pediatrics – psychiatry – child and adolescent …...pediatrics – psychiatry – child and...

Pediatrics – Psychiatry – Child and Adolescent Psychiatry (Combined) programs must annually report on each set of milestones.

The Pediatrics Milestone Project

A Joint Initiative of The Accreditation Council for Graduate Medical Education

and The American Board of Pediatrics

July 2017

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The Pediatrics Milestone Project

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

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Pediatrics Milestones

Working Group Advisory Group Chair: Carol Carraccio, MD, MA Carol Aschenbrener, MD

Bradley Benson, MD Richard Behrman, MD

Ann Burke, MD Timothy Brigham, MDiv, PhD

Robert Englander, MD, MPH Stephen Clyman, MD

Susan Guralnick, MD Eric Holmboe, MD

Patricia Hicks, MD, MHPE M. Douglas Jones Jr., MD

Stephen Ludwig, MD Gail McGuinness, MD

Daniel Schumacher, MD Victoria Norwood, MD

Jerry Vasilias, PhD Robert Perelman, MD

William Raszka, MD

Theodore Sectish, MD Susan Swing, PhD

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Milestone Reporting

This document presents milestones designed for programs to use in semi-annual review of resident performance and reporting to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced. The pediatrics milestones are designed to describe changes in observable attributes of the learner across the continuum of medical education from medical school through residency into practice. In the initial years of implementation, the Review Committee will examine milestone performance data for each program’s residents as one element in the Next Accreditation System (NAS) to determine whether residents overall are progressing. For each reporting period, review and reporting will involve selecting the level of milestones that best describes each resident’s current performance level in relation to milestones. Milestones are arranged into levels (See the figure on page iv). Progressing from Level 1 to Level 5 is synonymous with moving from novice to expert. Selection of a level implies that the resident substantially demonstrates the milestones in that level, as well as those in lower levels. Additional Notes Level 3 is designed as the graduation target but does not represent a graduation requirement. Making decisions about readiness for graduation is the purview of the residency program director (See the Milestones FAQ for further discussion of this issue: “Can a resident/fellow graduate if he or she does not reach every milestone?”). Study of Milestone performance data will be required before the ACGME and its partners will be able to determine whether Level 3 milestones and milestones in lower levels are in the appropriate level within the developmental framework, and whether Milestone data are of sufficient quality to be used for high stakes decisions.

Answers to Frequently Asked Questions about the Milestones are available on the Milestones web page: http://www.acgme.org/acgmeweb/Portals/0/MilestonesFAQ.pdf. A full report on the Pediatrics Milestone Project, including background information on each set of Milestones, is located at http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/320_PedsMilestonesProject.pdf.

http://www.acgme.org/acgmeweb/Portals/0/MilestonesFAQ.pdf

http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/320_PedsMilestonesProject.pdf

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The figure below presents an example set of milestones for one sub-competency in the same format as the milestone report worksheet. For each reporting period, a resident’s performance on the milestones for each sub-competency will be indicated by:

• selecting the level of milestones that best describes that resident’s performance in relation to the milestones or

• selecting the “Not yet Assessable” response option. This option should be used only when a resident has not yet had a learning experience in the sub-competency.

Selecting a response box in the middle of a level implies that milestones in that level and in lower levels have been substantially demonstrated.

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

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Copyright © 2012 Accreditation Council for Graduate Medical Education and American Board of Pediatrics. All rights reserved. The copyright owners grant third parties the right to use the Pediatrics Milestones on a non-exclusive basis for educational purposes.

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PEDIATRICS MILESTONES

ACGME Report Worksheet

PC1. Gather essential and accurate information about the patient

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Either gathers too little

information or exhaustively gathers information following a template regardless of the patient’s chief complaint, with each piece of information gathered seeming as important as the next. Recalls clinical information in the order elicited, with the ability to gather, filter, prioritize, and connect pieces of information being limited by and dependent upon analytic reasoning through basic pathophysiology alone

Clinical experience allows linkage of signs and symptoms of a current patient to those encountered in previous patients. Still relies primarily on analytic reasoning through basic pathophysiology to gather information, but has the ability to link current findings to prior clinical encounters allows information to be filtered, prioritized, and synthesized into pertinent positives and negatives, as well as broad diagnostic categories

Demonstrates an advanced development of pattern recognition that leads to the creation of illness scripts, which allow information to be gathered while simultaneously filtered, prioritized, and synthesized into specific diagnostic considerations. Data gathering is driven by real-time development of a differential diagnosis early in the information-gathering process

Creates well-developed illness scripts that allow essential and accurate information to be gathered and precise diagnoses to be reached with ease and efficiency when presented with most pediatric problems, but still relies on analytic reasoning through basic pathophysiology to gather information when presented with complex or uncommon problems

Creates robust illness scripts and instance scripts (where the specific features of individual patients are remembered and used in future clinical reasoning) that lead to unconscious gathering of essential and accurate information in a targeted and efficient manner when presented with all but the most complex or rare clinical problems. These illness and instance scripts are robust enough to enable discrimination among diagnoses with subtle distinguishing features

Comments:

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PC2. Organize and prioritize responsibilities to provide patient care that is safe, effective, and efficient

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Struggles to organize patient

care responsibilities, leading to focusing care on individual patients rather than multiple patients; responsibilities are prioritized as a reaction to unanticipated needs that arise (those responsibilities presenting the most significant crisis at the time are given the highest priority); even small interruptions in task often lead to a prolonged or permanent break in that task to attend to the interruption, making return to initial task difficult or unlikely

Organizes the simultaneous care of a few patients with efficiency; occasionally prioritizes patient care responsibilities to anticipate future needs; each additional patient or interruption in work leads to notable decreases in efficiency and ability to effectively prioritize; permanent breaks in task with interruptions are less common, but prolonged breaks in task are still common

Organizes the simultaneous care of many patients with efficiency; routinely prioritizes patient care responsibilities to proactively anticipate future needs; additional care responsibilities lead to decreases in efficiency and ability to effectively prioritize only when patient volume is quite large or there is a perception of competing priorities; interruptions in task are prioritized and only lead to prolonged breaks in task when workload or cognitive load is high

Organizes patient care responsibilities to optimize efficiency; provides care to a large volume of patients with marked efficiency; patient care responsibilities are prioritized to proactively prevent those urgent and emergent issues in patient care that can be anticipated; interruptions in task lead to only brief breaks in task in most situations

Serves as a role model of efficiency; patient care responsibilities are prioritized to proactively prevent interruption by routine aspects of patient care that can be anticipated; unavoidable interruptions are prioritized to maximize safe and effective multitasking of responsibilities in essentially all situations

Comments:

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PC3. Provide transfer of care that ensures seamless transitions

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Demonstrates variability in

transfer of information (content, accuracy, efficiency, and synthesis) from one patient to the next; makes frequent errors of both omission and commission in the hand-off

Uses a standard template for the information provided during the hand-off; is unable to deviate from that template to adapt to more complex situations; may have errors of omission or commission, particularly when clinical information is not synthesized; neither anticipates nor attends to the needs of the receiver of information

Adapts and applies a standardized template, relevant to individual contexts, reliably and reproducibly, with minimal errors of omission or commission; allows ample opportunity for clarification and questions; is beginning to anticipate potential issues for the transferee

Adapts and applies a standard template to increasingly complex situations in a broad variety of settings and disciplines; ensures open communication, whether in the receiver- or the provider-of-information role, through deliberative inquiry, including read-backs, repeat-backs (provider), and clarifying questions (receivers)

Adapts and applies the template without error and regardless of setting or complexity; internalizes the professional responsibility aspect of hand-off communication, as evidenced by formal and explicit sharing of the conditions of transfer (e.g., time and place) and communication of those conditions to patients, families, and other members of the health care team

Comments:

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PC4. Make informed diagnostic and therapeutic decisions that result in optimal clinical judgment

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Recalls and presents clinical

facts in the history and physical in the order they were elicited without filtering, reorganization, or synthesis; demonstrates analytic reasoning through basic pathophysiology results in a list of all diagnoses considered rather than the development of working diagnostic considerations, making it difficult to develop a therapeutic plan

Focuses on features of the clinical presentation, making a unifying diagnosis elusive and leading to a continual search for new diagnostic possibilities; largely uses analytic reasoning through basic pathophysiology in diagnostic and therapeutic reasoning; often reorganizes clinical facts in the history and physical examination to help decide on clarifying tests to order rather than to develop and prioritize a differential diagnosis, often resulting in a myriad of tests and therapies and unclear management plans, since there is no unifying diagnosis

Abstracts and reorganizes elicited clinical findings in memory, using semantic qualifiers (such as paired opposites that are used to describe clinical information [e.g., acute and chronic]) to compare and contrast the diagnoses being considered when presenting or discussing a case; shows the emergence of pattern recognition in diagnostic and therapeutic reasoning that often results in a well-synthesized and organized assessment of the focused differential diagnosis and management plan

Reorganizes and stores clinical information (illness and instance scripts) that lead to early directed diagnostic hypothesis testing with subsequent history, physical examination, and tests used to confirm this initial schema; demonstrates well-established pattern recognition that leads to the ability to identify discriminating features between similar patients and to avoid premature closure; Selects therapies that are focused and based on a unifying diagnosis, resulting in an effective and efficient diagnostic work-up and management plan tailored to address the individual patient

Current literature does not distinguish between behaviors of proficient and expert practitioners. Expertise is not an expectation of GME training, as it requires deliberate practice over time

Comments:

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PC5. Develop and carry out management plans

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Develops and carries out

management plans based on directives from others, either from the health care organization or the supervising physician; is unable to adjust plans based on individual patient differences or preferences; communication about the plan is unidirectional from the practitioner to the patient and family

Develops and carries out management plans based on one’s theoretical knowledge and/or directives from others; can adapt plans to the individual patient, but only within the framework of one’s own theoretical knowledge; is unable to focus on key information, so conclusions are often from arbitrary, poorly prioritized, and time-limited information gathering; develops management plans based on the framework of one’s own assumptions and values

Develops and carries out management plans based on both theoretical knowledge and some experience, especially in managing common problems; follows health care institution directives as a matter of habit and good practice rather than as an externally imposed sanction; is able to more effectively and efficiently focus on key information, but still may be limited by time and convenience; begins to incorporate patients’ assumptions and values into plans through more bidirectional communication

Develops and carries out management plans based most often on experience; effectively and efficiently focuses on key information to arrive at a plan; incorporates patients’ assumptions and values through bidirectional communication with little interference from personal biases

Develops and carries out management plans, even for complicated or rare situations, based primarily on experience that puts theoretical knowledge into context; rapidly focuses on key information to arrive at the plan and augments that with available information or seeks new information as needed; has insight into one’s own assumptions and values that allow one to filter them out and focus on the patient/family values in a bidirectional conversation about the management plan

Comments:

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MK1. Critically evaluate and apply current medical information and scientific evidence for patient care

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Explains basic principles of

Evidence-based Medicine (EBM), but relevance is limited by lack of clinical exposure

Recognizes the importance of using current information to care for patients and responds to external prompts to do so; is able to formulate questions with significant effort and time; online search efficiency is minimal; (e.g., may require multiple search strategies); knows how to read and interpret the literature but requires guidance for application

Identifies knowledge gaps as learning opportunities; makes an effort to ask answerable questions on a regular basis and is becoming increasingly able to do so; understands varying levels of evidence and can utilize advanced search methods; is able to critically appraise a topic by analyzing the major outcomes, however, may need guidance in understanding the subtleties of the evidence; begins to seek and apply evidence when needed, not just when assigned to do so

Formulates answerable clinical questions regularly; incorporates use of clinical evidence in rounds and teaches fellow learners; is quite capable with advanced searching; is able to critically appraise topics and does so regularly; shares findings with others to try to improve their abilities; practices EBM because of the benefit to the patient and the desire to learn more rather than in response to external prompts

Teaches critical appraisal of topics to others; strives for change at the organizational level as dictated by best current information; is able to easily formulate answerable clinical questions and does so with majority of patients as a habit; is able to effectively and efficiently search and access the literature; is seen by others as a role model for practicing EBM

Comments:

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SBP1. Coordinate patient care within the health care system relevant to their clinical specialty

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Performs the role of medical

decision-maker, developing care plans and setting goals of care independently; informs patient/family of the plan, but no written care plan is provided; makes referrals, and requests consultations and testing with little or no communication with team members or consultants; is not involved in the transition of care between settings (e.g., outpatient and inpatient, pediatric and adult); shows little or no recognition of social/educational/cultural issues affecting the patient/family

Begins to involve the patient/family in setting care goals and some of the decisions involved in the care plan; a written care plan is occasionally made available to the patient/family; care plan does not address key issues; has variable communication with team members and consultants regarding referrals, consultations, and testing; answers patient/family questions regarding results and recommendations; may inconsistently be involved in the transition of care between settings (e.g., outpatient and inpatient, pediatric and adult); makes some assessment of social/educational/cultural issues affecting the patient/family and applies this in interactions

Recognizes the responsibility to assist families in navigation of the complex health care system; frequently involves patient/family in decisions at all levels of care, setting goals, and defining care plans; frequently makes a written care plan available to the patient/family and to appropriately authorized members of the care team; care plan omits few key issues; has good communication with team members and consultants; consistently discusses results and recommendations with patient/family; is routinely involved in the transition of care between settings (e.g., outpatient and inpatient, pediatric and adult); considers social, educational and cultural issues in most care interactions

Actively assists families in navigating the complex health care system; has open communication, facilitating trust in the patient-physician interaction; develops goals and makes decisions jointly with the patient/family (shared-decision-making); routinely makes a written care plan available to the patient/family and to appropriately authorized members of the care team; makes a thorough care plan, addressing all key issues; facilitates care through consultation, referral, testing, monitoring, and follow-up, helping the family to interpret and act on results/recommendations; coordinates seamless transitions of care between settings (e.g., outpatient and inpatient, pediatric and adult; mental and dental health; education; housing; food security; family-to-family


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support); builds partnerships that foster family-centered, culturally-effective care, ensuring communication and collaboration along the continuum of care

Comments:

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SBP2. Advocate for quality patient care and optimal patient care systems

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Attends to medical needs of

individual patient(s); wants to take good care of patients and takes action for individual patients’ health care needs Example: Sees a child with a firearm injury and provides good care.

Demonstrates recognition that an individual patient’s issues are shared by other patients, that there are systems at play, and that there is a need for quality improvement of those systems; acts on the observed need to assess and improve quality of care Example: A physician notes on rounds, “We have sent home four-to-five firearm-injury patients and one has come back with repeated injury. We need to do something about that.”

Acts within the defined medical role to address an issue or problem that is confronting a cohort of patients; may enlist colleagues to help with this problem Example: The physician works with colleagues to develop an approach, protocol, or procedure for improving care for penetrating trauma injury in children and measures the outcomes of system changes.

Actively participates in hospital-initiated quality improvement and safety actions; demonstrates a desire to have an impact beyond the hospital walls Example: The physician attends a hospital symposium on gun-related trauma and what can be done about it and then arranges to speak on gun safety at the local meeting of the parent-teachers association.

Identifies and acts to begin the process of improvement projects both inside the hospital and within one’s practice community Example: Upon completion of quality improvement project, the physician works on new proposed legislation and testifies in City Council.

