Psychiatry Milestones

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The Psychiatry Milestone Project
A Joint Initiative of
The Accreditation Council for Graduate Medical Education and

The American Board of Psychiatry and Neurology

DRAFT
April 2013

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.

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Psychiatry Milestone Group Christopher R. Thomas M.D., Chair Working Group Sheldon Benjamin, M.D. Adrienne L. Bentman, M.D. Robert Boland , M.D. Deborah S. Cowley, M.D. Jeffrey Hunt, M.D., M.S. George A. Keepers, M.D. Louise King, M.S. Gail H. Manos, M.D. Donald E. Rosen, M.D. Kathy M. Sanders, M.D. Mark E. Servis, M.D. Kallie Shaw, M.D. Susan Swing, Ph.D. Alik Widge, M.D., Ph.D. Advisory Group Timothy Brigham, MDiv, PhD Carol A. Berstein, M.D. Beth Ann Brooks, M.D. Larry R. Faulkner, M.D. Deborah Hales, M.D. Victor I. Reus, M.D. Richard F. Summers, M.D.

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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. They are descriptors and targets for resident performance as a resident moves from entry into residency through graduation. 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 a resident’s current performance level in relation to milestones, using evidence from multiple methods, such as direct observation, multi-source feedback, tests, and record reviews, etc. Milestones are arranged into numbered levels. These levels do not correspond with postgraduate year of education. Selection of a level implies that the resident substantially demonstrates the milestones in that level, as well as those in lower levels (See the diagram on page v). A general interpretation of levels for psychiatry is below:

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 demonstratin g “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.

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Additional Notes Level 4 is designed as the graduation target and does not represent a graduation requirement. Making decisions about readiness for graduation is the purview of the residency program director (See the following NAS FAQ for educational milestones on the ACGM E’s NAS microsite for further discussion of this issue: “Can a resident 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.

Answers to Frequently Asked Questions about the Next Accreditation System (NAS) and milestones are available on the ACGME’s NAS microsite: http://www.acgme-nas.org/assets/pdf/NASFAQs.pdf.

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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 the milestones or  selecting the “Has not Achieved Level 1” response option PC2 Psychiatric Formulation and Differential Diagnosisa Has not Achieved Level 1 Level 2 Level 1
Accurately reports and summarizes information obtained from the patient evaluation Develops a working diagnosis based on patient evaluation Identifies patterns and recognizes phenomenology from the patient's presentation to generate diagnostic hypotheses Develops a basic differential diagnosis for common syndromes and patient presentations Describes patients’ symptoms and problems, precipitating stressors or events, predisposing life events or stressors, perpetuating and protective factors, and prognosis

Level 3
Organizes formulation around comprehensive models of phenomenology that take etiology into b account Develops a full differential diagnosis while avoiding premature closure Routinely identifies subtle, unusual, or conflicting findings that may influence clinical decision making

Level 4
Efficiently synthesizes all information into a concise but comprehensive formulation Incorporates subtle, unusual or conflicting findings into alternative hypotheses and formulations

Level 5
Serves as role model of efficient and accurate formulation Teaches formulation to advanced trainees

Comments: 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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PSYCHIATRY MILESTONES Report Form DRAFT
PC1. Psychiatric Evaluation
Has not Achieved Level 1 Level 1 1.1 Obtains general medical and psychiatric history and mental status examination 1.2 Obtains relevant collateral information from secondary sources 1.3 Screens for patient safety, including suicidal and homicidal ideation Level 2 2.1 Acquires efficient, accurate and relevant history customized to the patient complaints 2.2 Performs a targeted examination, including neurological examination, relevant to the patient complaints 2.3 Obtains information that is sensitive and not readily offered by the patient 2.4 Assesses patient safety, including suicidal and homicidal ideation 2.5 Recognizes that clinician’s emotional responses have 1 diagnostic value Level 3 3.1 Consistently obtains complete, accurate and relevant history 3.2 Selects laboratory and diagnostic tests appropriate to the clinical presentation 3.3 Performs efficient interview and examination with flexibility appropriate to the clinical setting and workload demands 3.4 Uses hypothesis driven information 2 gathering techniques Level 4 4.1 Routinely identifies subtle and unusual findings and accurately utilizes these findings in formulation of case 4.2 Practices cost-effective ordering of diagnostic studies 4.3 Follows clues to identify relevant historical findings in complex clinical situations and unfamiliar circumstances 4.4 Begins to use clinician's emotional responses to the patient as a diagnostic tool Level 5 5.1 Serves as a role model for gathering subtle and reliable information from the patient 5.2 Teaches and supervises trainees in clinical evaluation

Comments:
Footnotes 1 This milestone refers to the use of the clinician’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. 2 This milestone focuses on the efficient and deductive conduct of the interview in accordance with diagnostic hypotheses to refine the differential diagnosis
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.

