The Neurotology Milestone Project
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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. i 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 ii 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. 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 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. iv 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). v 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: 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. 2 Version 05/2014 Neurotology Milestones, ACGME Report Worksheet 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