizing infections (e.g., fungal, that simulate infection fasciitis) mycobacterial) (gout, synovitis, a factitious disorder)

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 11 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Soft Tissue Trauma, Infections — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5  Applies and manages  Performs skin grafting  Performs uncomplicated  Performs digital and/or  Performs toe-to-hand negative pressure wound  Manages acute infections soft tissue coverage (e.g., hand replantation and transfer therapy of the hand cross-finger, Moberg, flag revascularization  Performs hand transplant  Completes fingertip  Manages purulent flexor flaps)  Performs complex soft  Performs complex amputations tenosynovitis  Performs vascular repair tissue coverage procedures reconstruction of hand  Assesses level of burn  Performs deep burn (wrist level or proximal) (e.g., groin, radial forearm, burns injury debridement  Manages chronic infections neurovascular island and  Performs debridement of  Decompresses hand and of the hand (e.g., fungal, fillet flaps, microvascular traumatic and superficial forearm compartments mycobacterial, tissue transfer) burn wounds  Uses microsurgical osteomyelitis)  Manages complications of  Recognizes and diagnoses techniques in a simulated  Manages high-pressure failed flap and replantation/ compartment syndrome environment injection injuries revascularization  Provides post-operative management of flaps, including monitoring vascularity

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 12 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Tendon — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5  Describes tendon  Understands the  Understands treatment principles  Demonstrates  Publishes clinical and anatomy, biology, presentation of closed for flexor tendon and extensor understanding of secondary research work in the principles of tendon tendon ruptures (e.g., tendon injuries procedures for tendon literature healing and nutrition flexor digitorum  Understands treatment principles injuries (e.g., tenolysis,  Describes principles of profundus [FDP] for closed tendon injuries (e.g., staged tendon flexor and extensor avulsions, sagittal band timing and procedures for FDP reconstruction, pulley tendon repair (e.g., ruptures, extensor avulsions and sagittal band reconstruction) core and epitendinous pollicis longus [EPL] ruptures)  Demonstrates suturing, suture rupture)  Describes tendon transfers for understanding of location)  Understands principles of radial, median, and ulnar nerve management of  Describes tendon tenodesis palsies complications following biomechanics (e.g.,  Describes principles of  Describes reconstruction for tendon repair (e.g., rupture pulley system, tendon transfers and combined median and ulnar nerve of repaired tendon, bowstringing) tendon grafting palsies bowstringing)  Understands the  Describes reconstruction for  Demonstrates clinical presentation of complex tendon ruptures (e.g., understanding and traumatic tendon rheumatoid disease with extensor treatment for secondary conditions and injuries or flexor tendon ruptures, tendon tendon imbalance (e.g., (e.g., zone I-V flexor, ruptures following open reduction swan neck, Boutonniere and I-VIII extensor and internal fixation [ORIF] of deformity, mallet finger) tendon injuries) distal radius fractures, flexor  Understands treatment tendon ruptures following hook of options for patients with hamate fractures) systemic conditions  Describes rehabilitation principles requiring tendon (e.g., active and passive reconstruction, tendon rehabilitation protocols for transfer, or treatment for extensor and flexor tendon spasticity (e.g., traumatic injuries, the timing of brain injury, cerebral palsy, rehabilitation, work of flexion, stroke) gliding resistance)

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 13 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Tendon — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5  Obtains a focused  Performs repair of flexor  Performs zone II flexor  Performs secondary tendon  Performs tendon transfers for history and performs a tendon injuries outside tendon repairs procedures (e.g., tenolysis, brachial plexus focused physical zone II  Performs extensor tendon staged tendon reconstruction (e.g., shoulder examination for the  Recognizes adverse reconstruction (e.g., side to reconstruction, pulley or elbow) patient with a tendon outcomes after tendon side transfers, sagittal band reconstruction, tendon injury procedures (e.g.,adhesions, repair/reconstruction, grafting)  Constructs initial post- contractures, ruptures) reconstruction for ECU  Performs tendon transfers surgical dressings and instability, EIP to EPL for nerve palsies (e.g., splints transfer) radial, median, ulnar, or  Provides operative and  Develops management plan combined) non-operative for tendon procedure  Performs late management of complications (e.g., reconstruction for extensor tendon injuries adhesions, contractures, secondary tendon ruptures) conditions (e.g., swan neck  Prescribes rehabilitation deformity, mallet finger) following tendon repair or  Performs tendon reconstruction reconstruction for complex tendon ruptures (e.g., rheumatoid, attritional ruptures)

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 14 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Patient Safety, Resource Allocation, Practice Management — Systems-based Practice

