Spinal Cord Injury Medicine Milestones

The Spinal Cord Injury Medicine
Milestone Project
A Joint Initiative of
The Accreditation Council for Graduate Medical Education
and
The American Board of Physical Medicine and Rehabilitation
July 2015
The Spinal Cord Injury Medicine Milestone Project
The Milestones are designed only for use in evaluation of the fellow in the context of their participation in
ACGME-accredited residency or fellowship programs. The Milestones provide a framework for assessment of the
development of the fellow in key dimensions of the elements of physician competency in a specialty or
subspecialty. They neither represent the entirety of the dimensions of the six domains of physician competency,
nor are they designed to be relevant in any other context.
Spinal Cord Injury Medicine Milestones

Chair: Susan Garstang, MD
Working Group
Advisory Group
David Chen, MD
Laura Edgar, EdD, CAE
Michelle Gittler, MD
Steve Kirshblum, MD
Sunil Sabharwal, MD
Jelena Svircev, MD
Stephen Burns, MD
Mary Lieh-Lai, MD
Teresa L. Massagli, MD
ii
Milestone Reporting
This document presents Milestones designed for programs to use in semi-annual review of fellow performance and reporting to the
ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a
developmental framework from less to more advanced. They are descriptors and targets for fellow performance as a fellow moves
from entry into fellowship through graduation. In the initial years of implementation, the Review Committee will examine Milestone
performance data for each programs fellows as one element in the Next Accreditation System (NAS) to determine whether fellows
overall are progressing.
For each period, review and reporting will involve selecting milestone levels that best describe a fellows current performance and
attributes. Milestones are arranged into numbered levels. Tracking from Level 1 to Level 5 is synonymous with moving from novice
to expert in the subspecialty.
Selection of a level implies that the fellow substantially demonstrates the milestones in that level, as well as those in lower levels
(see the diagram on page v).
Level 1: The fellow demonstrates milestones expected of an incoming fellow.
Level 2: The fellow is advancing and demonstrates additional milestones, but is not yet performing at a mid-fellowship level.
Level 3: The fellow continues to advance and demonstrate additional milestones, consistently including the majority of
milestones targeted for fellowship.
Level 4: The fellow has advanced so that he or she now substantially demonstrates the milestones targeted for fellowship. This
level is designed as the graduation target.
Level 5: The fellow has advanced beyond performance targets set for fellowship and is demonstrating aspirational goals
which might describe the performance of someone who has been in practice for several years. It is expected that only
a few exceptional fellows will reach this level.
iii
Additional Notes
Level 4 is designed as the graduation target and does not represent a graduation requirement. Making decisions about readiness for
graduation is the purview of the fellowship program director. Study of Milestone performance data will be required before the
ACGME and its partners will be able to determine whether milestones in the first four levels appropriately represent the
developmental framework, and whether Milestone data are of sufficient quality to be used for high-stakes decisions.
Examples are provided with some milestones. Please note that the examples are not the required element or outcome; they are
provided as a way to share the intent of the element.
Some milestone descriptions include statements about performing independently. These activities must occur in conformity to the
ACGME supervision guidelines, as well as institutional and program policies. For example, a fellow who performs a procedure
independently must, at a minimum, be supervised through oversight.
Answers to Frequently Asked Questions about Milestones are available on the Milestones web page:
http://www.acgme.org/acgmeweb/Portals/0/MilestonesFAQ.pdf.
iv
The diagram below presents an example set of milestones for one sub-competency in the same format as the ACGME Report
Worksheet. For each reporting period, a fellows performance on the milestones for each sub-competency will be indicated
by selecting the level of milestones that best describes that fellows performance in relation to those milestones.
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
demonstrated as well as some milestones in the higher
level(s).
Version 06/2014
Spinal Cord Injury Medicine Milestones, ACGME Report Worksheet
Patient Care History and Physical Examination of Individuals with Spinal Cord Disorders
Level 1
Acquires a basic history,
including medical,
functional, and
psychosocial elements
Performs a basic physical
exam that identifies
impairments and
functional abilities
Level 2
Utilizes knowledge of
spinal cord medicine to
acquire a history and
perform a physical exam
and functional evaluation
in patients with common
conditions
Interprets the neurologic
exam to accurately
diagnose and classify
spinal cord injury
Level 3
Acquires a history and
performs a physical exam
and functional evaluation
in patients with complex
conditions and
comorbidities
Modifies history and exam
to accommodate a
patients impairments,
optimize assessment,
minimize discomfort, and
preserve patient dignity
Level 4
Efficiently acquires and
synthesizes a relevant
history and performs a
targeted physical exam
across a spectrum of ages,
impairments, and clinical
settings
Level 5
Serves as an exemplary
model for the gathering of
subtle and difficult
information
Serves as an exemplary
model for physical exam
skills in complex patients
Elicits subtleties and

