The Neurotology Milestone Project

A Joint Initiative of The Accreditation Council for Graduate Medical Education and The American Board of Otolaryngology

July 2015 The Neurotology Milestone Project

The Milestones are designed only for use in evaluation of the fellow in the context of their participation in ACGME-accredited residency or fellowship programs. The Milestones provide a framework for 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.

Neurotology Milestones

Chair: Walter Kutz, MD

Working Group Advisory Group Pam Derstine, PhD, MHPE Sukgi Choi, MD Laura Edgar, EdD, CAE Robert Miller, MD Abraham Jacob, MD John Potts III, MD Marlan Hansen, MD Barry Hirsch, 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 a 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.

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.

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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 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 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 demonstrated as well as some milestones in the higher demonstrated. level(s).

Version 05/2014 Neurotology Milestones, ACGME Report Worksheet

Internal Auditory Canal (IAC) and Cerebellopontine Angle (CPA) Lesions – Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Performs complete Formulates a differential Differentiates lesions based Interprets intra-operative Proficient at tumor removal neurotologic history and diagnosis of CPA tumors on imaging characteristics ABR monitoring physical Counsels patient regarding Demonstrates ability to the indications, outcomes, Interprets auditory and Performs complete tumor perform variations of Identifies normal risks, and complications of vestibular testing in the exposure and identifies standard transtemporal temporal bone and surgery of the CPA management of CPA cranial nerves approaches (transcochlear, posterior fossa anatomy tumors subtotal petrosectomy) on magnetic resonance Performs pre-operative (videonystagmography Counsels patient regarding imaging (MRI) and setup, including positioning [VNG], vestibular evoked the indications, outcomes, computed tomography and monitoring myogenic potential [VEMP], risks, and complications of (CT) auditory brainstem radiosurgery of the CPA Performs initial portion of response [ABR]) Describes standard the temporal bone Recognizes and manages surgical approaches to approach Performs surgical approach intra- and post-operative the IAC/CPA (translab, up to tumor exposure and complications (e.g., middle cranial fossa Identifies the advantages cranial nerve dissection cerebrospinal fluid [CSF] [MCF], Retrosigmoid) and disadvantages of (e.g., labyrinthectomy, leak, cranial nerve injuries, standard surgical identification of the IAC) vascular injury) approaches to the CPA

Identifies pertinent anatomy related to IAC dissections in the temporal bone laboratory

Comments:

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Otolaryngology. All rights reserved. The copyright owners grant third parties the right to use the Neurotology Milestones on a non-exclusive basis for educational purposes. 1 Version 05/2014 Neurotology Milestones, ACGME Report Worksheet

Lateral Skull Base Tumors – Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies normal Formulates a differential Differentiates lesions Creates a comprehensive Develops innovative jugular foramen, diagnosis of lateral skull based on imaging management plan (e.g., pre- management of lateral skull petrous apex, and base tumors characteristics operative work-up, multi- base tumors infratemporal fossa modality treatment) for anatomy on MRI and CT Performs pre-operative Counsels patient regarding paragangliomas setup, including positioning the indications, outcomes, Identifies cranial nerve and monitoring risks, and complications of Performs appropriate deficits on history and surgery of the lateral skull temporal bone resection physical examination Performs initial portion of base (e.g., lateral, subtotal) the temporal bone approach Stages temporal bone Performs approach for carcinoma and petrous apex lesions Utilizes a multidisciplinary paragangliomas approach to diagnosis and Identifies and manages management of lateral intra- and post-operative skull base tumors (e.g., complications (e.g., CSF radiation oncology, leak, cranial nerve injuries, endovascular surgical vascular injury) neuroradiology, neurosurgery)

Describes surgical approaches to lateral skull base tumors

Comments:

