The Addiction Psychiatry Milestone Project

A Joint Initiative of

The Accreditation Council for Graduate Medical Education

and

The American Board of Psychiatry and Neurology

July 2015

The Addiction Psychiatry Milestone Project

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

i Addiction Psychiatry Milestones

Psychiatry Subspecialty Milestones Chair: Christopher R. Thomas, MD

Working Group Chair: Marian Fireman, MD Laura Edgar, EdD, CAE Kyle Kampman, MD Robert Ronis, MD Andrew J. Saxon, MD Jeffrey J. Wilson, MD

Advisory Group Chair: George A. Keepers, MD Larry R. Faulkner, MD

Frances R. Levin, MD Christopher K. Varley, MD

Milestone Reporting

This document presents Milestones designed for programs to use in semi-annual review of fellow performance and reporting to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced. They are descriptors and targets for fellow performance as a fellow moves from entry into fellowship through graduation. In the initial years of implementation, the Review Committee will examine Milestone performance data for each program’s fellows as one element in the Next Accreditation System (NAS) to determine whether fellows overall are progressing.

For each period, review and reporting will involve selecting milestone levels that best describe each fellow’s current performance and attributes. Milestones are arranged into numbered levels. Tracking from Level 1 to Level 5 is synonymous with moving from novice to expert in the subspecialty. These levels do not correspond with post-graduate year of education.

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

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

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

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

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

Level 5: The fellow has advanced beyond performance targets set for fellowship and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional fellows will reach this level.

iii

Additional Notes

Level 4 is designed as the graduation target and does not represent a graduation requirement. Making decisions about readiness for graduation is the purview of the fellowship program director. Study of Milestone performance data will be required before the ACGME and its partners will be able to determine whether milestones in the first four levels appropriately represent the developmental framework, and whether Milestone data are of sufficient quality to be used for high-stakes decisions.

Examples are provided with some milestones. Please note that the examples are not the required element or outcome; they are provided as a way to share the intent of the element.

Some milestone descriptions include statements about performing independently. These activities must occur in conformity to the ACGME supervision guidelines, as well as to institutional and program policies. For example, a fellow who performs a procedure independently must, at a minimum, be supervised through oversight.

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

The diagram below presents an example set of milestones for one sub-competency in the same format as the ACGME Report Worksheet. For each reporting period, a fellow’s performance on the milestones for each sub-competency will be indicated by selecting the level of milestones that best describes that fellow’s performance in relation to those milestones.

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

the higher level(s).

v Version 9/2014 Addiction Psychiatry Milestones: ACGME Report Worksheet PC1 — Evaluation and diagnosis of the patient A. Thorough evaluation of the patient with substance use and addictive disorders including patient interview, gathering of collateral information, use of screening and assessment tools B. Risk assessment specific to substance use and addictive disorders C. Synthesis of information to generate patient formulation and differential diagnosis specific to substance use, addictive, and co-occurring disorders D. Development of an appropriate initial treatment plan for the patient

Level 1 Level 2 Level 3 Level 4 Level 5 1.1/A Obtains general 2.1/A Obtains complete, 3.1/A Consistently obtains 4.1/A Serves as a role model 5.1/A Performs research history relevant to the accurate, and relevant complete, accurate, and for gathering accurate, with regard to appropriate patient’s medical and history and performs a relevant history and performs reliable, and subtle assessment of patients with psychiatric disorders; targeted examination a targeted examination information from the patient addictive disorders performs a reliable relevant to the patient’s relevant to the patient’s and collateral sources, and evaluation of the patient’s addictive and co-occurring addictive and co-occurring for use of screening and 5.2/C Teaches general general psychiatric disorder disorders; obtains collateral disorders; obtains accurate assessment tools psychiatry residents or other information and is aware of collateral information and trainees techniques for 1.2/B Assesses for patient the use of screening and appropriately utilizes 4.2/A Integrates resolving inconsistencies in safety, including risk for assessment tools screening and assessment motivational interviewing data while generating a self-harm and harm to tools concepts and techniques differential diagnosis others, and risk of 2.2/C Organizes, accurately into patient assessment intoxication and overdose summarizes information, and 3.2/A Recognizes and develops a differential addresses inconsistencies in 4.3/A Provides instruction to 1.3/C Organizes, diagnosis for the patient collected information general psychiatry residents summarizes information, presenting with substance or other trainees on and develops a differential use, addictive, and co- 3.3/B Integrates all available techniques for obtaining an diagnosis for the patient occurring disorders while information, including relapse accurate and reliable history presenting with substance avoiding premature closure risk, into patient safety use, addictive, and co- assessment 4.4/C Utilizes all available occurring disorders 2.3/D Develops information to generate a comprehensive, 3.4/B Correctly and expertly complete and accurate 1.4/D Sets treatment goals individualized treatment interprets results of urine differential diagnosis; takes

