The Sports Medicine Milestone Project

A Joint Initiative of

The Accreditation Council for Graduate Medical Education, The American Board of Emergency Medicine, The American Board of Family Medicine, The American Board of Pediatrics, and The American Board of Physical Medicine and Rehabilitation

July 2015

The Sports Medicine 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.

Sports Medicine Milestones

Chair: Peter J. Carek, MD Working Group Advisory Group Holly J. Benjamin, MD Michael Beeson, MD Laura Edgar, EdD, CAE John DiFiori, MD Jolie C. Holschen, MD Gerard E. Francisco, MD Kenneth Mautner, MD Joseph Gilhooly, MD William Micheo, MD Philip Shayne, MD David Ross, MD Mark Stovak, 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 12/2014 Sports Medicine Milestones: ACGME Report Worksheet

History and Physical Examination: Medical and Musculoskeletal — Patient Care 1

Level 1 Level 2 Level 3 Level 4 Level 5 Obtains appropriate Obtains detailed history of Obtains advanced history Independently obtains Role models techniques medical history sports-related medical of sports-related medical complex history of to obtain subtle and condition or injury condition or injury (i.e., common and unusual sensitive information Performs basic medical mechanism, risk factors, conditions from patients and families examination Performs specific organ- genetic history, nutritional based medical deficiencies) Independently performs Role models efficiently Performs basic examination for common complex examinations of performing problem- musculoskeletal sports medicine Performs appropriate common and unusual based examination examination conditions (e.g., cardiac medical examination for conditions exam for murmurs, complex or high-risk neurologic exam for sports medicine Integrates functional and concussion) conditions (e.g., dynamic testing (e.g., compartment syndrome, landing technique Performs regional post-concussive assessment, running gait musculoskeletal syndrome, sudden cardiac analysis, ultrasound examination with specific arrest) guided assessment) maneuvers (e.g., Lachman’s test, ankle Consistently performs drawer test, shoulder regional musculoskeletal labral tests) examination with maneuvers specific to the presenting complaint

Comments:

Not yet achieved Level 1

Medical Management: Differential Diagnosis, Diagnostic Testing, Interpretation of Data and Treatment Planning — Patient Care 2

Level 1 Level 2 Level 3 Level 4 Level 5 Develops a basic Develops a basic Develops a comprehensive Independently Serves as a resource or differential diagnosis differential diagnosis differential diagnosis based upon interprets diagnostic role model for the pertinent to common pertinent to sports history and physical examination testing evaluation and medical conditions medicine conditions findings management of Utilizes evidence-based complex conditions in Orders and interprets Orders and interprets Utilizes results of diagnostic testing principles and cost- sports medicine basic diagnostic testing basic diagnostic testing to generate and modify a effective strategies to appropriate to appropriate to common treatment plan for athletes with generate and modify a common medical sports medicine medical conditions (e.g., abnormal treatment plan for conditions conditions EKG, laboratory studies, imaging) complex conditions

Generates a basic Generates a basic With supervision, manages acute Independently provides treatment plan for treatment plan for and chronic sports medicine patient care in all common medical common sports conditions, including rehabilitation aspects of sports conditions medicine conditions and return-to-participation medicine decisions

Refers patients to specialists appropriately

Understands evidence-based principles and cost-effective strategies to generate and modify a treatment plan

Comments: Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, the American Board of Emergency Medicine, the American Board of Family Medicine, the American Board of Pediatrics, and the American Board of Physical Medicine and Rehabilitation. All rights reserved. The copyright owners grant third parties the right to use the Sports Medicine Milestones on a non-exclusive bases for educational purposes. 2 Version 12/2014 Sports Medicine Milestones: ACGME Report Worksheet Team Coverage and Athletic Care: Coverage of Sporting Events, Pre-participation Physical Examinations, Training Room Coverage — Patient Care 3

Level 1 Level 2 Level 3 Level 4 Level 5 With direct supervision, With indirect supervision, Performs pre- Independently organizes Develops policies for team participates in team and organizes team and event participation physical team and event medical and event medical event medical coverage medical coverage examination coverage coverage independently With direct supervision, With indirect supervision, Directs and works Serves as a resource or participates in pre- performs pre- Manages common sports collaboratively with a role model in the participation physical participation physical medicine problems in the multidisciplinary team in community for examinations examinations athletic environment providing pre- implementing care at (e.g., athletic field, mass participation physical athletic events Manages common sports participation events) examinations medicine problems in the training room With indirect supervision, Treats and manages acute performs procedures and injuries, adverse clinical With direct supervision, basic resuscitations in the situations, and performs minor athletic environment determines return-to- procedures (e.g., participation laceration care, joint reduction) and basic resuscitation in the athletic environment

