Psychosomatics 2015:56:153–167
& 2015 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
Perspective The Milestones for Psychosomatic Medicine Subspecialty Training Robert J. Boland, M.D., Madeleine Becker, M.D., James L. Levenson, M.D., Mark Servis, M.D., Catherine C. Crone, M.D., Laura Edgar, Ed.D., C.A.E., Christopher R. Thomas, M.D.
Background: The Accreditation Council of Graduate Medical Education Milestones project is a key element in the Next Accreditation System for graduate medical education. On completing the general psychiatry milestones in 2013, the Accreditation Council of Graduate Medical Education began the process of creating milestones for the accredited psychiatric subspecialties. Methods: With consultation from the Academy of Psychosomatic Medicine, the Accreditation Council of Graduate Medical Education appointed a working group to create the psychosomatic medicine milestones, using the general psychiatry milestones as a starting point. Results: This article represents a record
of the work of this committee. It describes the history and rationale behind the milestones, the development process used by the working group, and the implications of these milestones on psychosomatic medicine fellowship training. Conclusions: The milestones, as presented in this article, will have an important influence on psychosomatic medicine training programs. The implications of these include changes in how fellowship programs will be reviewed and accredited by the Accreditation Council of Graduate Medical Education and changes in the process of assessment and feedback for fellows. (Psychosomatics 2015; 56:153–167)
INTRODUCTION
in 1997, which was developed to address concerns raised by the Institute of Medicine and other organizations regarding the quality of graduate medical education in the United States, particularly how training outcomes were measured.3 The intention of the project was to improve how programs evaluate residents, how curricula are developed and, ultimately,
The Accreditation Council of Graduate Medical Education (ACGME) milestones project is a key element in the Next Accreditation System for graduate medical education.1 The ACGME completed the general psychiatry milestones in 2013, which were implemented in July 2014. The ACGME then turned its attention to creating milestones for the accredited subspecialties. This article describes the history and rationale behind the milestones, the development process for the psychosomatic medicine (PM) milestones, and their implications on fellowship training. HISTORY AND RATIONALE FOR THE NEXT ACCREDITATION SYSTEM The Next Accreditation System was part of the Outcomes Project for graduate medical education,2 begun Psychosomatics 56:2, March/April 2015
Received October 12, 2014; revised November 6, 2014; accepted November 6, 2014. From Department of Psychiatry, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (RJB); Thomas Jefferson University, Philadelphia, PA (MB); Virginia Commonwealth University, Richmond, VA (JLL); University of California, Davis, Davis, CA (MS); George Washington University, Washington, DC (CCC); Accreditation Council for Graduate Medical Education, Chicago, IL (LE); University of Texas Medical Branch at Galveston, Galveston, TX (CRT). Send correspondence and reprint requests to Robert J. Boland, M.D., Department of Psychiatry, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115; e-mail: [email protected] & 2015 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
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The Milestones for Psychosomatic Medicine Subspecialty Training how programs are accredited. Thomas Nasca, M.D., the Chief Executive Officer of the ACGME, pointed out that the current system for evaluating programs was akin to an “episodic biopsy” model, in which a program is cross-sectionally sampled every 4–5 years.1 For resident evaluation, programs would assess residents on whether they had achieved a particular competency, and at graduation, training directors attested that the trainee had mastered all competencies on a checklist style form. Dr. Nasca, instead, suggested a developmental approach to assessment at stages during residency training. The milestones were introduced to provide a system for tracking the resident throughout their training with specialty-specific milestones or targets to demonstrate that they have achieved the required competencies. The 6 clinical competencies were introduced in 1999, which was the beginning of the restructuring of the medical accreditation process.1 Milestones describe the variety of performance levels trainees should demonstrate (including skills, knowledge, and behaviors) for each of these competencies: Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based Learning, Professionalism, and Interpersonal and Communication Skills, ranging from a novice to an expert. They are organized as a framework of observable behaviors and other attributes that track a resident’s development over the course of training.1 The ACGME saw the milestones as having several uses, each with implications for the future of graduate medical education. The ACGME will use aggregate milestone data as part of their process of continual accreditation for a training program. At the training program level, milestones will guide curriculum development, provide expectations that are more explicit to trainees, and help programs identify trainees who are not progressing at expected rates. For residents and fellows, milestones should provide explicit feedback on their progress and facilitate their understanding of expectations for satisfactory completion of their training. DEVELOPING THE SPECIALTY MILESTONES FOR PSYCHIATRY In developing the competencies for each specialty, the ACGME appointed working and advisory groups for each specialty. Psychiatry was part of the second phase 154
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of milestone development and thus able to benefit from knowledge gained during the first phase, after internal medicine, pediatrics, emergency medicine, diagnostic radiology, urology, neurologic surgery, and orthopedic surgery developed and implemented their milestones. A major challenge was finding the balance between clarity and specificity on the one hand and brevity and flexibility on the other. For each of the 6 competencies, each specialty workgroup had to decide how to subdivide that competency into the specific knowledge, skills, and attitudes that were most relevant to that particular specialty. Some of the first phase participants initially had large numbers of subcompetencies, and as the milestones were introduced to practice, it became clear that this was impractical, given the need for multiple evaluators and diverse rotations. Learning from this, the psychiatry milestone working group, attempting to streamline and simplify the process, combined some subcompetencies into more general categories. With input from the ACGME’s psychiatry advisory committees, including the American Psychiatric Association, the American Board of Psychiatry and Neurology and the American Association of Directors of Psychiatry Residency Training, the general psychiatry milestones went through several drafts. Several pilots also informed the process. The psychiatry milestones were released in November 2013 and implemented in July 2014. The milestone development process fostered several educational innovations, some common to all specialties and some unique to psychiatry. For example, in response to the milestones, many residency programs created new evaluation tools for assessment of trainees, which could be applied to the milestones. Previously, most residencies used global evaluations, in which a resident was evaluated more generally on all competencies during any given rotation. Now, with the detailed subcompetencies defined by each specialty and their level of specificity, this approach would no longer be suitable. It soon became clear that an alternate approach to evaluation was needed. One solution was to match specific rotations with the subset of subcompetencies most relevant to that rotation. To address this problem, the milestone working group created sample evaluations for different rotations (which are available at: https://www.acgme.org/acgmeweb/ Portals/0/PDFs/Milestones/PsychiatryAssessmentTools. pdf). In addition, some programs are using the Psychosomatics 56:2, March/April 2015
Boland et al. milestones as an opportunity to explore innovative methods of assessment. As an example, some specialties use entrustable professional activities, which are specific observable tasks that can be used to help assess competency. Although the ACGME did not discuss entrustable professional activities as part of psychiatry competency assessments, some psychiatry residencies have begun to pilot entrustable professional activities as part of their assessment process. Other innovative strategies include the use of standardized patients and simulations. The milestones also directly affected the process of evaluation and feedback in training programs. Previously, the process was principally and sometimes entirely in the hands of the training directors. The ACGME mandated that evaluation and assessment become a group process. Residencies were expected to create Clinical Competency Committees (CCCs), which collectively review evaluation data and assign milestone levels for each trainee. The structure of these CCCs varies by specialty, and some specialties chose to exclude training directors from the process.4 The Psychiatry Residency Review Committee of the ACGME and the working group decided to include training directors and allow them to chair the committees if desired. Patient Care and Medical Knowledge were considered the most specialty-specific competencies, requiring the most effort to customize for the specialty.5 The remaining competencies: Systems-Based Practice, Practice-Based Learning and Improvement, Professionalism, and Interpersonal and Communication Skills had more in common with other medical specialties and were considered “general competencies.”6 The psychiatry milestones working group found that these general competency milestones required only minor revisions to make them relevant to psychiatry, although certain features (e.g., Interpersonal and Communication Skills as it related to psychotherapy) required special modification.4,7 Ultimately, the working group settled on 22 subcompetencies.8 To further organize these, the working group created an additional layer of classification, by organizing developmentally or conceptually related skills, knowledge, or attributes into “threads” that cut across the different levels of expertise.9 The working group intended these threads to identify particular developmental themes within a subcompetency (Figure 1). Along with the 6 competencies and 22 subcompetencies, the group created 66 threads. Psychosomatics 56:2, March/April 2015
The milestone creation process included a number of opportunities for feedback and critique, both through several surveys to training directors and through pilot testing.10 Implementation began in July 2014. As this process is still just beginning, it is premature to judge the effect of the milestones on psychiatric training. Not surprisingly, they have come under some criticism, e.g., for being the product of expert consensus rather than educational research.11 However, it is anticipated that these milestones will have an important effect not only on the process of evaluation but on psychiatry training overall, as training directors reevaluate their curriculum and their educational and clinical environment.12 THE SUBSPECIALTY (PM) MILESTONES Once the specialty milestones were completed, the ACGME focused its attention on subspecialty fellowship programs and began the process of forming working and advisory groups for each of the subspecialties. (The represented subspecialties were Child and Adolescent Psychiatry, Forensic Psychiatry, Geriatric Psychiatry, Addiction Psychiatry, and Psychosomatic Medicine. Several other accredited subspecialties, such as Brain Injury Medicine and Pain Medicine were not included as they are co-sponsored with other specialties.) For PM, the ACGME selected the groups with input from the Academy of Psychosomatic Medicine (APM) (Table 1). Of the working group members, 2 had been part of the general psychiatry milestones process (Drs. Boland and Servis); however, most of the members were new to the process; this was an intentional choice meant to provide a novel perspective. The working group used the general psychiatry milestones as a starting point. As Patient Care and Medical Knowledge are most specific to each individual subspecialty, the ACGME expected that these competencies would require the most attention from the working groups. The subspecialty committee chairs created a common draft of the other “general competencies”: Systems-Based Practice, PracticeBased Learning and Improvement, Professionalism, and Interpersonal and Communication Skills. The working groups for all of the psychiatry subspecialties met in June 2014, with the task of developing the Patient Care and Medical Knowledge competency milestones and editing the remaining subcompetencies appropriately. www.psychosomaticsjournal.org
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The Milestones for Psychosomatic Medicine Subspecialty Training FIGURE 1.