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Addiction Psychiatry Milestones on a non-exclusive bases for educational purposes. 6 Version 9/2014 Addiction Psychiatry Milestones: ACGME Report Worksheet in collaboration with the plans for patients with drug screening and other steps to resolve apparent patient uncomplicated substance use forms of toxicological testing inconsistencies in the data and addictive disorders 3.5/C Incorporates collateral 4.5/D Develops information, other comprehensive, assessments, subtle findings, individualized treatment and conflicting information plans for patients with into a complete differential complex presentations diagnosis

3.6/D Incorporates co- occurring disorders into a comprehensive individualized treatment plan

Comments: Not yet rotated 1

Level 1 Level 2 Level 3 Level 4 Level 5 1.1/A Establishes and 2.1/B Identifies community 3.1/A Participates in the 4.1/A Effectively and 5.1/A Competently teaches maintains a therapeutic resources for patient delivery of evidence-based expertly delivers at least one at least one evidence-based alliance with, and provides treatment psychotherapy for treatment evidence-based psychotherapy to other appropriate psychotherapy of addictive disorders psychotherapy for the learners to, patients with general treatment of addictive psychiatric disorders 3.2/B Consistently refers disorders patients to appropriate treatment resources based 4.2/A Utilizes current on the given patient’s needs practice guidelines in evaluation and psychotherapeutic treatment of patients with addictive disorders

Comments: Not yet rotated 1

Level 1 Level 2 Level 3 Level 4 Level 5 1.1/A Appropriately 2.1/A Appropriately 3.1/A Manages 4.1/A Titrates dosages and manages 5.1/A Designs an prescribes commonly prescribes pharmacologic pharmacokinetic and side effects and complex drug educational curriculum used agents for substance use pharmacodynamic drug interactions for patients prescribed for primary care psychopharmacologic and addictive disorders, interactions for patients multiple medications, including providers on use of agents including for the prescribed multiple medications for substance use, psychopharmacology for management of intoxication medications and/or using addictive, and co-occurring disorders; addictive disorders 1.2/B Reviews with the and withdrawal states non-prescribed substances considers potential drug interactions patient/family general from substances of abuse; manages 5.2/A Participates in indications, dosing 2.2/C Demonstrates 3.2/B Incorporates complex intoxication and withdrawal evidence-based research parameters, and awareness of federal knowledge of proposed on psychopharmacology common side effects for regulations regarding mechanisms of action and 4.2/B Explains to patients and families of addictive disorders prescribed pharmacologic treatment of metabolism of prescribed the rationale and proposed psychopharmacologic opioid use disorders, psychopharmacologic mechanisms of action for less agents including regulations agents, including agents commonly prescribed and governing use of methadone prescribed for treatment of experimental treatment choices and buprenorphine; is able addictive disorders, in to apply this knowledge in treatment selection, and 4.3/B Demonstrates expertise in the recommending appropriate explains rationale to appropriate prescription of treatment patients/families methadone and buprenorphine for opioid use disorders; understands and appropriately incorporates current regulations into patient care

