The Obstetrics and Gynecology Milestone Project

A Joint Initiative of The Accreditation Council for Graduate Medical Education, The American Board of Obstetrics and Gynecology, and The American College of Obstetrics and Gynecology

September 2015 The Obstetrics and Gynecology Milestone Project

The Milestones are designed only for use in evaluation of resident physicians 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 resident physician 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 Obstetrics and Gynecology Milestones

Chair: Jessica Bienstock, MD, MPH Working Group Advisory Group Karen E. Adams, MD Timothy P. Brigham, MDiv, PhD AnnaMarie Connolly, MD Mary Ciotti, MD Laura Edgar, EdD, CAE Larry C. Gilstrap III, MD Gary N. Frishman, MD Hal C. Lawrence III, MD, FACOG Alice R. Goepfert, MD John R. Potts III, MD Robert V. Higgins, MD, FACOG, FACS Lee A. Learman, MD, PhD Rebecca McAlister, MD Mary Joyce Turner, RHIA, MJ George Wendel, MD Christopher M. Zahn, MD

*Acknowledgements. The authors, all of whom participated in milestone development as members of the Obstetrics and Gynecology Milestone Working Group, wish to thank the members of the original Obstetrics and Gynecology Working Group for their contributions to this work: Haywood L. Brown, MD; Tamara T. Chao, MD; Missy Fleming, PhD; Diane Hartmann, MD; Frank Ling, MD; Krista Reagan, MD; Jeffrey M. Rothenberg, MD; Andrew Satin, MD; Howard Shaw, MD; David Soper, MD; Ronald C. Strickler, MD; Susan Swing, PhD.

ii Milestone Reporting

This document presents milestones designed for programs to use in semi-annual review of resident 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 resident performance as a resident moves from entry into residency through graduation. In the initial years of implementation, the Review Committee will examine milestone performance data for each program’s residents as one element in the Next Accreditation System (NAS) to determine whether residents overall are progressing.

For each period, review and reporting will involve selecting milestone levels that best describe each resident’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. These levels do not correspond with post-graduate year of education.

Selection of a level implies that the resident substantially demonstrates the milestones in that level, as well as those in lower levels (see the diagram on page v).

Level 1: The resident demonstrates milestones expected of an incoming resident.

Level 2: The resident is advancing and demonstrates additional milestones, but is not yet performing at a mid-residency level.

Level 3: The resident continues to advance and demonstrate additional milestones, consistently including the majority of milestones targeted for residency.

Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target.

Level 5: The resident has advanced beyond performance targets set for residency 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 residents will reach this level.

iii Additional Notes

Level 4 is designed as the graduation target but does not represent a graduation requirement. Making decisions about readiness for graduation is the purview of the residency 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 institutional and program policies. For example, a resident 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 milestone 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 the milestones or • for Patient Care and Medical Knowledge milestones, selecting the option that says the resident has “Not yet rotated” or • for Interpersonal and Communication Skills, Practice-based Learning and Improvement, Professionalism, and Systems-based Practice, selecting the option that says the resident has “Not yet achieved Level 1”

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

Version 09/2013 The Obstetrics and Gynecology Milestones: Obstetrics, ACGME Report Worksheet

Antepartum Care and Complications of Pregnancy — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates basic Provides complete Manages common medical Demonstrates a Manages patients with knowledge of normal antepartum care for women complications (e.g., comprehensive understanding complex and atypical medical obstetrical care and with uncomplicated hypertension, diabetes, of the varying patterns of and obstetrical complications common medical pregnancies infectious diseases) presentation and treatment complications seen in options for a variety of Applies innovative pregnancy Recognizes basic risk factors, Manages common obstetrical medical and obstetrical approaches to complex and symptoms, and signs of complications (e.g., previous complications atypical antepartum common medical Cesarean section, abnormal conditions and implements complications (e.g., fetal growth, multifetal Recognizes atypical treatment plans based on hypertension, diabetes, gestation) presentations of medical and emerging evidence infectious diseases) obstetrical complications; identifies indications for Recognizes basic risk factors, consultation, referral, and/or symptoms, and signs of transfer of care for patients common obstetrical with medical and obstetrical conditions (e.g., post-term complications gestation, abnormal placentation, third trimester Effectively supervises and bleeding) educates lower level residents in antepartum care

Collaborates and provides consultation to other members of the health care team in antepartum care

