Internal Medicine Milestones

The Accreditation Council for Graduate Medical Education

Implementation Date: July 1, 2021 Second Revision: November 2020 First Revision: July 2013

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

Internal 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.

Internal Medicine Milestones Work Group Eva Aagaard, MD, FACP Jonathan Lim, MD Cinnamon Bradley, MD Monica Lypson, MD, MHPE Fred Buckhold, MD Allan Markus, MD, MS, MBA, FACP Alfred Burger, MD, MS, FACP, SFHM Bernadette Miller, MD Stephanie Call, MD, MSPH Attila Nemeth, MD Shobhina Chheda, MD, MPH Jacob Perrin, MD Davoren Chick, MD, FACP Raul Ramirez Velazquez, DO Jack DePriest, MD, MACM Rachel Robbins, MD Benjamin Doolittle, MD, MDiv Jacqueline Stocking, PhD, MBA, RN Laura Edgar, EdD, CAE Jane Trinh, MD Christin Giordano McAuliffe, MD Mark Tschanz, DO, MACM Neil Kothari, MD Asher Tulsky, MD Heather Laird-Fick, MD, MPH, FACP Eric Warm, MD

Advisory Group Mobola Campbell-Yesufu, MD, MPH Subha Ramani, MBBS, MMed, MPH Gretchen Diemer, MD Brijen Shah, MD Jodi Friedman, MD C. Christopher Smith, MD Janae Heath, MD Abby Spencer, MD, MS Benjamin Kinnear, MD Nicole Swallow, MD, FACP

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

Alliance for Academic Internal Medicine American Board of Internal Medicine American College of Physicians Association of Medical Colleges Review Committee for Internal Medicine Society of Hospital Medicine Society of General Internal 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: History

Level 1 Level 2 Level 3 Level 4 Level 5 Elicits and reports a Elicits and concisely Elicits and concisely Efficiently elicits and Efficiently and effectively comprehensive history reports a hypothesis- reports a hypothesis- concisely reports a tailors the history taking, for common patient driven patient history for driven patient history for patient history, including relevant presentations, with common patient complex patient incorporating pertinent historical subtleties, guidance presentations presentations psychosocial and other based on patient, family, determinants of health and system needs

Seeks data from Independently obtains Reconciles current data Uses history and Models effective use of secondary sources, with data from secondary with secondary sources secondary data to guide history to guide the need guidance sources the need for further for further diagnostic diagnostic testing testing

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 2: Physical Examination

Level 1 Level 2 Level 3 Level 4 Level 5 Performs a general Performs a hypothesis- Performs a hypothesis- Uses advanced Models effective physical examination driven physical driven physical maneuvers to elicit evidence-based physical while attending to patient examination for a examination for a subtle findings examination technique comfort and safety common patient complex patient presentation presentation

Identifies common Interprets common Identifies and interprets Integrates subtle Teaches the predictive abnormal findings abnormal findings uncommon and complex physical examination values of the examination abnormal findings findings to guide findings to guide diagnosis and diagnosis and management management

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 3: Clinical Reasoning

Level 1 Level 2 Level 3 Level 4 Level 5 Organizes and Integrates information Develops a thorough and Develops prioritized Coaches others to accurately summarizes from all sources to prioritized differential differential diagnoses in develop prioritized information obtained develop a basic diagnosis for common complex patient differential diagnoses in from the patient differential diagnosis for patient presentations presentations and complex patient evaluation to develop a common patient incorporates subtle, presentations clinical impression presentations unusual, or conflicting findings

Identifies clinical Retrospectively applies Continually re-appraises Models how to recognize reasoning errors within clinical reasoning one’s own clinical errors and reflect upon patient care, with principles to identify reasoning to improve one’s own clinical guidance errors patient care in real time reasoning

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 4: Patient Management – Inpatient

Level 1 Level 2 Level 3 Level 4 Level 5 Formulates management Develops and implements Develops and implements Uses shared decision Develops and implements plans for common management plans for value-based (high value) making to develop and comprehensive conditions, with guidance common conditions, management plans for implement value-based management plans for recognizing acuity, and patients with multisystem (high value) patients with rare or modifies based on the disease and comorbid comprehensive ambiguous presentations clinical course conditions; modifies management plans for or unusual comorbid based on the clinical patients with comorbid conditions course and multisystem disease, including those patients requiring critical care