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PC2 Psychiatric Formulation and Differential Diagnosisa
Has not Achieved Level 1 Level 1 1.1 Accurately summarizes, reports, and presents to colleagues information obtained from the patient evaluation 1.2 Develops a working diagnosis based on patient evaluation Level 2 2.1 Identifies patterns and recognizes phenomenology from the patient's presentation to generate diagnostic hypotheses 2.2 Develops a basic differential diagnosis for common syndromes and patient presentations 2.3 Describes patients’ symptoms and problems, precipitating stressors or events, predisposing life events or stressors, perpetuating and protective factors, and prognosis Level 3 3.1 Organizes formulation around comprehensive models of phenomenology that take etiology into b account 3.2 Develops a full differential diagnosis while avoiding premature closure 3.3 Routinely identifies subtle, unusual, or conflicting findings that may influence clinical decision making Level 4 4.1 Efficiently synthesizes all information into a concise but comprehensive formulation 4.2 Incorporates subtle, unusual or conflicting findings into alternative hypotheses and formulations Level 5 5.1 Serves as role model of efficient and accurate formulation 5.2 Teaches formulation to advanced trainees

Comments:
Footnotes: a See annotation at the end of the document b See annotation at the end of the document

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.

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PC3 Treatment Planning and Management
Has not Achieved Level 1 Level 1 1.1 Identifies potential treatment options 1.2 Recognizes patient in crisis or acute presentation 1.3 Recognizes patient readiness for treatment Level 2 2.1 Sets treatment goals in concert with the patient 2.2 Monitors treatment adherence and response 2.3 Manages patient crises with supervision 2.4 Incorporates a clinical practice guideline or treatment algorithm when available 2.5 Recognizes co-morbid conditions and side effects’ impact on treatment 2.6 Links treatment to formulation Level 3 3.1 Re-evaluates and revises treatment approach based on new information and or response to treatment 3.2 Incorporates manual based treatment when available 3.3 Recognizes need for consultation and supervision for complicated or refractory cases 3.4 Applies understanding of psychiatric, neurologic, and medical comorbidities 1 to treatment selection Level 4 4.1 Devises individualized treatment plan for complex presentations 4.2 Appropriately modifies treatment techniques and flexibly applies practice guidelines to fit patient needs Level 5 5.1 Supervises treatment planning of trainees and multidisciplinary providers 5.2 Integrates multiple modalities and providers in comprehensive 2 approach 5.3 Integrates emerging neurobiological and genetic knowledge into 3 treatment plan

Comments:
Footnotes: 1 Examples 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. 2 Understanding and use of an array of modalities and providers may include consideration of complementary and alternative medicine, occupational therapy, physical therapy, to name a few. 3 Examples may include cytochrome genetics; ethnic differences; family counseling; etc.

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.

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PC4 Psychotherapy Refers to 1) the practice and delivery of psychotherapies, including but not limited to psychodynamic 1, cognitive-behavioral2, and supportive therapies3; 2) exposure to couples, family, and group therapies; and 3) integrating psychotherapy with psychopharmacology
Has not Achieved Level 1 Level 1 1.1 Accurately identifies patient emotions, particularly sadness, anger, 4 and fear . 1.2 Demonstrates interest and curiosity in patient’s story Level 2 2.1 Identifies and reflects the core feeling and key issue for the patient during a session. 2.2 Establishes and maintains a therapeutic alliance with patients with uncomplicated problems 2.3 Utilizes elements of supportive therapy in treatment of patients 2.4 Maintains appropriate professional boundaries 2.5 Manages the emotional content of and feelings aroused during sessions Level 3 3.1 Identifies and reflects the core feeling, key issue, and what the issue means to the patient. 3.2 Maintains professional boundaries in psychotherapeutic relationships, while being 5 responsive to the patient 3.3 Establishes and maintains a therapeutic alliance with and provides psychotherapies (supportive, psychodynamic, and cognitive-behavioral therapy) to patients with uncomplicated problems 3.4 Balances autonomy with needs for consultation and supervision 3.5 Manages different phases of treatments Level 4 4.1 Links feelings, behavior, recurrent/central themes/schemas, and their meaning to the patient as they shift within and across sessions. 4.2 Tailors the indicated psychotherapy to the patient 4.3 Establishes and maintains a therapeutic alliance with and provides psychotherapies (including supportive and at least one of psychodynamic or cognitive behavioral therapy) to patients with moderately complicated problems 4.4 Integrates the selected psychotherapy with other treatment modalities and c other treatment providers Level 5 5.1 Provides psychotherapy supervision to others 5.2 Provides psychotherapies to patients with very complicated and/or refractory disorders/problems 5.3 Personalizes treatment based on awareness of one’s skill sets, strengths, and limitations

4.5 Recognizes, seeks
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.

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appropriate consultation about, and manages treatment impasses

Comments:
Footnotes: c See annotations at the end of the document 1 Includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to understand the concepts of resistance/defenses, transference/countertransference. 2 Includes the capacity to generate a case formulation, to demonstrate techniques of intervention, including behavior change, skills acquisition, and addressing cognitive distortions 3 Includes the capacity to generate a case formulation, to demonstrate te chniques of intervention, and to strengthen the patient’s adaptive defenses, resilience, and social supports 4 This thread, consisting of the first item at each level, regarding the development of empathy across residency is adapted from the AADPRT Psychotherapy Workgroup’s document “Benchmarks for Psychotherapy Training.” 5 This refers to the ability to maintain professional boundaries in psychotherapy without being aloof or overly detached.