Example Subcompetency, Demonstrating the Organization of the Milestones into Competency, Subcompetency, and Threads as Well as the Reporting Procedure.
Competency Subcompetency
Thread Names
Thread for “Development as a teacher” (all milestones with “A”)
Milestone
Selecng a response box in the middle of a level implies that milestones in that level and in lower levels have been substanally demonstrated.
The working group used the core competencies for fellowship training in PM as a beginning framework for creating the Medical Knowledge competencies. A number of expert groups have suggested ways to categorize the large body of knowledge encompassed by PM (Table 2). For example, the residency education subcommittee of the APM proposed 9 categories of knowledge.13 The European Association of Consultation-Liaison Psychiatry and Psychosomatics suggested 3 broad knowledge areas and 11 subcategories.14 A collaborative expert group representing the ACGME, the American Board of Psychiatry and Neurology, and the APM produced detailed recommendations for core competencies for fellowship training; this group identified 8 knowledge competencies, for which they then listed 19 psychiatric problems or disorders relevant to each of the knowledge competencies.15 The PM milestone working group chose from among these different lists with an emphasis on finding overarching themes that were common to each of the lists and condensed these many areas down to 3 broad subcompetencies: psychiatric 156
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Selecng a response box on the line in between levels indicates that milestones in lower levels have been substanally demonstrated as well as some milestones in the higher level(s).
illnesses in the medically ill, psychiatric manifestations of medical illnesses, and the practice of PM. Using this as framework, the principal task of the PM working group was to decide on the level of detail needed for the PM milestones. Different subspecialty working groups have varied in this regard; the psychosomatic working group unanimously chose to take a summative approach to allow program directors reasonable flexibility to customize their curriculum, given their individual resources and strengths. The working group worked carefully to generate milestones that were limited in number, inclusive, and avoided narrowness and detail. The major changes from the general psychiatry milestones were in the Patient Care and Medical Knowledge milestones. As described previously, the working group summarized the Medical Knowledge subcompetencies using 3 broad categories. For Patient Care, the general psychiatry milestones has 5 subcompetencies; the psychosomatic working group condensed this to 2 (consultative patient care and integrated patient care). Psychosomatics 56:2, March/April 2015
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TABLE 1.
Psychosomatic Medicine Milestone Groups
Psychiatry Subspecialty Milestones Chair: Christopher R. Thomas, M.D. (University of Texas Medical Branch at Galveston) Working group Chair: Robert Boland, M.D. (Brigham and Women’s Hospital/ Harvard Medical School and Brown University) Madeleine Becker, M.D. (Jefferson University) Catherine C. Crone, M.D. (George Washington University) Laura Edgar, Ed.D., C.A.E. (ACGME) James Levenson, M.D. (Virginia Commonwealth University) Mark Servis, M.D. (University of California, Davis) Advisory group Chair: George Keepers, M.D. (Oregon Health and Science University) Steven Epstein, M.D. (Georgetown University) Larry Faulkner, M.D. (American Board of Psychiatry and Neurology) Christopher K. Varly, M.D. (University of Washington) ACGME ¼ Accreditation Council of Graduate Medical Education.
Once completing the Patient Care and Medical Knowledge subcompetencies, the working group reviewed the 4 general competencies for psychiatric subspecialties (Systems-Based Practice, Practice-Based Learning and Improvement, Professionalism, and Interpersonal and Communication Skills) editing them to be specific to PM. As an example, regarding Interpersonal and Communication Skills, the PM specialist should be particularly skilled in communication with colleagues and in negotiating various systems of care. The working group maintained the number and structure of the general psychiatry subcompetencies for these competencies with the exception of “Formal Practice-Based Quality Improvement,” one of the general psychiatry Practice-Based Learning and Improvement subcompetencies, as there is no requirement for a formal quality improvement project during fellowship training. The final competencies, subcompetencies, and milestones are listed in Table 3. A challenge for the PM working group was choosing the range of milestone levels to correspond to what fellows should reasonably achieve in the limited time of 1 year. As with the general psychiatry milestones, each subcompetency has 4 levels, ranging from an entering level (level 1) to a graduating trainee (level 4), with a fifth “aspirational” level meant to describe trainees who exceed expectations. The Psychosomatics 56:2, March/April 2015
working group considered the diverse range of possible abilities at the entry level of training and chose to describe a full range of expertise for each subcompetency, even though different fellows start at different levels. Many fellows likely enter at a level 2 or 3 for some of the subcompetencies; however, the working group included a “beginner level” (level 1) to characterize those fellows who had less exposure to PM during their residency training (Figure 2). Similarly, the fifth level, by design, most often describes a very advanced level (a leadership level of expertise), to give training directors a very broad developmental range. When considering the subcompetencies, the group had to decide which of the general psychiatry milestone subcompetencies needed elaboration, which they should de-emphasize or eliminate, and what new additions were necessary. The skills and knowledge more specific to PM would require a more sophisticated level of development. For example, the Systems-Based Practice subcompetency of “Resource Management” is similar to the analogous general psychiatry subcompetency, reflecting the group’s belief that there was a “ceiling effect” in training for this area. This was handled similarly for the Professionalism subcompetencies, reflecting a belief that the core values of professionalism, such as compassion for others, high ethical standards, and accountability to oneself and one’s patients are already taught well by residency programs. In contrast, the Patient Care subcompetencies assume a higher level of expertise at the initial stages, with more rapid progression to leadership roles. FEEDBACK AND MODIFYING THE MILESTONES The initial draft then went through several cycles of review. The advisory committee first evaluated the draft and their suggested changes were incorporated; much of the advisory group’s comments were useful suggestions for making the milestones more specific to PM. The ACGME then shared the draft with stakeholders, conducting a survey with PM fellowship training directors. In addition, the Fellowship Education Subcommittee of the APM reviewed the milestones and submitted their own consensus comments. The comments by the subcommittee constituted substantial edits including multiple clarifying edits and the suggestion to collapse several of the threads, which further simplified the milestones. The ACGME collated the feedback www.psychosomaticsjournal.org
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Comparison of Approaches to Categorizing the Medical Knowledge Competency for Psychosomatic Medicine
APM Residency Education Subcommittee (2014)2
General psychiatric illnesses in the medical setting Psychiatric illnesses the manifest primarily in the medical setting
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Psychiatric treatment modalities in the medical setting
Psychiatric manifestations of medical/surgical illness
APA council on PM, ABPN psychosomatic committee, APM (2009)2
EACLPP workgroup (2006)3
Relevant sciences (e.g., neurosciences, psychology, psychopharmacology, epidemiology, and social sciences) that are important for the care of medically ill psychiatric patients and their families
Awareness of the different theoretical models used as bases of the subject (e.g., biopsychosocial, psychophysiologic, and psychoneuroimmunologic models)