Comments: Not yet rotated

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, The American Board of Obstetrics and Gynecology, and The American College of Obstetrics and Gynecology. All rights reserved. The copyright owners grant third parties the right to use the Obstetrics and Gynecology Milestones on a non-exclusive basis for educational purposes. 1

Version 09/2013 The Obstetrics and Gynecology Milestones: Obstetrics, ACGME Report Worksheet Care of Patients in the Intrapartum Period — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates basic Provides intrapartum Manages abnormal labor Provides care for women with Applies innovative knowledge of obstetrical care for women complex intrapartum approaches to complex and routine/uncomplicated with uncomplicated Manages intrapartum complications and conditions atypical intrapartum intrapartum obstetrical care pregnancies (e.g., complications (e.g., cord conditions and implements including, conduct of normal identification of fetal lie, prolapse, placental Identifies indications for treatment plans based on labor interpretation of fetal heart abruption) consultation, referral, and/or emerging evidence rate monitoring, and transfer of care for patients tocodynamometry) with intrapartum complications Differentiates between normal and abnormal labor Effectively supervises and educates lower-level residents Recognizes intrapartum in intrapartum care complications (e.g., chorioamnionitis, shoulder Collaborates and provides dystocia) consultation to other members of the health care team in intrapartum care

Comments: Not yet rotated

Version 09/2013 The Obstetrics and Gynecology Milestones: Obstetrics, ACGME Report Worksheet Care of Patients in the Postpartum Period — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates basic Provides postpartum care for Manages common Manages patients with Applies innovative knowledge of normal women with uncomplicated postpartum complications complex complications of the approaches to complex and postpartum care pregnancies, including postpartum period (e.g., septic atypical postpartum lactation counseling Correctly interprets the results pelvic thrombophlebitis, conditions and implements of obstetric pathology and pulmonary embolism) treatment plans based on Recognizes basic risk factors, laboratory reports to ascertain emerging evidence symptoms, and signs, of the etiology of obstetrical Determines the need for common postpartum outcomes consultation, referral, or complications (e.g., transfer for patients with postpartum hemorrhage, complex complications in the infection, venous postpartum period thromboembolism, depression) Counsels patients about the risk of recurrence of antepartum, intrapartum, and postpartum complications (e.g., preeclampsia, pre-term delivery, shoulder dystocia, depression)

Effectively supervises and educates lower-level residents in postpartum care

Collaborates and provides consultation to other members of the health care team in postpartum care

Comments: Not yet rotated

Version 09/2013 The Obstetrics and Gynecology Milestones: Obstetrics, ACGME Report Worksheet Obstetrical Technical Skills — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates basic surgical Performs basic obstetrical Performs obstetrical Educates and supervises lower- Applies innovative and principles, including use of skills, including: procedures, including: level residents in performing complex approaches universal precautions and • assessment of cervical • ultrasound to obtain fetal obstetrical procedures obstetrical care and aseptic technique dilation biometry implements treatment plans • spontaneous vaginal • biophysical profile Collaborates and provides based on emerging evidence Performs basic procedures, delivery • repair of second degree consultation to other members including speculum • ultrasound for assessment perineal or vaginal of the health care team in examination and cervical of fetal number, lie, lacerations performing obstetrical examination presentation, viability, and • primary Cesarean section procedures placental location • uterine evacuation in the second trimester (e.g., Performs complex obstetrical induction, postpartum procedures, including: curettage) • operative vaginal delivery • repair of 3rd- and 4th-degree perineal lacerations • repeat Cesarean section • cervical cerclage • breech vaginal delivery (including second twins) • cystotomy repair • surgical management of postpartum hemorrhage (e.g., Cesarean hysterectomy, peripartum hysterectomy)

Manages and repairs uterine rupture or perforation

Comments: Not yet rotated

Version 09/2013 The Obstetrics and Gynecology Milestones: Obstetrics, ACGME Report Worksheet Immediate Care of the Newborn — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Performs initial warming Demonstrates the Performs initial resuscitation Capable of performing Manages both the and drying of a non- performance of Apgar testing of a depressed infant neonatal resuscitation that resuscitation and the team in depressed infant does not include caring for infants who require Identifies an infant in need of Alerts appropriate team for administration of resuscitation resuscitation assistance medications (may be demonstrated by satisfactory completion of the Neonatal Resuscitation Program [NRP] Provider Course [including hands-on skills stations and simulation] and receipt of a Provider Course Completion Card)