Comments:

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SBP3. Work in inter-professional teams to enhance patient safety and improve patient care quality

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Seeks answers and responds to

authority from only intra-professional colleagues; does not recognize other members of the interdisciplinary team as being important or making significant contributions to the team; tends to dismiss input from other professionals aside from other physicians

Is beginning to have an understanding of the other professionals on the team, especially their unique knowledge base, and is open to their input, however, still acquiesces to physician authorities to resolve conflict and provide answers in the face of ambiguity; is not dismissive of other health care professionals, but is unlikely to seek out those individuals when confronted with ambiguous situations

Aware of the unique contributions (knowledge, skills, and attitudes) of other health care professionals, and seeks their input for appropriate issues, and as a result, is an excellent team player

Same as Level 3, but an individual at this stage understands the broader connectivity of the professions and their complementary nature; recognizes that quality patient care only occurs in the context of the inter-professional team; serves as a role model for others in interdisciplinary work and is an excellent team leader


Comments:

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PBLI1. Identify strengths, deficiencies, and limits in one’s knowledge and expertise

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

The learner acknowledges

external assessments, but understanding of his performance is superficial and limited to the overall grade or bottom line; has little understanding of how the performance measure relates in a meaningful way to his specific level of Knowledge, Skills and Attitudes (KSA)

Assessment of performance is seen as being able to do or not do the task at hand without appreciation for how well it is done and whether there is a need to improve the outcome

Prompts for understanding specifics of level of performance are internal and may be identified in response to uncertainty, discomfort, or tension in completing clinical duties; evidence of this stage is demonstrated by active questioning and application of knowledge in developing a rationale for care plans or in teaching activities

Prompted by anticipation or contemplation of potential clinical problems, the learner self-identifies gaps in KSA through reflection that assesses current KSA versus understanding of underlying basic science or pathophysiologic principles to generate new questions about limitations or mastery of KSA; evidence of this stage can be determined by the advanced nature and level of questioning or resource seeking

Prompted by a self-directed goal of improving the professional self, the practitioner anticipates hypothetical clinical scenarios that build on current experience and systematically addresses identified gaps to enhance the level of KSA; elaborate questioning occurs to further explore gaps and strengths

Example: During a semiannual review, a learner is unable to describe in any specific terms how he has performed when asked to do so by his mentor. In response, the mentor reviews and interprets the learner’s evaluations and then asks the learner to reflect on the discussion. The learner repeats the language used and recites the overall score/grade

Example: The learner seeks external assessment of performance as ability “to do” or “not able to do” with little understanding of what the assessment means. “Are these orders written correctly?” “Did I do that correctly?” Seeks feedback approval on whether KSA were “right” or “wrong.”

Example: Learner requests elaboration, clarification, or expansion on patient-care related task. “Why would we use this antibiotic for this condition?” or “The patient has underlying condition x. Does that alter therapy y for this patient?” or “I think we should order study w

Example: In caring for a patient with an illness not previously encountered, this practitioner says, “I have experience taking care of patients with this acute illness but have never had a patient with this acute illness who also had this particular underlying condition and wonder if

Example: In caring for a patient, a practitioner becomes aware of a gap in KSA, and in response (with or without consultation from a mentor) seeks to understand more about the identified KSA gap. A PICO-formatted question (P = Patient, I = Intervention, C = Comparison, O =

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without interpretation of further meaning or inference regarding the reported performance assessment

Does not seek “How?” or “Why?” as part of request for feedback to assist identification of KSA.

for this patient, since sometimes this disease presents with underlying condition z.”

the chronic condition might alter his clinical course?”

Outcome) is constructed, followed by a process of identification of learning needed.

Comments:

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PBLI2. Identify and perform appropriate learning activities to guide personal and professional development

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Sets learning activities based

on readily available curricular materials, irrespective of learning style, preferences, appropriateness of activity, or any outcome measures Example: After realizing a need to better understand what medications should be used in the management of a clinic patient with moderate asthma, the learner asks a peer who is working with him in clinic rather than pursuing the references suggested by his clinic preceptor.

Well-defined goals are mapped to appropriate learning activities and resources based on assigned curriculum; assignment may be part of a teacher-constructed curriculum, or part of a prescribed curriculum offered by others, or sought by the learner in response to a performance gap Example: A learner reads cases assigned for primary care in advance of coming to a scheduled clinic session where a discussion of the cases is to take place. Others have not read the case, and after the session the resident is left wondering about the case and its relevance to overall

Learning resources are sought based on analysis of learning needs assessment and constructed goals, and with consideration of the nature of the learning content and method Example: Having failed at intubation in the delivery room, the learner goes back to the simulation lab to receive further training on intubation with the manikin (and does not simply reread the Neonatal Resuscitation Protocol10).

Consideration of choice of activities is based on instructional methods that are known to be effective in the development of the relevant knowledge content, application of that knowledge, and development of skills or behaviors; learning takes place through collaborative interface with experts in which learning activities sought are ones that allow for constant course correction and interactive sharing of alternative perspectives and differing lenses Example: A learner is planning an advocacy workshop for parents of children with complex medical needs to improve their skills with managing medical devices. In the process of preparing for this workshop, he discovers that there is an in-service for parents of hospitalized patients in

Seeking resources to learn is undertaken with high efficiency and effectiveness, with open and flexible inclusion of the influences from outside sources (including regulatory and oversight groups); fruitful pathways and resources for learning are readily shared with peers and self-assessment of learning drives further resource seeking Example: The learner seeks to expand the types of devices discussed in the workshop and looks to the work published by the Institute of Medicine Committee on Safe Medical Devices for Children.11 He decides to pursue resources (experts in the field) to see if it would be possible to learn how to provide the

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learning. The case is part of a core curriculum with learning goals and objectives. Later, in clinic a patient presents with a problem similar to last week’s case discussion, and the learner is able to go back to that case to glean further information on how to manage the patient.

how to care for devices and participates in this learning activity. Through this in-service, he identifies written resources, models useful for demonstrations, and video-recorded illustrations of anticipated complications with device use. He chooses to conduct a practice rehearsal with some families in the inpatient setting, with course correction from the hospital’s nurse-educator.

instructional materials, plans, and workshops to parents throughout the state.

Comments:

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PBLI3. Systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Unable to gain insight from

encounters due to a lack of reflection on practice; does not understand the principles of quality improvement methodology or change management; is defensive when faced with data on performance improvement opportunities within one’s practice

Able to gain insight from reflection on individual patient encounters, but potential improvements are limited by a lack of systematic improvement strategies and team approach; is dependent upon external prompts to define improvement opportunities at the population level

Able to gain insight for improvement opportunities from reflection on both individual patients and populations; grasps improvement methodologies enough to apply to populations; is still reliant on external prompts to inform and prioritize improvement opportunities at the population level

Able to use both individual encounters and population data to drive improvement using improvement methodology; analyzes one’s own data on a continuous basis, without reliance on external forces, to prioritize improvement efforts, and uses that analysis in an iterative process for improvement; is able to lead a team in improvement

In addition to demonstrating continuous improvement activities and appropriately utilizing quality improvement methodologies, thinks and acts systemically to try to use one’s own successes to benefit other practices, systems, or populations; is open to analysis that at times requires course correction to optimize improvement

Comments:

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PBLI4. Incorporate formative evaluation feedback into daily practice

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Has difficulty in considering

others’ points of view when these differ from his or her own, leading to defensiveness and inability to receive feedback and/or avoidance of feedback; demonstrates a limited incorporation of formative feedback into daily practice

Is dependent on external sources of feedback for improvement; is beginning to acknowledge other points of view, but reinterprets feedback in a way that serves his or her own need for praise or consequence avoidance, rather than informing a personal quest for improvement; little to no behavioral change occurs in response to feedback (e.g., listens to feedback but takes away only those messages he or she wants to hear)

Understands others’ points of view and changes behavior to improve specific deficiencies that are noted by others (e.g., understands that the perceptions of others are important even when those perceptions are different from his or her own, (such as when a nurse interprets a response as abrupt when it was not intended to be) causing the learner to examine what prompted this perception)

Internal sources of feedback allow for insight into limitations and engagement in self-regulation; improves daily practice based on both external formative feedback and internal insights (e.g., is able to point out what went well and what did not go well in a given encounter, and makes positive changes in behavior as a result)

Demonstrates professional maturity and deep emotional commitment that lead to deliberate practice and result in the habits of continuous reflection, self-regulation, and internal feedback and that lead to continuous improvement beyond a focus solely on deficiencies

Comments:

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PROF1. Demonstrate humanism, compassion, integrity, and respect for others; based on the characteristics of an empathetic practitioner

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Interacts with patients and

families in a way that is detached and not sensitive to the human needs of the patient and family

Demonstrates compassion for patients in selected situations (e.g., tragic circumstances, such as unexpected death), but has a pattern of conduct that demonstrates a lack of sensitivity to many of the needs of others

Demonstrates consistent understanding of patient and family expressed needs and a desire to meet those needs on a regular basis; is responsive in demonstrating kindness and compassion

Goes beyond responding to expressed needs of patients and families; is altruistic and anticipates the human needs of patients and families and works to meet those needs as part of her skills in daily practice

Proactively advocates on behalf of individual patients, families, and groups of children in need

Comments:

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PROF2. Professionalization: A sense of duty and accountability to patients, society, and the profession

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Appears to be interested in

learning pediatrics but not fully engaged and involved as a professional, which results in an observational or passive role

Appreciates the role in providing care and being a professional, at times has difficulty in seeing self as a professional, which may result in not taking appropriate primary responsibility

Demonstrates understanding and appreciation of the professional role and the gravity of being the “doctor” by becoming fully engaged in patient care activities; has a sense of duty; has rare lapses into behaviors that do not reflect a professional self-view

Internalizes and accepts full responsibility of the professional role and develops fluency with patient care and professional relationships in caring for a broad range of patients and team members

Extends professional role beyond the care of patients and sees self as a professional who is contributing to something larger (e.g., a community, a specialty, or the medical profession)

Comments:

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PROF3. Professional Conduct: High standards of ethical behavior which includes maintaining appropriate professional boundaries

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Demonstrates repeated lapses

in professional conduct wherein responsibility to patients, peers, and/or the program are not met. These lapses may be due to an apparent lack of insight about the professional role and expected behaviors or other conditions or causes (e.g., depression, substance use, poor health)

Demonstrates lapses in professional conduct under conditions of stress or fatigue, that lead others to engage in reminding about and, enforcing professional behaviors as well as resolving conflicts; there may be some insight into behavior, but an inability to modify behavior when placed in stressful situations

Conducts interactions In nearly all circumstances with a professional mindset, sense of duty, and accountability; demonstrates conduct that illustrates insight into her own behavior, as well as likely triggers for professionalism lapses, and is able to use this information to remain professional

Demonstrates an in-depth understanding of professionalism that allows her to help other team members and colleagues with issues of professionalism; demonstrates self-reflection to identify and voice insights to prevent lapses in conduct as part of her duty to help others

Role models professional conduct; interactions with patients, families, and peers demonstrates high ethical standards across settings and circumstances; utilizes excellent emotional intelligence about human behavior and insight into self, to promote and engage in professional behavior as well as to prevent lapses in others and self

Comments:

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PROF4. Self-awareness of one’s own knowledge, skill, and emotional limitations that leads to appropriate help-seeking behaviors

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Demonstrates limited insight

into limitations in knowledge, skills or attitudes which results in the learner not seeking help when needed, sometimes resulting in unintended consequences

Expresses concern that limitations may be seen as weaknesses that will negatively impact evaluations; this results in help-seeking behaviors, typically only in response to external prompts rather than internal drive

Recognizes limitations, but has the perception that autonomy is a key element of one’s identity as a physician, and the need to emulate this behavior to belong to the profession may interfere with internal drive to engage in appropriate help-seeking behavior

Recognizes limitations and has matured to the stage where a personal value system of help-seeking for the sake of the patient supersedes any perceived value of physician autonomy, resulting in appropriate requests for help when needed

Demonstrates the personal drive to learn and improve results in the habit of engaging in help-seeking behaviors and explicitly role modeling and encouraging these behaviors in others

Comments:

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PROF5. Trustworthiness that makes colleagues feel secure when one is responsible for the care of patients

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Demonstrates gaps or is

unaware of significant knowledge, skills or attitudes (KSA) gaps; demonstrates lapses in data-gathering or in follow-through of assigned tasks; may misrepresent data (for a number of reasons) or omit important data, leaving others uncertain as to the nature of the learner’s truthfulness or awareness of the importance of attention to detail and accuracy (overt lack of truth-telling is assessed in another professionalism competency) Example: * A learner calls his supervisor at home to present a patient that he admitted. Key laboratory results are missing in the presentation and the supervisor requests that the learner seek this critical information and report back. Several hours later

Demonstrates gaps in KSA, but does not always voice awareness of or seek help when confronted with limitations; demonstrates lapses in follow-up or follow-through with tasks, despite awareness of the importance of these tasks; follow-through may be limited due to inconsistency or yielding to barriers; when such barriers are experienced, no escalation occurs (such as notifying others or pursuing alternative solutions) Example: On hand-over of patients from the day team to the night team, several tasks are identified as needing follow-up or completion during the next shift. The following day, when the service is handed back over

Demonstrates inadequate level of KSA for the level of clinical responsibility, with realistic insight into limits with responsive help seeking; data-gathering is complete with consideration of anticipated patient care needs, and careful consideration of high-risk conditions first and foremost; little prompting is required for follow-up Example: Presentation of a patient consultation is done in a comprehensive manner, without the need for prompting. Questions posed by the learner allow the consultant to appreciate the learner’s

Demonstrates competent level of KSA for the level of clinical responsibility and assumes full responsibility for all aspects of patient care, anticipating problems and demonstrating vigilance in all aspects of management; pursues answers to questions, and communications include open, transparent expression of uncertainty and limits of knowledge Example: An individual possesses the KSA to lead the team on rounds, asking for pertinent data not presented by other team members (assertive inquiry). Constant review and vigilance of patient

Demonstrates competent level of KSA for the level of clinical responsibility and assumes full responsibility for all aspects of patient care, anticipating problems and demonstrating vigilance in all aspects of management; pursues answers to questions, and communications include open, transparent expression of uncertainty and limits of knowledge; uncertainty brings about rigorous search for answers and conscientious and ongoing review of information; may seek the help of a consultant in addition to primary source literature Example: This is the practitioner who leaves no stone unturned. Colleagues are confident when handing-off a patient that the patient will receive exemplary care. In fact, when there is a complex patient, colleagues are

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on rounds, the learner is again questioned about the laboratory values, and reports that the results are normal, but is unable to locate those results in his paperwork. D-2, C-1, T-2 KSA= Knowledge, skills &

attitudes D= Discernment C= Conscientiousness T= Truth telling Number refers to

performance level (1-5)

to the original learner, several of these tasks were either incomplete or not completed as specified in the sign-out. When questioned about these tasks, the night-float individual indicated that things were busy, he forgot, or gives another excuse indicating an awareness of the expectation but failure to complete the tasks. KSA-3, D-2, C-3

understanding of the disease process and the learners’ awareness of gaps in his knowledge. Careful attention to detail and accuracy are evident in the history and physical examination that is presented. The next day, the service is busy and the learner needs reminding to re-check the send-out labs. KSA-3, D-3, C-3

status uncovers unexplained findings on laboratory or physical examination. Findings are reported to supervisors as change with un-identified meaning (and potential concern). KSA-4, D-4, T-4

relieved when this practitioner is on-call because he typically invests much time and energy in searching for needed answers and meticulously reports back on all important developments. KSA-4, D-4, C-4, T-4

Comments:

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PROF6. Recognize that ambiguity is part of clinical medicine and to recognize the need for and to utilize appropriate resources in dealing with uncertainty