Comments: Not yet rotated 1

Level 1 Level 2 Level 3 Level 4 Level 5 1.1/A Describes 2.1/A Describes the basic 3.1/C Demonstrates 4.1/A Demonstrates ability 5.1/A Designs a neurobiological and genetic neuroanatomy and understanding of the to incorporate the latest neuroscience curriculum hypotheses of common neurophysiology related to selection of pharmacologic research findings into focusing on substance use psychiatric disorders the pathophysiology of agents for addictive disorders discussions of the and addictive disorders addictive disorders based on current practice neuroscience of addictive 1.2/C Describes the general guidelines or treatment disorders 5.2/B Participates in indications and common 2.2/B Demonstrates algorithms research on the side effects for commonly knowledge of the basic 4.2/B Explains, in detail, the neuroscience of addiction prescribed principles of the 3.2/C Describes the evidence known neuropharmacology psychopharmacologic neuropharmacology of base for the use of of all classes of addictive 5.3/C Teaches the agents for addictive common addictive pharmacologic agents for substances neuropharmacology and disorders substances addictive disorders mechanisms of action of 4.3/C Explains the pharmacologic agents to 2.3/C Describes the 3.3/C Utilizes current neuropharmacology and other learners neuropharmacology and practice guidelines in the mechanisms of action of mechanisms of action of choice of pharmacologic pharmacologic agents for agents used for treatment of agents for treatment of addictive disorders addictive disorders addictive disorders

Comments: Not yet rotated 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Addiction Psychiatry Milestones on a non-exclusive bases for educational purposes. 10 Version 9/2014 Addiction Psychiatry Milestones: ACGME Report Worksheet MK2 — Psychopathology: including diagnostic criteria, epidemiology, pathophysiology, trajectory of illness, co-morbidities, and presentation of substance use and addictive disorders across the life cycle and in diverse patient populations A. Knowledge of the developmental trajectories, risk factors, biological, environmental, social and psychological factors that contribute to the development of addictive disorders B. Knowledge of the epidemiology and diagnostic criteria for co-occurring, addictive and substance use disorders C. Knowledge of criteria to determine appropriate level of care for the patient (including risk factors for morbidity and mortality) D. Knowledge at the interface of addiction psychiatry and the rest of medicine

Level 1 Level 2 Level 3 Level 4 Level 5 1.1/A Demonstrates 2.1/C Is aware of and begins 3.1/A Demonstrates 4.1/A Demonstrates detailed 5.1/B Engages in knowledge of risk factors to utilize appropriate criteria knowledge of and the ability and advanced knowledge of epidemiologic and/or that contribute to the to determine the necessary to describe biological, social, the developmental phenomenological research development of addictive level of care for the patient and psychological factors that trajectories of addictive on addictive disorders disorders contribute to or protect disorders 2.2/D Is aware of the medical against the development of 5.2/A Teaches others about 1.2/B Demonstrates effects of addictive addictive disorders 4.2/A Demonstrates detailed biological, environmental, sufficient knowledge to substances knowledge about biological, social, and psychological identify and treat most 3.2/B Demonstrates environmental, social, and factors that contribute to psychiatric conditions knowledge of the psychological factors that the development of throughout the life cycle epidemiology and diagnostic contribute to the addictive disorders and in a variety of settings criteria for co-occurring, development of addictive addictive and substance use disorders 1.3/D Demonstrates disorders sufficient knowledge to 4.3/A Demonstrates perform initial evaluations 3.3/C Incorporates risk of knowledge of the current of patients with medical morbidity and mortality from practice guidelines for the and addictive disorders substance use in describing treatment of addictive the appropriate level of care disorders for the patient 4.4/C Consistently applies 3.4/D Demonstrates appropriate criteria to

4.6/D Demonstrates advanced knowledge sufficient to treat patients with complex medical and addictive disorders