Comments: Not yet rotated

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Gynecology Technical Skills: Laparotomy (e.g., Hysterectomy, Myomectomy, Adnexectomy) — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates knowledge of Works effectively as a Demonstrates appropriate Independently performs Applies innovative and basic abdominal and pelvic surgical assistant tissue handling, request for gynecologic procedures complex approaches to anatomy instruments, and flow of the laparotomy and Performs simple abdominal procedure Demonstrates good intra- implements treatment Demonstrates basic surgical incision and closure operative decision making, plans based on emerging principles, including use of Understands and uses including the ability to modify a evidence universal precautions and Demonstrates basic surgical various forms of energy surgical plan based on operative aseptic technique skills, including: sources used in surgery findings • knot tying Positions patient • simple suturing Performs uncomplicated Demonstrates the ability to appropriately for surgery • suture and staple removal gynecologic procedures recognize and manage surgical complications, including the Recognizes surgical appropriate use of intra- complications and operative consultation formulates an initial management plan Applies an evidence-based approach to the adoption of new technologies

Effectively supervises and educates lower-level residents regarding laparotomy

Collaborates and provides consultation to other members of the health care team regarding laparotomy

Comments: Not yet rotated

Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet Gynecology Technical Skills: Vaginal Surgery (e.g. , Vaginal Hysterectomy, Colporrhaphy, Mid-urethral Sling) — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates knowledge of Works effectively as a Displays appropriate tissue Independently performs Applies innovative and basic pelvic anatomy surgical assistant handling, request for vaginal procedures complex approaches to instruments, and flow of the vaginal surgery and Demonstrates basic surgical Performs simple vaginal or procedure Demonstrates good intra- implements treatment plans principles, including use of vulvar incision and repair operative decision making, based on emerging evidence universal precautions and Understand and uses various including the ability to modify aseptic technique Demonstrates basic surgical forms of energy sources used a surgical plan based on skills, including: in surgery operative findings Positions patient • knot tying appropriately for surgery • simple suturing Performs uncomplicated Recognizes and manages procedures surgical complications, including the appropriate use Recognizes surgical of intra-operative consultation complications and formulates an initial management plan Applies an evidence-based approach to the adoption of new technologies

Effectively supervises and educates lower-level residents regarding vaginal surgery

Collaborates and provides consultation to other members of the health care team regarding vaginal surgery

Comments: Not yet rotated

Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet Gynecology Technical Skills: Endoscopy (Laparoscopy, Hysteroscopy, Cystoscopy) — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates basic Assembles endoscopic Performs diagnostic Performs operative endoscopy Applies innovative and understanding of abdominal instruments and checks procedures independently (e.g., complex approaches to and pelvic anatomy proper functioning hysterectomy, myomectomy) endoscopy and implements Performs operative treatment plans based on Demonstrates basic surgical Performs proper insertion of procedures Demonstrates good intra- emerging evidence principles, including use of endoscopic instruments operative decision making, universal precautions and Displays appropriate tissue including the ability to modify aseptic technique Demonstrates an handling, request for surgical plan based on understanding of the instruments, and flow of the operative findings Positions patient indications for endoscopy procedure appropriately for surgery Recognizes and manages Uses various forms of energy surgical complications, sources used in surgery including the appropriate use of intra-operative consultation Recognizes complications and formulates an initial Applies an evidence-based management plan approach to the adoption of new technologies

Effectively supervises and educates lower-level residents regarding endoscopy

Collaborates and provides consultation to other members of the health care team regarding endoscopy

Comments: Not yet rotated

Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet

Family Planning — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Verbalizes basic knowledge Demonstrates a basic Counsels on the Formulates comprehensive Applies innovative and about common understanding of the effectiveness, risks, benefits, management plans for complex approaches to contraceptive options effectiveness, risks, benefits, and contraindications of patients with medical diseases family planning and complications, and available forms of complicating their use of implements treatment plans contraindications of contraception contraceptive methods based on emerging evidence contraception, including emergency contraception, Counsels on the Manages complications of and pregnancy termination effectiveness, risks, benefits, contraceptive methods and and contraindications for pregnancy termination male and female sterilization Determines the need for Performs intra-uterine and consultation, referral, or implantable contraceptive transfer of patients with placement complex complications