information that may not
be readily volunteered by
the patient
Identifies and correctly
interprets subtle or
atypical physical findings
Comments:
Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Physical Medicine and
Rehabilitation. All rights reserved. The copyright owners grant third parties the right to use the Spinal Cord Injury Medicine Milestones on a
non-exclusive basis for educational purposes.
1
Version 06/2014
Patient Care Diagnostic Evaluation of Individuals with Spinal Cord Disorders

This includes:
Differential diagnosis of primary and secondary conditions
Diagnostic testing
Level 1
Level 2
Level 3
Produces a differential
Generates a differential
Develops a comprehensive
diagnosis for common
diagnosis that considers
differential diagnosis,
medical presentations
atypical presentations and including for less common
conditions commonly seen conditions
Orders appropriate
in spinal cord disorders
diagnostic studies for
Appropriately prioritizes
common medical
Orders appropriate
the sequence and urgency
presentations
diagnostic studies for
of diagnostic testing
conditions commonly seen
in spinal cord disorders
Correctly interprets
diagnostic study results
and appropriately pursues
further testing or specialist
input
Level 4
Orders diagnostic testing
based on costeffectiveness and
likelihood that results will
influence clinical
management
Level 5
Efficiently produces a
focused and prioritized
differential diagnosis
accounting for rare
conditions
Streamlines diagnostic
evaluation for maximal
cost-effectiveness and
minimal patient burden
Comments:
2
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Patient Care Medical/Surgical Management of Individuals with Spinal Cord Disorders

This includes inpatient, outpatient, and consultative management of:
Current co-morbidities
Secondary conditions
Potential complications
Level 1
Level 2
Level 3
Level 4
Evaluates general medical Identifies and manages
Manages patients with
Develops and implements
problems and initiates
common co-morbidities
complex co-morbidities
a comprehensive
and secondary conditions
treatment plan that
treatment
and secondary conditions
associated with spinal cord
identifies and addresses all
Identifies
individual
risk
pertinent co-morbidities,
disorders
factors for complications,
secondary conditions, and
Identifies level of medical
and institutes preventive
potential complications
acuity and triages
care
appropriately
Counsels patients
Provides consultations to
regarding treatment risks
Uses appropriate
other services
and benefits, outcomes,
consultations to guide
and prognosis
treatment plan
Level 5
Consistently performs
evidence-based
management and
consultative care in an
efficient and effective
manner
Evaluates and
appropriately applies
emerging treatments for
individual patients
Comments:
3
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Patient Care Rehabilitation/Functional Management of Individuals with Spinal Cord Disorders

Includes rehabilitation interventions in inpatient, outpatient, and consultative management, such as:
Rehabilitation therapies (e.g., therapeutic exercise, modalities)
Orthoses (e.g., upper and lower extremity, spine)
Equipment/devices (e.g., adaptive equipment, seating systems, assistive technologies)
Level 1
Prescribes rehabilitation
therapies by discipline
based on functional need
Prescribes commonly used
adaptive devices in
partnership with the
interdisciplinary team
Level 2
Determines how key
structural components of
wheelchairs and
modifications can
influence function
Applies domains of
international classification
of function (body structure
and function, activities,
and participation)
resulting from disease or
injury
Level 3
Provides detailed therapy
prescription for specific
conditions with
appropriate precautions
Prescribes commonly used
orthoses
Level 4
Prescribes orthoses for a
variety of complex
conditions
Effectively problem solves
when medical equipment
and assistive devices are
suboptimal or poorly
tolerated
Prescribes assistive
technologies, seating
systems, and mobility
Incorporates change in
devices in partnership with status (e.g., growth,
the interdisciplinary team
development, disease
progression) when
prescribing durable
medical equipment and
assistive technology
Level 5
Serves as a resource to
orthotists, therapists, and
other health care
professionals for problem
solving unusual clinical
and functional challenges
Serves as an expert
resource to other
stakeholders (e.g.,
insurance companies) for
the appropriateness of
durable medical
equipment and assistive
technologies
Comments:
4
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Medical Knowledge Traumatic and Non-Traumatic Spinal Cord Disorders