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Demonstrates state of being

overwhelmed and unsure when faced with uncertainty or ambiguity; communications with patients/families and development of therapeutic plan are approached in a limited and authoritarian manner;; patient/family numeracy (understanding of probability/risk) is presumed; seeks only self or self-available resources to manage response to this uncertainty, resulting in a response characterized by their (individual) preexisting state of risk aversion or risk taking; does not regard patient need for hope; feels compelled to make sure that patients understand full potential for negative outcome (defensive/protective of physician)

Expresses recognition of uncertainty and the tension/pressure from not knowing or knowing with limited control of outcomes; explains situation to the patient in framework most familiar to the physician, rather than framing it with terms, graphics, or analogies familiar to the patient; seeks rules and statistics and feels compelled to transfer all information to the patient immediately, regardless of patient readiness, patient goals, and patient ability to manage information

Anticipates and focuses on uncertainty, looking for resolution by seeking additional information; informs the patient of the more optimal outcome(s), framed by physician goals; does not manage overall balance of patient/family uncertainty with quality of life, need for hope, and ability to adhere to therapeutic plan; focuses on own risk management position for a given problem and does not suggest that more or less risk taking (different from physician’s position) could be chosen; still seeks patient/parent recitation of uncertainty/morbidity as proof that patient/family understands the uncertainty; unresolved balance of physician/patient expectations with physician expectations taking precedence

Anticipates that uncertainty at the time of diagnostic deliberation will be likely; uses such uncertainty or ambiguity as a prompt/motivation to seek information or understanding of unknown (to self or world); balances delivery of diagnosis with hope, information, and exploration of individual patient goals; works through concepts of risk versus hope using conceptual framework that includes cost (e.g., suffering, lifestyle changes, financial) versus benefit, framed by patient health care goals; expresses openness to patient position and patient uncertainty about his or her position and response

Acknowledges and manages personal level of risk aversion or risk-taking tendencies; seeks to understand patient/family goals for health and their capacity to achieve those goals,; engages in discussion with high sensitivity towards health literacy and numeracy, emphasizing patient/family control of choices; openly and comfortably discusses strategies and outcomes anticipated with the patient/family, emphasizing that all plans are subject to the imperfect knowledge and state of uncertainty; ongoing information sharing through changes as knowledge and patient health status evolve; remains flexible and committed to engagement with the patient/family throughout the patient’s illness, serving as a

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resource to gather information; constant revisiting of knowledge, uncertainty, and developed plans is balanced with acceptance of what is unknown; transparent communication of limits of treatment plan outcomes

Comments:

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ICS1. Communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Uses standard medical

interview template to prompt all questions; does not vary the approach based on a patient’s unique physical, cultural, socioeconomic, or situational needs; may feel intimidated or uncomfortable asking personal questions of patients

Uses the medical interview to establish rapport and focus on information exchange relevant to a patient’s or family’s primary concerns; identifies physical, cultural, psychological, and social barriers to communication, but often has difficulty managing them; begins to use non-judgmental questioning scripts in response to sensitive situations

Uses the interview to effectively establish rapport; is able to mitigate physical, cultural, psychological, and social barriers in most situations; verbal and non-verbal communication skills promote trust, respect, and understanding; develops scripts to approach most difficult communication scenarios

Uses communication to establish and maintain a therapeutic alliance; sees beyond stereotypes and works to tailor communication to the individual; a wealth of experience has led to development of scripts for the gamut of difficult communication scenarios; is able to adjust scripts ad hoc for specific encounters

Connects with patients and families in an authentic manner that fosters a trusting and loyal relationship; effectively educates patients, families, and the public as part of all communication; intuitively handles the gamut of difficult communication scenarios with grace and humility

Comments:

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ICS2. Demonstrate the insight and understanding into emotion and human response to emotion that allows one to appropriately develop and manage human interactions

Not yet Assessable

Level 1

Level 2

Level 3

Level 4

Level 5

Does not accurately anticipate

or read others’ emotions in verbal and non-verbal communication; is unaware of one’s own emotional and behavioral cues and may transmit emotions in communication (e.g., anxiety, exuberance, anger) that can precipitate unintended emotional responses in others; does not effectively manage strong emotions in oneself or others

Begins to use past experiences to anticipate and read (in real time) the emotional responses in himself and others across a limited range of medical communication scenarios, but does not yet have the ability or insight to moderate behavior to effectively manage the emotions; strong emotions in oneself and others may still become overwhelming

Anticipates, reads, and reacts to emotions in real time with appropriate and professional behavior in nearly all typical medical communication scenarios, including those evoking very strong emotions; uses these abilities to gain and maintain therapeutic alliances with others

Perceives, understands, uses, and manages emotions in a broad range of medical communication scenarios and learns from new or unexpected emotional experiences; effectively manages own emotions appropriately in all situations; effectively and consistently uses emotions to gain and maintain therapeutic alliances with others; is perceived as a humanistic provider

Intuitively perceives, understands, uses, and manages emotions to improve the health and well-being of others and to foster therapeutic relationships in any and all situations; is seen as an authentic role model of humanism in medicine

Comments:

July 2015

The Psychiatry Milestone Project

A Joint Initiative of

The Accreditation Council for Graduate Medical Education

and

The American Board of Psychiatry and Neurology

i

The Psychiatry Milestone Project

The Milestones are designed only for use in evaluation of resident physicians in the context of their participation

in ACGME-accredited residency or fellowship programs. The Milestones provide a framework for the assessment

of the development of the resident physician in key dimensions of the elements of physician competency in a

specialty or subspecialty. They neither represent the entirety of the dimensions of the six domains of physician

competency, nor are they designed to be relevant in any other context.

ii

Psychiatry Milestone Group

Christopher R. Thomas MD, Chair

Working Group Advisory Group

Sheldon Benjamin, MD Timothy Brigham, MDiv, PhD

Adrienne L. Bentman, MD Carol A. Bernstein, MD

Robert Boland , MD Beth Ann Brooks, MD

Deborah S. Cowley, MD Larry R. Faulkner, MD

Jeffrey Hunt, MD, MS Deborah Hales, MD

George A. Keepers, MD Victor I. Reus, MD

Louise King, MS Richard F. Summers, MD

Gail H. Manos, MD

Donald E. Rosen, MD

Kathy M. Sanders, MD

Mark E. Servis, MD

Kallie Shaw, MD

Susan Swing, PhD

Alik Widge, MD, PhD

iii

Milestone Reporting

This document presents milestones designed for programs to use in semi-annual review of resident performance and reporting to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced. They are descriptors and targets for resident performance as a resident progresses from entry into residency through graduation. In the initial years of implementation, the Review Committee will examine aggregate milestone performance data for each program’s residents as one element in the Next Accreditation System to determine whether residents overall are progressing. Thus, aggregate resident performance will be an additional measure of a program’s ability to educate its residents. Program directors have the responsibility of ensuring that residents’ progress on all 22 psychiatry subcompetencies (as identified in the top row of each milestone table) is documented every six months through the Clinical Competency Committee (CCC) review process. The CCC’s decisions should be guided by information gathered through formal and informal assessments of residents during the prior six-month period. The ACGME does not expect formal, written evaluations of all milestones (each numbered item within a subcompetency table) every six months. For example, formal evaluations, documented observed encounters in inpatient and outpatient settings, and multisource evaluation should focus on those subcompetencies and milestones that are central to the resident’s development during that time period. Progress through the Milestones will vary from resident to resident, depending on a variety of factors, including prior experience, education, and capacity to learn. Residents learn and demonstrate some skills in episodic or concentrated time periods (e.g., formal presentations, participation in quality improvement project, child/adolescent rotation scheduling, etc.). Milestones relevant to these activities can be evaluated at those times. The ACGME does not expect that resident progress will be linear in all areas or that programs organize their curricula to correspond year by year to the Psychiatry Milestones. All milestone threads (as indicated by the letter in each milestone reference number, the “A” in PC1, 1.1/A ) should be formally evaluated and discussed by the CCC on at least two occasions during a resident’s educational program. Thread names, preceded by their indicator letters, are listed in the top row of each milestone table. Each thread describes a type of activity, behavior, skill, or knowledge, and typically consists of two-to-four milestones at different levels. For example, the “B” thread for PC1, named “collateral information gathering and use,” consists of the set of progressively more advanced and comprehensive behaviors identified as 1.2/B, 2.3/B, 3.3/B, 4.2/B, 4.3/B and 5.2/A,B. The thread identifies the unit of observation and evaluation. For, PC1, thread “B,” faculty members would observe a resident’s evaluation of a patient to see whether he or she demonstrates the

iv

collateral information gathering and use behaviors described in that milestone. Threads do not always have milestones at each level 1-5; some threads may consist of only one milestone (see the diagram on page vi). For each six-month reporting period, review and reporting will involve selecting the level of milestones that best describes a resident’s current performance level. Milestones are arranged into numbered levels. These levels do not correspond with post-graduate year of education. Selection of a level for a subcompetency implies that the resident substantially demonstrates the milestones in that level, as well as those in lower levels (see the diagram on page vi). A general interpretation of levels for psychiatry is below:

Has not Achieved Level 1: The resident does not demonstrate the milestones expected of an incoming resident.

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

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

Level 3: The resident continues to advance and demonstrate additional milestones; the resident demonstrates the majority of milestones targeted for residency in this sub-competency.

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

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

*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 residency program (See the Milestones FAQ for further discussion of this issue: “Can a

resident/fellow graduate if he or she does not reach every milestone?”). Study of Milestone performance data will be required

before the ACGME and its partners will be able to determine whether Level 4 milestones and milestones in lower levels are in the

appropriate level within the developmental framework, and whether Milestone data are of sufficient quality to be used for high

stakes decisions.

v

Selecting the Appropriate Milestone Level for your Residents: The Role of Supervision Faculty supervisors, especially those overseeing clinical care, will directly assess many milestones. The CCC assessment is based on evaluations completed by these clinical supervisors along with other assessments, including performance on tests and evaluations from other sources. The process of Milestone assignment assumes that all residents are supervised in their clinical work, as outlined in the ACGME’s supervision levels and requirements. For the purposes of evaluating a resident’s progress in achieving Patient Care and Medical Knowledge Milestones, though, it is important that the evaluator(s) determine what the resident knows and can do, separate from the skills and knowledge of his or her supervisor. Implicit in milestone level evaluation of Patient Care (PC) and Medical Knowledge (MK) is the assumption that during the normal course of patient care activities and supervision, the evaluating faculty member and resident participate in a clinical discussion of the patient's care. During these reviews the resident should be prompted to present his or her clinical thinking and decisions regarding the patient. This may include evidence for a prioritized differential diagnosis, a diagnostic workup, or initiation, maintenance, or modification of the treatment plan, etc. In offering his or her independent ideas, the resident demonstrates his or her capacity for clinical reasoning and its application to patient care in real-time. As residents progress, their knowledge and skills should grow, allowing them to assume more responsibility and handle cases of greater complexity. They are afforded greater autonomy - within the bounds of the ACGME supervisory guidelines - in caring for patients. At Levels 1 and 2 of the Milestones, a resident's knowledge and independent clinical reasoning will meet the needs of patients with lower acuity, complexity, and level of risk, whereas, at Level 4, residents are expected to independently demonstrate knowledge and reasoning skills in caring for patients of higher acuity, complexity, and risk. Thus, one would expect residents achieving Level 4 milestones to be senior residents at an oversight level of supervision. In general, one would not expect beginning or junior residents to achieve Level 4 milestones. At all levels, it is important that residents ask for, listen to, and process the advice they receive from supervisors, consult the literature, and incorporate this supervisory input and evidence into their thinking. Additional Notes Please note that most milestone sets include explanatory footnotes for selected concepts. These appear at the bottom of each milestone table. The footnotes are essential tools in milestone evaluation.

vi

The diagram below presents an example set of milestones for one sub-competency in the same format as the milestone report

worksheet. For each reporting period, a resident’s performance on the milestones for each sub-competency will be indicated by:

selecting the level of milestones that best describes the resident’s performance in relation to those milestones or

selecting the “Has not Achieved Level 1” response option



Competency Domain

Subcompetency Thread for: “Development as a teacher” (all milestones with “A”) Thread Names

Milestone

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The Milestones are a product of the Psychiatry Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology. 1

PSYCHIATRY MILESTONES ACGME Report Worksheet

PC1. Psychiatric Evaluation A: General interview skills B: Collateral information gathering and use C: Safety assessment D: Use of clinician's emotional response

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Obtains general medical and psychiatric history and completes a mental status examination

1.2/B Obtains relevant collateral information from secondary sources

1.3/C Screens for patient safety, including suicidal and homicidal ideation

2.1/A Acquires efficient, accurate, and relevant history customized to the patient’s complaints 2.2/A Performs a targeted examination, including neurological examination, relevant to the patient’s complaints

2.3/B Obtains information that is sensitive and not readily offered by the patient

2.4/C Assesses patient safety, including suicidal and homicidal ideation 2.5/D Recognizes that the clinician’s emotional responses have diagnostic value1

3.1/A Consistently obtains complete, accurate, and relevant history

3.2/A Performs efficient interview and examination with flexibility appropriate to the clinical setting and workload demands 3.3/B Selects laboratory and diagnostic tests appropriate to the clinical presentation 3.4/B Uses hypothesis-driven information gathering techniques2

4.1/A Routinely identifies subtle and unusual findings

4.2/B Follows clues to identify relevant historical findings in complex clinical situations and unfamiliar circumstances 4.3/D Begins to use the clinician's emotional responses to the patient as a diagnostic tool

5.1/A Serves as a role model for gathering subtle and reliable information from the patient 5.2/A, B Teaches and supervises other learners in clinical evaluation

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Comments:

Footnotes: 1This milestone refers to the use of the resident’s own emotional response to the patient’s presentation as a source of information to generate ideas about the patient’s own inner emotional state, both conscious and unconsious.

2This milestone focuses on the efficient and deductive conduct of the interview in accordance with diagnostic hypotheses to refine the differential diagnosis.

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PC2. Psychiatric Formulation and Differential Diagnosis1 A: Organizes and summarizes findings and generates differential diagnosis B: Identifies contributing factors and contextual features and creates a formulation

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Organizes and accurately summarizes, reports, and presents to colleagues information obtained from the patient evaluation

1.2/A Develops a working diagnosis based on the patient evaluation

2.1/A Identifies patterns and recognizes phenomenology from the patient's presentation to generate a diagnostic hypotheses

2.2/A Develops a basic differential diagnosis for common syndromes and patient presentations

2.3/B Describes patients’ symptoms and problems, precipitating stressors or events, predisposing life events or stressors, perpetuating and protective factors, and prognosis

3.1/A Develops a full differential diagnosis while avoiding premature closure 3.2/B Organizes formulation around comprehensive models of phenomenology that take etiology into account 2

4.1/A Incorporates subtle, unusual, or conflicting findings into hypotheses and formulations 4.2/B Efficiently synthesizes all information into a concise but comprehensive formulation

5.1/B Serves as a role model of efficient and accurate formulation

5.2/B Teaches formulation to advanced learners

Comments: Footnotes:

1A psychiatric formulation is a theoretically-based conceptualization of the patient’s mental disorder(s). It provides an organized summary of those individual factors thought to contribute to the patient’s unique psychopathology. This includes elements of possible etiology, as well as those that modify or influence presentation, such as risk and protective factors. It is therefore distinct from a differential diagnosis that lists the possible diagnoses for a patient, or an assessment that summarizes the patient’s signs and symptoms, as it seeks to understand the underlying mechanisms of the patient’s unique problems by proposing a hypothesis as to the causes of mental disorders.