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.

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PC5 Somatic Therapies Somatic Therapies including, but not limited to psychopharmacology, ECT, and emerging somatic therapies such as TMS and VNS.
Has not Achieved Level 1 Level 1 1.1 Assesses basic patient symptoms and has beginning understanding of commonly used psychopharmacologic agents 1.2 Reviews with the patient the following: general indications, dosing parameters, and common side effects for commonly prescribed 1 psychopharmacologic agents Level 2 2.1 Appropriately prescribes commonly used psychopharmacologic agents 2.2 Incorporates basic knowledge of mechanisms of action and metabolism of commonly prescribed psychopharmacologic agents in treatment selection and explains rationale to patients 2.3 Obtains physical and lab studies necessary to initiate treatment with commonly prescribed medications 2.4 Seeks consultation and supervision regarding potential referral for ECT treatments Level 3 3.1 Manages pharmacokinetic and pharmacodynamic drug interactions when using multiple medications concurrently 3.2 Monitors relevant lab studies, and incorporates emerging physical and laboratory findings into somatic treatment strategy 3.3 Seeks consultation and supervision regarding the potential use of emerging somatic therapies such as TMS and VNS Level 4 4.1 Titrates dosage and manages side effects of multiple medications 4.2 Appropriately incorporates second and third line agents as indicated in the management of treatment resistant symptoms Level 5 5.1 Integrates emerging studies of somatic treatments into their clinical practice 5.2 Explains less common somatic treatment choices to patients in terms of hypothesized mechanisms of action

Comments:
Footnotes: 1 PGY1 residents should be supervised directly or indirectly with supervision immediately available.

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.

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MK1 Development through the life cycle
Has not Achieved Level 1 Level 1 1.1 Describes developmental milestones Level 2 2.1 Describes neural development across the life cycle 2.2 Describes effect of pathological processes and insults on the nervous system across the life cycle 2.3 Gives examples of gene-environment interaction influences on development and 1 psychopathology Level 3 3.1 Explains influence of general medical and neurological illness on processes of development 3.2 Describes the influence of acquisition and loss of specific capacities across life cycle 3.3 Describes major theories of personality development Level 4 4.1 Explains developmental tasks and transitions throughout the life cycle 4.2 Explains influence of psychosocial (gender, ethnic, economic) and other environmental influences on development Level 5 5.1 Integrates knowledge of neuroscience with theories of personality development

Comments:
Footnotes: 1 For example bipolar disorder with genetic diathesis + environmental stress leading to manic behavior

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.

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MK2 Psychopathologyd Includes knowledge of diagnostic criteria, epidemiology, pathophysiology, course of illness, comorbidities, and differential diagnosis of psychiatric disorders, including substance use disorders; presentation of psychiatric disorders across the life cycle and in diverse patient populations (e.g. different cultures, genders, sexual orientation, ethnicity, etc.)
Has not Achieved Level 1 Level 1 1.1 Identifies the major psychiatric diagnostic systems (e.g. DSM) 1.2 Lists major risk factors for danger to self and others 1.3 Gives examples of interactions between medical and psychiatric symptoms and disorders Level 2 2.1 Demonstrates sufficient knowledge to identify and treat common psychiatric conditions in adults in inpatient and emergency settings e.g. major depression, bipolar disorder, schizophrenia. 2.2 Displays sufficient knowledge to determine need for hospitalization due to danger to self and/or others in adult patients with common psychiatric and behavioral conditions 2.3 Shows sufficient knowledge to perform an initial medical and neurological evaluation in psychiatric inpatients Level 3 3.1 Demonstrates sufficient knowledge to identify and treat most psychiatric conditions throughout the life cycle and in a variety of 1 settings 3.2 Displays knowledge of, and the ability to weigh, risk factors for danger to self and/or others across the life cycle in emergency and inpatient settings 3.3 Shows sufficient knowledge to identify and treat common psychiatric manifestations of medical illness (e.g. delirium, depression, steroidinduced psychosis), and medical and neurological conditions in psychiatric patients 3.4 Demonstrates sufficient knowledge to include relevant medical and neurological conditions in the differential diagnosis of Level 4 4.1 Demonstrates sufficient knowledge to identify and treat atypical and complex psychiatric conditions in a range of settings (inpatient, outpatient, emergency, 2 consultation-liaison) 4.2 Displays knowledge sufficient to determine the appropriate level of care for complex patients expressing, or who may represent, danger to self and/or others, across the life cycle, 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, and to identify medical conditions in patients with psychiatric disorders 4.4 Demonstrates sufficient knowledge to identify Level 5 5.1 Demonstrates sufficient knowledge to identify and treat undifferentiated and rare psychiatric conditions in a 3 range of settings 5.2 Displays knowledge sufficient to teach assessment of the appropriate level of care for complex patients who may represent a danger to self and others. 5.3 Shows sufficient knowledge to identify and treat uncommon psychiatric conditions in patients with medical disorders 5.4 Demonstrates sufficient knowledge to manage common medical conditions in patients with psychiatric disorders, in collaboration with other medical providers.