Demonstrates ability to Demonstrates ability to perform basic first trimester perform basic second uterine evacuation (medical trimester uterine evacuation and surgical) (medical and surgical)

Comments: Not yet rotated

Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet Ambulatory Gynecology — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates basic Performs the initial Formulates management Effectively cares for patients Applies innovative knowledge about common assessment, formulates a plans and initiates treatment with complex presentations approaches to complex and ambulatory gynecologic differential diagnosis, and for complex ambulatory (e.g., refractory to initial atypical ambulatory problems initiates treatment for gynecologic problems (e.g., management, unusual gynecology and implements common ambulatory cervical dysplasia, infertility, presentations, complications) treatment plans based on gynecologic problems (e.g., ovulatory disorders, breast emerging evidence sexually transmitted disorders) Uses a multi-disciplinary infections, vaginitis) approach and makes Understands and applies Performs colposcopy, basic appropriate referrals when principles of office gynecologic ultrasound, and caring for patients with management (e.g., billing) other indicated office complex ambulatory procedures gynecologic problems (e.g., sexual dysfunction, menopausal symptoms, vulvovaginal syndromes and lesions)

Leads an inter-professional team, including supervision, education, and coordination of care

Monitors one’s own outcomes to improve practice

Comments: Not yet rotated

Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet Care of the Patient with Non-Reproductive Medical Disorders — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates an Performs history and Interprets test results and Initiates management plans Provides on-going, understanding of common physical, forms a differential screens for related conditions for patients with complex comprehensive care for non-reproductive medical diagnosis, and evaluates for of non-reproductive medical non-reproductive medical patients with complex and disorders common non-reproductive disorders (e.g., metabolic disorders (e.g., osteoporosis, atypical non-reproductive medical disorders (e.g., syndrome, BRCA mutation, metabolic syndrome, BRCA medical disorders chronic hypertension, eating disorders) mutation, eating disorders, obesity, depression) human immunodeficiency Initiates management for virus [HIV] infection) and common non-reproductive provides referrals disorders (e.g., hypertension, diabetes)

Comments: Not yet rotated

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Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet

Peri-operative Care — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates knowledge of Demonstrates knowledge of: Demonstrates knowledge Demonstrates advanced Applies innovative basic abdominal and pelvic • relevant surgical anatomy about the management of: knowledge necessary for approaches to complex and anatomy • common procedural • medical comorbidities management of medically atypical peri-operative care indications relevant to gynecologic complex patients and implements treatment • comorbidities relevant to surgery plans based on emerging gynecologic surgery • appropriate procedural Demonstrates the ability to evidence • prophylactic strategies to options for the relevant recognize and manage peri- reduce post-operative gynecological condition operative complications complications Effectively supervises and educates lower -level residents regarding peri- operative care

Collaborates and provides consultation to other members of the team regarding peri-operative care

Manages or co-manages critically-ill patients requiring care in an intensive care unit

Comments: Not yet rotated

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Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet Abdominal/Pelvic Pain (Acute and Chronic) — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates a basic Demonstrates the ability to Demonstrates the ability to: Demonstrates an in-depth Leads a multidisciplinary understanding of patients formulate a differential • utilize focused diagnostic knowledge regarding patients team for care of patients presenting with diagnosis approaches presenting with abdominal with chronic pelvic pain abdominal/pelvic pain • formulate comprehensive and pelvic pain relevant to: regarding: Demonstrates an management plans • varying patterns of Applies innovative • risk factors understanding of initial: presentation approaches to complex and • signs and symptoms • evaluation • treatment options atypical abdominal/pelvic • treatment options • refractory pelvic pain pain and implements treatment plans based on Manages patients with emerging evidence complex and atypical chronic pelvic pain

Demonstrates the ability to formulate comprehensive plans of management for patients with multiple and/or complex comorbidities

Comments: Not yet rotated

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Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet Abnormal Uterine Bleeding (Acute and Chronic) — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates basic Demonstrates the ability to Demonstrates in-depth Demonstrates an in-depth Applies innovative knowledge about what formulate a differential knowledge of the physiology knowledge regarding patients approaches to complex and constitutes normal and diagnosis of the normal menstrual cycle presenting with abnormal atypical abnormal uterine abnormal uterine bleeding uterine bleeding relevant to: bleeding and implements Demonstrates an Demonstrates the ability to: • varying patterns of treatment plans based on Verbalizes the phases of the understanding of initial: • utilize focused diagnostic presentation emerging evidence normal menstrual cycle • evaluation approaches • comprehensive treatment • treatment options • formulate a comprehensive options management plan • refractory bleeding