2Models of formulation include those based on either major theoretical systems of the etiology of mental disorders, such as behavioral, biological, cognitive, cultural, psychological, psychoanalytic, sociological, or traumatic, or comprehensive frameworks of understanding, such as bio-psycho-social or predisposing, precipitating, perpetuating, and prognostic outlines. Models of formulation set forth a hypothesis about the unique features of a patient’s illness that can serve to guide further

evaluation or develop individualized treatment plans.

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PC3. Treatment Planning and Management A: Creates treatment plan B: Manages patient crises, recognizing need for supervision when indicated C: Monitors and revises treatment when indicated

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Identifies potential treatment options 1.2/B Recognizes patient in crisis or acute presentation 1.3/C Recognizes patient readiness for treatment

2.1/A Sets treatment goals in collaboration with the patient 2.2/A Incorporates a clinical practice guideline or treatment algorithm when available 2.3/A Recognizes co-morbid conditions and side effects’ impact on treatment 2.4/B Manages patient crises with supervision 2.5/C Monitors treatment adherence and response

3.1/A Incorporates manual-based treatment1 when appropriate 3.2/A Applies an understanding of psychiatric, neurologic, and medical co-morbidities to treatment selection2

3.3/A Links treatment to formulation 3.4/B Recognizes need for consultation and supervision for complicated or refractory cases 3.5/C Re-evaluates and revises treatment approach based on new information and or response to treatment

4.1/A Devises individualized treatment plan for complex presentations 4.2/A Integrates multiple modalities and providers in comprehensive approach3 4.3/C Appropriately modifies treatment techniques and flexibly applies practice guidelines to fit patient need

5.1/A Supervises treatment planning of other learners and multidisciplinary providers 5.2/A Integrates emerging neurobiological and genetic knowledge into treatment plan4

Comments: Footnotes: 1Manual-based treatment is any psychotherapy that relies on written instructions for the therapist on the steps and conduct of treatment, often including specific

indications, techniques, goals, and objectives. Manual-based treatments are frequently theory-driven and evidence-based. Examples of manual-based treatments include Interpersonal Psychotherapy, Dialectical-Behavioral Therapy, and many Cognitive-Behavioral Therapies.

2Examples might include psychopharmacology in the presence of neurodegenerative disorders, traumatic brain injury, critical medical illness, and cancer treatment, as well as understanding the family, systems, and multidisciplinary team efforts for the best outcome for treatment.

3Understanding and use of an array of modalities and providers may include consideration of complementary and alternative medicine, occupational therapy, and

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physical therapy. 4Examples may include cytochrome genetics, ethnic differences, and family counseling, etc.

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PC4. Psychotherapy Refers to 1) the practice and delivery of psychotherapies, including psychodynamic1, cognitive-behavioral2, and supportive therapies3; 2) exposure to couples, family, and group therapies; and 3) integrating psychotherapy with psychopharmacology A: Empathy and process B: Boundaries C: The alliance and provision of psychotherapies D: Seeking and providing psychotherapy supervision

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Accurately identifies patient emotions, particularly sadness, anger, and fear4

1.2/B Maintains appropriate professional boundaries 1.3/C Demonstrates a professional interest and curiosity in a patient’s story

2.1/A Identifies and reflects the core feeling and key issue for the patient during a session 2.2/B Maintains appropriate professional boundaries in psychotherapeutic relationships while being responsive to the patient5 2.3/C Establishes and maintains a therapeutic alliance with patients with uncomplicated problems6

2.4/C Utilizes elements of supportive therapy in treatment of patients

3.1/A Identifies and reflects the core feeling, key issue, and what the issue means to the patient 3.2/B Recognizes and avoids potential boundary violations

3.3/C Establishes and maintains a therapeutic alliance with, and provides psychotherapies (at least supportive, psychodynamic, and cognitive-behavioral) to, patients with uncomplicated problems 3.4/C Manages the emotional content of, and feelings aroused during, sessions 3.5/C Integrates the selected psychotherapy with other treatment modalities and other treatment providers 7

4.1/A Links feelings, behavior, recurrent/central themes/schemas, and their meaning to the patient as they shift within and across sessions 4.2/B Anticipates and appropriately manages potential boundary crossings and avoids boundary violations

4.3/C Provides different modalities of psychotherapy (including supportive therapy and at least one of psychodynamic or cognitive behavioral therapies) to patients with moderately complicated problems 4.4/C Selects a psychotherapeutic modality and tailors the selected psychotherapy to the patient on the basis of an appropriate case formulation

4.5/C Successfully guides

5.1/C Provides psychotherapies to patients with very complicated and/or refractory disorders/problems

5.2/C Personalizes treatment based on awareness of one’s own skill sets, strengths, and limitations

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3.6/D Balances autonomy with needs for consultation and supervision

the patient through the different phases of psychotherapy, including termination 4.6/C, D Recognizes, seeks appropriate consultation about, and manages treatment impasses

5.3/D Provides psychotherapy supervision to others


1Psychodynamic therapy includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to understand the concepts of resistance/defenses, transference/countertransference.

2Cognitive-behavioral therapy includes the capacity to generate a case formulation, to demonstrate techniques of intervention, including behavior change, skills acquisition, and to address cognitive distortions.

3Supportive therapy includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to strengthen the patient’s adaptive defenses, resilience, and social supports.

4This thread (A), consisting of the first items in Levels 1-4, regarding the development of empathy across residency, is adapted from the American Association of Directors of Psychiatric Residency Training (AADPRT) Psychotherapy Workgroup’s document “Benchmarks for Psychotherapy Training.”

5This refers to the ability to maintain professional boundaries in psychotherapy without being aloof or overly detached. 6Examples of uncomplicated problems are major depression or panic disorder without co-morbidity. 7At this level, the resident is expected to be able to integrate both psychotherapy and psychopharmacology in combined treatment of a patient, to deliver psychotherapy

or psychopharmacology in collaboration with another provider who is doing the other treatment (shared treatment), and to be able to anticipate, discuss, and manage issues that result from a patient’s receiving other treatments (e.g., family, couples, or group therapy; psychopharmacology) at the same time as individual psychotherapy.

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PC5. Somatic Therapies Somatic therapies including psychopharmacology, electroconvulsive therapy (ECT), and emerging neuromodulation therapies A: Using psychopharmacologic agents in treatment B: Education of patient about medications C: Monitoring of patient response to treatment and adjusting accordingly D: Other somatic treatments

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Lists commonly used psychopharmacologic agents and their indications to target specific psychiatric symptoms (e.g., depression, psychosis) 1.2/B Reviews with the patient/family general indications, dosing parameters, and common side effects for commonly prescribed psychopharmacologic agents

2.1/A Appropriately prescribes1 commonly used psychopharmacologic agents 2.2/B Incorporates basic knowledge of proposed mechanisms of action and metabolism of commonly prescribed psychopharmacologic agents in treatment selection, and explains rationale to patients/families 2.3/C Obtains basic physical exam and lab studies necessary to initiate treatment with commonly prescribed medications 2.4/D Seeks consultation and

3.1/A Manages pharmacokinetic and pharmacodynamic drug interactions when using multiple medications concurrently 3.2/C Monitors relevant lab studies throughout treatment, and incorporates emerging physical and laboratory findings into somatic treatment strategy 3.3/C Uses augmentation strategies, with supervision, when primary pharmacological interventions are only partially successful1

4.1/A Titrates dosage and manages side effects of multiple medications 4.2/C Appropriately selects evidence-based somatic treatment options (including second and third line agents and other somatic treatments2) for patients whose symptoms are partially responsive or not responsive to treatment

5.1/B Explains less common somatic treatment choices to patients/families in terms of proposed mechanisms of action 5.2/C Integrates emerging studies of somatic treatments into clinical practice

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supervision regarding potential referral for ECT


1This includes: (a) selection of agent, dose, and titration, based on psychiatric diagnoses, target symptoms, and specifics of patient’s history; (b) discussion of potential risks and benefits with patients (and family members, where appropriate); (c) decision regarding whether or not to prescribe a medication (or medication versus other type of treatment).

2Examples of other somatic therapies include neuromodulation, biofeedback, and phototherapy.

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MK1. Development through the life cycle (including the impact of psychopathology on the trajectory of development and development on the expression of psychopathology) A: Knowledge of human development B: Knowledge of pathological and environmental influences on development C: Incorporation of developmental concepts in understanding

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Describes the basic

stages of normal physical, social, and cognitive development through the life cycle1

2.1/A Describes neural development across the life cycle2 2.2/A Recognizes deviation from normal development, including arrests and regressions at a basic level 2.3/B Describes the effects of emotional and sexual abuse on the development of personality and psychiatric disorders in infancy, childhood, adolescence, and adulthood at a basic level 2.4/C Utilizes developmental concepts in case formulation

3.1/A Explains developmental tasks and transitions throughout the life cycle, utilizing multiple conceptual models3 3.2/B Describes the influence of psychosocial factors (gender, ethnic, cultural, economic), general medical, and neurological illness on personality development

3.2 De 3.3/C Utilizes appropriate

conceptual models of development in case formulation

4.1/B Describes the influence of acquisition and loss of specific capacities in the expression of psychopathology across the life cycle 4.2/B Gives examples of gene-environment interaction influences on development and psychopathology4

5.1/A Incorporates new neuroscientific knowledge into his or her understanding of development


1Includes knowledge of motoric, linguistic, and cognitive development at the level required to pass the United States Medical Licensing Examination (USMLE) Step 2, and also knowledge of developmental milestones in infancy through senescence, such as language acquisition, Piagetian cognitive development, and social and emotional development, such as the emergence of stranger wariness in infancy and the theme of independence versus dependence in adolescence.

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2Knowledge of fetal, childhood, adolescent, and early adult brain development, including abnormal brain development caused by genetic disorders (Tay-Sachs), environmental toxins, malnutrition, social deprivation, and other factors.

3Using the theoretical models proposed by psychodynamic, cognitive, and behavioral theorists. 4An example is bipolar disorder with genetic diathesis + environmental stress leading to manic behavior.

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MK2. Psychopathology1 Includes knowledge of diagnostic criteria, epidemiology, pathophysiology, course of illness, co-morbidities, and differential diagnosis of psychiatric disorders, including substance use disorders and presentation of psychiatric disorders across the life cycle and in diverse patient populations (e.g., different cultures, families, genders, sexual orientation, ethnicity, etc.) A: Knowledge to identify and treat psychiatric conditions B: Knowledge to assess risk and determine level of care C: Knowledge at the interface of psychiatry and the rest of medicine

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Identifies the major psychiatric diagnostic system (DSM) 1.2/B Lists major risk and protective factors for danger to self and others 1.3/C Gives examples of interactions between medical and psychiatric symptoms and disorders

2.1/A Demonstrates sufficient knowledge to identify and treat common psychiatric conditions in adults in inpatient and emergency settings (e.g., depression, mania, acute

psychosis) 2.2/B Demonstrates knowledge of, and ability to weigh risks and protective factors for, danger to self and/or others in emergency and inpatient settings 2.3/C Shows sufficient knowledge to perform an initial medical and neurological evaluation in psychiatric inpatients 2.4/C Demonstrates sufficient knowledge to identify common medical conditions (e.g., hypothyroidism,

3.1/A Demonstrates sufficient knowledge to identify and treat most psychiatric conditions throughout the life cycle and in a variety of settings2 3.2/B Displays knowledge of, and the ability to weigh, risk and protective factors for, danger to self and/or others across the life cycle, as well as the ability to determine the need for acute psychiatric hospitalization 3.3/C Shows sufficient knowledge to identify and treat common psychiatric manifestations of medical illness (e.g., delirium, depression, steroid-induced syndromes) 3.4/C Demonstrates sufficient knowledge to include relevant medical

4.1/A Demonstrates sufficient knowledge to identify and treat atypical and complex psychiatric conditions throughout the life cycle and in a range of settings (inpatient, outpatient, emergency, consultation liaison)3

4.2/B Displays knowledge sufficient to determine the appropriate level of care for patients expressing, or who may represent, danger to self and/or others, across the life cycle and in a full range of treatment settings 4.3/C Shows knowledge sufficient to identify and treat a wide range of psychiatric conditions in patients with medical disorders 4.4/C Demonstrates sufficient knowledge to systematically screen for, evaluate, and diagnose

5.1/B Displays knowledge sufficient to teach assessment of risks and the appropriate level of care for patients who may represent a danger to self and/or others 5.2/C Shows sufficient knowledge to identify and treat uncommon psychiatric conditions in patients with medical disorders

5.3/C Demonstrates sufficient knowledge to detect and ensure appropriate treatment of

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hyperlipidemia, diabetes) in psychiatric patients

and neurological conditions in the differential diagnoses of psychiatric patients

common medical conditions in psychiatric patients, and to ensure appropriate further evaluation and treatment of these conditions in collaboration with other medical providers

uncommon medical conditions in patients with psychiatric disorders


1This milestone focuses on knowledge needed for patient care. Thus, knowledge of psychopathology can be assessed through multiple choice knowledge examinations (e.g., the Psychiatry Resident In-Training Examination (PRITE)), and/or through evaluations of the application of knowledge of psychopathology to patient care, such as standardized patients or case vignettes, clinical skills evaluations, and knowledge evidenced during clinical rotations and the routine, supervised care of patients during residency.

2This level includes identification and treatment of a wider array of conditions, across the life cycle (including childhood, adolescent, adult, and geriatric conditions), and in a variety of settings (e.g., outpatient, consultation liaison, subspecialty settings).

3“Atypical” and “complex” psychiatric conditions refer to unusual presentations of common disorders, co-occurring disorders in patients with multiple co-morbid conditions, and diagnostically challenging clinical presentations.

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MK3. Clinical Neuroscience1 Includes knowledge of neurology, neuropsychiatry, neurodiagnostic testing, and relevant neuroscience and their application in clinical settings A: Neurodiagnostic testing B: Neuropsychological testing C: Neuropsychiatric co-morbidity D: Neurobiology E: Applied neuroscience

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Knows commonly available neuroimaging and neurophysiologic diagnostic modalities and how to order them 1.2/B Knows how to order neuropsychological testing

2.1/A Knows indications for structural neuroimaging (cranial computed tomography [CT] and magnetic resonance imaging [MRI]) and neurophysiological testing (electroencephalography [EEG], evoked potentials, sleep studies)

2.2/B Describes common neuropsychological tests and their indications2 2.3/C Describes psychiatric disorders co-morbid with common neurologic disorders3 and neurological disorders frequently seen in psychiatric patients4

3.1/A Recognizes the significance of abnormal findings in routine neurodiagnostic test6 reports in psychiatric patients 3.2/B Knows indications for specific neuropsychological tests and understands meaning of common abnormal findings 3.3/D Describes neurobiological and genetic hypotheses of common psychiatric disorders and their limitations

4.1/A Explains the significance of routine neuroimaging, neurophysiological, and neuropsychological testing abnormalities to patients 4.2/A Knows clinical indications and limitations of functional neuroimaging7

4.3/C Describes psychiatric co-morbidities of less common neurologic disorders8 and less common neurologic co-morbidities of psychiatric disorders9

4.4/D Explains neurobiological hypotheses and genetic risks of common psychiatric disorders to patients

5.1/A Integrates recent neurodiagnostic research into understanding of psychopathology 5.2/B Flexibly applies knowledge of neuropsychological findings to the differential diagnoses of complex patients 5.3/D Explains neurobiological hypotheses and genetic risks of less common psychiatric disorders11 to patients

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2.4/E Identifies the brain areas thought to be important in social and emotional behavior5

4.5/E Demonstrates sufficient knowledge to incorporate leading neuroscientific hypotheses of emotions and social behaviors10 into case formulation

5.4/D Integrates knowledge of neurobiology into advocacy for psychiatric patient care and stigma reduction12


1This milestone focuses on knowledge needed for patient care. Thus, knowledge of clinical neuroscience can be assessed through multiple choice knowledge examination (e.g., PRITE), and/or through evaluations of the application of knowledge of clinical neuroscience to patient care, such as standardized patients or case vignettes, clinical skills evaluations, and knowledge evidenced during clinical rotations and the routine, supervised care of patients during residency.