The nature and extent of psychiatric morbidity in medical populations For each area, consider the following problems and disorders as possibly presenting in medical-surgical-obstetric patients: Mood disorders, anxiety disorders, adjustment disorders, bereavement, acute stress disorders, delirium, dementia, psychotic disorders, catatonia, substance-related disorders, psychiatric disorders owing to a general medical condition or a toxic substance, somatoform disorders, factitious disorders and malingering, sleep disorders, sexual disorders, psychologic factors that affect physical illness, personality disorders in the medical setting, developmental disorders, and eating disorders Appropriate treatment interventions for co-existing psychiatric disorders in medically ill patients, including pharmacotherapy, other somatic therapies (e.g., ECT), and psychotherapy (especially, evidencebased psychotherapies) Indications for and use of psychiatric medications in medically ill patients, including knowledge of drug-drug interactions
Assessment and management of the following clinical disorders or situations: Delirium/dementia and other psychiatric disorders with organic cause; somatization; depression and anxiety in medically ill patients; suicide/ self-harm (with special emphasis on the management of a medical unit and transference/countertransference issues); addiction problems in medical settings; abnormal illness behavior in somatically ill patients; chronic pain; gender-specific disorders, sexual dysfunction in medically ill patients, and sexual abuse in specific patient populations (e.g., somatoform disorder and chronic pain)
The effect of psychologic factors and co-morbid psychiatric disorders on the course of medical illnesses
Coping with chronic disease and terminal illness
ACGME psychosomatic working group (2014)
Psychiatric illnesses, including major psychiatric disorders, substance use disorders, somatic symptom disorders, adjustment disorders, and psychologic factors affecting another medical condition in medically ill patients Diagnostic and phenomenologic issues Management and treatment
Psychiatric manifestations of medical illnesses Diagnostic issues Management and treatment
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Psychiatric co-morbidities associated with specific medical/surgical illnesses
Psychiatric treatment modalities in the medical setting
Psychiatric complications of medical illnesses, including trauma, psychologic and psychiatric effects of toxins, and medical and surgical treatments and medications Appropriate treatment interventions for co-existing psychiatric disorders in medically ill patients, including pharmacotherapy, other somatic therapies (e.g., ECT), and psychotherapy (especially, evidencebased psychotherapies) Indications for and use of psychiatric medications in medically ill patients, including knowledge of drug-drug interactions
Pediatric C-L psychiatry
Legal aspects of ConsultationLiaison (C-L) psychiatry Psychiatric practices in specific medical or surgical settings Psychiatric consultation and or liaison in the outpatient medical or surgical setting
Forensic psychiatric issues (e.g., capacity and guardianship) as they apply to psychosomatic medicine
Management of patients with psychiatric disorders (e.g., psychotic and bipolar) in need of medical/ surgical treatment.
Psychiatric co-morbidity and psychologic problems in child and adolescent disorders Ethical and medicolegal issues (general ethical topics such as limitation of treatment and genetic testing as well as special issues relevant to a particular country)
Practice of psychosomatic medicine Ethical and legal issues Models of consultation and collaborative care Issue in diverse populations (e.g., cultural, ethnic, developmental, gender, and sexual orientation)
ABPN ¼ American Board of Psychiatry and Neurology; ACGME ¼ Accreditation Council of Graduate Medical Education; APA ¼ American Psychiatric Association; APM ¼ Academy of Psychosomatic Medicine; EACLPP ¼ European Association of Consultation-Liaison Psychiatry and Psychosomatics; ECT ¼ electroconvulsive therapy; PM ¼ psychosomatic medicine.
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Level 1
Summary of the Milestones Level 2
Level 3
Level 4
Level 5
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Patient Care PC1—Consultative patient care: clarifying the question, gathering data and collateral information, interviewing the patient, and suggesting appropriate diagnostic and treatment options and communicating them effectively to the primary service Performs simple consultations Manages simple consultations Manages a broad range of routine Independently manages Supervises and serves as a role with indirect supervision, with in inpatient and outpatient consultation requests in complicated and challenging model for trainees direct supervision immediately settings inpatient and outpatient settings consultation patients or available Recognizes and addresses situations (e.g., patients who Effectively runs a unrecognized psychiatric issues cannot/will not participate in psychosomatic medicine that are uncovered during the the interview, are highly inpatient consult service or process of consultation agitated/high risk, or with outpatient clinic complicated medical/ psychiatric illness) PC2—Integrated patient care: performing, coordinating, and supervising care in multidisciplinary settings, inpatient or outpatient, and including liaison and educational roles Provides basic psychiatric Provides basic psychiatric Provides comprehensive Provides effective care, Leads the psychosocial assessment and treatment information and integrated care for patients guidance, and education in a component of a recommendations, requiring recommendations to through collaboration with other multidisciplinary medical multidisciplinary medical indirect supervision with direct multidisciplinary medical providers treatment team, including treatment team supervision available treatment team managing complex dynamics affecting the patient and treatment team (e.g., patient who splits treatment team)
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Medical Knowledge MK1—Knowledge regarding psychiatric illnesses in the medically ill: assessment and management of major psychiatric disorders, substance use disorders, somatic symptom disorders, adjustment disorders, and psychologic factors affecting medical conditions Demonstrates limited knowledge Demonstrates basic knowledge Demonstrates comprehensive Demonstrates comprehensive Develops, synthesizes, or regarding common psychiatric regarding epidemiology, knowledge regarding the knowledge regarding the presents new knowledge illnesses and their treatments in etiology, phenomenology, assessment and management of presentation and assessment regarding psychiatric the medically ill prognosis, and treatment of psychiatric illnesses in the of complex/atypical illnesses and their treatments common psychiatric illnesses medically ill, including detailed psychiatric illnesses in the in the medically ill in the medically ill, including knowledge of adverse effects and medically ill, including common adverse effects and drug-drug interactions advanced knowledge in drug-drug interactions specific medical populations (e.g., cancer, transplant, or OB-GYN) MK2—Knowledge regarding psychiatric manifestations of medical illnesses: assessment and management of physical and psychologic reactions to medical illness and its treatment Demonstrates basic knowledge Demonstrates comprehensive Demonstrates comprehensive Develops, synthesizes, or Demonstrates limited knowledge regarding common psychiatric regarding the presentation knowledge regarding the knowledge regarding the presents new knowledge manifestations of medical and treatment of psychiatric assessment and management of assessment and management regarding psychiatric illnesses and their treatments symptoms caused by psychiatric symptoms caused by of psychiatric symptoms symptoms caused by medical (e.g., delirium or syndromes and common medical illnesses common medical illnesses and caused by complex/ illnesses and their treatments symptoms secondary to medical and their treatments their treatments uncommon medical illnesses conditions) and their treatments
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TABLE 3.