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.

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psychiatric patients.

common medical conditions (e.g. hypothyroidism, hyperlipidemia, diabetes) in psychiatric patients.

Comments:
Footnotes: d See annotations at the end of the document 1 This level includes identification and treatment of a wider array of conditions, across the life cycle (i.e. including childhood and geriatric conditions), and in a variety of settings (e.g. in outpatient, consultation liaison, subspecialty settings). 2 “atypical” and “complex” psychiatric conditions refer to unusual presentations of common disorders, co -occurring disorders in patients with multiple comorbid conditions, and diagnostically challenging clinical presentations 3 “undifferentiated” or “rare” psychiatric conditions refer to challenging presentations without a clear diagnosis as yet, or to very uncommon conditions (e.g. Bonnet’s syndrome, limbic encephalitis).

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.

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MK3 Clinical Neuroscience Includes knowledge of neurology, neuropsychiatry, neurodiagnostic testing, and relevant neuroscience
Has not Achieved Level 1 Level 1 1.1 Knows available neuroimaging and 1 neurophysiologic diagnostic modalities available in one’s own system and how to order them 1.2 Knows how to order neuropsychological testing Level 2 2.1 Knows indications for structural neuroimaging (cranial CT & MRI) and neurophysiological testing (EEG, evoked potentials, sleep studies). 2.2 Describes psychiatric disorders co-morbid with common neurologic 1 disorders and neurological disorders frequently seen in 2 psychiatric patients 2.3 Describes the common neuropsychological tests and their indications 2.4 Identifies the brain areas thought important in social and emotional 3 behavior Level 3 3.1 Recognizes the significance of abnormal findings in routine 4 neurodiagnostic test reports in psychiatric patients. 3.2 Knows clinical indications and limitations of functional 5 neuroimaging 3.3 Describes neurobiological and genetic hypotheses of common psychiatric disorders and their limitations 3.4 Knows indications for specific neuropsychological tests and understands meaning of common abnormal findings Level 4 4.1 Explains the significance of routine neuroimaging, neurophysiological, and neuropsychological testing abnormalities to patients. 4.2 Explains neurobiological hypotheses and genetic risks of common psychiatric disorders to patients 4.3 Describes psychiatric comorbidities of less common neurologic 6 disorders and less common neurologic comorbidities of 7 psychiatric disorders 4.4 Describes leading neuroscientific hypotheses of emotions and social 8 behaviors Level 5 5.1 Integrates recent neurodiagnostic research into understanding of psychopathology 5.2 Explains neurobiological hypotheses and genetic risks of less common 9 psychiatric disorders to patients 5.3 Integrates knowledge of neurobiology into advocacy for psychiatric 10 patient care 5.4 Flexibly applies knowledge of neuropsychological findings to the differential diagnosis of complex patients

Comments:
Footnotes: 1 Psychosis, Mood disorders, Personality changes, and cognitive impairments seen in common neurological disorders 2 Includes drug-induced and idiopathic extrapyramidal syndromes; neuropathies; TBI; vascular lesions; dementias; encephalopathies

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.

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3 4

Areas might include: Dorsolateral prefrontal cortex, anterior cingulate, amygdala, hippocampus, etc Structural imaging (CT & MRI) and electrophysiologic testing (see #1) 5 For example, PET/SPECT in diagnosis of Alzheimer disease (supportive but non-diagnostic); fMRI is not yet reimbursable for clinical use 6 For example, 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 7 For example, neuroleptic malignant syndrome; lethal catatonia; “parkinson plus” syndromes (e.g. multisystem atrophy, dementia with Lewy bodies, etc) 8 Social behaviors might include attachment, empathy, attraction, reward/addiction, aggression, appetites, etc 9 For example, OCD; eating disorders, ADHD, Gilles de la Tourette syndrome 10 Use neurobiologic hypotheses of psychiatric disorders to advocate for health coverage, treatment availability, etc

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.

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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.
Has not Achieved Level 1 Level 1 1.1 Identifies psycho-dynamic, cognitive-behavioral, and supportive therapies as major psychotherapeutic modalities Level 2 2.1 Describes the basic principles of each of the three core individual 4 psychotherapy modalities 2.2 Discusses common factors across 5 psychotherapies 2.3 Lists the basic indications and contraindications for supportive, psychodynamic, and cognitive behavioral psychotherapies 2.4 Describes potential benefits and risks of psychotherapies Level 3 3.1 Describes differences among the three core individual therapies 3.2 Describes the basic techniques of the three core individual therapies 3.3 Summarizes the evidence base for each of the three core individual therapies 3.4 Describes the basic principles, indications, contraindications, benefits, and risks of couples, group, and family therapy 3.5 Describes the development and evolution of psychotherapeutic paradigms Level 4 4.1 Describes mechanisms of therapeutic change 4.2 Discusses the evidence base for combining psychotherapy and psychopharmacology 4.3 Critically appraises the evidence for psychotherapies Level 5 5.1 Incorporates new theoretical developments into knowledge base

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

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2

Includes the capacity to generate a case formulation, to demonstrate techniques of intervention, including behavior change, skills acquisition, and addressing cognitive distortions 3 Includes the capacity to generate a case formulation, to demonstrate techniques of intervention, and to strengthen the patien t’s adaptive defenses, resilience, and social supports 4 Throughout this milestone, the three “core” or “major” individual psychotherapies refer to supportive, psychodynamic, and cognitive -behavioral therapy. 5 Common 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.