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Facial Nerve Disorders – Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5 Assesses and grades Formulates a differential Orders and interprets Performs surgical exposure Develops innovative facial nerve function diagnosis of facial nerve appropriate facial nerve of all segments of the facial techniques for the disorders electrodiagnostic and nerve, including medial to management of facial nerve Identifies normal facial imaging tests, and makes the geniculate ganglion disorders nerve anatomy on MRI Counsels patient regarding management decisions (e.g., middle fossa, and CT the indications, outcomes, based on results translabyrinthine) Designs evidence-based risks, and complications of clinical pathways surgery involving the facial Surgically identifies the Performs facial nerve graft nerve facial nerve lateral to the geniculate ganglion Seeks appropriate consultation and counsels Manages the sequelae of patient regarding the acute facial nerve injury indications, outcomes, risks, (e.g., eye care) and complications of surgery involving facial nerve rehabilitation

Provides comprehensive management of neoplasms involving the facial nerve

Comments:

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Hearing Loss – Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Demonstrates proficient Demonstrates Demonstrates Publishes original peer- understanding of the knowledge of normal and understanding of the comprehensive reviewed research related to anatomy and physiology abnormal temporal bone pathophysiology and understanding of the hearing loss of the middle and inner and cochleovestibular treatment options for medical management for ear histopathology auditory neuropathy/ hearing loss (e.g., Develops a course or dysynchrony autoimmune disease, conference related to Demonstrates basic Lists unusual causes for sudden hearing loss) hearing loss for a regional or understanding of hearing loss in pediatric and Demonstrates national meeting comprehensive audiologic adult patients, and understanding of the Demonstrates testing (e.g., pure tone orders/interprets implications of unilateral understanding of the audiometry, speech appropriate advanced hearing loss and surgical management of testing, immittance audiometric, laboratory, and management options complex causes of testing) imaging studies conductive hearing loss Demonstrates (e.g., ossicular Demonstrates basic Demonstrates understanding of malformations, aural understanding of common comprehensive knowledge indications and outcomes atresia) causes of pediatric and of non-surgical and surgical of active middle ear adult hearing loss options for aural implants Demonstrates rehabilitation understanding of Demonstrates basic indications, outcomes, understanding of non- risks, and complications of surgical and surgical cochlear implantation in options for aural patients with temporal rehabilitation bone abnormalities

Comments:

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Dizziness – Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Describes normal anatomy Describes the integration of Describes diagnostic criteria Demonstrates comprehensive Publishes original peer- and physiology of the the peripheral vestibular and treatment options for understanding and reviewed research related to peripheral vestibular system system with other sensory central vestibular disorders interpretation of vestibular dizziness and motor systems (e.g., (e.g., multiple sclerosis, testing (e.g., VNG, ocular Lists common causes of vision, proprioception) migraine associated dizziness, vestibular-evoked myogenic Develops a course or peripheral vertigo stroke) potential [oVEMP], cervical conference related to Differentiates otologic from vestibular evoked myogenic dizziness for a regional or Demonstrates non-otologic causes of Demonstrates understanding potential [cVEMP], rotary national meeting understanding of non- vertigo of a multidisciplinary chair, posturography) surgical management of approach to evaluate and positional vertigo, Describes mechanisms manage dizziness (e.g., Demonstrates knowledge of labyrinthitis, vestibular underlying central vestibular rehabilitation, the indications, outcomes, neuritis, and Meniere’s compensation for peripheral neurologic consultation) risks, and complications of disease vestibular disorders ablative and non-ablative vestibular interventions (e.g., semicircular canal dehiscence, Meniere’s disease)

Comments:

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Patient Safety – Systems-based Practice

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates an Recognizes medical errors as Anticipates potentially Advocates for quality patient Participates as an advocate understanding of the systemic events and dangerous situations and care and optimal patient care on local, regional, or importance of patient facilitates reporting in a intervenes appropriately systems national levels for patient safety and the occurrence blame-free environment safety of medical errors in Analyzes quality Educates other services neurotology patients Uses multidisciplinary improvement findings and about patient safety issues Designs evidence-based approaches for patient care provides feedback to related to neurotology clinical pathways to Participates in an effective improve patient safety decrease medical errors patient hand-off and surgical time-out processes

Presents at quality improvement conference (organizes data and identification of pertinent patient safety issues)

Comments: Not yet achieved Level 1

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Resource Utilization – Systems-based Practice