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MK3—Practice of psychosomatic medicine: A. Ethics and legal issues B. Models of consultation and collaborative care C. Issues in diverse populations (e.g., cultural, ethnic, developmental, gender, and sexual orientation) 1A. Demonstrates limited knowledge of clinically relevant legal and ethical issues in medical settings (e.g., capacity evaluations)
2A. Demonstrates knowledge of essential ethical and legal issues
3A. Demonstrates comprehensive knowledge of clinically relevant legal and ethical issues in medical settings (e.g., capacity evaluations)
1B. Demonstrates limited knowledge of consultation and collaborative care models
2B. Demonstrates basic knowledge of common consultation and collaborative care models
3B. Demonstrates comprehensive knowledge of consultation and collaborative care models
1C. Recognizes importance of delivering culturally competent care
2C. Demonstrates recognition of issues in delivering culturally competent care
3C. Consistently demonstrates awareness and skill regarding the effect of cultural differences in patient care
4A. Demonstrates advanced knowledge of clinically relevant legal and ethical issues in medical settings, including in difficult and challenging situations 4B. Demonstrates advanced knowledge of consultation and collaborative care models, including emerging new modes of clinical care 4C. Anticipates the effect of diversity on patient care and serves as role model in provision of care in diverse groups
5A. Functions as leader or expert in institutional ethical or legal processes
5B. Explores new forms of care models or performs health services research in consultation and collaborative care 5C. Generates new understanding of diversity issues
Systems-Based Practice SBP1—Patient safety and the health care team A. Medical errors and quality improvement activities B. Communication and patient safety C. Regulatory and educational activities related to patient safety 1A/B. Describes the common system causes for errors (e.g., communication failures, equipment failures, and other failures of the health care delivery system)
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3A. Understands and consistently uses safety procedures
2B. Effectively and regularly uses all appropriate forms of communication to ensure accurate transitions of care
3B. Displays effective communication with colleagues and recognizes special circumstances that will affect safety
2C. Follows regulatory requirements related to reporting requirements and prescribing practices
3C. Effectively communicates safety procedures and requirements to trainees and other audiences
4C. Develops content for and/ or facilitates patient safety presentations/conferences focusing on systems-based errors in patient care
Consistently provides costeffective care, using a variety of resources, including the electronic medical record (EMR)
Practices efficient, costeffective, high-value clinical care, using a full range of resources, in routine and complex cases
SBP2—Resource management: costs of care and resource selection Recognizes disparities in health Coordinates patient access to care at individual and community and system community levels resources
4A. Skillfully participates and contributes in a multidisciplinary context in quality improvement and patient safety projects (e.g., morbidity and mortality conference, root cause analysis meeting) 4B. Takes a leadership role in ensuring coordinated patient care, including accurate transitions of care
5A/B/C. Provides organizational leadership or consultation to improve care quality and patient safety
5A/B/C. Implements innovative systems to improve care quality and patient safety 5A/B/C. Develops new curricula and approaches to education in safety and quality issues 5A/B/C. Contributes on a regulatory level to safety and quality improvement
Designs new approaches to provide efficient care to monitor and educate regarding health care resource use
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1C. Follows institutional safety policies, including reporting of problematic behaviors and processes, errors, and near misses
2A. Describes systems and procedures that promote patient safety
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Level 1
Level 2
Knows the relative cost of care (e.g., medications, diagnostics, levels of care, and procedures)
Understands health care funding and regulations related to organization of health care services
Level 3
Level 4
Level 5 Advocates for improved access to and additional resources within systems of care
SBP3—Community-based care: community-based programs; self-help groups, including 12-step approaches; medical, psychiatric, and substance abuse recovery/rehabilitation programs Has a basic knowledge of local Has a basic knowledge of Incorporates community Skillfully uses a wide range of Develops new care programs health care delivery systems community resources; resources, self-help groups community-based resources and new approaches to link coordinates care with (including 12-step approaches), for rehabilitation and medical and communitycommunity mental health and social networks in clinical recovery, including in based programs agencies, schools, and other care; appropriately refers to challenging cases of agencies; recognizes rehabilitation and recovery co-morbid chronic medical importance of self-help programs and psychiatric illnesses groups, and recovery and rehabilitation approaches SBP4—Consultation to health care systems Describes how systems issues Identifies systems issues in affect clinical care clinical care and clarifies required interactions and communication
Communicates with other providers and provides effective recommendations regarding systems issues in clinical care
Provides expert advanced recommendations to address systems issues in clinical care, including challenging and complex situations requiring novel management
Measures outcomes of systems-based interventions, contributes to improvement of existing service delivery systems, or develops new modes of health care delivery
4A. Identifies and meets selfdirected learning goals with little external guidance; keeps up with relevant changes in medical knowledge using a system or process2; recognizes limits of own knowledge 4B. Consistently makes informed, evidence-based clinical decisions; demonstrates a recognized mastery of the knowledge base of psychosomatic medicine
5A/B. Synthesizes and presents new findings; develops educational methodology to communicate new medical knowledge
Practice-Based Learning and Improvement PBLI1—Lifelong learning A. Self-assessment and self-improvement B. Use of evidence-based medical knowledge
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1A. Regularly seeks and incorporates feedback to improve performance; identifies self-directed learning goals, and periodically reviews them with supervisory guidance
2A. Demonstrates a balanced and accurate self-assessment of own competence, using clinical outcomes to identify areas for continued improvement
3A. Demonstrates improvement in clinical practice based on continual self-assessment and evidence-based information
1B. Formulates a searchable question from a clinical question
2B. Selects an appropriate, evidence-based information tool1 to meet self-identified learning goals
3B. Efficiently searches and uses medical literature to answer clinical questions; critically appraises different types of research, including randomized controlled trials, systematic reviews, meta-analyses, and practice guidelines
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162 TABLE 3. Continued
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PBLI2—Teaching A. Development as a teacher B. Observable teaching skills 1A. Assumes a role in the clinical teaching of trainees and assists faculty members in providing supervision to these learners
1B. Recognizes the role of physician as teacher
2A. Participates in activities designed to develop and improve teaching skills and assists faculty members in providing supervision to trainees (e.g., medical students and residents) in psychosomatic medicine settings 2B. Evaluates and provides feedback to trainees, and communicates goals and objectives for instruction of trainees
3A. Actively participates in didactic presentations on psychosomatic medicine topics to groups (e.g., grand rounds, case conference, and journal club)
4A. Independently develops and provides consistently effective presentations on psychosomatic medicine to groups, including to health professionals in nonpsychiatric disciplines
5A. Is recognized as an educator of colleagues, the broader professional community, and/or the public
3B. Effectively teaches individual trainees in clinical settings; effectively uses feedback on teaching to improve teaching methods and approaches
4B. Demonstrates recognized skill in the education of trainees, including those in nonpsychiatric disciplines
5B. Organizes and develops curriculum materials relevant to psychosomatic medicine
4A. Consistently displays compassion, integrity, and sensitivity, including in the more challenging areas of medical practice
5A. Serves as a role model and teacher of compassion, integrity, respect for others, and sensitivity to diverse patient populations
Professionalism PROF1—Compassion, integrity, and respect A. Compassion for others, self-reflection, and sensitivity to diverse patient populations B. Adherence to ethical principles 2A. Routinely displays empathy, compassion, and sensitivity to diversity in psychiatric evaluation and treatment
1B. Recognizes ethical conflicts in practice and seeks supervision to manage them
2B. Analyzes and manages ethical issues in common clinical situations in the psychosomatic medicine setting