Level 1 Level 2 Level 3 Level 4 Level 5  Understands the  Describes the common  Consistently uses tools  Leads team by promoting  Leads curriculum design to differences between system causes for errors to prevent adverse input by all team members teach teamwork and medical errors, near  Practices cost-effective events (e.g., checklists,  Conducts quality assurance communication skills to health misses, and sentinel care (e.g., stewardship time-outs, hand-offs) activities to improve patient care professionals events of resources, awareness  Reports problematic safety  Leads multidisciplinary teams  Understands the roles of of costs, managing behaviors, processes,  Codes diagnoses, encounters, (e.g., human factors engineers, care team members length of stay, operative and devices, including and surgical procedures social scientists) to address  Understands basic efficiency) errors and near misses  Establishes timeline and patient safety issues health payment systems,  Understands principles  Recognizes basic identifies resources for  Participates in advocacy including uninsured care of procedure coding elements needed to transition to practice activities for hand-related  Understands different  Compares and contrasts establish practice (e.g., health policy practice models different practice negotiations, models malpractice insurance,  Understands principles contracts, staffing, of good documentation compliance, facility in all aspects of patient accreditation) care

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 15 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

The ability to investigate and evaluate the care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning — Practice-based Learning and Improvement

Level 1 Level 2 Level 3 Level 4 Level 5  Identifies one’s own  Continually seeks and  Demonstrates a balanced  Demonstrates improvement  Independently plans and level of knowledge and incorporates feedback and accurate self- in clinical outcomes based executes a research expertise, and uses to improve performance assessment of competence; on continual self- program feedback from teachers,  Develops a learning plan reviews own clinical assessment  Develops educational colleagues, and patients and uses published outcomes and identifies  Performs self-directed curriculum and assessment  Describes basic concepts review articles and areas for continued learning tools in clinical epidemiology, guidelines improvement  Formulates a searchable biostatistics, and clinical  Ranks study designs and  Critically appraises the question, describes a plan to reasoning can distinguish relevant existing literature investigate it, and executes  Can categorize research research outcomes (e.g.,  Teaches colleagues and a research project study design by levels of patient-oriented other health professionals  Organizes educational evidence evidence that matters) in formal and informal activities at the program from other types of settings level evidence  Assesses and provides  Teaches patients, feedback to junior learners families, and junior learners

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 16 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Ethics and Values — Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5  Understands basic  Recognizes ethical issues  Analyzes and manages  Uses a systematic  Leads institutional and bioethical principles and in practice and is able to ethical issues in approach to analyzing organizational ethics is able to identify ethical discuss, analyze, and complicated and and managing ethical programs issues in hand surgery manage common ethical challenging situations issues, including  Develops programs to ensure  Demonstrates behavior situations  Understands the beliefs, advertising, billing, and equality of care in diverse, that conveys caring,  Demonstrates behavior values, and practices of conflicts of interest vulnerable, and underserved honesty, and genuine that shows insight into diverse and vulnerable  Develops a mutually- populations interest in patients and the impact of one’s core patient populations, and agreeable care plan in  Develops institutional and families values and beliefs on the potential impact of the context of conflicting organizational strategies to  Understands and patient care these on patient care physician and patient improve physician wellness manages the issues  Demonstrates  Identifies and manages values and beliefs related to fatigue management of situations in which  Recognizes signs of  Exhibits professional personal emotional, maintaining personal physician impairment, behavior (e.g., reliability, physical, and mental emotional, physical, and and demonstrates industry, integrity, and health mental health is appropriate steps to confidentiality)  Recognizes individual challenged address impairment in limits in clinical  Understands conflicting self and in colleagues situations and asks for interests of self, family,  Prioritizes and balances assistance when needed and others, and their conflicting interests of effects on the delivery of self, family, and others medical care to optimize medical care

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 17 Version 12/2013 Hand Surgery Milestones, ACGME Report Worksheet

Interpersonal and Communication Skills

Level 1 Level 2 Level 3 Level 4 Level 5  Develops a positive  Negotiates and  Sustains working  Negotiates and manages  Develops relationship with manages simple relationships and conflict in complex and models/approaches to patients and teams in patient- and family- manages complex and challenging situations managing difficult uncomplicated related, and team challenging situations, (including vulnerable communications, and situations, and conflicts including transitions of populations), and develops seeks leadership recognizes  Responds to the social care working relationships opportunities within communication and cultural context of  Customizes the delivery across specialties and professional conflicts the patient and family of emotionally-difficult systems of care organizations  Understands the to ensure the patient issues, including for the  Organizes and facilitates  Coaches others to patient’s/family’s understands and is able upset patient or family family/health care team improve communication perspective while to participate in health member who has conferences skills engaged in active care decision-making concerns about the  Uses multiple forms of listening  Ensures that the patient’s care communication (e.g., e-  Utilizes interpreters as medical record  Manages transitions of mail, patient portal, social needed (including the care and optimizes media) ethically and with  Appreciates effective electronic medical communication across respect for patient privacy communication to record [EMR] and systems/teams  Understands the use of prevent medical error photographs) is timely,  Communicates ethical marketing practices  Participates in effective accurate, and complete controversies within the transitions of care  Understands the effects field and develops  Safeguards patient of computer use on treatment plans based privacy when using information accuracy on patient shared photographic and potential effects on decision model documentation the physician/patient  Counsels family relationship regarding natural history of congenital disorders

Comments:

The Milestones are a product of the Hand Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery, Inc. 18