Identifies opportunities to Develops and implements Independently develops Independently develops maintain and promote management plans to and implements plans to and implements health maintain and promote maintain and promote comprehensive plans to health, with guidance health, incorporating maintain and promote pertinent psychosocial health, incorporating and other determinants of pertinent psychosocial health and other determinants of health

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 5: Patient Management – Outpatient

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies opportunities to Develops and implements Develops and implements Develops and maintain and promote management plans to plans to maintain and implements value- health maintain and promote promote health, based (high-value) health incorporating pertinent comprehensive plans to psychosocial and other maintain and promote determinants of health health

Formulates management Develops and implements Develops and implements Develops and Creates and leads a plans for a common management plans for management plans for implements value- comprehensive patient- chronic condition, with common chronic multiple chronic based (high value) centered management guidance conditions conditions comprehensive plan for the patient with management plans for highly complex chronic multiple chronic conditions, integrating conditions, recommendations from incorporating pertinent multiple disciplines psychosocial and other determinants of health

Formulates management Develops and implements Develops and implements Develops and Develops and implements plans for acute common management plans for an initial management implements value- management plans for conditions, with guidance common acute conditions plan for patients with based (high value) patients with subtle urgent or emergent management plans for presentations, including conditions in the setting of patients with acute rare or ambiguous chronic comorbidities conditions conditions

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 6: Digital Health

Level 1 Level 2 Level 3 Level 4 Level 5 Uses electronic health Expands use of EHR to Effectively uses EHR Uses EHR to facilitate Leads improvements to record (EHR) for routine include and reconcile capabilities in managing achievement of quality the EHR patient care activities secondary data sources acute and chronic care of targets for patient panels in patient care activities patients

Identifies the required Performs assigned Identifies clinical Integrates telehealth Develops and innovates components for a telehealth visits using situations that can be effectively into clinical new ways to use telehealth visit approved technology managed through a practice for the emerging technologies to telehealth visit management of acute augment telehealth visits and chronic illness

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care The resident is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training program. The resident is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.

_____ Yes _____ No _____ Conditional on Improvement

Medical Knowledge 1: Applied Foundational Sciences

Level 1 Level 2 Level 3 Level 4 Level 5 Explains the scientific Explains the scientific Integrates scientific Integrates scientific Demonstrates a nuanced knowledge (e.g., knowledge for complex knowledge to address knowledge to address understanding of the physiology, social medical conditions comorbid conditions uncommon, atypical, or scientific knowledge sciences, mechanism of within the context of complex comorbid related to uncommon, disease) for normal multisystem disease conditions within the atypical, or complex function and common context of multisystem conditions medical conditions disease

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge 2: Therapeutic Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Explains the scientific Explains the indications, Integrates knowledge of Integrates knowledge of Demonstrates a nuanced basis for common contraindications, risks, therapeutic options in therapeutic options understanding of therapies and benefits of common patients with comorbid within the clinical and emerging, atypical, or therapies conditions, multisystem psychosocial context of complex therapeutic disease, or uncertain the patient to formulate options diagnosis treatment options

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge 3: Knowledge of Diagnostic Testing

Level 1 Level 2 Level 3 Level 4 Level 5 Explains the rationale, Explains the rationale, Integrates value and test Integrates value and Demonstrates a nuanced risks, and benefits for risks, and benefits for characteristics of various test characteristics of understanding of common diagnostic complex diagnostic diagnostic strategies in various diagnostic emerging diagnostic tests testing testing patients with common strategies in patients and procedures diseases with comorbid conditions or multisystem disease

Interprets results of Interprets complex Integrates complex Anticipates and common diagnostic tests diagnostic data diagnostic data accurately accounts for limitations to reach high-probability when interpreting diagnoses diagnostic data

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge The resident is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training program. The resident is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.

