Thoracic Surgery Independent Milestones

The Accreditation Council for Graduate Medical Education

Implementation Date: July 1, 2021 Second Revision: December 2020 First Revision: January 2014

Thoracic Surgery – Independent 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.

©2020 Accreditation Council for Graduate Medical Education (ACGME) All rights reserved except the copyright owners grant third parties the right to use the Thoracic Surgery – Independent Milestones on a non-exclusive basis for educational purposes. ii Thoracic Surgery – Independent Milestones Work Group Jared Beller, MD Taryne Imai, MD Kathleen Berfield, MD Shari Meyerson, MD Luther Brewster, PhD Brian Mitzman, MD David Bull, MD Paul Schipper, MD Jonathan D’Cunha, MD, PhD Frederick Tibayan, MD Laura Edgar, EdD, CAE Ara Vaporciyan, MD Jordan Hoffman, MD, MPH Thomas Varghese, MD, MS Ann Hwalek, DO, MS Steve Yang, MD

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

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 v).

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.

©2020 Accreditation Council for Graduate Medical Education (ACGME) All rights reserved except the copyright owners grant third parties the right to use the Thoracic Surgery – Independent Milestones on a non-exclusive basis for educational purposes. iv The diagram below presents an example set of milestones for one subcompetency in the same format as the ACGME Report Worksheet. For each reporting period, a resident’s performance on the milestones for each subcompetency 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: Ischemic Heart Disease

Level 1 Level 2 Level 3 Level 4 Level 5 Performs a disease Interprets diagnostic Develops a treatment Develops a treatment specific history and testing and develops a plan, including outpatient plan, including physical and develops a treatment plan, including follow-up, for a patient outpatient follow-up, for diagnostic plan for a outpatient follow-up, for a with complex ischemic a patient with multiple patient with ischemic patient with routine heart disease comorbidities and heart disease ischemic heart disease complex ischemic heart disease

Assists in routine Performs components of Performs basic coronary Performs complex Performs advanced coronary procedures, coronary procedures procedures and coronary procedures coronary procedures including set-up and recognizes intra-operative and manages intra- positioning complications operative complications

Performs routine post- Manages simple post- Recognizes and creates a Manages complex Manages advanced intra- operative care and operative complications of plan for complex complications of and post-operative recognizes complications coronary procedures complications of coronary coronary procedures in complications of coronary of coronary procedures critically ill patients procedures in critically ill patients

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 2: Mechanical Circulatory Support

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies a patient in Develops a diagnostic Develops a treatment Manages a patient on Manages a patient who is need of mechanical and treatment plan for a plan for a patient in need mechanical circulatory able to be discontinued circulatory support patient in need of of mechanical circulatory support and knows the from mechanical mechanical circulatory support with complex principles of weaning a circulatory support or in support disease patient need of long-term strategy for end-stage failure Assists in routine Assists in initiation of Performs components of Initiates routine procedures, including mechanical circulatory mechanical circulatory mechanical circulatory set-up and positioning support support support, and manages routine complications

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 3: Valvular Disease

Level 1 Level 2 Level 3 Level 4 Level 5 Performs a disease Interprets diagnostic Develops a treatment Develops a treatment specific history and testing and develops a plan, including outpatient plan, including physical and develops a treatment plan for a follow-up, for a patient outpatient follow-up, for diagnostic plan for patient with routine with complex valvular a patient with multiple patients with valvular valvular heart disease heart disease comorbidities and heart disease advanced valvular heart disease

Assists in routine Performs components of Performs basic Performs complex Performs advanced procedures, including routine procedures for procedures on patients procedures and procedures for valvular set-up and positioning, patients undergoing with valvular heart manages intra-operative heart disease for patients with valvular surgery for valvular heart disease and recognizes complications in heart disease disease intra-operative patients undergoing complications surgery for valvular heart disease

Performs routine post- Manages routine post- Recognizes and creates a Manages complex Manages advanced intra- operative care and operative complications plan for complex complications and post-operative recognizes complications complications complications related to heart valve surgery

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 4: Great Vessel Disease

Level 1 Level 2 Level 3 Level 4 Level 5 Performs a disease- Interprets diagnostic Develops a treatment Develops a treatment specific history and testing and develops a plan, including outpatient plan, including physical and develops a treatment plan, including follow-up, for a patient outpatient follow-up, for diagnostic plan for outpatient follow-up, for a with complex disease of a patient with multiple patients with disease of patient with routine great the great vessels comorbidities and the great vessels vessel disease complex disease of the great vessels

Assists in routine Performs components of Plans and performs basic Plans and performs Performs advanced procedures, including routine procedures on the procedures and complex procedures procedures set-up and positioning great vessels recognizes intra-operative and manages intra- for patients with disease complications operative complications of the great vessels

Performs routine post- Manages simple post- Recognizes and creates a Manages complex Manages advanced intra- operative care and operative complications in plan for complex complications in and post-operative recognizes complications patients with disease of complications critically ill patients complications in patients with disease the great vessels of the great vessels