2Common neuropsychological tests include the Montreal Cognitive Assessment (or Mini Mental State Examination), Wechsler Adult Intelligence Scale (or Halstead-Reitan battery), Wechsler Memory Scale, Wide Range Achievement Test, Wisconsin Card Sorting Test, Clock Drawing Test.

3Examples include psychosis, mood disorders, personality changes, and cognitive impairments seen in common neurological disorders. 4These include drug-induced and idiopathic extrapyramidal syndromes, neuropathies, traumatic brain injury (TBI), vascular lesions, dementias, and encephalopathies. 5Areas might include dorsolateral prefrontal cortex, anterior cingulate, amygdala, hippocampus, etc. 6These include structural imaging and electrophysiologic testing. 7For example, positron emission tomography (PET)/single-photon emission computed tomography (SPECT) in the diagnosis of Alzheimer’s disease (supportive but non-diagnostic); functional magnetic resonance imaging (fMRI) is not yet reimbursable for clinical use.

8Examples include: mood disorder due to neurological condition, manic type, in right hemisphere or orbitofrontal strokes/tumors; depression in peri-basal ganglionic infarcts; manic behavior in limbic encephalitis.

9Examples include: neuroleptic malignant syndrome; lethal catatonia; “Parkinson plus” syndromes (e.g., multisystem atrophy, dementia with Lewy bodies, etc).

10Social behaviors might include attachment, empathy, attraction, reward/addiction, aggression, appetites, etc. 11Examples include : Obsessive-Compulsive Disorder (OCD); eating disorders ; Gilles de la Tourette syndrome. 12Uses neurobiologic hypotheses of psychiatric disorders to advocate for health coverage, treatment availability, etc.

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MK4. Psychotherapy Refers to knowledge regarding: 1) individual psychotherapies, including but not limited to psychodynamic1, cognitive-behavioral2, and supportive therapies3; 2) couples, family, and group therapies; and, 3) integrating psychotherapy and psychopharmacology A: Knowledge of psychotherapy: theories B: Knowledge of psychotherapy: practice C: Knowledge of psychotherapy: evidence base

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Identifies psycho-dynamic, cognitive-behavioral, and supportive therapies as major psychotherapeutic modalities

2.1/A Describes the basic principles of each of the three core individual psychotherapy modalities4 2.2/A Discusses common factors across psychotherapies5 2.3/B Lists the basic indications, contraindications, benefits, and risks of supportive, psychodynamic and cognitive behavioral psychotherapies

3.1/A Describes differences among the three core individual therapies 3.2/A Describes the historical and conceptual development of psychotherapeutic paradigms 3.3/B Describes the basic techniques of the three core individual therapies 3.4/B Describes the basic principles, indications, contraindications, benefits, and risks of couples, group, and family therapies 3.5/C Summarizes the evidence base for each of the three core individual therapies

4.1/A Describes proposed mechanisms of therapeutic change 4.2/C Discusses the evidence base for combining different psychotherapies and psychopharmacology 4.3/C Critically appraises the evidence for efficacy of psychotherapies

5.1/A Incorporates new theoretical developments into knowledge base

5.2/A, B Demonstrates sufficient knowledge of psychotherapy to teach others effectively

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1This includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to understand the concepts of resistance/defenses, and transference/countertransference.

2This includes the capacity to generate a case formulation, and to demonstrate techniques of intervention, including behavior change, skills acquisition, and addressing cognitive distortions.

3This includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to strengthen the patient’s adaptive defenses, resilience, and social supports.

4Throughout this subcompetency, the three “core” or “major” individual psychotherapies refer to supportive, psychodynamic, and cognitive-behavioral therapy. 5Common factors refer to elements that different psychotherapeutic modalities have in common, and that are considered central to the efficacy of psychotherapy. These

include accurate empathy, therapeutic alliance, and appropriate professional boundaries.

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MK5. Somatic Therapies Medical Knowledge of somatic therapies, including psychopharmacology, ECT, and emerging somatic therapies, such as transcranial magnetic stimulation (TMS) and vagnus nerve stimulation (VNS) A: Knowledge of indications, metabolism and mechanism of action for medications B: Knowledge of ECT and other emerging somatic treatments C: Knowledge of lab studies and measures in monitoring treatment

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Describes general indications and common side effects for commonly prescribed psychopharmacologic agents 1.2/B Describes indications for ECT

2.1/A Describes hypothesized mechanisms of action and metabolism for commonly prescribed psychopharmacologic agents 2.2/A Describes indications for second- and third-line pharmacologic agents 2.3/A Describes less frequent but potentially serious/dangerous adverse effects for commonly prescribed psychopharmacological agents 2.4/A Describes expected time course of response for commonly prescribed classes of psychotropic agents 2.5/B Describes length and frequency of ECT treatments, as well as relative contraindications 2.6/C Describes the physical

3.1/A Demonstrates an understanding of pharmacokinetic and pharmacodynamic drug interactions 3.2/A Demonstrates an understanding of psychotropic selection based on current practice guidelines or treatment algorithms for common psychiatric disorders 3.3/B Describes specific techniques in ECT 3.4/B Lists emerging neuro-modulation therapies1

4.1/A Describes the evidence supporting the use of multiple medications in certain treatment situations (e.g., polypharmacy and augmentation) 4.2/ C Integrates knowledge

5.1/A Integrates emerging studies of somatic treatments into knowledge base 5.2/A Effectively teaches at a post-graduate level evidence-based or best somatic treatment practices

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and lab studies necessary to initiate treatment with commonly prescribed medications

of the titration and side effect management of multiple medications, monitoring the appropriate lab studies, and how emerging physical and laboratory findings impact somatic treatments


1Examples of neuromodulation techniques include TMS and variations, VNS, Deep Brain Stimulation, etc.

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MK6. Practice of Psychiatry A: Ethics B: Regulatory compliance C: Professional development and frameworks

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Lists common ethical issues in psychiatry 1.2/B Recognizes and describes institutional policies and procedures1

1.3/C Lists ACGME Competencies

2.1/A Lists and discusses sources of professional standards of ethical practice 2.2/A Lists situations that mandate reporting or breach of confidentiality 2.3/C Describes how to keep current on regulatory and practice management issues

3.1/A Discusses conflict of interest and management 3.2/B Describes applicable regulations for billing and reimbursement

4.1/B Describes the existence of state and regional variations regarding practice, involuntary treatment, health regulations, and psychiatric forensic evaluation 4.2/C Describes professional advocacy2

4.3/C Describes how to seek out and integrate new information on the practice of psychiatry

5.1/B Describes international variations regarding practice, involuntary treatment, and health regulations 5.2/C Proposes advocacy activities, policy development, or scholarly contributions related to professional standards


1“Institutional policies and procedures” refers to those related to the practice of medicine and psychiatry at the specific institution where the resident is credentialed. These include a Code of Conduct (addressing gifts, etc.) and privacy policies (related to HIPAA, etc.), but not patient safety policies. These are usually covered during an orientation to the institution and program.

2 Advocacy includes efforts to promote the wellbeing and interests of patients and their families, the mental health care system, and the profession of psychiatry. While advocacy can include work on behalf of specific individuals, it is usually focused on broader system issues, such as access to mental health care services or public

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awareness of mental health issues. The focus on larger societal problems typically involves work with policy makers (state and federal legislators) and peer or professional organizations (American Psychiatry Association (APA), National Alliance on Mental Illness (NAMI), etc.).

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SBP1. Patient Safety and the Health care Team A: Medical errors and improvement activities B: Communication and patient safety C: Regulatory and educational activities related to patient safety

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Differentiates among medical errors, near misses, and sentinel events 1.2/B Recognizes failure in teamwork and communication as leading cause of preventable patient harm 1.3/C Follows institutional safety policies, including reporting of problematic behaviors and processes, errors, and near misses

2.1/A Describes the common system causes for errors 2.2/B Consistently uses structured communication tools to prevent adverse events (e.g., checklists, safe hand-off procedures, briefings) 2.3/C Actively participates in conferences focusing on systems-based errors in patient care

3.1/A Describes systems and procedures that promote patient safety

4.1/A Participates in formal analysis (e.g., root-cause analysis, failure mode effects analysis) of medical errors and sentinel events 4.2/C Develops content for and facilitates a patient safety presentation or conference focusing on systems-based errors in patient care (i.e., a morbidity and mortality [M&M] conference)

5.1/A Leads multidisciplinary teams (e.g., human factors engineers1, social scientists) to address patient safety issues 5.2/A, C Provides consultation to organizations to improve personal and patient safety


1 Human Factors Engineering (HFE) is a framework for efficient and constructive thinking which includes methods and tools to help health care teams perform patient safety analyses (see: Gosbee J, Human factors engineering and patient safety, Quality and Safety in Health Care, 2002;11:352–354).

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SBP2. Resource Management (may include diagnostics, medications, level of care, other treatment providers, access to community assistance) A: Costs of care and resource management

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Recognizes need for efficient and equitable use of resources

2.1/A Recognizes disparities in health care at individual and community levels

2.2/A Knows the relative cost of care (e.g., medication costs, diagnostic costs, level of care costs, procedure costs)

3.2/A Coordinates patient access to community and system resources

4.1/A Practices cost-effective, high-value clinical care1, using evidence-based tools and information technologies to support decision making

4.2/A Balances the best interests of the patient with the availability of resources

5.1/A Designs measurement tools to monitor and provide feedback to providers/teams on resource consumption to facilitate improvement 5.2/A Advocates for improved access to and additional resources within systems of care

Comments: Footnotes: 1 Examples include: avoids higher-cost, newer antipsychotics when older formulations are adequate; recommends levels of care that are matched to clinical need and

available in the community.

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SBP3. Community-Based Care A: Community-based programs B: Self-help groups C: Prevention D: Recovery and rehabilitation

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Gives examples of

community mental health systems of care 1.2/B Gives examples of self-help groups (Alcoholics Anonymous [AA], Narcotics Anonymous [NA]), other community resources (church, school) and social networks (e.g., family, friends, acquaintances)

2.1/A Coordinates care with community mental health agencies, including with case managers 2.2/B Recognizes role and explains importance of self-help groups and community resource groups (e.g., disorder-specific support and advocacy groups) 2.3/C Describes individual and population risk factors for mental illness

3.1/B Incorporates disorder-specific support and advocacy groups in clinical care 3.2/C Describes prevention measures: universal, selective and indicated1 3.3/D Describes rehabilitation programs (vocational, brain injury, etc.) and the recovery model2

4.1/B Routinely uses self-help groups, community resources, and social networks in treatment3

4.2/C Employs prevention and risk reduction strategies in clinical care 4.3/D Appropriately refers to rehabilitation and recovery programs 4.4/D Uses principles of evidence-based practice and patient centered care in management of chronically ill patients

5.1/A Participates in the administration of community-based treatment programs

5.2/A Participates in creating new community-based programs 5.3/D Practices effectively in a rehabilitation and/or recovery-based program

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Comments: Footnotes: 1Universal prevention strategies are designed to reach the entire population; selective prevention are designed for a targeted subgroup of the general population; and indicated prevention intervention targets individuals. 2The Substance Abuse and Mental Health Services Administration (SAMHSA) has a working definition for the recovery model applied to mental health and addictions. This definition acknowledges that recovery is a process of change for an individual consumer to improve health and wellness, live a self-directed life, and strive and reach his or her full potential. The guiding principles that inform a recovery model of care include hope, person-driven, holistic, peer supports, social networks, culturally-based, trauma-informed, strength-based, responsibility, and respect (see: http://www.samhsa.gov/newsroom/advisories/1112223420.aspx). 3These community resources include supports and services from both the peer and professional workforces.

http://www.samhsa.gov/newsroom/advisories/1112223420.aspx

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SBP4. Consultation to non-psychiatric medical providers and non-medical systems (e.g., military, schools, businesses, forensic ) A: Distinguishes care provider roles related to consultation B: Provides care as a consultant and collaborator C: Specific consultative activities

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Describes the difference between consultant and primary treatment provider

2.1/A Describes differences in providing consultation for the system or team versus the individual patient

2.2/B Provides consultation to other medical services 2.3/C Clarifies the consultation question 2.4/C Conducts and reports a basic decisional capacity evaluation

3.1/C Assists primary treatment care team in identifying unrecognized clinical care issues

3.2/C Identifies system issues in clinical care and provides recommendations 3.3/C Discusses methods for integrating mental health and medical care in treatment planning

4.1/B Provides integrated care for psychiatric patients through collaboration with other physicians1

4.2/C Manages complicated and challenging consultation requests

5.1/B Provides psychiatric consultations to larger systems

5.2/B Leads a consultation team

Comments: Footnotes: 1 Provides communication back to the primary care physicians in the outpatient setting, including collaborative and co-located settings such as a medical home.

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PBLI1. Development and execution of lifelong learning through constant self-evaluation, including critical evaluation of research and clinical evidence A: Self-Assessment and self-Improvement B: Evidence in the clinical workflow

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Uses feedback from teachers, colleagues, and patients to assess own level of knowledge and expertise 1.2/A Recognizes limits of one’s knowledge and skills and seeks supervision 1.3/B Describes and ranks levels of clinical evidence1

2.1/A Regularly seeks and incorporates feedback to improve performance

2.2/A Identifies self-directed learning goals and periodically reviews them with supervisory guidance 2.3/B Formulates a searchable question from a clinical question2

3.1/A Demonstrates a balanced and accurate self-assessment of competence, using clinical outcomes to identify areas for continued improvement 3.2/B Selects an appropriate, evidence-based information tool1 to meet self-identified learning goals

3.3/B Critically appraises different types of research, including randomized controlled trials (RCTs), systematic reviews, meta-analyses, and practice guidelines

4.1/A Demonstrates improvement in clinical practice based on continual self-assessment and evidence-based information 4.2/A Identifies and meets self-directed learning goals with little external guidance 4.3/A, B Demonstrates use of a system or process for keeping up with relevant changes in medicine2

4.4/B Independently searches for and discriminates evidence relevant to clinical practice problems

5.1/A, B Sustains practice of self-assessment and keeping up with relevant changes in medicine, and makes informed, evidence-based clinical decisions 5.2/B Teaches others techniques to efficiently incorporate evidence gathering into clinical workflow 5.3/B Independently teaches appraisal of clinical evidence


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

process; or regular and structured readings of specific evidence sources.

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PBLI2. Formal practice-based quality improvement based on established and accepted methodologies1

A: Specific quality improvement project B: Quality improvement didactic knowledge

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Recognizes potential gaps in quality of care and system-level inefficiencies2 1.2/B Discusses with supervisors possible quality gaps and problems with psychiatric care delivery

2.1/A Narrows problems within own clinical service(s) to a specific and achievable aim for a quality improvement (QI) project

2.2/B Outlines factors and causal chains contributing to quality gaps within own institution and practice3

3.1/A Involves appropriate stakeholders in design of a QI project4

3.2/B Lists common responses of teams and individuals to changes in clinical operations and describes strategies for managing same

4.1/A Substantially contributes to a supervised project to address specific quality deficit within own clinical service(s), and measures relevant outcomes

4.2/B Describes basic methods for implementation and evaluation of clinical QI projects5

5.1/A Independently proposes and leads projects to enhance patient care

5.2/A Uses advanced quality measurement and “dashboard” tools 5.3/B Describes core concepts of advanced QI methodologies and business processes6

Comments:

Footnotes: 1Many of these requirements would be satisfied by active participation in an individual or group project within the residency program, department, or institution.