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.

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MK5 Somatic Therapies Medical Knowledge of Somatic Therapies including, but not limited to psychopharmacology, ECT, and emerging somatic therapies such as TMS and VNS.
Has not Achieved Level 1 Level 1 1.1 Describes general indications and common side effects for commonly prescribed psychopharmacologic agents 1.2 Describes indications for ECT Level 2 2.1 Describes hypothesized mechanisms of action and metabolism for commonly prescribed psychopharmacologic agents 2.2 Describes indications for second and third line agents 2.3 Describes the physical and lab studies necessary to initiate treatment with commonly prescribed medications 2.4 Describes length and frequency of ECT treatments, as well as relative contraindications 2.5 Lists practice guidelines or treatment algorithms for common psychiatric disorders Level 3 3.1 Demonstrates an understanding of pharmacokinetic and pharmacodynamics drug interactions 3.2 Describes specific techniques in ECT 3.3 Lists emerging neuro1 modulation therapies Level 4 4.1 Integrates knowledge 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 4.2 Understands the evidence supporting the use of multiple medications in certain treatment situations (e.g. polypharmacy and augmentation) Level 5 5.1 Integrates emerging studies of somatic treatments into their knowledge base

Comments:
Footnotes: 1 I Examples of neuromodulation techniques include Transcranial Magnetic Stimulation and variations, Vagnus Nerve Stimulation, Deep Brain Stimulation, etc.
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.

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MK6 Practice of Psychiatry
Has not Achieved Level 1 Level 1 1.1 Lists common ethical issues in psychiatry 1.2 Recognizes and describes institutional policies and 1 procedures 1.3 Lists ACGME/ABMS Core Competencies Level 2 2.1 Lists and discusses sources of professional standards of ethical practice 2.2 Lists situations that mandate reporting or breach of confidentiality 2.3 Describes state regulations and institutional policies and procedures for involuntary treatment Level 3 3.1 Describes applicable regulations for billing and reimbursement 3.2 Discusses conflict of interest and management Level 4 4.1 Understands the existence of state and regional variations regarding practice, involuntary treatment, health regulations, and psychiatric forensic evaluation 4.2 Describes professional advocacy 4.3 Describes how to seek out and integrate new information on practice of psychiatry Level 5 5.1 Describes international variations regarding practice, involuntary treatment, health regulations 5.2 Discusses advocacy and policy development 5.3 Proposes policy development or scholarly contributions related to professional standards

Comments:
Footnotes: 1 Institutional Policies and Procedures refer to the practice of medicine and psychiatry at the specific institution where trainee is credentialed that relates to Code of Conduct (gifts etc), Privacy policies (related to HIPAA etc) but not patient safety policies. These are usually covered during an orientation to the institution and training program.

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.

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PROF1 Compassion, integrity, respect for others, sensitivity to diverse patient populations 1,2, adherence to ethical principlese
Has not Achieved Level 1 Level 1 1.1 Demonstrates behaviors that convey caring, honesty, genuine interest, and respect for patients and their families 1.2 Recognizes that patient diversity affects patient care. 1.3 Displays familiarity with some basic ethical principles (e.g. confidentiality, informed consent) Level 2 2.1 Demonstrates capacity for self- reflection, curiosity about and openness to different beliefs and points of view, and respect for diversity 2.2 Recognizes role of diversity in psychiatric evaluation and treatment 2.3 Recognizes ethical conflicts in practice, and seeks supervision to manage them Level 3 3.1 Elicits beliefs, values, and diverse practices of patients and their families and understands their potential impact on patient care 3.2 Delivers treatment sensitive to diversity 3.3 Recognizes ethical issues in practice and is able to discuss, analyze, and manage these in common clinical situations Level 4 4.1 Develops a mutually agreeable care plan in context of conflicting physician and patient and/or family values and beliefs 4.2 Routinely incorporates sensitivity to diversity in patient care. 4.3 Can discuss own cultural background and beliefs, and the ways in which these affect interactions with patients Level 5 5.1 Serves as a role model and teacher of compassion, integrity, respect for others, and sensitivity to diverse patient populations. 5.2 Leads resident case discussions regarding ethical issues 5.3 Adapts to evolving ethical standards (can manage conflicting ethical standards and values and can apply to practice) 5.4 Systematically analyzes and manages ethical issues in complicated and challenging clinical situations

Comments:
Footnotes: e See annotations at the end of the document 1 Diversity refers to unique aspects of each individual patient including, but not limited to, gender, age, socioeconomic status, culture, race, religion, disabilities, and sexual orientation. 2 For milestones regarding health disparities, please see SBP #2.
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.