Comments: Not yet rotated 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Addiction Psychiatry Milestones on a non-exclusive bases for educational purposes. 12 Version 9/2014 Addiction Psychiatry Milestones: ACGME Report Worksheet MK3 — Psychotherapy, behavioral, and psychosocial treatments: including individual therapies; motivational-based therapies; contingency management; group therapies; family therapies; 12-step facilitation; self-help groups; cognitive behavioral therapies, including relapse prevention; comprehensive rehabilitation approaches; and integration of psychotherapy and psychopharmacology A. Knowledge of the theoretical underpinnings of the psychotherapies and behavioral and psychosocial treatments specific to substance use and addictive disorders B. Knowledge of components and techniques for delivering the variety of therapies specific to substance use and addictive disorders C. Knowledge of the evidence base for psychotherapy, behavioral, and psychosocial treatments specific to substance use and addictive disorders

Level 1 Level 2 Level 3 Level 4 Level 5 1.1/A Is aware of at least 2.1/A Lists the currently- 3.1/A Describes the history and 4.1/A Describes the theoretical 5.1/C Participates in three non-pharmacologic available non-pharmacologic basic theoretical principles differences among research on non- treatment modalities for treatment modalities for underlying the use of non- psychotherapies and pharmacologic treatments addictive disorders addictive disorders pharmacologic treatments for behavioral and psychosocial for addictions addictive disorders treatments for addictive 2.2/C Is aware of the disorders 5.2/C Performs a existence of evidence-based 3.2/B Describes, in detail, the comprehensive review on research into non- techniques included in a 4.2/B Describes, in detail, the evidence-based pharmacologic treatments manual for an evidence-based components and techniques treatments and presents for addictive disorders, and psychotherapy for addictive utilized in common non- to colleagues can describe one study disorders pharmacologic treatment modalities for addictive 3.3/C Critically discusses a key disorders study describing the evidence for use of non-pharmacologic 4.3/C Describes, in detail, the treatment for addictive current evidence for use of disorders behavioral, psychotherapeutic, and psychosocial treatments for addictive disorders

Comments: Not yet rotated 1

Level 1 Level 2 Level 3 Level 4 Level 5 1.1/A Describes the 2.1/A Describes systems and 3.1/B Recognizes special 4.1/A Participates in a team- 5.1/A Leads common system causes for procedures that promote patient or family based approach to medical multidisciplinary teams (e.g., errors patient safety circumstances that will affect error analysis, including human factors engineers, discharge planning quality improvement projects social scientists) to address 1.2/C Follows institutional 2.2/B Effectively and patient safety issues safety policies, including regularly utilizes all 3.2/B Negotiates patient- 4.2/B Takes a leadership role reporting of problematic appropriate forms of centered care among in ensuring accurate 5.2/A,C Provides behaviors and processes, communication to ensure multiple care providers transitions of care and consultation to errors, and near misses accurate transitions of care optimizing communication organizations to improve and to optimize across systems and the personal and patient safety 1.3/C Actively participates communication across continuum of care in conferences focusing on systems and the continuum systems-based errors in of care 4.3/C Develops content for a patient care patient safety presentation 2.3/C Follows regulatory or conference focusing on requirements related to systems-based errors in reporting requirements and patient care (i.e., morbidity prescribing practices and mortality [M&M] conference, root cause analysis meeting)

Comments: Not yet achieved Level 1

SBP2 — Resource Management: Costs of care and resource management in addiction treatment

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 Recognizes disparities 2.1 Coordinates patient 3.1 Balances the best 4.1 Practices cost-effective, 5.1 Designs measurement in health care at individual access to community and interests of the patient and high-value clinical care, using tools to monitor and and community levels system resources family with the availability of evidence-based tools and provide feedback to resources information technologies to providers/teams on 1.2 Knows the relative cost 2.2 Is aware of health care support decision making resource consumption to of care (e.g., medication funding and regulations 3.2 Uses available resources, facilitate improvement costs, diagnostic costs, related to organization of including the Electronic level of care costs, health care services Medical Record (EMR), to 5.2 Advocates for improved procedure costs) reduce cost of care, improve access to and additional patient safety, and/or resources within systems of improve quality of care care