Active participation, at a minimum, should include observation and participation through a full feedback cycle (e.g., one Plan-Do-Study-Act loop). Some didactic material or assigned readings may be helpful to supplement the case-based learning. Resources for didactics include the Institute for Health Care Improvement Open School (http://www.ihi.org/offerings/IHIOpenSchool/), World Health Organization Patient Safety Curriculum (http://www.who.int/patientsafety/education /curriculum/download/en/index.html), and Department of Veterans Affairs Patient Safety Curriculum (http://www.patientsafety.va.gov/curriculum/index.html). 2 Examples include: problems with transfer of information during sign-out or patient movement between care areas; difficulty in moving needed resources to a patient’s location; prescribing practices that markedly deviate from guidelines. 3 Chooses an inefficient/ineffective practice or recent adverse outcome, identifies some factors contributing to the status quo, and displays some sense of which factors are amenable to intervention. 4 Examples include, for a project involving a standard order protocol on an inpatient unit: meets with nurse managers and ancillary clinical staff members and learns about their needs/constraints before designing intervention; recognizes fear of change as a common characteristic in clinical environments and provides staff members space/time to adequately process and modify proposals. At this stage, requires supervision/guidance in such efforts. 5 This might include variations on the Plan-Do-Study-Act theme (i.e., stating an understanding that an effective project should include a target population and intervention, an outcome measure, and some form of iterative refinement). 6 Can state some core philosophical concepts of Lean Production, the Six-Sigma/Total Quality Management methods, or other emerging management philosophies, and gives examples of how these could apply in health care.

http://www.ihi.org/offerings/IHIOpenSchool/

http://www.who.int/patientsafety/education%20/curriculum/download/en/index.html

http://www.who.int/patientsafety/education%20/curriculum/download/en/index.html

http://www.patientsafety.va.gov/curriculum/index.html

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PBLI3. Teaching A: Development as a teacher B: Observable teaching skills

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Recognizes role of physician as teacher

2.1/A Assumes a role in the clinical teaching of early learners 2.2/B Communicates goals and objectives for instruction of early learners 2.3/B Evaluates and provides feedback to early learners

3.1/A Participates in activities designed to develop and improve teaching skills

3.2/B Organizes content and methods for individual instruction for early learners

4.1/A Gives formal didactic presentation to groups (e.g., grand rounds, case conference, journal club) 4.2/B Effectively uses feedback on teaching to improve teaching methods and approaches

5.1/A Educates broader professional community and/or public (e.g., presents at regional or national meeting) 5.2/B Organizes and develops curriculum materials

Comments:

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PROF1.1 Compassion, integrity, respect for others, sensitivity to diverse patient populations2, 3, adherence to ethical principles A: Compassion, reflection, sensitivity to diversity B: Ethics

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Demonstrates behaviors that convey caring, honesty, genuine interest, and respect for patients and their families 1.2/A Recognizes that patient diversity affects patient care 1.3/B Displays familiarity with some basic ethical principles (e.g., confidentiality, informed consent, professional boundaries)

2.1/A Demonstrates capacity for self-reflection, empathy, and curiosity about and openness to different beliefs and points of view, and respect for diversity 2.2/A Provides examples of the importance of attention to diversity in psychiatric evaluation and treatment 2.3/B Recognizes ethical conflicts in practice and seeks supervision to manage them

3.1/A Elicits beliefs, values, and diverse practices of patients and their families, and understands their potential impact on patient care 3.2/A Routinely displays sensitivity to diversity in psychiatric evaluation and treatment 3.3/B Recognizes ethical issues in practice and is able to discuss, analyze, and manage these in common clinical situations

4.1/A Develops a mutually agreeable care plan in the context of conflicting physician and patient and/or family values and beliefs 4.2/A Discusses own cultural background and beliefs and the ways in which these affect interactions with patients

5.1/A Serves as a role model and teacher of compassion, integrity, respect for others, and sensitivity to diverse patient populations 5.2/B Leads resident case discussions regarding ethical issues 5.3/B Adapts to evolving ethical standards (i.e. can manage conflicting ethical standards and values and can apply these to practice) 5.4/B Systematically analyzes and manages ethical issues in complicated and challenging clinical situations

Comments:

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Footnotes: 1The two Professionalism subcompetencies (PROF1 and PROF2) reflect the following overall values: Residents 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. 3For milestones regarding health disparities, please see SBP2.

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PROF2. Accountability to self, patients, colleagues, and the profession A: Fatigue management and work balance B: Professional behavior and participation in professional community C: Ownership of patient care

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Understands the need for sleep, and the impact of fatigue on work 1.2/A Lists ways to manage fatigue, and seeks back-up as needed to ensure good patient care

1.3/B Exhibits core professional behaviors1 1.4/B Displays openness to feedback 1.5/C Introduces self as patient’s physician

2.1/A Notifies team and enlists back-up when fatigued or ill, so as to ensure good patient care 2.2/B Follows institutional policies for physician conduct 2.3/C Accepts the role of the patient’s physician and takes responsibility (under supervision) for ensuring that the patient receives the best possible care

3.1/A Identifies and manages situations in which maintaining personal emotional, physical, and mental health is challenged, and seeks assistance when needed 3.2/A Recognizes the tension between the needs of personal/family life and professional responsibilities, and its effect on medical care 3.3/B Recognizes the importance of participating in one’s professional community

3.4/C Is recognized by self, patient, patient’s family, and medical staff members as the patient’s primary psychiatric provider

4.1/A Knows how to take steps to address impairment in self and in colleagues

4.2/A Prioritizes and balances conflicting interests of self, family, and others to optimize medical care and practice of profession2 4.3/B Prepares for obtaining and maintaining board certification 4.4/C Displays increasing autonomy and leadership in taking responsibility for ensuring that patients receive the best possible care

5.1/A Develops physician wellness programs or interventions

5.2/B Develops organizational policies, programs, or curricula for physician professionalism 5.3/B Participates in the professional community (e.g., professional societies, patient advocacy groups, community service organizations) 5.4/C Serves as a role model in demonstrating responsibility for ensuring that patients receive the best possible care

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Comments:

Footnotes: 1Professional behavior refers to the global comportment of the resident in carrying out clinical and professional responsibilities. This includes:

a. timeliness (e.g., reports for duty, answers pages, and completes work assignments on time); b. maintaining professional appearance and attire; c. being reliable, responsible, and trustworthy (e.g., knows and fulfills assignments without needing reminders); d. being respectful and courteous (e.g., listens to the ideas of others, is not hostile or disruptive, maintains measured emotional responses and equanimity despite

stressful circumstances); e. maintaining professional boundaries; and, f. understanding that the role of a physician involves professionalism and consistency of one’s behaviors, both on and off duty.

These descriptors and examples are not intended to represent all elements of professional behavior. 2Residents are expected to demonstrate responsibility for patient care that supersedes self-interest. It is important that residents 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 resident is not present to provide direct care for the patient.

11/15/2013


ICS1. Relationship development and conflict management with patients, families, colleagues, and members of the health care team A: Relationship with patients B: Conflict management C: Team-based care

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Cultivates positive relationships with patients, families, and team members

1.2/B Recognizes communication conflicts in work relationships

1.3/C Identifies team-based care as preferred treatment approach, and collaborates as a member of the team

2.1/A Develops a therapeutic relationship with patients in uncomplicated situations

2.2/A Develops working relationships across specialties and systems of care in uncomplicated situations

2.3/B Negotiates and manages simple patient/family-related conflicts

2.4/C Actively participates in team-based care; supports activities of other team members, and communicates their value to the patient and family

3.1/A Develops therapeutic relationships in complicated situations

3.2/B Sustains working relationships in the face of conflict

3.3/C Facilitates team-based activities in clinical and/or non-clinical situations (including on committees)

4.1/A Sustains therapeutic and working relationships during complex and challenging situations, including transitions of care 4.2/C Leads a multidisciplinary care team

5.1/A Sustains relationships across systems of care and with patients during long-term follow-up 5.2/A, B Develops models/approaches to managing difficult communications

5.3/B, C Manages treatment team conflicts as team leader 5.4/C Leads and facilitates meetings within the organization/system

Comments:

11/15/2013


ICS2. Information sharing and record keeping A: Accurate and effective communication with health care team B: Effective communications with patients C: Maintaining professional boundaries in communication D: Knowledge of factors which compromise communication

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.1/A Ensures transitions of

care are accurately documented, and optimizes communication across systems and continuums of care 1.2/A Ensures that the written record (electronic medical record [EMR], personal health records [PHR]/patient portal, hand-offs, discharge summaries, etc.) are accurate and timely, with attention to preventing confusion and error, consistent with institutional policies 1.3/B Engages in active listening, “teach back,” and other strategies to ensure patient and family understanding 1.4/C Maintains appropriate boundaries in sharing information by electronic communication

2.1/A, B Organizes both written and oral information to be shared with patient, family, team, and others 2.2/B Consistently demonstrates communication strategies to ensure patient and family understanding 2.3/B Demonstrates appropriate face-to-face interaction while using EMR 2.4/C Understands issues raised by the use of social media by patients and providers

3.1/ A, B Uses easy-to-understand language in all phases of communication, including working with interpreters

3.2/B Consistently engages patients and families in shared decision making

4.1/A, B Demonstrates effective verbal communication with patients, families, colleagues, and other health care providers that is appropriate, efficient, concise, and pertinent

4.2/A, B Demonstrates written communication with patients, families, colleagues, and other health care providers that is appropriate, efficient, concise, and pertinent

4.3/C Uses discretion and judgment in the inclusion of sensitive patient material in the medical record

5.1/A Models continuous improvement in record keeping 5.2/C Participates in the development of changes in rules, policies, and procedures related to technology

11/15/2013


2.5/D Lists factors that affect information sharing (e.g., intended audience, purpose, need to know) 2.6/D Lists effects of computer use on accuracy of information gathering and recording and potential disruption of the physician/patient/family relationship

3.3/D Gives examples of situations in which communication can be compromised (e.g., perceptual impairment, cultural differences, transference, limitations of electronic media)

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

Comments:

July 2015

The Child & Adolescent Psychiatry Milestone Project

A Joint Initiative of

The Accreditation Council for Graduate Medical Education

and

The American Board of Psychiatry and Neurology

1

The Child and Adolescent 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 resident physician in key dimensions of the elements of physician competency in a specialty

or subspecialty. They neither represent the entirety of the dimensions of the six domains of physician

competency, nor are they designed to be relevant in any other content.

2

Child and Adolescent Psychiatry Milestone Group

Psychiatry Subspecialty Milestones Chair: Christopher R. Thomas, MD

Working Group

Chair: Jeffrey Hunt, MD

Sandra M. DeJong, MD

Laura Edgar, EdD, CAE

Howard Liu, MD

Cynthia Santos, MD

Advisory Group

Chair: George A. Keepers, MD

Larry R. Faulkner, MD

Paramjit T. Joshi, MD

Christopher K. Varley, MD

3

Milestone Reporting

This document presents Milestones designed for programs to use in semi-annual review of 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.

4

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.

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.

Definitions used in this document:

Systems – includes schools, courts, community based organizations (advocacy, community mental health), governmental agencies

(e.g. child protective agencies), health care (primary care, etc.).

Families – includes parents, foster parents, legal guardians

Developmental domains – includes social/emotional, cognitive, behavioral, gross motor, fine motor, speech and language

development

Answers to Frequently Asked Questions about Milestones are available on the Milestones web page:

http://www.acgme.org/acgmeweb/Portals/0/MilestonesFAQ.pdf.

http://www.acgme.org/acgmeweb/Portals/0/MilestonesFAQ.pdf

5

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.



Version 9/2014 Child and Adolescent Psychiatry Milestones: ACGME Report Worksheet

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 Child and Adolescent Psychiatry Milestones on a non-exclusive bases for educational purposes. 1

PC1 — Psychiatric Evaluation

Level 1 Level 2 Level 3 Level 4 Level 5

1.1 For adolescents,

acquires accurate

history and mental

status examination

findings, customized to

the patient’s complaints

1.2 Assesses patient

safety, including suicidal

and homicidal ideation,

and considers the

potential for trauma,

abuse, aggression, and

high-risk behaviors

1.3 Demonstrates a

respectful manner with

children and adolescents

and their families

1.4 Seeks supervision

appropriately

2.1 For adolescents, obtains

information that is sensitive and

not readily offered by the patient

2.2 Considers the structure and

functioning of the family, including

strengths, vulnerabilities, and

cultural factors, as they pertain to

the child

2.3 Conducts assessment that

includes observation of child’s

interaction with caretakers

2.4 Conducts basic assessment of

the child’s development

2.5 Selects laboratory and

diagnostic tests (medical work-up)

appropriate to the clinical

presentation

2.6 Uses hypothesis-driven

information-gathering techniques

2.7 Begins to use the clinician's

emotional responses to the patient

and family as a diagnostic tool

3.1 Evaluates the structure and

functioning of the family, including

strengths, vulnerabilities, and

cultural factors, as they pertain to

the child

3.2 Assesses development across

all domains

3.3 For school-age and adolescent

patients, obtains information that

is sensitive and not readily offered

by the patient

3.4 Selects and uses appropriate

diagnostic tests (screening

instruments, rating scales,

psychoeducational testing)

appropriate to the clinical

presentation

3.5 Regularly uses the clinician's

emotional responses to the patient

and family as a diagnostic tool

3.6 Demonstrates ability to shift

focus when verbal and non-verbal

information is conflicting

4.1 Acquires efficient,

accurate, thorough and

relevant history for

preschool, school-age, and

adolescent patients,

customized to each patient’s

complaints

4.2 Modifies interview

approach to assess patients

at different developmental

levels, including use of non-

verbal techniques and play

4.3 Effectively assesses

development, including

atypical development

(intellectual disability, etc.)

4.4 Collects information from

the pertinent systems

4.5 Assesses the family in a

sophisticated and culturally-

sensitive manner

5.1 Incorporates

therapeutic interventions

as part of the evaluation

patients and families

5.2 Utilizes creative use of

evaluation techniques,

both verbal and non-

verbal

5.3 Serves as a role model

for gathering subtle and

reliable information from

the patient

5.4 Independently teaches

and supervises other

learners in clinical

evaluation

Comments:

Not yet achieved Level 1



PC2 — Psychiatric Formulation and Differential Diagnosis1


1.1 Organizes and accurately

summarizes, reports, and

presents information from

the patient, family, and

collateral sources to

colleagues

1.2 Develops a working

diagnosis based on patient

evaluation

2.1 Develops comprehensive

differential diagnosis for

common syndromes,

synthesizing data from the

patient, family, and

collateral sources

2.2 Describes patients’

symptoms and problems,

precipitating stressors or

events, predisposing life

events or stressors,

perpetuating and protective

factors, and prognosis

3.1 Describes how

development influences the

presentation of

psychopathology

3.2 Develops a comprehensive

differential diagnosis while

avoiding premature closure

3.3 Organizes formulation in a

systematic manner that

follows a conceptual model2

4.1 Efficiently synthesizes all

information into a concise but

comprehensive formulation

4.2 Incorporates subtle,

unusual, or conflicting reports

into hypotheses and

formulations, including

developmental, family, and

systems factors

4.3 Includes the interaction

between contributing factors in

the diagnostic formulation

5.1 Formulates a case

based on different

conceptual models

5.2 Expands the

differential diagnosis to

include subtle or rare

presentations or

disorders

5.3 Serves as a role

model of efficient and

accurate formulation

5.4 Teaches formulation

to advanced learners

Comments:

Footnotes: 1A psychiatric formulation is a theoretically-based conceptualization of the patient’s mental disorder(s). It provides an organized summary of those individual factors thought to contribute to the patient’s unique psychopathology. This includes elements of possible etiology, as well as those that modify or influence presentation, such as risk and protective factors. It is therefore distinct from a differential diagnosis that lists the possible diagnoses for a patient, or an assessment that summarizes the patient’s signs and symptoms, as it seeks to understand the underlying mechanisms of the patient’s unique problems by proposing a hypothesis as to the causes of mental disorders.