Comments: Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, the American Board of Emergency Medicine, the American Board of Family Medicine, the American Board of Pediatrics, and the American Board of Physical Medicine and Rehabilitation. All rights reserved. The copyright owners grant third parties the right to use the Sports Medicine Milestones on a non-exclusive bases for educational purposes. 3 Version 12/2014 Sports Medicine Milestones: ACGME Report Worksheet Science of Sports Medicine, including Anatomy, Physiology, Cellular Biology, Epidemiology, Pharmacology, Nutrition, Biomechanics, Rehabilitation, and Psychology — Medical Knowledge 1

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates knowledge Demonstrates knowledge Synthesizes scientific Synthesizes and applies Publishes peer-reviewed of basic sciences, of basic sciences related knowledge in managing scientific knowledge in work related to the including anatomy, to sports medicine in common sports medicine complex sports medicine science of sports medicine physiology, epidemiology, patients of all ages conditions conditions pharmacology, nutrition, Possesses the scientific, biomechanics, Demonstrates basic Demonstrates knowledge Integrates basic and socioeconomic, and rehabilitation, and knowledge of of factors associated with clinical science knowledge behavioral knowledge psychology rehabilitation, preventive risk of injury, including of pathophysiology, tissue required to successfully strategies, and age, gender, and disability healing, and treatment incorporate basic and Demonstrates knowledge therapeutic modalities interventions in return-to- clinical science to of anatomy and (e.g., ice, ultrasound, Demonstrates both basic activity decisions (e.g., diagnose and treat physiology related to electrical stimulation) science and clinical ACL rehabilitation, high- uncommon, ambiguous, growth, development, knowledge of the details risk stress fractures, and complex conditions and aging of tissue healing and concussion management) cellular physiology across the lifespan in selecting treatment options (e.g., injections, medications, manual therapy)

Comments: Not yet achieved Level 1

Medical Issues in Sports Medicine — Medical Knowledge 2

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Demonstrates Synthesizes knowledge of the Synthesizes and applies Publishes peer-reviewed general knowledge knowledge of illness pathophysiology, evaluation and knowledge of the scientific work related to of medical issues in and injury associated management, and prevention of pathophysiology, medical issues in sports sports medicine with athletic activities sports medicine-related illness and evaluation and medicine injury management, and Demonstrates Demonstrates prevention of sports Collaborates with other knowledge of knowledge of Interprets common diagnostic studies medicine-related illness experts to advance the pathophysiology of pathophysiology of used to evaluate medical conditions and injury medical management of common medical common sports- in sport medicine (e.g., EKG, sports medicine-related conditions in sports related medical pulmonary function test) Demonstrates knowledge conditions medicine conditions and risk of return-to-activity and factors Demonstrates knowledge of return- participation guidelines Possesses the scientific, to-activity and participation for life threatening socioeconomic, and Demonstrates guidelines for common medical medical conditions in behavioral knowledge knowledge of conditions in sports medicine sports medicine required to diagnose and diagnostic testing to treat uncommon, evaluate sports-related Demonstrates knowledge of Demonstrates knowledge ambiguous, and complex medical conditions complications of medical of alternative approaches medical conditions and management in sports medicine to the medical injuries conditions management of sports medicine conditions and Demonstrates knowledge of the role associated controversies of performance enhancing drugs in sports, including doping regulations, testing, and risks

Comments: Not yet achieved Level 1

Musculoskeletal Issues in Sports Medicine — Medical Knowledge 3

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Demonstrates Synthesizes knowledge of the Synthesizes and applies Publishes peer-reviewed general knowledge of pathophysiology, evaluation, and knowledge of the work related to knowledge of musculoskeletal injury management of sports medicine- pathophysiology, evaluation, musculoskeletal issues in musculoskeletal associated with athletic related musculoskeletal injury and management of sports sports medicine issues in sports activities medicine-related medicine Interprets common diagnostic studies musculoskeletal injury Possesses the scientific Demonstrates used to evaluate musculoskeletal socioeconomic and knowledge of conditions in sport medicine Demonstrates knowledge of behavioral knowledge pathophysiology of return-to-activity and required to successfully common Demonstrates knowledge of return- participation guidelines for incorporate basic and musculoskeletal to-activity and participation guidelines life threatening clinical science to diagnose conditions for common musculoskeletal musculoskeletal conditions in and treat uncommon, conditions in sports medicine sports medicine ambiguous, and complex Demonstrates musculoskeletal conditions knowledge of Demonstrates knowledge of Demonstrates knowledge of diagnostic testing to treatment options of operative and complications and Develops policies for evaluate sports-related non-operative management of controversies in operative and evaluation and musculoskeletal musculoskeletal conditions in sports non-operative management management of sports conditions medicine of musculoskeletal conditions medicine-related in sports medicine musculoskeletal injury, and Demonstrates knowledge of return-to-activity and biomechanics of injury and how it Integrates knowledge of participation guidelines for applies to preventive strategies (e.g., biomechanics into individual life threatening pitching mechanics, ACL prevention treatment plans and musculoskeletal conditions programs) prevention programs in sports medicine