This includes:
Epidemiology and etiology
Anatomy and pathophysiology
Secondary conditions and complications
Therapeutic and diagnostic options
Level 1
Level 2
Level 3
Describes basic spine and
Demonstrates knowledge
Synthesizes knowledge of
spinal cord anatomy
of pathophysiology of
spinal cord disorders,
spinal cord disorders, and
secondary conditions,
Demonstrates basic
the effects of insult to
treatment options, and
knowledge of common
specific anatomical regions complications across a
spinal cord disorders (e.g.,
spectrum of impairments
multiple sclerosis,
Describes prevention and
traumatic injury)
management of secondary Demonstrates knowledge
conditions and
of the continuum of spinal
Describes secondary
complications, including
cord injury care, including
conditions and
expected effects, side
acute care (e.g., precomplications in spinal
effects, and
hospital, emergency
cord disorders
contraindications of
department [ED], intensive
treatment
care unit [ICU])
management of spinal
cord injuries
Level 4
Possesses the knowledge
required to successfully
diagnose and treat
complex spinal cord
conditions and
complications (e.g., dual
diagnosis, polytrauma)
Level 5
Serves as an expert
resource to health care
professionals regarding
spinal cord disorders and
sequelae
Delineates a spinal cord

injury-specific health
maintenance and
management program
across the life span
Comments:
5
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Medical Knowledge Functional Outcomes and Interventions

Level 1
of spinal cord disorders on
various aspects of function
Level 2
of commonly used
outcome measures in
spinal cord medicine (e.g.,
Functional Independence
Measure [FIM], expanded
disability status scale
[EDSS])
of functional outcome and
prognosis based on
impairment
Level 3
Integrates knowledge of
functional goals and
prognosis into an
individualized treatment
plan
Describes advanced
treatments and
technology (e.g., electrical
stimulation, tendon
transfers, robotics)
Level 4
Understands properties
and application of
measurement scales used
in spinal cord injury
medicine (e.g.,
International Classification
Functioning [ICF], Craig
Handicap Assessment and
Reporting Technique
[CHART], walking index for
spinal cord injury [WISCI])
Level 5
Serves as an expert
resource regarding
functional outcomes and
interventions in spinal
cord disorders
of controversial and
emerging evaluations and
interventions for
functional outcome
Comments:
6
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Systems-based Practice Systems Thinking for Individuals with Spinal Cord Disorders: demonstrates awareness of and responsiveness to
larger context and system of care
Level 1
Level 2
Level 3
Level 4
Level 5
Describes and
Coordinates care within
Efficiently manages and
Serves as an expert
differentiates between the health care systems (e.g.,
of eligibility criteria and
coordinates safe and
resource in care
various settings and
inpatient, outpatient,
mechanisms to access
effective patient
coordination and advocacy
systems of care
consultative)
commonly used
transitions between
for improved systems of
community and
various settings
care
governmental programs
of commonly used
community and
Facilitates high-quality,
of regulatory compliance,
governmental programs
safe, well-coordinated,
including accurate coding
available that provide
patient-centered care
and billing
support and services (e.g., within and across health
Supplemental Security
care systems
Organizes appeals for
Income [SSI], Department
coverage and advocates
of Veteran Affairs [VA],
for patients in complex
vocational rehabilitation)
situations
Comments:
7
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Systems-based Practice Patient Safety for Individuals with Spinal Cord Disorders: Understands ways to improve health care safety through
participation in identifying system errors and implementing potential systems solutions
Level 1
Recognizes the impact of
process and systems
failures on patient safety
Practices in established
safety initiatives (e.g., use
of approved abbreviations,
isolation precautions,
hand washing)
Level 2
Applies a structured
process to foster clear,
concise, accurate, and
specific communication
during patient hand-offs
Utilizes existing processes
and procedures for
reporting problematic
events
Level 3
Identifies health system
factors that increase risk
for errors, (e.g., errors in
the electronic medical
record [EMR], lack of
health information
exchange)
Level 4
Partners with others in
activities to improve
patient safety
Level 5
Leads systems-level
patient safety
interventions
Identifies formal system

resources to investigate or
mitigate real or potential
system error
Anticipates and prevents

critical incidents or
systems failures that may
impact patient safety
Comments:
8
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Practice-based Learning and Improvement Self-Directed Learning and Teaching