2Models of formulation include those based on either major theoretical systems of the etiology of mental disorders (such as behavioral, biological, cognitive, cultural, psychological, psychoanalytic, sociological, or traumatic), or comprehensive frameworks of understanding (such as bio-psycho-social or predisposing, precipitating, perpetuating, protective, and prognostic outlines). Models of formulation set forth a hypothesis about the unique features of a patient’s illness that can serve to guide further evaluation or develop individualized treatment plans.




PC3 — Treatment Planning and Management


1.1 Sets treatment goals in

collaboration with the

patient and family

1.2 Manages patient crises

and safety concerns with

supervision

1.3 Monitors treatment

adherence and response

2.1 Incorporates a clinical

practice guideline or

treatment algorithm when

available

2.2 Links treatment to

formulation

2.3 Recognizes need for

consultation and supervision

for complicated or

refractory cases

2.4 Re-evaluates and revises

treatment approach based

on new information and or

response to treatment

3.1 Applies an understanding

of psychiatric, neurologic, and

medical co-morbidities to

treatment selection

3.2 Applies an understanding

of family strengths and

vulnerabilities in the

treatment plan and its

implementation

4.1 Devises individualized,

developmentally-sensitive,

and systems-informed

treatment plans for complex

presentations

4.2 Integrates multiple

modalities and systems, as

appropriate, with a

comprehensive approach

4.3 Integrates

neurobiological and genetic

knowledge into treatment

plan

4.4 Appropriately modifies

treatment techniques and

flexibly applies practice

guidelines to fit patient

needs

5.1 Supervises treatment

planning of other learners

and multidisciplinary

providers

5.2 Integrates emerging


knowledge into treatment

plan

5.3 Demonstrates ability to

mobilize appropriate

systems of care to optimize

patient outcomes

Comments:




PC4 — Psychotherapy

Level 1 Level 2 Level 3 Level 4 Level 5 1.1 For all child and

adolescent age

groups, approaches

the therapeutic

encounter with

curiosity and

empathy, and

substantially

recognizes and starts

to manage own

anxiety

1.2 Begins to identify

patient emotions

across the

developmental

spectrum

1.3 Able to use non-

verbal techniques to

start to build an

alliance with children

and adolescents

1.4 Establishes

appropriate

professional

boundaries and avoids

boundary violations

2.1 Recognizes that overt

affect and behavior may

mask underlying feelings

2.2 Selects and implements

a psychotherapeutic

modality based on an

appropriate formulation

2.3 Discusses the structure/

frame of psychotherapy,

including the limits of

confidentiality, with patient

and family

2.4 Maintains

developmentally-

appropriate professional

boundaries in

psychotherapeutic

relationships while being

responsive to the patient

and family

2.5 Establishes and

maintains a therapeutic

alliance with both patients

and families

3.1 Establishes and maintains a

therapeutic alliance with, and

provides psychotherapies to,

patients with uncomplicated

problems

3.2 Uses verbal and non-verbal

strategies to access internal

processes of the patient

3.3 Links feelings, behavior,

recurrent/central

themes/schemas, and their

meaning to the patient as they

shift within and across sessions

3.4 Successfully guides the patient

and family through the different

phases of psychotherapy in a

developmentally-appropriate way

3.5 Balances autonomy with need

for consultation and supervision

3.6 Integrates the selected

psychotherapy with other

treatment modalities and other

treatment providers

4.1 For all child and adolescent age groups,

demonstrates capacity to listen and observe

and use information obtained this way in

psychotherapy

4.2 Substantially manages the

structure/frame of psychotherapy with

patient and/or family

4.3 Anticipates and appropriately manages

potential boundary crossings and avoids

boundary violations

4.4 Consistently uses developmentally-

appropriate psychotherapeutic techniques,

including non-verbal strategies

4.5 Provides different modalities of

psychotherapy (including family or supportive

therapy and at least one psychodynamic or

cognitive behavioral therapy) to patients with

moderately complicated problems

4.6 Recognizes and manages treatment

impasses

4.7 Appropriately manages own feelings

elicited by work with patients and families

5.1 Creatively

integrates different

therapy modalities

tailored to the

individual patient

and family

5.2 Provides

psychotherapies to

patients with very

complicated and/or

refractory

disorders/problems

5.3 Personalizes

treatment based on

awareness of one’s

own skill set,

strengths, and

limitations

5.4 Provides

psychotherapy

supervision to others

Comments:




PC5 — Somatic Therapies, including Psychopharmacology and Other Somatic Treatments


1.1 With supervision,

selects and prescribes

commonly used

psychopharmacologic

agents targeting specific

child and adolescent

psychiatric disorders

1.2 Engages in an

informed

consent/assent process

with family and patient,

including general

indications, dosing

parameters, and

common side effects for

commonly prescribed

medications

1.3 Obtains basic

physical exam and lab

studies necessary to

initiate treatment with

commonly prescribed

medications

2.1 Discusses medication use

with children in a

developmentally-appropriate

manner

2.2 Applies appropriate judgment

about off-label use of somatic

treatments with supervision

2.3 Describes contraindications

and adverse effects of commonly

prescribed medications

2.4 Titrates medication dosage

and prevents or manages side

effects with a single medication

2.5 Incorporates basic knowledge

of mechanisms of action and

metabolism across development

in treatment selection

2.6 Monitors and responds to

relevant lab studies throughout

treatment

3.1 Independently applies

appropriate judgment about

off-label use of somatic

treatments

3.2 Manages

pharmacokinetic and

pharmacodynamic drug

interactions when using

multiple medications

concurrently

3.3 Appropriately selects

evidence-based somatic

treatment options and

incorporates evidence into

psychoeducation of patient

and family

3.4 With supervision, uses

evidenced-based

augmentation strategies

when primary

pharmacological

interventions are only

partially successful

4.1 Appropriately titrates dosage

and prevents and manages side

effects, including when patients

are on multiple medications

4.2 Appropriately selects

evidence-based somatic

treatment options and safely

manages patients when the

evidence base is limited

4.3 Follows practice guidelines

for management of multiple

medications, and if deviating

from guidelines, provides

appropriate rationale

4.4 Engages in a fully-informed

consent/assent process with

families and patients, including

off-label use, specific

contraindications, level of

evidence, etc.

4.5 Recognizes limitations of

psychopharmacological

treatment

5.1 Integrates

emerging studies of

somatic treatments

into clinical practice

5.2 Skillfully

demonstrates

management of

complex patients using

multimodal somatic

treatments

Comments:




MK1 — Development in Infancy, Childhood, and Adolescence, Including the Impact of Psychopathology on the Trajectory of Development and Development on the Expression of Psychopathology


1.1 Describes the basic

stages of normal physical,

social, and cognitive

development from infancy

to young adulthood

2.1 Demonstrates basic

knowledge of the major

developmental theories

across all developmental

domains

2.2 Describes the effects of

trauma, neglect, and early

adverse events on

development

2.3 Recognizes deviation

from normal development,

including arrests and

regressions

2.4 Utilizes developmental

concepts in case

formulation

2.5 Describes family

development

3.1 Explains developmental

tasks and transitions

throughout the life cycle,

utilizing multiple conceptual

models

3.2 Gives examples of gene-

environment interaction

influences on development and

psychopathology

3.3 Describes the influence of

psychosocial factors (gender,

ethnic, cultural, economic),

medical conditions, perinatal

factors, and neurological illness

on development

3.4 Describes interaction

between family organization

and development and

developmental stages of all

family members

3.4 Describe the

4.1 Describes in detail the

stages of normal physical,

social/emotional, speech

and language, sexual,

gender identity, and

cognitive development from

infancy to young adulthood

4.2 Describes how

developmental capacities

and limitations influence the

differing presentation of

psychopathology from


4.3 Describes the impact of

cultural factors on

development

4.4 Interprets the impact of

major life events in the

context of the patient’s

developmental stage

5.1 Teaches or develops

curricula on the stages of

normal physical (gross

motor, fine motor, sensory

integration),

social/emotional, speech

and language, sexual,

gender identity, and

cognitive development from


5.2 Incorporates new

neuroscientific knowledge

into his/her understanding

of development

Comments:




MK2 — Psychopathology and Wellness, including Knowledge of Diagnostic Criteria, Epidemiology, Risk and Protective Factors, Pathophysiology, Course

of Illness, Co-morbidities, and Differential Diagnosis of Psychiatric Disorders


1.1 Lists common

Diagnostic and Statistical

Manual of Mental

Disorders, Fifth Edition

(DSM-5) diagnoses that

begin in infancy,

childhood, and

adolescence

1.2 Lists major risk and

protective factors for

danger to self and others

and abuse/neglect

1.3 Gives examples of

interactions between

medical and psychiatric

symptoms and disorders

1.4 Lists examples of

interactions between

psychiatric symptoms and

psychosocial stressors

2.1 Demonstrates sufficient

knowledge to identify and

treat common psychiatric

conditions in youth in a

variety of settings


knowledge to identify co-

morbid medical conditions

in psychiatric patients

2.3 Identifies factors that

contribute to wellness


knowledge to identify and treat

most psychiatric conditions

from infancy to young

adulthood and in a variety of

settings

3.2 Displays knowledge to

conduct a risk assessment and

determine the appropriate

level of care for older children

and adolescents

3.3 Shows sufficient knowledge

to identify and treat common

psychiatric manifestations of

medical illness


knowledge to include relevant

medical and neurological

conditions in the differential

diagnoses of psychiatric

patients



treat complex psychiatric

conditions from infancy

through young adulthood and

in a range of settings

4.2 Demonstrates the

knowledge of the appropriate

level of care for patients at

risk of harm to self or others

from infancy to young

adulthood and in a full range

of treatment settings

4.3 Shows knowledge

sufficient to identify and treat

a wide range of psychiatric

conditions in patients with

medical disorders

5.1 Displays knowledge

sufficient to teach risk

assessment

5.2 Demonstrates a

sophisticated understanding

of current controversies in

diagnosis

5.3 Shows sufficient


treat uncommon psychiatric

conditions in patients with

medical disorders

Comments:




MK3 — Clinical Neuroscience and Genetics, including Knowledge of Neurology, Neuropsychiatry, Neurodiagnostic Testing, and Relevant Neuroscience and their Application in Clinical Settings


1.1 Demonstrates

knowledge of commonly

available neuroimaging

and neurophysiologic

diagnostic modalities and

how to order them

1.2 Lists common factors

in neural development

that may impact the

overall development and

the presentation of

psychiatric symptoms

2.1 Demonstrates

knowledge of general

indications for structural

neuroimaging, magnetic

resonance imaging [MRI]),

and neurophysiological

testing

2.2 Describes common

neuropsychological tests

and their indications

2.3 Describes psychiatric

disorders co-morbid with

common neurologic

disorders and neurological

disorders frequently seen in

psychiatric patients

2.4 Identifies the brain areas

thought to be important in

social and emotional

behavior

3.1 Describes neural

development from infancy

to young adulthood

3.2 Recognizes the

significance of abnormal

findings in routine

neurodiagnostic test

reports in psychiatric

patients

3.3 Demonstrates

knowledge of indications

for specific

neuropsychological tests

and understands meaning

of common abnormal

findings

3.4 Describes


hypotheses of common

psychiatric disorders and

their limitations

4.1 Explains the significance of

routine neuroimaging,

neurophysiological,

neuropsychological testing, and

genetic abnormalities to patients

and families

4.2 Demonstrates knowledge of

clinical indications and limitations of

functional neuroimaging

4.3 Explains neurobiological

hypotheses and genetic risks of

common psychiatric disorders to

patients

4.4 Describes psychiatric co-

morbidities of less common

neurologic and genetic disorders and

less common neurologic co-

morbidities of psychiatric disorders


knowledge to incorporate pertinent

neuroscientific and genetic

hypotheses of emotions and social

behaviors into case formulation

5.1 Integrates recent

neurodiagnostic research

into understanding of

psychopathology

5.2 Flexibly applies

knowledge of

neuropsychological

findings to the differential

diagnoses of complex

patients

5.3 Explains

neurobiological

hypotheses and genetic

risks of less common

psychiatric disorders to

patients

5.4 Integrates knowledge

of neurobiology into

advocacy for psychiatric

patient care, prevention,

and stigma reduction

Comments:




MK4 — Psychotherapy: Refers to knowledge regarding: 1) individual psychotherapies, including psychodynamic1, IPT, cognitive-behavioral2, and supportive therapies3; 2) family and group therapies; 3) dyadic therapies (PCIT, etc.); and 4) integrating psychotherapy and psychopharmacology


1.1 Identifies psycho-

dynamic, cognitive-

behavioral, family, dyadic,

and supportive therapies as

major psychotherapeutic

modalities in relationship

to child and adolescent

patients

1.2 Recognizes the core

differences in therapeutic

approaches when working

with children vs. adults


principles of each of the

psychotherapy modalities4

2.2 Discusses common

factors across psychotherapy

modalities5

2.3 Lists the basic indications,

contraindications, benefits,

and risks of each of the

psychotherapy modalities,

including whether to use

individual vs. family-based

approaches


techniques of the core


3.2 Summarizes the evidence

base for the core


4.1 Describes proposed

mechanisms of therapeutic

change

4.2 Discusses the evidence

base for combining different

psychotherapies and

psychopharmacology

4.3 Critically appraises the

evidence for efficacy of the

core psychotherapies

5.1 Incorporates new

theoretical developments

into knowledge base


knowledge of psychotherapy

to teach and supervise

others effectively

Comments:

Footnotes: 1This includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to understand the concepts of resistance/defenses, and transference/countertransference.

2This includes the capacity to generate a case formulation, and to demonstrate techniques of intervention, including behavior change, skills acquisition, and addressing cognitive distortions.

3This includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to strengthen the patient’s adaptive defenses, resilience, and social supports.

4Throughout this subcompetency, the three “major” or “core” individual psychotherapies refer to supportive, psychodynamic, and cognitive-behavioral therapies.

5“Common factors” refers to elements that different psychotherapeutic modalities have in common and that are considered central to the efficacy of psychotherapy. These include accurate empathy, therapeutic alliance, and appropriate professional boundaries.