Demonstrates the ability to formulate comprehensive management plans for patients with multiple and/or complex comorbidities

Effectively supervises and educates lower-level residents regarding abnormal bleeding

Collaborates and provides consultation to other members of the health care team regarding abnormal uterine bleeding

Comments: Not yet rotated

basis for educational purposes. 14

Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet Pelvic Mass — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates a basic Demonstrates the ability to Demonstrates the ability to: Demonstrates an in-depth Applies innovative understanding of patients formulate a focused • utilize focused diagnostic knowledge regarding patients approaches to complex and presenting with a pelvic differential diagnosis approaches presenting with a pelvic mass atypical pelvic mass and mass, including: • formulate a comprehensive relevant to: implements treatment plans • differential diagnosis Demonstrates an management plan • varying patterns of based on emerging evidence • signs and symptoms understanding of initial: presentation • evaluation • comprehensive treatment • treatment options options

Determines the need for consultation, referral, or transfer of patients

Demonstrates the ability to formulate comprehensive management plans for patients with multiple and/or complex comorbidities

Effectively supervises and educates lower-level residents regarding pelvic mass

Collaborates and provides consultation to other members of the health care team regarding pelvic mass

Comments: Not yet rotated

basis for educational purposes. 15

Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet Pelvic Floor Disorders (Urinary Incontinence, Pelvic Prolapse, Anal Incontinence) — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates basic Demonstrates knowledge of Demonstrates knowledge of For patients with Effectively supervises and knowledge of normal pelvic basic pelvic floor physiology abnormal pelvic floor uncomplicated pelvic floor educates lower-level residents floor anatomy and functional anatomy anatomy and physiology disorders: regarding complex and • utilizes focused diagnostic atypical pelvic floor disorders Demonstrates a basic Demonstrates an approaches understanding of patients understanding of patients • uses non-surgical and Collaborates and provides presenting with pelvic floor presenting with pelvic floor surgical therapies consultation to other disorders relevant to: disorders relevant to: • formulates comprehensive members of the health care • risk factors • evaluation and management plans for team regarding pelvic floor • symptoms interpretation of results patients with comorbidities disorders • physical exam findings • treatment options • determines the need for consultation, referral, or Treats patients with Demonstrates the ability to Formulates an initial plan of transfer of patients complicated, atypical, or formulate a differential management for patients recurrent pelvic floor diagnosis with uncomplicated pelvic disorders floor disorders Applies innovative approaches to complex and atypical pelvic floor disorders and implements treatment plans based on emerging evidence

Comments: Not yet rotated

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Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet First Trimester Bleeding — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates basic Demonstrates the ability to Counsels patients regarding Manages patients with Applies innovative approaches understanding of normal formulate a differential natural history and treatment complications of first to complex or atypical first early pregnancy diagnosis (e.g., ectopic options trimester bleeding or its trimester bleeding and development, including pregnancy, spontaneous management (e.g., implements treatment plans implantation, early abortion, non-obstetric Utilizes non-surgical and hemorrhage, infection) based on emerging evidence embryology, and placental etiologies) surgical methods to manage development patients with: Effectively supervises and • ectopic pregnancy educates lower-level • abortion (spontaneous, residents regarding first induced) trimester bleeding • other etiologies Collaborates and provides Demonstrates an consultation to other understanding of members of the health care complications related to first team regarding first trimester trimester bleeding and its bleeding management

Comments: Not yet rotated

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Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet Health Care Maintenance and Disease Prevention — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates knowledge of Demonstrates knowledge of Interprets age- and risk- Formulates comprehensive Manages patients with highly the characteristics of a good evidence-based, age- appropriate tests (e.g., bone management plans for high- complex medical diseases for screening test appropriate guidelines for mineral density, risk patients (e.g., vulnerable health care maintenance and women’s health maintenance mammogram, lipids, thyroid populations) disease prevention Demonstrates knowledge of and disease prevention (e.g., studies) indications and limitations breast screening, cervical Monitors one’s own Applies innovative and of commonly used screening cancer screening) Develops patient-centered outcomes to improve complex approaches to health tests management plans to practice care maintenance and disease Recommends age- and risk- maintain health and prevent prevention and implements appropriate vaccinations disease treatment plans based on emerging evidence