3A. Facilitates positive communication and develops a mutually agreeable care plan in the context of conflicting physician, patient, and/or family values and beliefs 3A. Discusses own cultural background and beliefs and the ways in which these affect interactions with patients 3B. Manages ethical issues in a wide range of clinical situations in the psychosomatic medicine setting
4A. Displays recognized expertise in and leads educational activities regarding ethical and practice issues 4B. Systematically analyzes and manages complex ethical issues in psychosomatic medicine (e.g., end-of-life decisions)
5B. Identifies emerging ethical issues within subspecialty practice and can discuss opposing viewpoints
PROF2—Accountability to self, patients, colleagues, and profession A. Work balance and fatigue management B. Professional behavior and participation in professional community
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1A. Notifies team and enlists appropriate coverage for clinical and nonclinical responsibilities when fatigued or ill
2A. Identifies and manages situations in which maintaining personal health is challenged and seeks assistance when needed
3A. Demonstrates healthy and responsible work style; takes steps to address impairment in self and in colleagues if present
4A. Effectively prioritizes and balances conflicting interests of self, family, and others to optimize medical care and practice of profession
5A. Participates as an active member on committees or in organizations that address physician wellness
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1A. Demonstrates capacity for self-reflection, empathy, openness to different beliefs, and respect for diversity; provides examples of the importance of attention to diversity in psychiatric evaluation and treatment
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Level 1
Level 2
Level 3
Level 4
Level 5
1B. Follows institutional policies for physician conduct and responsibility
2B. Recognizes the importance of participating in one’s professional community
3B. Displays professionalism in work, collaborates effectively with colleagues, maintains skills (e.g., prepares for obtaining and maintaining board certification), and consistently displays responsibility for ensuring that patients receive the best possible care
4B. Participates in the primary specialty and subspecialty professional community (e.g., professional societies, patient advocacy groups, and community service organizations); displays exemplary professionalism and serves as role model in ensuring that patients receive best possible care
5B. Develops organizational policies, programs, or curricula for professionalism
4A/B. Sustains therapeutic and working relationships in complex and challenging contexts, including in situations with significant differences of opinion among care providers, families, and patients
5A/B. Develops approaches to managing difficult situations and communications in the psychosomatic medicine setting 5A/B. Effectively mentors other health care providers in leadership, communication skills, and conflict management 5A/B. Engages in scholarly activity (e.g., teaching or research) regarding teamwork and conflict management
4A. Demonstrates communication that is appropriate, efficient, concise, and pertinent in challenging situations (e.g., significant differences of opinion, with patients with limited communication and/ or cognitive abilities)
5A/B. Develops new modes of system organization to facilitate communication and maintenance of professional relationships
Interpersonal and Communication Skills ICS1—Relationship development and conflict management A. Relationship with patients B. Conflict management with patients, families, colleagues, and members of the health care team 1A. Develops therapeutic relationship with patients and their families and is aware of cultural diversity in communicating with people of different backgrounds
2A. Develops therapeutic relationships with patients and is respectful of cultural diversity in discussions with patients and their families
3A. Skillfully forms therapeutic relationship with a wide range of patients in the psychosomatic medicine setting
1B. Recognizes communication conflicts in work relationships
2B. Develops working relationships across specialties and systems of care in uncomplicated situations
3B. Appropriately sustains working relationships in the face of conflict or differences in opinions with other services or colleagues and is able to efficiently resolve routinely encountered conflicts
ICS2—Information sharing and record keeping A. Accurate documentation and effective communication with health care team and patients B. Maintaining professional boundaries 1A. Ensures transitions of care are accurately documented and that the written record is accurate and timely, with attention to preventing confusion and error, consistent with institutional policies
2A. Provides complete, timely, and accurate documentation
3A. Demonstrates effective verbal and written communication with patients, families, colleagues, and other health care providers that is appropriate, efficient, concise, and pertinent
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TABLE 3. Continued
4B. Uses discretion and judgment in the inclusion of sensitive patient material in the medical record and in all communication with patients, families, and colleagues 3B. Consistently maintains professional boundaries and respect for confidentiality 1B. Maintains appropriate boundaries in sharing information by electronic communication and in the use of social media
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OB-GYN ¼ obstetrics and gynecology; ICS ¼ Interpersonal and Communication Skills; MK ¼ Medical Knowledge; PBL ¼ Practice-Based Learning and Improvement; PC ¼ Patient Care; PROF ¼ Professionalism; SBP ¼ Systems-Based Practice.
4A. Recruits appropriate assistance when cultural differences create barriers to patient care 1A. Organizes both written and oral information to be shared with patient, family, team, and others
2A. Consistently demonstrates communication strategies to ensure patient and family understanding, including use of easy-to-understand language, skillful use of interpreters, and face-to-face interaction while using EMR 2B. Demonstrates respect for patient confidentiality
3A. Consistently engages patients and families in shared decision making
Boland et al. from the different sources, and the PM working group convened to incorporate these critiques and finalize the milestones. The final draft contained a total of 15 subcompetencies and 24 threads, which was a substantial reduction from the original draft. DISSEMINATION AND IMPLEMENTATION Having completed a final draft, the milestones were posted by the ACGME in October 2014 (https://www. acgme.org/acgmeweb/tabid/147/ProgramandInstitution alAccreditation/MedicalSpecialties/Psychiatry.aspx) with a scheduled implementation in PM fellowship programs for July 2015. With this tight timeline, a pilot was not feasible and rapid dissemination and education about the milestones is now a priority. The working group introduced the rationale and plan for milestones in a summer 2014 APM newsletter and discussed the milestones with psychosomatic fellowship training directors at the 2014 annual APM meeting.16 Additional online communications (e.g., webinars) will be considered if there is need and interest. IMPLICATIONS OF THE MILESTONES ON FELLOWSHIP PROGRAMS AND RECOMMENDATIONS As with the general milestones, the PM milestones should improve the process of assessment and feedback in a fellowship program by providing objective, standardized criteria for evaluation.4 The milestones will help organize the semiannual feedback meetings between training directors and residents, allow for a clear description of the fellow’s progress, and identify areas of deficiencies as the fellow advances through fellowship training. The milestones will also encourage and, hopefully, improve self-assessment by fellows as they progress through their training. The milestones will also shape the evaluation process. The primary function of the CCC is to integrate the various trainee evaluations and identify which milestones have been achieved by each trainee. The CCC must meet at the midpoint and near the completion of the fellowship training year. With this relatively short timeline, it will be particularly important to have a well-organized CCC meeting at the midpoint of training so that the group can identify potential deficiencies and make corrective plans in time to have a meaningful influence on training. It is www.psychosomaticsjournal.org
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The 5 Developmental Levels for Fellowship Training.
recommended that the CCC also meet early in the program to provide the opportunity for earlier remediation, if needed. Such a process will only be as good as the information provided, and we expect that the implementation of milestones will require new and innovative methods of fellow assessment.17 Unlike the general psychiatry milestone working group, which produced sample assessment instruments, the subspecialty working groups have left it to each individual program to modify or create evaluation tools to map the milestones.18 Although each individual fellowship program is unique, many of the challenges for
milestone assessment are not. It is our hope that the implementation process be a group effort among PM training directors. There is no doubt that such an effort would be of enormous help, by standardizing assessment tools, limiting the administrative workload and improving the quality of assessments. We see this as an important role for the subspecialty organizations and expect that the APM will help lead this process. Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.