Level 1
Acknowledges gaps in
personal knowledge
Utilizes information
technology, and/or clinical
supervisors for immediate
patient-specific
information needs
Level 2
Actively participates in and
seeks out educational
offerings and clinical
learning opportunities
Accepts feedback and
utilizes it to improve areas
of deficiency
Level 3
Identifies diagnosisspecific knowledge gaps
and uses information
technology to optimize
self-directed learning
Level 4
Engages in a deliberate
process to maintain up-todate knowledge and skills
medicine
Actively seeks out

feedback and utilizes it to
improve areas of
deficiency
Independently identifies
areas of deficiency and
effectively implements a
plan for self-improvement
Participates in teaching of
residents and students
Engages in teaching of
colleagues and other
medical professionals
Level 5
Presents as an invited
expert speaker at a
national meeting
Serves as primary author
in a peer-reviewed
publication
Comments:
9
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Practice-based Learning and Improvement Locate, Appraise, Assimilate, and Apply Evidence from Scientific Studies to Clinical Practice
Level 1
Demonstrates the ability
to search and select
appropriate evidencebased information tools to
answer specific clinical
questions
Level 2
Effectively appraises
evidence for its validity
and applicability to
individual patient care
Level 3
Demonstrates the use of
evidence-based research
and tools (e.g., clinical
practice guidelines) to
inform clinical decisions
Level 4
Stays current on the best
evidence for select topics
medicine and regularly
uses evidence-based
research and tools to
guide clinical practice
Level 5
Identifies gaps in the
evidence of spinal cord
injury medicine and
contributes to building the
knowledge
Comments:
10
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Practice-based Learning and Improvement Quality Improvement (QI)

Systematically analyzes practice using QI methods, and implements changes with the goal of improving systems of care, reducing health care
disparities, and improving patient outcomes
Level 1
Understands basic quality
improvement principles
Level 2
Demonstrates active
involvement in processes
aimed at improving
patient care and
decreasing inefficiency
and waste in everyday
practice
Level 3
Identifies opportunities for
process improvement in
the delivery of care
Level 4
Actively participates in a
project that involves the
application of QI principles
Level 5
Leads QI projects
Comments:
11
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Professionalism Compassion, Integrity, and Respect for Others, as well as Sensitivity and Responsiveness to Diverse Patient Populations,
and Adherence to Ethical Principles
Level 1
Demonstrates
compassion, integrity,
respect, sensitivity, and
responsiveness in routine
interactions with patients,
families, and team
members
Demonstrates awareness
of how personal values
and beliefs can impact
patient care
Level 2
Displays understanding of
diverse patient groups and
their support systems
Identifies ethical issues in
clinical situations (e.g.,
declining a feeding tube
and/or mechanical
ventilation, right to die,
requests for unnecessary
equipment or treatments,
unrealistic patient goals)
Level 3
Analyzes common ethical
issues and seeks guidance
when appropriate (e.g.,
ethics consult, pastoral
counseling, compliance)
Exhibits compassion with
patients and families when
discussing prognosis
Consistently demonstrates
disability etiquette in
clinical practice
Level 4
Exhibits compassion,
integrity, and respect in
challenging interactions
with patients and families,
including when beliefs and
choices vary from those of
the treatment team
Level 5
Participates in ethics
scholar program
Leads and mentors others
regarding application of
bioethical principles
Effectively manages
ethical issues in clinical
situations
Comments:
12
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Professionalism Professional Behaviors and Accountability to Self, Patients, Society, and the Profession
Level 1
Complies with HIPAA
guidelines
Demonstrates awareness
of the influence of
personal health and
wellness, including the
effect of substance misuse
on safe and effective
patient care
Establishes appropriate
boundaries with patients
and families (e.g., social
media, personal
relationships)
Level 2
Demonstrates that the
responsibility of patient
care supersedes selfinterest (e.g., ensures
patient care hand-offs are
completed before leaving
the hospital)
Utilizes effective individual
strategies and local
resources, as necessary, to
limit stress or burnout
Demonstrates professional
accountability and timely
completion of professional
responsibilities
Level 3
Recognizes conflicts of
interest and how they
affect clinical decisionmaking, teaching, or
research activities
Takes on responsibility
related to learning,
coordination of care,
continuous quality
improvement (CQI), and
compliance issues
Level 4
Actively participates in
service activities, such as
program or institutional
committees
Recognizes and
demonstrates steps to
address impairment in
colleagues
Level 5
Contributes to regional- or
national-level service
Models altruism and
professional behaviors
Exemplifies effective
management of multiple
competing tasks with
reliable follow-up
Willingly assumes
professional responsibility
and prioritizes multiple
competing demands to
ensure the best patient
care
Comments:
13
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Interpersonal and Communication Skills Relationship Management