Comments: Not yet achieved Level 1

Level 1 Level 2 Level 3 Level 4 Level 5 1.1/A Understands and 2.1/A Coordinates care with 3.1/B Incorporates self-help 4.1/C Uses principles of 5.1/A Participates in the makes use of local health community agencies and groups, community evidence-based practice and administration of care delivery systems other resources resources, and social patient-centered care in community-based networks in treatment clinical management of chronically ill treatment programs 2.2/B Recognizes role and care patients explains importance of self- 5.2/A Participates in help groups (including 12- 3.2/C Appropriately refers to 4.2/C Practices effectively in creating new community- step groups) and community rehabilitation and recovery a rehabilitation and/or based programs resource groups (e.g., family programs recovery-based program based and disorder-specific 5.3/A,C Demonstrates support and advocacy capacity to provide medical- groups) psychiatric leadership to health care facilities

Comments: Not yet achieved Level 1

Level 1 Level 2 Level 3 Level 4 Level 5 1.1/A Provides consultation 2.1/A Assists primary 3.1/A Provides integrated 4.1/A,B Manages 5.1/B Provides addiction to other general psychiatry treatment care team in care for patients with complicated and challenging psychiatry consultations to and medical services identifying unrecognized addictive disorders through consultation requests larger systems, such as a clinical care issues related to collaboration with other college or community 1.2/B Clarifies the addictive disorders physicians and advanced- mental health clinic or consultation question level practitioners community hospital 2.2/B Discusses methods for integrating addiction 3.2/B Identifies system issues 5.2/B Leads a consultation treatment, mental health, in clinical care and provides team and medical care in recommendations treatment planning

Comments: Not yet achieved Level 1

Level 1 Level 2 Level 3 Level 4 Level 5 1.1/A Regularly seeks and 2.1/A Demonstrates a 3.1/A Demonstrates 4.1/A Identifies and meets 5.1/B Teaches others incorporates feedback to balanced and accurate self- improvement in clinical self-directed learning goals techniques to efficiently improve performance assessment of competence, practice based on continual with little external guidance incorporate evidence using clinical outcomes to self-assessment and gathering into clinical 1.2/A Identifies self- identify areas for continued evidence-based information 4.2/A Sustains practice of workflow directed learning goals and improvement self-assessment and keeping periodically reviews them 3.2/B Independently up with relevant changes in 5.2/B Independently with supervisory guidance 2.2/B Selects an appropriate, searches for and medicine, and makes teaches appraisal of clinical evidence-based information discriminates evidence informed, evidence-based evidence 1.3/B Formulates a tool2 to meet self-identified relevant to clinical practice clinical decisions searchable question from a learning goals problems clinical question1 4.3/A Demonstrates use of a 2.3/B Critically appraises system or process for different types of research, keeping up with relevant including randomized changes in medicine controlled trials (RCTs), systematic reviews, meta- analyses, and practice guidelines

Comments: Not yet achieved Level 1

Footnotes: 1Examples include: a performance-in-practice (PIP) module as included in the American Board of Psychiatry and Neurology (ABPN) Maintenance of Certification (MOC) process; regular and structured readings of specific evidence sources. 2Examples include: practice guidelines; PubMed Clinical Queries; Cochrane, DARE, or other evidence-based reviews; Up-to-Date, etc.

Level 1 Level 2 Level 3 Level 4 Level 5 1.1/A Assumes a role in the 2.1/A Participates in activities 3.1/A Gives informal and 4.1/A Develops and gives 5.1/A Educates broader clinical teaching of early, designed to develop and formal didactic presentations specialty- and subspecialty- professional community mid-level, and advanced improve teaching skills to groups (e.g., grand rounds, specific presentations to and/or public (e.g., presents learners; assists faculty case conference, journal groups at regional or national members in providing 2.2/B Evaluates and provides club) meeting) supervision to these feedback to early, mid-level, 4.2/B Effectively uses learners and advanced learners 3.2/B Organizes content and feedback on teaching to 5.2/B Organizes and methods for individual improve teaching methods develops curriculum 1.2/B Communicates goals instruction for early, mid- and approaches materials and objectives for level, and advanced learners instruction of early, mid- level, and advanced learners