Comments: Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, the American Board of Emergency Medicine, the American Board of Family Medicine, the American Board of Pediatrics, and the American Board of Physical Medicine and Rehabilitation. All rights reserved. The copyright owners grant third parties the right to use the Sports Medicine Milestones on a non-exclusive bases for educational purposes. 6 Version 12/2014 Sports Medicine Milestones: ACGME Report Worksheet Working with Inter-professional Teams (consultants, certified athletic trainers [ATCs], physical therapists [PTs], occupational therapists [OTs], chiropractors, etc.) to Enhance Athletic Care and Safety — Systems-based Practice 1

Level 1 Level 2 Level 3 Level 4 Level 5 Collaborates with health Demonstrates Maintains an interdisciplinary Leads the incorporation Serves as a leader in the care colleagues in the knowledge of the role of and team-based approach of quality improvement community for the care of patients each team member and has situational and athletic safety into development of awareness to the care of the clinical care interdisciplinary programs Collaborates with health athlete to enhance athletic care care colleagues in the Participates in a team- and safety care of athletes or active Implements emergency based approach to individuals action plans (simulation or medical error analysis real scenario) Identifies emergency Leads the development action plans for use in Describes potential sources and maintenance of different settings (i.e., of system failure in clinical emergency action plans clinic vs. event) care, such as minor, major, and sentinel events

Participates in quality improvement projects addressing athletic safety and clinical care

Participates in the development or maintenance of emergency action plans

Comments: Not yet achieved Level 1

Systems Thinking — Systems-based Practice 2

Level 1 Level 2 Level 3 Level 4 Level 5 Describes basic levels of Describes cost Prioritizes cost Manages workflow of a Serves as a primary care systems of care for the containment and value containment and value sports medicine clinic and sports medicine expert for athlete implications of care implications when training room/athletic a practice group or coordinating care for event community Demonstrates knowledge individual athletes, of the economic balancing quality and Serves as a medical Develops policies for team challenges of patient care safety director for a team or or event management within the health system event Demonstrates knowledge Serves as a resource or of the financial Utilizes a broad spectrum role model for cost implications of different of resources to efficiently containment and value health care systems for manage team care and implications when athletes event coverage coordinating care within sports medicine Demonstrates knowledge Incorporates practices to of medicolegal issues mitigate medical-legal risk related to sports medicine

Comments: Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, the American Board of Emergency Medicine, the American Board of Family Medicine, the American Board of Pediatrics, and the American Board of Physical Medicine and Rehabilitation. All rights reserved. The copyright owners grant third parties the right to use the Sports Medicine Milestones on a non-exclusive bases for educational purposes. 8 Version 12/2014 Sports Medicine Milestones: ACGME Report Worksheet Self-directed Learning — Practice-based Learning and Improvement 1  Identify strengths, deficiencies, and limits in one’s knowledge and expertise  Set learning and improvement goals  Identify and perform appropriate learning activities  Use information technology to optimize learning

Level 1 Level 2 Level 3 Level 4 Level 5 Acknowledges gaps in Accepts external feedback Develops an appropriate Completes an appropriate Independently uses self- knowledge and clinical regarding knowledge base learning plan based upon learning plan based upon evaluation and external expertise in sports and clinical performance, sports medicine sports medicine feedback, including medicine and understands plan for experience experience patient feedback improvement regarding clinical Actively seeks external Independently uses self- performance, and feedback regarding evaluation and peer independently develops a knowledge base and feedback regarding plan for improvement clinical performance, and knowledge base and independently develops a clinical performance, and Continuously re-evaluates plan for improvement independently develops a improvement plan and plan for improvement makes adjustments as needed Periodically re-evaluates improvement plan and makes adjustments as needed