Level 1
Identifies factors that
affect communication
(e.g., language,
mechanical ventilator,
cognitive impairments)
Develops positive working
relationships with
patients, families, and
health care providers
Level 2
Utilizes effective verbal
and non-verbal
communication strategies,
including active listening,
augmentative
communication devices,
and interpreters
Collaborates effectively
and respectfully with the
patient and family,
multiple providers, and
the interdisciplinary team
to develop patientcentered goals
Level 3
Effectively educates and
counsels patients and
families, utilizing
strategies to ensure
understanding
Engages patients in shared
decision making
Identifies resolution
options for patient carerelated conflicts
Level 4
Consistently anticipates
the need for, and
effectively facilitates
patient and family
meetings, including all
relevant disciplines
Sustains positive
relationships with
health care providers
during challenging
situations
Level 5
Uses knowledge to lead
complex discussions,
education and counseling
with patients and families
regarding life-changing
effects of disability and
sequelae
Serves as an expert
resource in complex
relationship management
Manages conflict and

discordant opinions
effectively among
health care providers to
ensure patient-centered
care
Comments:
14
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Interpersonal and Communication Skills Information Gathering and Sharing

Level 1
Describes the positive and
negative effects of
information technology on
accuracy of information
Ensures medical records
are accurate and
complete, with attention
to preventing confusion
and error
Level 2
Utilizes most appropriate
form of communication in
various clinical situations
(e.g., telephonic, face-toface, electronic)
Regularly updates the
medical record,
communicating clinical
reasoning as care evolves
Level 3
Demonstrates effective
integration and
dissemination of
information between all
available sources to
facilitate patient-centered
care
Level 4
Independently documents
information in compliance
with current regulatory
requirements
Level 5
Role models and teaches
importance of organized,
accurate, and
comprehensive health
records that are succinct
and patient specific
Comments:
15

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The Spinal Cord Injury Medicine

The American Board of Physical Medicine and Rehabilitation

The Spinal Cord Injury Medicine Milestone Project

Spinal Cord Injury Medicine Milestones

Selecting a response box in the middle of a

Selecting a response box on the line in between levels

Spinal Cord Injury Medicine Milestones, ACGME Report Worksheet

Elicits subtleties and

Spinal Cord Injury Medicine Milestones, ACGME Report Worksheet

Patient Care Diagnostic Evaluation of Individuals with Spinal Cord Disorders

Spinal Cord Injury Medicine Milestones, ACGME Report Worksheet

Patient Care Medical/Surgical Management of Individuals with Spinal Cord Disorders

Spinal Cord Injury Medicine Milestones, ACGME Report Worksheet

Patient Care Rehabilitation/Functional Management of Individuals with Spinal Cord Disorders

Spinal Cord Injury Medicine Milestones, ACGME Report Worksheet

Medical Knowledge Traumatic and Non-Traumatic Spinal Cord Disorders

Delineates a spinal cord

Spinal Cord Injury Medicine Milestones, ACGME Report Worksheet

Medical Knowledge Functional Outcomes and Interventions

Spinal Cord Injury Medicine Milestones, ACGME Report Worksheet

Spinal Cord Injury Medicine Milestones, ACGME Report Worksheet

Identifies formal system

Anticipates and prevents

Spinal Cord Injury Medicine Milestones, ACGME Report Worksheet

Practice-based Learning and Improvement Self-Directed Learning and Teaching

Actively seeks out

Spinal Cord Injury Medicine Milestones, ACGME Report Worksheet

Spinal Cord Injury Medicine Milestones, ACGME Report Worksheet

Practice-based Learning and Improvement Quality Improvement (QI)

Spinal Cord Injury Medicine Milestones, ACGME Report Worksheet

Spinal Cord Injury Medicine Milestones, ACGME Report Worksheet

Spinal Cord Injury Medicine Milestones, ACGME Report Worksheet

Interpersonal and Communication Skills Relationship Management

Manages conflict and

Spinal Cord Injury Medicine Milestones, ACGME Report Worksheet

Interpersonal and Communication Skills Information Gathering and Sharing

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