MK5 — Somatic Therapies: Medical Knowledge of Somatic Therapies, including Psychopharmacology, ECT, and Emerging Somatic Therapies, such as

Transcranial Magnetic Stimulation (TMS) and Vagal Nerve Stimulation (VNS)


1.1 Describes general

indications and common

side effects for commonly

prescribed

psychopharmacologic

agents for children and

adolescents

1.2 Accesses practice

parameters and other

appropriate resources to

answer questions about

somatic treatments

2.1 Describes hypothesized

mechanisms of action and

metabolism for commonly

prescribed

psychopharmacologic

agents

2.2 Describes less frequent,

but potentially serious,

adverse effects for

commonly prescribed

psychopharmacological

agents

2.3 Describes practical

issues for initiation or

maintenance of medications

for children and adolescents

2.4 Describes the physical

and lab studies necessary to

initiate treatment with

commonly prescribed

medications

3.1 Demonstrates an

understanding of developmental

impacts on pharmacokinetics and

pharmacodynamic drug

interactions

3.2 Demonstrates an

understanding of the potential

impact of medication on

development

3.3 Demonstrates an

understanding of psychotropic

selection based on current

practice guidelines or treatment

algorithms for common

psychiatric disorders in children

and adolescents

3.4 Describes indications for

second- and third-line

pharmacologic agents

3.5 Lists indications, evidence-

base, and how to implement non-

medication somatic treatments

4.1 Describes the

strengths and limitations

of the evidence

supporting the use of

medications and other

somatic therapies in

certain treatment

situations in children and

adolescents

4.2 When deviating from

practice guidelines,

demonstrates knowledge

of the potential risks and

appropriate management

for children and

adolescents

5.1 Integrates emerging

studies of somatic

treatments into

knowledge base

5.2 Effectively teaches

evidence-based or best

somatic treatment

practices

Comments:




MK6 — Practice of Psychiatry


1.1 Lists common ethical

issues in child and

adolescent psychiatry

1.2 Recognizes and

describes institutional

policies and procedures

2.1 Demonstrates

knowledge of the regulatory

compliance requirements of

his/her own jurisdiction

(e.g., mandatory reporting,

age of consent, etc.)

2.2 Lists and discusses

sources of professional

standards of ethical practice

2.3 Describes how to keep

current on regulatory and

practice management issues

2.4 Demonstrates

knowledge of telehealth as a

modality of care

3.1 Discusses potential

conflicts of interest related to

having multiple professional

roles

3.2 Discusses potential

conflicting interests and

obligations of the patient,

family, and systems of care

3.3 Describes applicable

regulations for billing and

reimbursement

3.4 Demonstrates familiarity

with the American Academy

of Child and Adolescent

Psychiatry (AACAP) Code of

Ethics

3.5 Demonstrates knowledge

of educational laws

4.1 Understands that there

are state and regional

differences regarding

practice, involuntary

treatment, health

regulations, and psychiatric

forensic evaluation

4.2 Describes ways to

advocate for patients and

the profession

4.3 Describes how to seek

out and integrate new

information on the practice

of child and adolescent

psychiatry

5.1 Describes evolving issues

regarding practice,

involuntary treatment, and

health regulations

5.2 Proposes advocacy

activities, policy

development, or scholarly

contributions related to

professional standards

Comments:




SBP1 — Patient Safety and the Health Care Team


1.1 Describes the common

system causes for errors

1.2 Follows institutional

safety policies, including

reporting of problematic

behaviors and processes,

errors, and near misses

1.3 Actively participates in

conferences focusing on

systems-based errors in

patient care

2.1 Describes systems and

procedures that promote

patient safety

2.2 Effectively and regularly

utilizes all appropriate forms

of communication to ensure

safe transitions of care and

optimize communication

across systems and the

continuum of care

2.3 Follows regulatory

requirements related to

prescribing practices

3.1 Recognizes special patient

or family circumstances that

will affect discharge planning

3.2 Negotiates patient-

centered care among multiple

care providers and systems

4.1 Participates in a team-

based approach to medical

error or root-cause analysis,

including quality

improvement projects

4.2 Takes a leadership role

in ensuring safe transitions

of care and optimizing

communication across

systems and the continuum

of care

4.3 Participates in a patient

safety presentation or a

critical case conference

focusing on systems-based

errors in patient care

5.1 Leads multidisciplinary

teams (e.g., human factors

engineers, social scientists)

to address patient safety

issues

5.2 Provides consultation to

organizations to improve

the health care team and

patient safety

Comments:




SBP2 — Resource Management


1.1 Recognizes disparities in

health care access at

individual and community

levels

1.2 Knows the relative costs

of care and reimbursement

2.1 Coordinates, or oversees

the coordination of, patient

access to community and

system resources

2.2 Is aware of health care

funding and regulations

related to organization of

health care services

3.1 Balances the best interests

of the patient and family with

the availability of resources

3.2 Uses available resources

(e.g., Electronic Medical

Record [EMR]) to improve

patient safety and quality

4.1 Practices cost-effective,

high-value clinical care,

using evidence-based tools

and information

technologies to support

decision making

5.1 Designs measurement

tools to monitor and

provide feedback to

providers/teams on

resource consumption to

facilitate improvement

5.2 Advocates for improved

access to and additional

resources within systems of

care

Comments:




SBP3 — Community-based Care


1.1 Understands the local

health care delivery systems

and other community

organizations, including

advocacy groups

2.1 Understands cultural

and community differences

in use of systems

2.2 Recognizes role and

explains importance of self-

help groups and community

resource groups (e.g.,

family-based and disorder-

specific support and

advocacy groups)

2.3 Identifies community-

based systems of care for

the chronically mentally ill

and disabled

3.1 Participates in planning

care with community mental

health agencies, schools, and

community organizations

3.2 Incorporates self-help

groups, community resources,

and social networks in

treatment and clinical care

4.1 Demonstrates capacity

to provide medical-

psychiatric leadership to

health care facilities

4.2 Assists families in

coordinating long-term

treatment and care of

patients in a community

setting

5.1 Participates in the

administration of

community-based

treatment programs

5.2 Participates in creating

new community-based

programs

Comments:




SBP4 — Consultation to and Integration with Non-psychiatric Medical Providers and Non-medical Systems (e.g., primary care providers, schools,

community-based agencies, forensics)


1.1 Describes various

consultative approaches

and the basic consultative

frame

2.1 Provides basic

consultation to non-

psychiatric medical

providers

2.2 Discusses methods for

integrating mental health

and medical care in

treatment planning

3.1 Describes consultative

frames across a variety of

community-based systems

3.2 Identifies systems issues

and provides basic

recommendations for change

in the settings where

consultation occurs

4.1 Skillfully provides

consultation to non-

psychiatric medical

providers, including in

complex cases

4.2 Provides integrated care

for psychiatric patients and

families through

collaboration with

physicians and other health

care providers at

community-based sites

4.3 Skillfully provides

consultation to a variety of

community-based systems

(e.g., schools, courts)

5.1 Designs novel ways to

improve mental health care

delivery to other systems

5.2 Leads a consultation

team

5.3 Supervises junior

learners in consultation to

other systems

Comments




PBLI1 — Development and Execution of Lifelong Learning through Constant Self-evaluation, including Critical Evaluation of Research and Clinical Evidence


1.1 Regularly seeks and

incorporates feedback to

improve performance

1.2 Identifies self-directed

learning goals and

periodically reviews them

with supervisory guidance

1.3 Formulates a searchable

question from a clinical

practice problem [see 3.3]

and conducts a basic online

search to answer it

2.1 Demonstrates a

balanced and accurate self-

assessment of competence,

using clinical outcomes to

identify areas for continued

improvement

2.2 Selects an appropriate,

evidence-based information

tool to meet self-identified

learning goals

3.1 Critically appraises

different types of research,

including randomized

controlled trials (RCTs),

systematic reviews, meta-

analyses, and practice

guidelines

3.2 Demonstrates

improvement in clinical

practice based on continual

self-assessment and evidence-

based information

3.3 Independently searches

for and discriminates among

evidence relevant to clinical

practice problems

4.1 Identifies and meets

self-directed learning goals

with little external guidance

4.2 Demonstrates use of a

system or process for

keeping up with relevant

changes in medicine

4.3 Sustains a practice of

self-assessment and keeping

up with relevant changes in

medicine, and applies the

evidence appropriately to

practice

5.1 Teaches others

techniques to efficiently

incorporate evidence

gathering into clinical

workflow

5.2 Contributes to the

knowledge base and

disseminates new

information through peer-

reviewed publication and

other scholarly activity

Comments:




PBLI2 — Teaching


1.1 Assumes a role in the

clinical teaching of early

learners

1.2 Communicates goals and

objectives for instruction of

early learners

2.1 Participates in activities

designed to develop and

improve teaching skills

2.2 Provides feedback to

early and advanced-level

learners

2.3 Describes basic

principles of adult learning

3.1 Teaches groups and

individuals in clinical settings

3.2 Teaches in formal didactic

presentations to groups (e.g.,

grand rounds, departmental

case conference)

3.3 Participates in and

contributes to educational

program review (e.g., resident

retreat, annual program

evaluation, education

committees)

4.1 Develops and gives

specialty- and subspecialty-

specific presentations to

groups

4.2 Effectively uses feedback

on teaching to improve

teaching methods and

approaches

4.3 Implements basic

principles of adult learning

in his/her teaching

5.1 Educates broader

professional community

and/or public (e.g., presents

at regional or national

meeting)

5.2 Organizes, develops, and

delivers curricular materials

Comments:




PROF1 — Compassion, Integrity, Respect for Others, Sensitivity to Diverse Patient Populations, Adherence to Ethical Principles


1.1 Demonstrates respect

for trainees and other

members of the treatment

team

1.2 Demonstrates capacity

for self-reflection, empathy,

curiosity about patient and

family, and openness to

different beliefs and points

of view

1.3 Provides examples of

the importance of attention

to diversity in psychiatric

evaluation and treatment

1.4 Recognizes basic ethical

conflicts in practice and

seeks supervision to manage

them

2.1 Elicits beliefs, values,

and diverse cultural

practices of patients and

their families, and

understands their potential

impact on patient care

2.2 Routinely displays

sensitivity to diversity in

psychiatric evaluation and

treatment

2.3 Recognizes ethical issues

in practice and is able to

discuss, analyze, and

manage them in common

clinical situations

3.1 Discusses, in educational

settings, his/her own cultural

background and beliefs and

the ways in which these affect

interactions with patients

3.2 Recognizes ethical

conflicts in child psychiatry

practice and seeks supervision

to manage them

4.1 Adapts clinical approach

to meet the needs of diverse

patients and populations

4.2 Incorporates ethical

issues into case discussion

and clinical care

4.3 Recognizes and skillfully

manages ethical conflicts in

child psychiatry practice and

seeks consultation

appropriately

4.4 Develops a mutually

agreeable care plan in the

context of conflicting

physician and patient

and/or family values and

beliefs

5.1 Leads educational

activities and case

discussions regarding ethical

issues specific to child

psychiatry

5.2 Serves as a role model

and teacher of compassion,

integrity, respect for others,

and sensitivity to diverse

patient populations

5.3 Identifies emerging

ethical issues within

subspecialty practice, and

can discuss opposing

viewpoints

Comments:




PROF2 — Accountability to Self, Patients, Colleagues, and the Profession


1.1 Follows procedures for

coverage for clinical and

non-clinical responsibilities

1.2 Follows institutional

policies for physician

conduct and responsibility

1.3 Accepts the role as the

patient’s physician and

takes responsibility (under

supervision) for ensuring

that the patient receives

the best possible care

1.4 Demonstrates ability to

accept professional

feedback from supervisors

2.1 Identifies and manages

situations in which

maintaining personal

emotional, physical, and

mental health is challenged,

and seeks assistance when

needed

2.2 Describes the importance

of participating in one’s

professional community

2.3 Is recognized by self,

patient, patient’s family, and

medical staff members as an

active member of the clinical

team

2.4 Displays increasing

autonomy and leadership in

taking primary responsibility

for patient care

3.1 Knows appropriate steps

for addressing impairment in

self and colleagues

3.2 Prepares for obtaining

and maintaining board

certification

3.3 Covers professional

duties for colleagues when

appropriate

4.1 Appropriately prioritizes

and balances conflicting

interests of patient, family,

self, co-workers, and others to

optimize clinical care and the

work environment


professional community (e.g.,

house officer association,

professional societies, patient

advocacy groups, community

service organizations)

4.3 When relevant, takes

appropriate steps in

addressing impairment in self

and colleagues

4.4 Applies ethical principles

to practice based on AACAP’s

Code of Ethics

5.1 Demonstrates

leadership in covering

professional duties for

colleagues when

appropriate

5.2 Participates in physician

wellness programs or

interventions and

organizations that address

physician wellness

5.3 Develops

professionalism policies,

programs, or curricula for

child psychiatry

Comments:




ICS1 — Relationship Development and Conflict Management with Patients and Families, Colleagues, Members of the Health Care team, and Other Systems


1.1 Develops therapeutic

relationship with patients

and their families in

uncomplicated situations

1.2 Describes and respects

cultural and linguistic

diversity in communicating

with people of different

backgrounds

1.3 Recognizes

communication conflicts in

work relationships

2.1 Develops working

relationships across

specialties and systems in

uncomplicated situations

2.2 Manages simple

patient/family-related

conflicts

2.3 Actively participates in

and supports activities of

team-based care

3.1 Develops therapeutic

relationships with patients

and families in complicated

situations

3.2 Sustains working

relationships with co-workers

in the face of conflict

3.3 Takes a leadership role in a

multidisciplinary care team

3.4 Recognizes differing

philosophies within and

between different disciplines

in care provision

4.1 Skillfully manages

therapeutic and working

relationships during

complex and challenging

situations, including

transitions of care

4.2. Sustains relationships

across systems of care and

with patients and families

during long-term follow-up

4.3 Takes a leadership role

in managing team conflicts

4.4 Effectively leads

multidisciplinary patient

care and family meetings

5.1 Develops

models/approaches to

managing difficult

communications

5.2 Effectively mentors

other health care providers

in leadership,

communication skills, and

conflict management

5.3 Leads and facilitates

meetings within the

organization/system

Comments:




ICS2 — Information Sharing and Record Keeping


1.1 Ensures transitions of

care are optimally

communicated across

systems and continuums of

care

1.2 Sufficiently documents

clinical encounters in the

medical record in an

accurate and timely way

consistent with institutional

policies

1.3 Effectively

communicates information

with patients and families in

clinical encounters

1.4 Maintains appropriate

boundaries in sharing

information by electronic

communication and in the

use of social media

2.1 Uses developmentally-

appropriate language in all

phases of communication

with patients

2.2 Communicates with

families at an appropriate

level of sophistication

2.3 Consistently

demonstrates

communication strategies

to ensure patient and family

understanding

3.1 Demonstrates written

communication with patients,

families, colleagues, and other

health care providers that is

appropriate, efficient, concise,

and pertinent

3.2 Appropriately balances

patient confidentiality and the

family’s right to know

information

3.3 Appropriately balances

patient confidentiality and

communication with the

treatment team

3.4 Consistently engages

patients and families in shared

decision making

3.5 Demonstrates appropriate

face-to-face interaction while

using EMR

4.1 Demonstrates skillful

communication that is

appropriate, efficient,

concise, and pertinent with

patients and families,

colleagues, and co-workers

4.2 Recruits appropriate

assistance from external

sources when cultural

differences create barriers

to patient care

4.3 Thoroughly and

efficiently documents

patient encounters and uses

discretion and judgment in

the inclusion of sensitive

patient material in the

medical record

4.4 Uses discretion and

judgment in electronic

communication with

patients, families, and

colleagues


development of changes in

rules, policies, and

procedures related to

technology

5.2 Engages in scholarly

activity regarding effective

communication and

documentation

Comments:


pediatrics – psychiatry – child and adolescent …...pediatrics – psychiatry – child and...

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