References 1. Nasca TJ, Philibert I, Brigham T, Flynn TC: The next GME accreditation system—rationale and benefits. N Engl J Med 2012; 366(11):1051–1056 2. Manthous CA: On the Outcome Project. Yale J Biol Med 2014; 87(2):213–220 3. Beresin EV, Balon R, Coverdale J: The psychiatry milestones: new developments and challenges. Acad Psychiatry 2014; 38(3):249–252 4. Thomas CR: Educational milestone development for psychiatry. J Grad Med Educ 2014; 6(1 Suppl 1):281–283 5. Hunt J, Thomas C: ACGME milestone development in general psychiatry: patient care and medical knowledge. Acad Psychiatry 2014; 38(3):261–267 6. Sanders K, Servis M, Boland R: The four general competencies. Acad Psychiatry 2014; 38(3):268–274 7. Widge A, Hunt J, Servis M: Systems-based practice and practice-based learning for the general psychiatrist: old
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competencies, new emphasis. Acad Psychiatry 2014; 38(3): 288–293 ACGME, ABPN: The Psychiatry Milestone Project. Available from: http://acgme.org/acgmeweb/Portals/0/PDFs/ Milestones/PsychiatryMilestones.pdf. 2013. Accessed 9/6/14 Thomas CR, Keepers G: The milestones for general psychiatry residency training. Acad Psychiatry 2014; 38(3): 255–260 Thomas CR: Introduction and commentary on the psychiatry milestones. Acad Psychiatry 2014; 38(3): 253–254 Dewan M, Manring J, Satish U: The new milestones: do we need to take a step back to go a mile forward? Acad Psychiatry 2014 [Epub ahead of print] Widge A, Schultz H: Opportunities and challenges: residents’ perspectives on the next accreditation system in psychiatry. Acad Psychiatry 2014; 38(3):303–304
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Boland et al. 13. Heinrich TW, Schwartz AC, Zimbrean PC, et al: Recommendations for training psychiatry residents in psychosomatic medicine. Psychosomatics 2014; 55(5):438–449 14. Sollner W, Creed F: European guidelines for training in consultation-liaison psychiatry and psychosomatics: report of the EACLPP Workgroup on Training in ConsultationLiaison Psychiatry and Psychosomatics. J Psychosom Res 2007; 62(4):501–509 15. Worley LL, Levenson JL, Stern TA, et al: Core competencies for fellowship training in psychosomatic medicine: a collaborative effort by the APA Council on Psychosomatic Medicine, the ABPN Psychosomatic Committee, and the
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Academy of Psychosomatic Medicine. Psychosomatics 2009; 50(6):557–562 16. Boland R: Psychosomatic milestones update. Academy of Psychosomatic Medicine Newsletter. Available from: http://www.apm.org/newslett/14summer_APMnews.pdf. 2014 (Summer) 17. French JC, Dannefer EF, Colbert CY: A systematic approach toward building a fully operational clinical competency committee. J Surg Educ 2014; 71(6):e22–e27 18. Swing SR, Cowley DS, Bentman A: Assessing resident performance on the psychiatry milestones. Acad Psychiatry 2014; 38(3):294–302
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& 2015 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
Perspective The Milestones for Psychosomatic Medicine Subspecialty Training Robert J. Boland, M.D., Madeleine Becker, M.D., James L. Levenson, M.D., Mark Servis, M.D., Catherine C. Crone, M.D., Laura Edgar, Ed.D., C.A.E., Christopher R. Thomas, M.D.
Background: The Accreditation Council of Graduate Medical Education Milestones project is a key element in the Next Accreditation System for graduate medical education. On completing the general psychiatry milestones in 2013, the Accreditation Council of Graduate Medical Education began the process of creating milestones for the accredited psychiatric subspecialties. Methods: With consultation from the Academy of Psychosomatic Medicine, the Accreditation Council of Graduate Medical Education appointed a working group to create the psychosomatic medicine milestones, using the general psychiatry milestones as a starting point. Results: This article represents a record
of the work of this committee. It describes the history and rationale behind the milestones, the development process used by the working group, and the implications of these milestones on psychosomatic medicine fellowship training. Conclusions: The milestones, as presented in this article, will have an important influence on psychosomatic medicine training programs. The implications of these include changes in how fellowship programs will be reviewed and accredited by the Accreditation Council of Graduate Medical Education and changes in the process of assessment and feedback for fellows. (Psychosomatics 2015; 56:153–167)
INTRODUCTION
in 1997, which was developed to address concerns raised by the Institute of Medicine and other organizations regarding the quality of graduate medical education in the United States, particularly how training outcomes were measured.3 The intention of the project was to improve how programs evaluate residents, how curricula are developed and, ultimately,
The Accreditation Council of Graduate Medical Education (ACGME) milestones project is a key element in the Next Accreditation System for graduate medical education.1 The ACGME completed the general psychiatry milestones in 2013, which were implemented in July 2014. The ACGME then turned its attention to creating milestones for the accredited subspecialties. This article describes the history and rationale behind the milestones, the development process for the psychosomatic medicine (PM) milestones, and their implications on fellowship training. HISTORY AND RATIONALE FOR THE NEXT ACCREDITATION SYSTEM The Next Accreditation System was part of the Outcomes Project for graduate medical education,2 begun Psychosomatics 56:2, March/April 2015
Received October 12, 2014; revised November 6, 2014; accepted November 6, 2014. From Department of Psychiatry, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (RJB); Thomas Jefferson University, Philadelphia, PA (MB); Virginia Commonwealth University, Richmond, VA (JLL); University of California, Davis, Davis, CA (MS); George Washington University, Washington, DC (CCC); Accreditation Council for Graduate Medical Education, Chicago, IL (LE); University of Texas Medical Branch at Galveston, Galveston, TX (CRT). Send correspondence and reprint requests to Robert J. Boland, M.D., Department of Psychiatry, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115; e-mail: [email protected] & 2015 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
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The Milestones for Psychosomatic Medicine Subspecialty Training how programs are accredited. Thomas Nasca, M.D., the Chief Executive Officer of the ACGME, pointed out that the current system for evaluating programs was akin to an “episodic biopsy” model, in which a program is cross-sectionally sampled every 4–5 years.1 For resident evaluation, programs would assess residents on whether they had achieved a particular competency, and at graduation, training directors attested that the trainee had mastered all competencies on a checklist style form. Dr. Nasca, instead, suggested a developmental approach to assessment at stages during residency training. The milestones were introduced to provide a system for tracking the resident throughout their training with specialty-specific milestones or targets to demonstrate that they have achieved the required competencies. The 6 clinical competencies were introduced in 1999, which was the beginning of the restructuring of the medical accreditation process.1 Milestones describe the variety of performance levels trainees should demonstrate (including skills, knowledge, and behaviors) for each of these competencies: Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based Learning, Professionalism, and Interpersonal and Communication Skills, ranging from a novice to an expert. They are organized as a framework of observable behaviors and other attributes that track a resident’s development over the course of training.1 The ACGME saw the milestones as having several uses, each with implications for the future of graduate medical education. The ACGME will use aggregate milestone data as part of their process of continual accreditation for a training program. At the training program level, milestones will guide curriculum development, provide expectations that are more explicit to trainees, and help programs identify trainees who are not progressing at expected rates. For residents and fellows, milestones should provide explicit feedback on their progress and facilitate their understanding of expectations for satisfactory completion of their training. DEVELOPING THE SPECIALTY MILESTONES FOR PSYCHIATRY In developing the competencies for each specialty, the ACGME appointed working and advisory groups for each specialty. Psychiatry was part of the second phase 154