Comments: Not yet rotated

Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet Patient Safety and Systems Approach to Medical Errors: Participate in identifying system errors and implementing potential systems solutions — Systems- based Practice

Level 1 Level 2 Level 3 Level 4 Level 5 Recognizes limitations and Demonstrates knowledge of Participates in patient safety Reports errors and near- Contributes to peer-reviewed failures of a team approach institutional surveillance reporting and analyzing misses to the institutional medical literature (e.g., hand-offs, systems to monitor for systems surveillance system and miscommunication) in patient safety (e.g., surgical superiors Organizes and leads health care as the leading site infection, medical error Participates in team drills institutional QI/patient safety cause of preventable patient reporting) Recognizes when root cause projects harm Demonstrates knowledge of analysis is necessary, and is Participates in “time-out” national patient safety capable of participating in standards, as well as their root cause analysis Appropriately utilizes check use/application in the lists to promote patient institution Actively participates in safety (e.g., medication quality improvement reconciliation) (QI)/patient safety projects

Demonstrates knowledge of the epidemiology of medical errors and the differences between near misses, medical errors, and sentinel events

Comments: Not yet achieved Level 1

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Cost-effective Care and Patient Advocacy — Systems-based Practice

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the importance Is aware of common Demonstrates the Practices cost-effective care Participates in advocacy or of providing cost-effective socioeconomic barriers that incorporation of cost (e.g., formulary drugs, health care legislation locally, care impact patient care awareness into clinical generic drugs, tailoring of regionally, or nationally judgment and decision diagnostic tests) Understands the role of Demonstrates an awareness making Effectively communicates physicians in advocating for of the need for coordination Analyzes patient care options within health care systems to appropriate women’s health of patient care and patient Coordinates and advocates from a quality of life advocate for the needs of care advocacy for needed resources to (QOL)/cost-of-care patient populations facilitate patient care (e.g., perspective, and includes in effective discharge planning) patient counseling Demonstrates an understanding of the political Effectively communicates economics of health care within his or her own legislation locally, regionally, hospital/clinic to advocate and nationally for patient needs

Comments: Not yet achieved Level 1

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Self-directed Learning/Critical Appraisal of Medical Literature — Practice-based Learning and Improvement

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates an Identifies resources (e.g., Applies patient-appropriate Tailors evidence-based Designs a hypothesis-driven understanding of critical texts, search engines) to evidence-based information practice based on the values or hypothesis-generating appraisal of the literature answer questions while from review articles or and preferences of each study providing patient care guidelines on common topics patient Demonstrates in practice Contributes to peer-reviewed responsiveness to Recognizes limits of Reads and assesses strength medical literature constructive feedback knowledge, expertise, and Critically reviews and of evidence in current technical skills interprets the literature with literature and applies it to the ability to identify study one’s own practice Describes commonly used aims, hypotheses, design, study designs (e.g., and biases Analyzes his or her own randomized controlled trial outcomes as compared to [RCT], cohort; case-control, national standards cross-sectional)

Comments: Not yet achieved Level 1

Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet Quality Improvement Process: Systematically analyze practice using quality improvement methods and implement changes with the goal of practice improvement — Practice-based Learning and Improvement

Level 1 Level 2 Level 3 Level 4 Level 5 Has a commitment to self- Demonstrates understanding References and utilizes Participates in departmental Analyzes department or evaluation, lifelong learning, of the basic concepts of QI national standards or or institutional Q institutional outcomes and patient safety guidelines in patient care process/committees Reads appropriate plans Contributes to peer-reviewed information, as assigned by Implements changes with a medical literature the program or related to Identifies quality of care goal of practice improvement patient-specific topics issues within one’s own Organizes and leads effective practice with a systems- institutional QI/patient safety Understands level of evidence based approach projects for patient care recommendations

Comments: Not yet achieved Level 1

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Compassion, Integrity, and Respect for Others — Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the importance Consistently shows Consistently shows Consistently models Assumes long-term or of compassion, integrity, compassion, integrity, and compassion, integrity, and compassion, integrity, and leadership role in community and respect for others respect in typical situations respect for patients who respect for others outreach activities to with patients, peers, and decline medical advice or improve the health of Demonstrates sensitivity members of the health care request un-indicated tests or Coaches others to improve vulnerable populations and responsiveness to team treatments, for patients who compassion, integrity, and patients have psychiatric respect for patients Consistently demonstrates comorbidities, and for team sensitivity and members in circumstances of responsiveness to diversity of conflict or high stress patients’ ages, cultures, races, religions, abilities, or Modifies one’s own behavior sexual orientations based on feedback to improve his or her ability to Accepts constructive demonstrate compassion, feedback to improve his or integrity, and respect for her ability to demonstrate others compassion, integrity, and respect for others