Comments: Not yet achieved Level 1

Level 1 Level 2 Level 3 Level 4 Level 5 1.1/A Demonstrates 2.1/A Elicits beliefs, values, 3.1/A Develops a mutually 4.1/A Recognizes and adapts 5.1/A Serves as a role capacity for self- and diverse practices of agreeable care plan in the approach based on subspecialty- model and teacher of reflection, empathy, and patients and their families, context of conflicting related issues of diversity and compassion, integrity, curiosity about and and understands their physician and patient and/or special needs populations respect for others, and openness to different potential impact on patient family values and beliefs sensitivity to diverse beliefs and points of care 4.2/B Leads educational patient populations view, and respect for 3.2/A Discusses own cultural activities and case discussions diversity 2.2/A Routinely displays background and beliefs and regarding ethical issues specific 5.2/B Identifies emerging sensitivity to diversity in the ways in which these affect to both general psychiatry and ethical issues within 1.2/A Provides examples psychiatric evaluation and interactions with patients the subspecialty subspecialty practice, and of the importance of treatment can discuss opposing attention to diversity in 3.3/B Systematically analyzes 4.3/B Adapts to evolving ethical viewpoints psychiatric evaluation 2.3/B Recognizes ethical and manages ethical issues, standards (i.e., can manage and treatment issues in practice, and is able including those specific to the conflicting ethical standards and to discuss, analyze, and subspecialty values and apply these to 1.3/B Recognizes ethical manage these in common practice) conflicts in practice and clinical situations 3.4/B Effectively participates seeks supervision to as a team member along with 4.4/B Demonstrates the ability manage them other medical and non- to be an effective team medical professionals member/team leader, including respect and consideration of the opinions and expertise of others

Comments: Not yet achieved Level 1

Footnotes:

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Addiction Psychiatry Milestones on a non-exclusive bases for educational purposes. 20 Version 9/2014 Addiction Psychiatry Milestones: ACGME Report Worksheet 1The two Professionalism subcompetencies (PROF1 and PROF2) reflect the following overall values: Fellows must demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles. Residents must develop and acquire a professional identity consistent with values of oneself, the specialty, and the practice of medicine. Residents are expected to demonstrate compassion, integrity, and respect for others; sensitivity to diverse populations; responsibility for patient care that supersedes self-interest; and accountability to patients, society, and the profession. 2Diversity refers to unique aspects of each individual patient, including gender, age, socioeconomic status, culture, race, religion, disabilities, and sexual orientation.

Level 1 Level 2 Level 3 Level 4 Level 5 1.1/A Notifies team and 2.1/A Identifies and manages 3.1/A Knows how to take 4.1/A Prioritizes and balances 5.1/A Develops physician enlists appropriate situations in which steps to address impairment conflicting interests of self, wellness programs or coverage for clinical and maintaining personal in self and colleagues family, and others to optimize interventions, and/or non-clinical emotional, physical, and medical care and practice of the participates as an active responsibilities when mental health is challenged, 3.2/B Prepares for obtaining profession1 member on committees fatigued or ill and seeks assistance when and maintaining board or in organizations that needed certification 4.2/B Participates in the primary address physician wellness 1.2/B Follows institutional specialty and subspecialty policies for physician 2.2/B Recognizes the 3.3/C Displays increasing professional community (e.g., 5.2/B Develops conduct and responsibility importance of participating in autonomy and leadership in professional societies, patient organizational policies, one’s professional community taking responsibility for advocacy groups, community programs, or curricula for 1.3/C Accepts role of the ensuring that patients service organizations) subspecialty patient’s physician and 2.3/C Recognized by self, receive the best possible professionalism takes responsibility (under patient, patient’s family, and care 4.3/C Serves as a role model in supervision) for ensuring medical staff members as the demonstrating responsibility for the patient receives the patient’s primary psychiatric ensuring that patients receive best possible care provider the best possible care