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of milestone development and thus able to benefit from knowledge gained during the first phase, after internal medicine, pediatrics, emergency medicine, diagnostic radiology, urology, neurologic surgery, and orthopedic surgery developed and implemented their milestones. A major challenge was finding the balance between clarity and specificity on the one hand and brevity and flexibility on the other. For each of the 6 competencies, each specialty workgroup had to decide how to subdivide that competency into the specific knowledge, skills, and attitudes that were most relevant to that particular specialty. Some of the first phase participants initially had large numbers of subcompetencies, and as the milestones were introduced to practice, it became clear that this was impractical, given the need for multiple evaluators and diverse rotations. Learning from this, the psychiatry milestone working group, attempting to streamline and simplify the process, combined some subcompetencies into more general categories. With input from the ACGME’s psychiatry advisory committees, including the American Psychiatric Association, the American Board of Psychiatry and Neurology and the American Association of Directors of Psychiatry Residency Training, the general psychiatry milestones went through several drafts. Several pilots also informed the process. The psychiatry milestones were released in November 2013 and implemented in July 2014. The milestone development process fostered several educational innovations, some common to all specialties and some unique to psychiatry. For example, in response to the milestones, many residency programs created new evaluation tools for assessment of trainees, which could be applied to the milestones. Previously, most residencies used global evaluations, in which a resident was evaluated more generally on all competencies during any given rotation. Now, with the detailed subcompetencies defined by each specialty and their level of specificity, this approach would no longer be suitable. It soon became clear that an alternate approach to evaluation was needed. One solution was to match specific rotations with the subset of subcompetencies most relevant to that rotation. To address this problem, the milestone working group created sample evaluations for different rotations (which are available at: https://www.acgme.org/acgmeweb/ Portals/0/PDFs/Milestones/PsychiatryAssessmentTools. pdf). In addition, some programs are using the Psychosomatics 56:2, March/April 2015
Boland et al. milestones as an opportunity to explore innovative methods of assessment. As an example, some specialties use entrustable professional activities, which are specific observable tasks that can be used to help assess competency. Although the ACGME did not discuss entrustable professional activities as part of psychiatry competency assessments, some psychiatry residencies have begun to pilot entrustable professional activities as part of their assessment process. Other innovative strategies include the use of standardized patients and simulations. The milestones also directly affected the process of evaluation and feedback in training programs. Previously, the process was principally and sometimes entirely in the hands of the training directors. The ACGME mandated that evaluation and assessment become a group process. Residencies were expected to create Clinical Competency Committees (CCCs), which collectively review evaluation data and assign milestone levels for each trainee. The structure of these CCCs varies by specialty, and some specialties chose to exclude training directors from the process.4 The Psychiatry Residency Review Committee of the ACGME and the working group decided to include training directors and allow them to chair the committees if desired. Patient Care and Medical Knowledge were considered the most specialty-specific competencies, requiring the most effort to customize for the specialty.5 The remaining competencies: Systems-Based Practice, Practice-Based Learning and Improvement, Professionalism, and Interpersonal and Communication Skills had more in common with other medical specialties and were considered “general competencies.”6 The psychiatry milestones working group found that these general competency milestones required only minor revisions to make them relevant to psychiatry, although certain features (e.g., Interpersonal and Communication Skills as it related to psychotherapy) required special modification.4,7 Ultimately, the working group settled on 22 subcompetencies.8 To further organize these, the working group created an additional layer of classification, by organizing developmentally or conceptually related skills, knowledge, or attributes into “threads” that cut across the different levels of expertise.9 The working group intended these threads to identify particular developmental themes within a subcompetency (Figure 1). Along with the 6 competencies and 22 subcompetencies, the group created 66 threads. Psychosomatics 56:2, March/April 2015
The milestone creation process included a number of opportunities for feedback and critique, both through several surveys to training directors and through pilot testing.10 Implementation began in July 2014. As this process is still just beginning, it is premature to judge the effect of the milestones on psychiatric training. Not surprisingly, they have come under some criticism, e.g., for being the product of expert consensus rather than educational research.11 However, it is anticipated that these milestones will have an important effect not only on the process of evaluation but on psychiatry training overall, as training directors reevaluate their curriculum and their educational and clinical environment.12 THE SUBSPECIALTY (PM) MILESTONES Once the specialty milestones were completed, the ACGME focused its attention on subspecialty fellowship programs and began the process of forming working and advisory groups for each of the subspecialties. (The represented subspecialties were Child and Adolescent Psychiatry, Forensic Psychiatry, Geriatric Psychiatry, Addiction Psychiatry, and Psychosomatic Medicine. Several other accredited subspecialties, such as Brain Injury Medicine and Pain Medicine were not included as they are co-sponsored with other specialties.) For PM, the ACGME selected the groups with input from the Academy of Psychosomatic Medicine (APM) (Table 1). Of the working group members, 2 had been part of the general psychiatry milestones process (Drs. Boland and Servis); however, most of the members were new to the process; this was an intentional choice meant to provide a novel perspective. The working group used the general psychiatry milestones as a starting point. As Patient Care and Medical Knowledge are most specific to each individual subspecialty, the ACGME expected that these competencies would require the most attention from the working groups. The subspecialty committee chairs created a common draft of the other “general competencies”: Systems-Based Practice, PracticeBased Learning and Improvement, Professionalism, and Interpersonal and Communication Skills. The working groups for all of the psychiatry subspecialties met in June 2014, with the task of developing the Patient Care and Medical Knowledge competency milestones and editing the remaining subcompetencies appropriately. www.psychosomaticsjournal.org
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Example Subcompetency, Demonstrating the Organization of the Milestones into Competency, Subcompetency, and Threads as Well as the Reporting Procedure.
Competency Subcompetency
Thread Names
Thread for “Development as a teacher” (all milestones with “A”)
Milestone
Selecng a response box in the middle of a level implies that milestones in that level and in lower levels have been substanally demonstrated.
The working group used the core competencies for fellowship training in PM as a beginning framework for creating the Medical Knowledge competencies. A number of expert groups have suggested ways to categorize the large body of knowledge encompassed by PM (Table 2). For example, the residency education subcommittee of the APM proposed 9 categories of knowledge.13 The European Association of Consultation-Liaison Psychiatry and Psychosomatics suggested 3 broad knowledge areas and 11 subcategories.14 A collaborative expert group representing the ACGME, the American Board of Psychiatry and Neurology, and the APM produced detailed recommendations for core competencies for fellowship training; this group identified 8 knowledge competencies, for which they then listed 19 psychiatric problems or disorders relevant to each of the knowledge competencies.15 The PM milestone working group chose from among these different lists with an emphasis on finding overarching themes that were common to each of the lists and condensed these many areas down to 3 broad subcompetencies: psychiatric 156
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Selecng a response box on the line in between levels indicates that milestones in lower levels have been substanally demonstrated as well as some milestones in the higher level(s).
illnesses in the medically ill, psychiatric manifestations of medical illnesses, and the practice of PM. Using this as framework, the principal task of the PM working group was to decide on the level of detail needed for the PM milestones. Different subspecialty working groups have varied in this regard; the psychosomatic working group unanimously chose to take a summative approach to allow program directors reasonable flexibility to customize their curriculum, given their individual resources and strengths. The working group worked carefully to generate milestones that were limited in number, inclusive, and avoided narrowness and detail. The major changes from the general psychiatry milestones were in the Patient Care and Medical Knowledge milestones. As described previously, the working group summarized the Medical Knowledge subcompetencies using 3 broad categories. For Patient Care, the general psychiatry milestones has 5 subcompetencies; the psychosomatic working group condensed this to 2 (consultative patient care and integrated patient care). Psychosomatics 56:2, March/April 2015
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TABLE 1.
Psychosomatic Medicine Milestone Groups
Psychiatry Subspecialty Milestones Chair: Christopher R. Thomas, M.D. (University of Texas Medical Branch at Galveston) Working group Chair: Robert Boland, M.D. (Brigham and Women’s Hospital/ Harvard Medical School and Brown University) Madeleine Becker, M.D. (Jefferson University) Catherine C. Crone, M.D. (George Washington University) Laura Edgar, Ed.D., C.A.E. (ACGME) James Levenson, M.D. (Virginia Commonwealth University) Mark Servis, M.D. (University of California, Davis) Advisory group Chair: George Keepers, M.D. (Oregon Health and Science University) Steven Epstein, M.D. (Georgetown University) Larry Faulkner, M.D. (American Board of Psychiatry and Neurology) Christopher K. Varly, M.D. (University of Washington) ACGME ¼ Accreditation Council of Graduate Medical Education.