_____ Yes _____ No _____ Conditional on Improvement

Systems-Based Practice 1: Patient Safety and Quality Improvement

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Identifies system factors Contributes to the Conducts analysis of Leads teams and knowledge of common that lead to patient safety analysis of patient safety patient safety events processes to modify patient safety events events events (simulated or and offers error systems to prevent actual) prevention strategies patient safety events (simulated or actual)

Demonstrates Reports patient safety Participates in disclosure Discloses patient safety Models the disclosure of knowledge of how to events through of patient safety events to events to patients and patient safety events report patient safety institutional reporting patients and families families (simulated or events systems (actual or (simulated or actual) actual) simulated)

Demonstrates Describes local quality Contributes to local Demonstrates the skills Creates, implements, and knowledge of basic improvement initiatives quality improvement required to identify, assesses sustainable quality improvement (e.g., community initiatives develop, implement, quality improvement methodologies and vaccination rate, infection and analyze a quality initiatives at the metrics rate, smoking cessation) improvement project institutional or 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 Models effective Analyzes the process of knowledge of care patients by effectively patients by effectively coordination of patient- care coordination and coordination engaging engaging centered care among leads in the design and interprofessional teams in interprofessional teams in different disciplines and implementation of routine clinical situations complex clinical situations specialties improvements

Identifies key elements Performs safe and Performs safe and Models and advocates Improves quality of for safe and effective effective transitions of effective transitions of for safe and effective transitions of care within transitions of care and care/hand-offs in routine care/hand-offs in complex transitions of care/hand- and across health care hand-offs clinical situations clinical situations offs within and across delivery systems to health care delivery optimize patient outcomes 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 for the local population and specific populations health care inequities 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 health care system health care system are regional and national complex health care enhances high-value, interrelated, and how this health care system system to provide efficient, and effective impacts patient care efficient and effective patient care patient care

Describes basic health Delivers care with Engages with patients in Advocates for patient Actively engaged in payment systems consideration of each shared decision making, care needs with influencing health policy patient’s payment model informed by each consideration of the through advocacy patient’s payment models limitations of each activities at the local, patient’s payment regional, or national level model

Comments: Not Yet Completed Level 1

Systems-Based Practice The resident is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training program. The resident is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.

_____ Yes _____ No _____ Conditional on Improvement

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 Critically appraises and Applies evidence, even Coaches others to access, categorize, and questions and elicits applies the best available in the face of critically appraise and analyze clinical patient preferences and evidence, integrated with uncertainty and apply evidence to patient evidence, with guidance values to guide evidence- patient preference, to the conflicting evidence, to care based care care of complex patients guide care, tailored to the individual patient

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 Seeks performance Models consistently personal and to performance data episodically, with data consistently with seeking performance data professional (feedback and other adaptability, and humility adaptability, and with adaptability and development by input) to inform goals humility humility establishing goals

Identifies the factors that Analyzes and reflects on Institutes behavioral Challenges one’s own Coaches others on contribute to gap(s) the factors which change(s) to narrow the assumptions and reflective practice between ideal and actual contribute to gap(s) gap(s) between ideal and considers alternatives in performance, with between ideal and actual actual performance narrowing the gap(s) guidance performance, with between ideal and guidance actual performance

Actively seeks Designs and implements Independently creates Uses performance data to opportunities to improve an individualized learning and implements an measure the plan, with prompting individualized learning effectiveness of the plan individualized learning plan and when necessary, improves it

Comments: Not Yet Completed Level 1

Practice-Based Learning and Improvement The resident is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training program. The resident is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.

_____ Yes _____ No _____ Conditional on Improvement

Professionalism 1: Professional Behavior

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Identifies potential Demonstrates a pattern of Recognizes situations Coaches others when professional behavior in triggers for professional behavior in that may trigger their behavior fails to routine situations professionalism lapses complex or stressful professionalism lapses meet professional and accepts responsibility situations and intervenes to expectations for one’s own prevent lapses in professionalism lapses oneself and others

Comments: Not Yet Completed Level 1

Professionalism 2: Ethical Principles

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Applies basic principles to Analyzes complex Analyzes complex Identifies and seeks to knowledge of basic address straightforward situations using ethical situations and engages address system-level ethical principles ethical situations principles and identifies with appropriate factors that induce or the need to seek help in resources for managing exacerbate ethical addressing complex and addressing ethical problems or impede their ethical situations dilemmas as needed resolution