Comments: Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, the American Board of Emergency Medicine, the American Board of Family Medicine, the American Board of Pediatrics, and the American Board of Physical Medicine and Rehabilitation. All rights reserved. The copyright owners grant third parties the right to use the Sports Medicine Milestones on a non-exclusive bases for educational purposes. 9 Version 12/2014 Sports Medicine Milestones: ACGME Report Worksheet Locate, Appraise, and Assimilate Evidence from Scientific Studies Related to the Patient’s Health Problems — Practice-based Learning and Improvement 2

Level 1 Level 2 Level 3 Level 4 Level 5 Uses information Uses scholarly articles and Critically evaluates Incorporates appropriate Publishes peer-reviewed technology to search and guidelines to address scientific literature in evidence-based scientific work related to access relevant and valid patient care issues in sports medicine information into patient sports medicine medical information sports medicine care Understands the limits of evidence-based medicine in patient care

Comments: Not yet achieved Level 1

Compassion, Integrity, Accountability, and Respect for Self and Others — Professionalism 1

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Describes effects of sleep Demonstrates Mentors others in the Serves as a resource or compassion, sensitivity, deprivation and substance compassionate practice of compassionate practice of role model for and responsiveness to abuse on provider medicine, even in the medicine, even in the professionalism in sports patients and families performance context of disagreement context of disagreement medicine with patient beliefs and with patient beliefs Demonstrates non- Demonstrates knowledge expectations Role models compassion, discriminatory behavior in of appropriate steps to Mentors others in empathy, and respect for all interactions, including address impairment in self Incorporates patients’ sensitivity and patients with diverse and or colleagues socio-cultural needs and responsiveness to diverse vulnerable populations beliefs into patient care and vulnerable populations Consistently demonstrates professional behavior, Advocates for quality including dress and patient care and well- timeliness being, even when faced with competing outside interests (e.g., employer, coach, administrator, sports agent)

Fosters collegiality that promotes a high- functioning inter- professional team

Comments: Not yet achieved Level 1

Knowledge about and Adherence to the Ethical Principles Relevant to the Practice of Sports Medicine — Professionalism 2

Level 1 Level 2 Level 3 Level 4 Level 5

Describes basic ethical Determines presence of Analyzes and manages Analyzes and manages Demonstrates leadership principles ethical issues in sports ethical issues in ethical issues in complex and mentorship in medicine straightforward clinical clinical situations, applying ethical principles Demonstrates integrity situations including removal from in sports medicine and respect for patients competition (e.g., career- settings and colleagues Analyzes and describes ending injury) ethical issues inherent in Role models and sets clinical research Role models respectful expectations for others in interactions between regards to respectful Promotes integrity and patients and colleagues interactions between respect for patients and patients and colleagues colleagues

Comments: Not yet achieved Level 1

Relationship Development, Teamwork, and Managing Conflict — Interpersonal and Communication Skills 1

Level 1 Level 2 Level 3 Level 4 Level 5 Develops a positive Manages patient- and/or Manages conflict in Manages conflict across Serves as a resource or relationship with patients family-related conflicts complex situations specialties and systems of role model for teamwork in uncomplicated care and conflict management situations Uses easy-to-understand Engages patients in language in all phases of shared decision making Leads team-based patient Role models effective Actively participates in communication care activities communication and team-based care relationship development Effectively communicates as to minimize the occurrence of conflict

Comments: Not yet achieved Level 1

Information Sharing, Gathering, and Technology — Interpersonal and Communication Skills 2

Level 1 Level 2 Level 3 Level 4 Level 5 Effectively Provides effective and Effectively communicates the Effectively leads patient Serves as a role model communicates patient- timely communication results of a sports medicine care meetings, including for interpersonal related information with members of the consultation in a timely manner those related to career communication in health care team during ending injuries sports medicine Accurately documents clinical activities and Educates coaches and other transitions of care event coverage health care professionals about Effectively and ethically Serves as an expert in the illness or injury and uses all forms of the discovery, Completes Educates patients and management, including risks and communication in a integration, or teaching documentation in a families about the illness benefits of treatment options manner that protects of knowledge related timely fashion or injury and patient confidentiality to primary care in management, including Provides effective and timely sports medicine risks and benefits of communication regarding Develops patient treatment options changes in patient status, education materials including removal or return to related to the field of Effectively gathers participation sports medicine information from appropriate additional Provides patient education resources when materials in health, wellness, necessary activity, and prevention related to the field of sports medicine

Comments: Not yet achieved Level 1