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PROF2 Accountability to self, patients, colleagues, and the professione
Has not Achieved Level 1 Level 1 1.1 Understands the need for sleep and the impact of fatigue on work 1.2 Lists ways to manage fatigue and seek backup as needed to ensure good patient care. 1.3 Exhibits professional f behavior 1.4 Displays openness to feedback 1.5 Introduces self as patient’s physician 1.6 Obtains appropriate initial medical license Level 2 2.1 Seeks help with own emotional, behavioral, and physical conditions when these interfere with professional responsibilities 2.2 Knows and follows institutional policies for physician conduct 2.3 Accepts the role of the patient’s physician and takes responsibility (under supervision) for ensuring that the patient receives the best possible care 2.4 Maintains appropriate medical licensure Level 3 3.1 Identifies and manages situations in which maintaining personal emotional, physical and mental health is challenged and seeks assistance when needed 3.2 Understands the tension between the needs of personal/family life and professional responsibilities, and its effect on medical care 3.3 Resident, as well as patient, family, and staff, recognize the resident as the patient’s primary psychiatric provider 3.4 Recognizes the importance of participating in one’s professional community Level 4 4.1 Knows how to take steps to address impairment in self and in colleagues 4.2 Prioritizes and balances conflicting interests of self, family, and others to optimize medical care and g practice of profession 4.3 Displays increasing autonomy and leadership in taking responsibility for ensuring that patients receive the best possible care 4.4 Prepares for obtaining, and maintaining board certification Level 5 5.1 Develops institutional and organizational strategies to improve physician wellness 5.2 Develops organizational policies, programs, or curricula for physician professionalism 5.3 Serves as a role model in demonstrating responsibility for ensuring that patients receive the best possible care 5.4 Maintains appropriate medical licensure and certifications. 5.5 Participates in the professional community (e.g. professional societies)

Comments:
Footnotes: e See annotations at the end of the document f See annotations at the end of the document g See annotations at the end of the document

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.

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ICS1 Relationship development and conflict management with patients, families, colleagues, and members of the health care team (GK,GM)
Has not Achieved Level 1 Level 1 1.1 Cultivates positive relationships with patients, families and team members 1.2 Recognizes communication conflicts in work relationships 1.3 Identifies team-based care as preferred treatment approach and collaborates as a member of the team Level 2 Level 3 3.1 Develops therapeutic relationships in complicated situations 3.2 Sustains working relationships in the face of conflict 3.3 Facilitates and leads team-based activities in clinical and non-clinical situations (includes committees) Level 4 4.1 Sustains therapeutic and working relationships during complex and challenging situations including transitions of care 4.2 Leads a team and manages conflict within the team Level 5 5.1 Sustains relationships across systems of care and with patients during long-term follow-up 5.2 Develops models/approaches to managing difficult communications 5.3 Leads and facilitates meetings within organization/system

2.1 Develops a therapeutic relationship with patients in uncomplicated situations
2.2 Develops working relationships across specialties and systems of care in uncomplicated situations 2.3 Negotiates and manages simple patient/family-related conflicts 2.4 Actively participates in team-based care. Supports activities of other team members, communicates their value to the patient and family

Comments:
Footnotes:

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.

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ICS2 Information sharing and record keeping
Has not Achieved Level 1 Level 1 1.1 Lists factors that affect information sharing (intended audience, purpose, need to know) 1.2 Gives examples of situations in which communication can be compromised (perceptual impairment, cultural differences, transference, limitations of media) 1.3 Engages in active listening, “teach back” and other strategies to ensure patient understanding 1.4 Maintains appropriate boundaries in sharing information by electronic communication Level 2 2.1 Organizes both written and oral information to be shared with patient, family, team and others 2.2 Consistently demonstrates communication strategies to ensure patient understanding 2.3 Demonstrates appropriate face-to-face interaction while using EMR 2.4 Ensures that the written record (EMR, PHR/patient portal, hand-offs, discharge summaries, etc.) are accurate and complete, with attention to preventing confusion and error, consistent with institutional policies 2.5 Lists effects of computer use on accuracy of information gathering and recording, and potential disruption of the physician/ patient relationship Level 3 3.1 Uses easy-tounderstand language in all phases of communication, including working with interpreters 3.2 Consistently engages patients and families in shared decision making 3.3 Ensures transitions of care are accurately documented and optimizes communication across systems and continuums of care 3.4 Understands issues raised by the use of social media by patients and providers Level 4 4.1 Effectively and ethically uses all forms of communication including face-to-face, telephone, and electronic media. Level 5 5.1 Participates in the development of changes in rules, policies, and procedures related to technology 5.2 Models continuous improvement in record keeping

Comments:

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.