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 5: Esophagus

Level 1 Level 2 Level 3 Level 4 Level 5

Performs a disease Develops a treatment Develops a treatment Develops a treatment Develops a treatment plan specific history and plan, including outpatient plan, including outpatient plan, including for a patient condition that physical and develops a follow-up, for patients with follow-up, for patients with outpatient follow-up, for does not have clear diagnostic plan routine esophageal complex esophageal a patient with multiple guidelines disease disease comorbidities and complex esophageal disease

Assists in routine Performs components of Performs routine Performs complex Performs advanced procedures, including procedures procedures and procedures and procedures and manages set-up and positioning recognizes intra-operative manages intra-operative intra-operative complications complications complications

Performs routine post- Manages routine post- Recognizes and creates a Manages complex Manages advanced operative care and operative complications plan for complex complications in critically complications without recognizes complications complications ill patients clear guidelines

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 6: Lung and Airway

Level 1 Level 2 Level 3 Level 4 Level 5 Performs a disease Interprets diagnostic Develops a treatment Develops a treatment Develops a treatment specific history and testing and develops a plan, including outpatient plan, including plan for a condition that physical and develops a treatment plan, including follow-up, for a patient outpatient follow-up, for does not have clear diagnostic plan outpatient follow-up, for a with routine disease and a patient with complex guidelines patient with routine multiple comorbidities or disease disease anatomic complexity

Assists in routine Performs bedside Performs routine Performs complex Performs advanced procedures, including procedures and procedures and procedures and procedures and manages set-up and positioning components of routine recognizes intra-operative manages intra-operative intra-operative procedures complications complications complications

Performs routine post- Manages routine post- Recognizes and creates a Manages complex Manages advanced operative care and operative complications plan for complex complications in complications without recognizes complications complications critically ill patients clear guidelines

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 7: Chest Wall/Pleura/Mediastinum/Diaphragm

Level 1 Level 2 Level 3 Level 4 Level 5 Performs a disease- Interprets diagnostic Develops a treatment Develops a treatment specific history and testing and develops a plan, including outpatient plan, including physical and develops a treatment plan, including follow-up, for a patient outpatient follow-up, for diagnostic plan outpatient follow-up, for a with complex disease a patient with multiple patient with routine comorbidities and disease complex disease

Assists in routine Performs bedside Performs routine Performs complex Performs advanced procedures, including procedures and procedures and procedures and procedures set-up and positioning components of routine recognizes intra-operative manages intra-operative procedures complications complications

Performs routine post- Manages routine post- Recognizes and creates a Manages complex Manages advanced intra- operative care and operative complications plan for complex complications in and post-operative recognizes complications complications critically ill patients complications

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 8: Critical Care

Level 1 Level 2 Level 3 Level 4 Level 5

Interprets diagnostic data Implements a treatment Implements a treatment Implements a treatment Implements a treatment for a critically ill patient plan for peri-operative plan for peri-operative plan for a patient with plan for a patient condition patients with routine patients with complex multiple comorbidities that does not have clear procedures procedures and complex disease guidelines

Performs routine critical Recognizes need for Performs complex Performs complex Performs advanced care-related procedures complex procedures bedside procedures bedside procedures bedside procedures during an emergency situation

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge 1: Cardiovascular Surgical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies normal Identifies variants of Integrates knowledge of Integrates knowledge of Uses advanced imaging cardiovascular anatomy cardiovascular anatomy anatomy with diagnostic anatomical changes techniques to help identify testing after prior surgery with anatomic variability for diagnostic testing operative planning

Identifies normal Identifies cardiovascular Integrates knowledge of Integrates knowledge of Contributes to medical cardiovascular pathophysiology pathophysiology with pathophysiologic literature physiology diagnostic testing changes after prior surgery with diagnostic testing

Lists components of Demonstrates knowledge Discusses cannulation Explains management cardiopulmonary bypass of cardioplegia solutions, techniques and options strategies of complex apparatus delivery modes, and for cardiopulmonary complications related to complications of bypass bypass cardiopulmonary bypass

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge 2: General Thoracic Surgical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies normal general Identifies variants of Integrates knowledge of Integrates knowledge of Uses advanced imaging thoracic anatomy general thoracic anatomy anatomy with diagnostic anatomical changes techniques to help identify testing after prior surgery with anatomic variability for diagnostic testing operative planning

Identifies normal general Identifies general thoracic Integrates knowledge of Integrates knowledge of Contributes to medical thoracic physiology pathophysiology and pathophysiology with pathophysiologic literature staging of thoracic diagnostic testing changes after prior malignancies surgery with diagnostic testing

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge 3: Congenital Heart Disease

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Demonstrates knowledge Demonstrates knowledge Demonstrates Demonstrates knowledge knowledge of of embryology, anatomy, of operative principles knowledge of operative of operative principles embryology, anatomy, and physiology related to and non-operative options principles and non- and non-operative options and physiology related to complex forms of for routine forms of operative options for for advanced forms of routine forms of congenital heart disease congenital heart disease complex forms of congenital heart disease congenital heart disease congenital heart disease

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 Reports patient safety Participates in Role models or mentors knowledge of how to events to superiors/ events through disclosure of patient others in the report patient safety faculty members institutional reporting safety events to patients reporting/disclosure of events systems (actual or and families (simulated patient safety events to simulated) or actual) superiors/organization

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 initiatives develop, implement, improvement initiatives at methodologies and and analyze a quality the institutional or metrics improvement project community level