Comments: Not yet achieved Level 1

Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet Accountability and Responsiveness to the Needs of Patients, Society, and the Profession — Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5 Understands that physicians Is consistently punctual for Serves as an example for Coaches others to improve Participates in institutional are accountable to patients, clinical assignments and others in punctuality, punctuality and or community peer society, and the profession responsive to requests for responsiveness, and timely responsiveness; offers counseling related to assistance; completes completion of duties assistance to ensure patient professionalism Acts with honesty and administrative duties (e.g., care duties are completed in truthfulness medical records, reports) on Recognizes signs and a timely fashion time and without reminders symptoms of fatigue, stress, and substance abuse Demonstrates self-awareness Understands the signs and of fatigue and stress, and symptoms of fatigue, stress, mitigates the effects and substance abuse

Comments: Not yet achieved Level 1

Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet Respect for Patient Privacy, Autonomy, Patient-Physician Relationship — Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the importance Shows respect for patient Assesses a patient’s capacity Successfully navigates Successfully leads others of respect for patient privacy privacy for medical decision making ethically complex clinical through complex and and autonomy issues involving patient atypical clinical issues Elicits patient goals for care, Successfully navigates autonomy involving patient autonomy Understands the ethical and patient preferences conflicts between patient principles of appropriate regarding treatment preferences that are Balances patient privacy with Longitudinally participates patient-physician alternatives discordant with personal ethical and legal on hospital ethics relationships beliefs requirements in complex committee Demonstrates an circumstances understanding of ethical Efficiently counsels patients to principles, including help align treatment decisions boundary issues, and with individual preferences consciously applies them in patient care

Comments: Not yet achieved Level 1

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Communication with Patients and Families — Interpersonal and Communication Skills

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates adequate Checks for patient and family Communicates effectively in Delivers bad new to families Capable of effective listening skills understanding of illness and stressful, emergent, and about complications or death communication in the most management plan complex situations challenging situations, and Communicates effectively in Capable of informing patients invites participation from all routine clinical situations Allows for opportunities for Capable of delivering bad and families about a medical stakeholders patient questions news to patients and families error that caused harm regarding poor prognoses For hospitalized patients, Incorporates risk maintains communication Communicates effectively management in this process with patient and family with patients and families regarding plan of care across a broad range of socio- Role models effective economic and cultural communication to junior backgrounds colleagues

Participates in education of patients and families

Comments: Not yet achieved Level 1

Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet Communication with Physicians and Other Health Professionals and Teamwork — Interpersonal and Communication Skills

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the importance Demonstrates an Works effectively in Leads inter-professional and Educates other health care of relationship understanding of the roles of interprofessional and interdisciplinary health care professionals regarding development, information health care team members, interdisciplinary health care teams to achieve optimal obstetrics and gynecology gathering and sharing, and and communicates teams outcomes teamwork effectively within the team Provides effective Participates in effective Leads effective transitions of consultation in complex and Demonstrates an transitions of care and team care and team debriefing atypical patients understanding of transitions debriefing of care and team debriefing Responds to requests for Communicates effectively consultation in a timely with physicians and other manner and communicates health care professionals recommendations to the regarding patient care requesting team

Comments: Not yet achieved Level 1

Version 09/2013 The Obstetrics and Gynecology Milestones: Gynecology, ACGME Report Worksheet Informed Consent and Shared Decision Making — Interpersonal and Communication Skills

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the importance Begins to engage patients in Uses appropriate, easy-to- Organizes and participates in Models and coaches shared of informed consent shared decision making, and understand language in all multidisciplinary decision making in complex obtains informed consent for phases of communication, family/patient/team member and highly stressful situations basic procedures utilizing an interpreter where conferences necessary Leads multidisciplinary family/patient/team member Engages in shared decision conferences making, incorporating patients’ and families’ cultural frameworks

Obtains informed consent for complex procedures

Comments: Not yet achieved Level 1