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PBLI1 Critical evaluation of research and clinical evidence
Has not Achieved Level 1 Level 1 1.1 Describes and ranks levels 1 of clinical evidence Level 2 2.1 Formulates a searchable question from a 2 clinical question Level 3 3.1 Critically appraises different types of research, including RCTs, systematic reviews, meta-analyses, and practice guidelines Level 4 4.1 Independently searches for and discriminates evidence relevant to clinical practice problems Level 5 5.1 Independently teaches appraisal of clinical evidence

Comments:
Footnotes: 1 Examples include randomized controlled trials and meta-analyses vs retrospective designs vs case series 2 Examples include translating a clinical scenario into a question containing a Problem, proposed Intervention, Comparison intervention, and target Outcome (PICO)

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.

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PBLI2 Development and execution of life-long learning through constant self-evaluation
Has not Achieved Level 1 Level 1 1.1 Uses feedback from teachers, colleagues, and patients, to assess own level of knowledge and expertise 1.2 Recognizes limits of one’s knowledge and skills and seeks supervision Level 2 2.1 Continually seeks and incorporates feedback to improve performance 2.2 Identifies self-directed learning goals & periodically reviews them with supervisory guidance Level 3 3.1 Demonstrates a balanced and accurate selfassessment of competence, using clinical outcomes to identify areas for continued improvement 3.2 Selects an appropriate evidence-based 1 information tool to meet learning goals Level 4 4.1 Demonstrates improvement in clinical practice based on continual self-assessment and evidence-based information 4.2 Identifies and meets self-directed learning goals with little external guidance 4.3 Demonstrates use of a system, or process for keeping up with relevant 2 changes in medicine Level 5 5.1 Sustains practice of self-assessment and keeping up with relevant changes in medicine and makes informed, evidence-based clinical decisions

Comments:
Footnotes: 1 Examples include practice guidelines; PubMed Clinical Queries; Cochrane, DARE, or other evidence-based reviews; Up-to-Date, etc 2 Examples include a PIP module as included in the ABPN MOC process, regular and structured readings of specific evidence sources

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.

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PBLI3 Formal practice-based quality improvement based on established and accepted methodologies. Many of these requirements would be satisfied by completion of a mentored QI project within residencyh
Has not Achieved Level 1 Level 1 1.1 Recognizes potential gaps in quality of care and system1 level inefficiencies 1.2 Discusses possible quality gaps and problems with psychiatric care delivery with supervisors Level 2 2.1 Narrows problems within own clinical service(s) to a specific and achievable aim for a quality improvement project. 2.2 Outlines factors and causal chains contributing to quality gaps within own 2 institution Level 3 3.1 Involves appropriate stakeholders in design of a QI project and manages affective responses to 3 proposed changes 3.2 Lists common responses of teams and individuals to changes in clinical operations and describes strategies for managing same Level 4 4.1 Completes a supervised project to address specific quality deficit within own clinical service(s) and measures relevant outcomes 4.2 Describes basic methods for implementation and evaluation of clinical QI 4 projects Level 5 5.1 Independently proposes and leads projects to enhance patient care 5.2 Describes core concepts of advanced QI methodologies and 5 business processes 5.3 Uses advanced quality measurement and “dashboard” tools

Comments:
Footnotes: h See annotations at the end of the document 1 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. 2 Chooses an inefficient/ineffective practice or recent adverse outcome then identifies (not exhaustively) factors contributing to the status quo, with some sense of which factors are amenable to intervention. 3 Examples include, for a project involving a standard order protocol on an inpatient unit, meets with nurse managers and ancillary clinical staff and learns about their needs/constraints before designing intervention. Recognizes fear of change as a common characteristic in clinical environments and provides staff space/time to adequately process and modify proposals. 4 Variations on the Plan-Do-Study-Act theme, i.e. stating an understanding at an effective project should include a target population and intervention, an outcome measure, and some form of iterative refinement. 5 Can state some core philosophical concepts of Lean Production, the Six-Sigma/Total Quality Management methods, or other emerging management philosophies and give examples of how these could apply in health care.

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.

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PBLI4 Teaching
Has not Achieved Level 1 Level 1 1.1 Educates patients and families Level 2 2.1 Teaches and supervises students Level 3 3.1 Teaches and supervises junior residents Level 4 4.1 Educates peers Level 5 5.1 Educates broader professional community and/or public

Comments:
Footnotes:

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.

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SBP1 Patient Safety and the Healthcare Team
Has not Achieved Level 1 Level 1 1.1 Understands the differences between medical errors, near misses, and sentinel events 1.2 Recognizes failure in teamwork and communication as leading cause of preventable patient harm 1.3 Follows institutional safety policies, including reporting of problematic behaviors and processes, errors and near misses Level 2 2.1 Consistently uses structured communication tools to prevent adverse events (e.g., checklists, safe hand-off procedures, and briefings) 2.2 Describes the common system causes for errors 2.3 Actively participates in M&M conferences focusing on systems-based errors in patient care Level 3 3.1 Participates in root cause analysis (RCA) of medical error and sentinel events 3.2 Understands systems and procedures that promote patient safety (e.g. human factor 1 engineering ) Level 4 4.1 Formally analyzes shared team experiences to prevent future errors using proven analysis techniques (e.g., root cause analysis, failure mode effects analysis) 4.2 Develops content for and facilitates a patient safety M&M presentation or conference focusing on systems-based errors in patient care Level 5 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 personal and patient safety

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

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.