Comments: Not Yet Completed Level 1

Professionalism 3: Accountability/Conscientiousness

Level 1 Level 2 Level 3 Level 4 Level 5 Performs administrative Performs administrative Performs administrative Proactively implements Creates strategies to tasks and patient care tasks and patient care tasks and patient care strategies to ensure that enhance other’s ability to responsibilities, with responsibilities in a timely responsibilities in a timely the needs of patients, efficiently complete prompting manner in routine manner in complex or teams, and systems are administrative tasks and situations stressful situations met patient care responsibilities

Comments: Not Yet Completed Level 1

Professionalism 4: Knowledge of Systemic and Individual Factors of Well-Being*

Level 1 Level 2 Level 3 Level 4 Level 5 Recognizes the Lists resources to support With prompting, reflects Reflects on actions in real Participates in importance of getting personal and professional on how personal and time to proactively institutional changes to help when needed to well-being professional well-being respond to the inherent promote personal and address personal and may impact one’s clinical emotional challenges of professional well-being professional well-being practice physician work

Recognizes that Describes institutional Suggests potential institutional factors affect factors that affect well- solutions to institutional well-being being factors that affect well-

being

Comments: Not Yet Completed Level 1

*This subcompetency is not intended to evaluate a resident’s well-being. Rather, the intent is to ensure that each resident has the fundamental knowledge of factors that impact well-being, the mechanism by which those factors impact well-being, and available resources and tools to improve well-being.

Professionalism The resident is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training program. The resident is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.

_____ Yes _____ No _____ Conditional on Improvement

Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication

Level 1 Level 2 Level 3 Level 4 Level 5 Uses language and non- Establishes and maintains Establishes and maintains Establishes and Coaches others in verbal behavior to a therapeutic relationship a therapeutic relationship maintains therapeutic developing and demonstrate respect and using effective using effective relationships using maintaining therapeutic establish rapport communication behaviors communication behaviors shared decision making, relationships and in straightforward in challenging patient regardless of complexity mitigating communication encounters encounters barriers

Identifies common Identifies complex Mitigates Models the mitigation of barriers to effective barriers to effective communication barriers communication barriers communication communication, including personal bias

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 requests Clearly and concisely Checks own and others’ Coordinates Facilitates conflict and responds to a requests and responds to understanding of recommendations from resolution between and consultation a consultation recommendations when different consultants to amongst consultants providing or receiving optimize patient care when disagreement exists consultation

Uses verbal and non- Communicates Facilitates Adapts communication Models flexible verbal communication information, including interprofessional team style to fit communication strategies that values all members basic feedback with all communication to interprofessional team that facilitate excellence of the interprofessional interprofessional team reconcile conflict and needs and maximizes in interprofessional team members provides difficult feedback impact of feedback to teamwork the team

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 documents Documents clinical Documents clinical Documents clinical Guides departmental or comprehensive and encounter, including encounter through encounter clearly, institutional current information reasoning, through concise and thorough concisely, timely, and in communication policies organized notes notes an organized form, and procedures including anticipatory guidance

Communicates using Selects direct (e.g., Appropriately selects Models effective written formats specified by telephone, in-person) and direct and indirect forms and verbal institutional policy to indirect (e.g., progress of communication based communication safeguard patient notes, text messages) on context personal health forms of communication information based on context, with assistance

Comments: Not Yet Completed Level 1

Interpersonal and Communication Skills The resident is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training program. The resident is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.

_____ Yes _____ No _____ Conditional on Improvement

Overall Clinical Competence

This rating represents the assessment of the resident’s development of overall clinical competence during this year of training:

____Superior: Far exceeds the expected level of development for this year of training

____Satisfactory: Always meets and occasionally exceeds the expected level of development for this year of training

____Conditional on Improvement: Meets some developmental milestones but occasionally falls short of the expected level of development for this year of training. An improvement plan is in place to facilitate achievement of competence appropriate to the level of training.

____Unsatisfactory: Consistently falls short of the expected level of development for this year of training.