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the resources Considers socio-economic Incorporates cost issues Practices cost-effective Develops and implements (e.g., social work, case issues when developing into care decisions care (e.g., managing cost efficient clinical manager) necessary to patient care plans length of stay, operative pathways coordinate patient care Uses technology and other efficiency) Appropriately collaborates hospital/clinic resources to Advocates on local, with allied health improve patient care Understands issues of regional, or national levels practitioners (e.g., nurse transition to practice (e.g., for health care policy practitioners, physician Understands the principles coding, quality measures, assistants) of insurance coverage and documentation, access to care compensation)

Comments:

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Evidence-based Medicine – Practice-based Learning and Improvement

Level 1 Level 2 Level 3 Level 4 Level 5 Understands currently Incorporates evidence-based Synthesizes a clinical plan Recognizes gaps in current Formulates an outcomes- available evidence-based guidelines into clinical from multiple sources of evidence based quality improvement guidelines relevant to decisions evidence project to answer a clinical neurotology question

Understands the quality and limitations of available literature and data

Comments: Not yet achieved Level 1

Self-directed Learning – Practice-based Learning and Improvement

Level 1 Level 2 Level 3 Level 4 Level 5 Takes responsibility for Committed to self- Is self-reflective about Applies critical analysis of Publishes original research actions improvement academic, professional, and literature to patient care personal needs, strengths, Contributes to regional or Acknowledges own errors Responds well to feedback and limitations national educational activities Analyzes and interprets own experience

Comments: Not yet achieved Level 1

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Behavior – Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates behavior Is aware of ethical issues Discusses, analyzes, and Discusses, analyzes, and Helps lead institutional that conveys caring, in patient care, including manages common ethical manages ethical issues in and organizational ethics honesty, and genuine issues of beginning and situations complicated and programs interest in patients and end-of-life care challenging situations families Displays sensitivity and Mentors and teaches Recognizes individual responsiveness toward all Develops a mutually integrity, altruism, Demonstrates respect for limits in clinical situations patient populations agreeable care plan in the individual responsibility, patients and families and asks for assistance context of conflicting and professionalism when needed Demonstrates respectful physician, patient, and Exhibits professional behavior in challenging caregiver values and behavior (e.g., reliability, Understands and manages situations and earns the beliefs industry, integrity, the issues related to respect of other providers confidentiality) fatigue and sleep within the system Understands the ethical deprivation implications of Maintains respect for incorporating new patient confidentiality Recognizes issues related interventions into practice to research ethics Completes paperwork, administrative tasks, and Demonstrates respect for assignments in a timely all members of the health manner care team

Comments:

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Leadership – Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5 Works effectively with Manages team efficiently Demonstrates leadership Demonstrates advanced Models leadership others on the treatment and effectively skills in adverse situations skills in leading qualities and teaches team and environments multidisciplinary teams others to be leaders

Motivates the team to high Develops the talents of performance others

Comments: Not yet achieved Level 1

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Health Care Team Communications – Interpersonal and Communication Skills

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates an Communicates effectively Resolves disagreements Negotiates and manages Is viewed as an exemplary understanding of the with attending staff with other health care conflict among care communicator, problem importance of effective members, peers, and other providers in a professional providers solver, and ambassador for communication with other health care providers manner the neurotology service providers Communicates effectively Conducts appropriate Generates clear and concise in times of crises transitions of care (e.g., documentation of patient hand-offs, sign-outs, interactions transfers of care)

Comments: Not yet achieved Level 1

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Patient- and Family-centered Care – Interpersonal and Communication Skills

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates an Communicates effectively Demonstrates effective Facilitates and participates Serves on local, regional, or understanding of the value with patients and families in communication with in patient/family/health national committees of patient- and family- the inpatient and outpatient challenging families care team conferences addressing ethical or centered care settings, with special advocacy issues consideration for Obtains thorough informed Mentors and teaches Obtains thorough informed communication with the consent for complex others patient and family- consent for routine hearing-impaired patient procedures centered communication procedures skills Uses interpreter services Appropriately uses multiple Demonstrates sensitivity in appropriately forms of communication caring for culturally diverse (e.g., e-mail, patient portal, patients social media) with respect for patient privacy

Comments: Not yet achieved Level 1