Comments: Not yet achieved Level 1

Footnotes: 1Fellows are expected to demonstrate responsibility for patient care that supersedes self-interest. It is important that fellows recognize the inherent conflicts and competing values involved in balancing dedication to patient care with attention to the interests of their own well-being and responsibilities to their families and others. Balancing these interests while maintaining an overriding commitment to patient care requires, for example, ensuring excellent transitions of care, sign- out, and continuity of care for each patient during times that the fellow is not present to provide direct care for the patient.

Level 1 Level 2 Level 3 Level 4 Level 5 1.1/A Develops 2.1/A Is respectful of cultural 3.1/A Develops therapeutic 4.1/A Sustains therapeutic 5.1/A, B Develops therapeutic relationship diversity in discussions and relationships in complicated and working relationships models/approaches to with patients of all ages management suggestions with situations during complex and managing difficult and their families in patients and their families challenging situations, communications uncomplicated situations 3.2/B Sustains working including transitions of care 2.2/A Develops working relationships in the face of 5.2/B Effectively mentors 1.2/A Is aware of cultural relationships across specialties conflict 4.2/A Sustains relationships other health care providers diversity in and systems of care in across systems of care and in leadership, communicating with uncomplicated situations 3.3/C Begins to take a with patients during long- communication skills, and people of different leadership role in a term follow-up conflict management backgrounds 2.3/B Negotiates and manages multidisciplinary care team simple patient/family-related 4.3/B Manages treatment 5.3/C Leads and facilitates 1.3/B Recognizes conflicts across the lifespan 3.4/C Recognizes differing team conflicts as team leader meetings within the communication conflicts philosophies within and organization/system in work relationships 2.4/C Actively participates in between different disciplines 4.4/C Effectively assumes a team-based care; supports in care provision leadership role in 5.4/C Designs research or 1.4/C Collaborates with activities of other team multidisciplinary patient care quality improvement project team members in patient members, and communicates and family meetings on the benefits of team- care their value to the patient and based care family

Comments: Not yet achieved Level 1

Level 1 Level 2 Level 3 Level 4 Level 5 1.1/A Ensures transitions of 2.1/A,B Uses easy-to- 3.1/A,B Demonstrates 4.1/A,B Demonstrates 5.1/C Participates in the care are accurately understand language in all effective verbal communication that is development of changes in documented and optimizes phases of communication, communication, with appropriate, efficient, rules, policies, and communication across including working with patients of all ages, families, concise, and pertinent with procedures related to systems and continuums of interpreters and patients of colleagues, and other health patients with limited technology care all ages care providers, that is communication and cognitive appropriate, efficient, abilities 5.2/B Engages in scholarly 1.2/A Ensures that the 2.2/B Consistently concise, and pertinent activity (e.g., teaching, written records (electronic demonstrates 4.2/B Recruits appropriate research) regarding medical record [EMR], communication strategies to 3.2/A,B Demonstrates assistance from external effective health care personal health records ensure patient and family written communication, with sources when cultural communication [PHR]/patient portal, hand- understanding patients, families, colleagues, differences create barriers to offs, discharge summaries, and other health care patient care etc.) are accurate and 2.3/B Demonstrates providers, that is timely, with attention to appropriate face-to-face appropriate, efficient, 4.3/C Serves as a role model preventing confusion and interaction while using EMR concise, and pertinent and teacher in following error, consistent with federal regulations with institutional policies 2.4/C Understands and 3.3/B Consistently engages regard to release of follows specific federal patients and families in information pertaining to 1.3/A,B Organizes both regulations regarding release shared decision making patients who have received written and oral information of information pertaining to treatment for addictive to be shared with patients, patients who have received disorder families, team, and others treatment for addictive disorders 1.4/C Maintains appropriate

2.6/C Uses discretion and judgment in electronic communication with patients, families, and colleagues

Comments: Not yet achieved Level 1