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SBP2 Resource Management
Has not Achieved Level 1 Level 1 1.1 Recognizes need for efficient and equitable use of resources Level 2 2.1 Recognizes disparities in health care at individual and community levels Level 3 3.1 Prioritizes use of resources in developing 1 patient treatment plans 3.2 Advocates for patient access to community and system resources Level 4 4.1 Practices cost effective, high-value clinical care, using tools and information technologies to support decision making Level 5 5.1 Designs measurement tools to monitor and provide feedback to providers/teams on resource consumption to facilitate improvement 5.2 Advocates for improved systems of care

Comments:
Footnotes: 1 Examples: 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

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.

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SBP3 Community Based Care
Has not Achieved Level 1 Level 1 1.1 Gives examples of community mental health systems of care 1.2 Gives examples of self-help groups (AA, NA), other community resources (church, school) and social networks (i.e. family, friends and acquaintances) Level 2 2.1 Coordinates care with community mental health agencies 2.2 Recognizes role and explains importance of selfhelp groups, and community resource groups (disorder specific support and advocacy groups ) 2.3 Describes individual and population risk factors for mental illness Level 3 3.1 Incorporates disorder specific support and advocacy groups in clinical care 3.2 Describes rehabilitation programs (vocational, brain injury, etc) and the recovery model 3.3 Describes prevention measures-universal, 1 selective, and indicated Level 4 4.1 Demonstrates competence working in community-based treatment programs 4.2 Uses principles of evidence-based practice and patient centered care in management of chronically ill patients 4.3 Routinely uses self-help groups, community resources, and social networks in treatment 4.4 Appropriately refers to rehabilitation and recovery programs 4.5 Employs prevention and risk reduction strategies in clinical care Level 5 5.1 Participates in the administration of community-based treatment programs 5.2 Participates in creating new community based programs 5.3 Practices effectively in a rehabilitation and/or recovery-based program 5.4 Manages conflict with partners in transitioning care

Comments:
Footnotes: 1 Universal prevention strategies are designed to reach the entire population, selective prevention a targeted subgroup of the general population, and indicated prevention intervention targets individuals

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.

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SBP4 Consultation to non-psychiatric medical providers and non-medical systems (e.g. military, schools, businesses, forensic )
Has not Achieved Level 1 Level 1 1.1 Describes the difference between consultant and primary treatment provider Level 2 2.1 Clarifies the consultation question 2.2 Describes differences in providing consultation for the system or team versus the individual patient 2.3 Provides consultation to other medical services Level 3 3.1 Assists primary treatment care team to identify unrecognized clinical care issues 3.2 Identifies system issues in clinical care and provides recommendations 3.3 Discusses methods for integrating mental health and medical care Level 4 4.1 Manages complicated and challenging consultation requests 4.2 Educates referral sources 4.3 Provides integrated care for psychiatric patients through collaboration with 1 other physicians Level 5 5.1 Provides psychiatric consultations to larger systems 5.2 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 the Medical Home

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.

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ANNOTATIONS
Milestone Set, Level, Footnote PC2, Header Annotation Topic and Annotation

a

What is meant by the term “psychiatric formulation? A 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. What is meant by “models of formulation? Models 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. Integration of psychotherapy with other treatment modalities and other treatment providers. At 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.

PC2, Level 3, Item 1

b

PC4, Level 4, Item 4

c

MK2.

d

Psychopathology medical knowledge milestone assessment. The Psychopathology medical knowledge milestone focuses on knowledge needed for patient care. Thus, knowledge of psychopathology can be assessed through multiple choice knowledge examinations (e.g. the PRITE examination), and/or through evaluations of the application of knowledge of psychopathology to patient care, such as standardized patients

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.

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Milestone Set, Level, Footnote

Annotation

Topic and Annotation

or case vignettes, clinical skills evaluations, and knowledge evidenced during clinical rotations and the routine, supervised care of patients during residency. PROF1, PROF2 e Psychiatry Professionalism milestones. The Psychiatry Professionalism milestones reflect the values articulated in the ACGME Expert Panel Milestones. Namely, 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 self, 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. Professional Behavior. Professional 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 on time, 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. 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.

PROF2, Level 1, Item 3

f

PROF2, Level 4, Item 2

g

Patient care that supersedes self-interest. Residents are expected to demonstrate responsibility for patient care that supersedes self-interest, while also displaying appropriate self-care. 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

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.

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Milestone Set, Level, Footnote

Annotation

Topic and Annotation

not present to provide direct care for the patient. PBLI3 h Quality Improvement learning methods. The quality improvement milestones could be satisfied largely by completion of an individual or group quality improvement project during residency. 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.gov/curriculum/index.html).

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.

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