Once completing the Patient Care and Medical Knowledge subcompetencies, the working group reviewed the 4 general competencies for psychiatric subspecialties (Systems-Based Practice, Practice-Based Learning and Improvement, Professionalism, and Interpersonal and Communication Skills) editing them to be specific to PM. As an example, regarding Interpersonal and Communication Skills, the PM specialist should be particularly skilled in communication with colleagues and in negotiating various systems of care. The working group maintained the number and structure of the general psychiatry subcompetencies for these competencies with the exception of “Formal Practice-Based Quality Improvement,” one of the general psychiatry Practice-Based Learning and Improvement subcompetencies, as there is no requirement for a formal quality improvement project during fellowship training. The final competencies, subcompetencies, and milestones are listed in Table 3. A challenge for the PM working group was choosing the range of milestone levels to correspond to what fellows should reasonably achieve in the limited time of 1 year. As with the general psychiatry milestones, each subcompetency has 4 levels, ranging from an entering level (level 1) to a graduating trainee (level 4), with a fifth “aspirational” level meant to describe trainees who exceed expectations. The Psychosomatics 56:2, March/April 2015
working group considered the diverse range of possible abilities at the entry level of training and chose to describe a full range of expertise for each subcompetency, even though different fellows start at different levels. Many fellows likely enter at a level 2 or 3 for some of the subcompetencies; however, the working group included a “beginner level” (level 1) to characterize those fellows who had less exposure to PM during their residency training (Figure 2). Similarly, the fifth level, by design, most often describes a very advanced level (a leadership level of expertise), to give training directors a very broad developmental range. When considering the subcompetencies, the group had to decide which of the general psychiatry milestone subcompetencies needed elaboration, which they should de-emphasize or eliminate, and what new additions were necessary. The skills and knowledge more specific to PM would require a more sophisticated level of development. For example, the Systems-Based Practice subcompetency of “Resource Management” is similar to the analogous general psychiatry subcompetency, reflecting the group’s belief that there was a “ceiling effect” in training for this area. This was handled similarly for the Professionalism subcompetencies, reflecting a belief that the core values of professionalism, such as compassion for others, high ethical standards, and accountability to oneself and one’s patients are already taught well by residency programs. In contrast, the Patient Care subcompetencies assume a higher level of expertise at the initial stages, with more rapid progression to leadership roles. FEEDBACK AND MODIFYING THE MILESTONES The initial draft then went through several cycles of review. The advisory committee first evaluated the draft and their suggested changes were incorporated; much of the advisory group’s comments were useful suggestions for making the milestones more specific to PM. The ACGME then shared the draft with stakeholders, conducting a survey with PM fellowship training directors. In addition, the Fellowship Education Subcommittee of the APM reviewed the milestones and submitted their own consensus comments. The comments by the subcommittee constituted substantial edits including multiple clarifying edits and the suggestion to collapse several of the threads, which further simplified the milestones. The ACGME collated the feedback www.psychosomaticsjournal.org
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Comparison of Approaches to Categorizing the Medical Knowledge Competency for Psychosomatic Medicine
APM Residency Education Subcommittee (2014)2
General psychiatric illnesses in the medical setting Psychiatric illnesses the manifest primarily in the medical setting
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Psychiatric treatment modalities in the medical setting
Psychiatric manifestations of medical/surgical illness
APA council on PM, ABPN psychosomatic committee, APM (2009)2
EACLPP workgroup (2006)3
Relevant sciences (e.g., neurosciences, psychology, psychopharmacology, epidemiology, and social sciences) that are important for the care of medically ill psychiatric patients and their families
Awareness of the different theoretical models used as bases of the subject (e.g., biopsychosocial, psychophysiologic, and psychoneuroimmunologic models)
The nature and extent of psychiatric morbidity in medical populations For each area, consider the following problems and disorders as possibly presenting in medical-surgical-obstetric patients: Mood disorders, anxiety disorders, adjustment disorders, bereavement, acute stress disorders, delirium, dementia, psychotic disorders, catatonia, substance-related disorders, psychiatric disorders owing to a general medical condition or a toxic substance, somatoform disorders, factitious disorders and malingering, sleep disorders, sexual disorders, psychologic factors that affect physical illness, personality disorders in the medical setting, developmental disorders, and eating disorders Appropriate treatment interventions for co-existing psychiatric disorders in medically ill patients, including pharmacotherapy, other somatic therapies (e.g., ECT), and psychotherapy (especially, evidencebased psychotherapies) Indications for and use of psychiatric medications in medically ill patients, including knowledge of drug-drug interactions
Assessment and management of the following clinical disorders or situations: Delirium/dementia and other psychiatric disorders with organic cause; somatization; depression and anxiety in medically ill patients; suicide/ self-harm (with special emphasis on the management of a medical unit and transference/countertransference issues); addiction problems in medical settings; abnormal illness behavior in somatically ill patients; chronic pain; gender-specific disorders, sexual dysfunction in medically ill patients, and sexual abuse in specific patient populations (e.g., somatoform disorder and chronic pain)
The effect of psychologic factors and co-morbid psychiatric disorders on the course of medical illnesses
Coping with chronic disease and terminal illness
ACGME psychosomatic working group (2014)
Psychiatric illnesses, including major psychiatric disorders, substance use disorders, somatic symptom disorders, adjustment disorders, and psychologic factors affecting another medical condition in medically ill patients Diagnostic and phenomenologic issues Management and treatment
Psychiatric manifestations of medical illnesses Diagnostic issues Management and treatment
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Psychiatric co-morbidities associated with specific medical/surgical illnesses
Psychiatric treatment modalities in the medical setting
Psychiatric complications of medical illnesses, including trauma, psychologic and psychiatric effects of toxins, and medical and surgical treatments and medications Appropriate treatment interventions for co-existing psychiatric disorders in medically ill patients, including pharmacotherapy, other somatic therapies (e.g., ECT), and psychotherapy (especially, evidencebased psychotherapies) Indications for and use of psychiatric medications in medically ill patients, including knowledge of drug-drug interactions
Pediatric C-L psychiatry
Legal aspects of ConsultationLiaison (C-L) psychiatry Psychiatric practices in specific medical or surgical settings Psychiatric consultation and or liaison in the outpatient medical or surgical setting
Forensic psychiatric issues (e.g., capacity and guardianship) as they apply to psychosomatic medicine
Management of patients with psychiatric disorders (e.g., psychotic and bipolar) in need of medical/ surgical treatment.
Psychiatric co-morbidity and psychologic problems in child and adolescent disorders Ethical and medicolegal issues (general ethical topics such as limitation of treatment and genetic testing as well as special issues relevant to a particular country)
Practice of psychosomatic medicine Ethical and legal issues Models of consultation and collaborative care Issue in diverse populations (e.g., cultural, ethnic, developmental, gender, and sexual orientation)
ABPN ¼ American Board of Psychiatry and Neurology; ACGME ¼ Accreditation Council of Graduate Medical Education; APA ¼ American Psychiatric Association; APM ¼ Academy of Psychosomatic Medicine; EACLPP ¼ European Association of Consultation-Liaison Psychiatry and Psychosomatics; ECT ¼ electroconvulsive therapy; PM ¼ psychosomatic medicine.
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Level 1
Summary of the Milestones Level 2
Level 3
Level 4
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Patient Care PC1—Consultative patient care: clarifying the question, gathering data and collateral information, interviewing the patient, and suggesting appropriate diagnostic and treatment options and communicating them effectively to the primary service Performs simple consultations Manages simple consultations Manages a broad range of routine Independently manages Supervises and serves as a role with indirect supervision, with in inpatient and outpatient consultation requests in complicated and challenging model for trainees direct supervision immediately settings inpatient and outpatient settings consultation patients or available Recognizes and addresses situations (e.g., patients who Effectively runs a unrecognized psychiatric issues cannot/will not participate in psychosomatic medicine that are uncovered during the the interview, are highly inpatient consult service or process of consultation agitated/high risk, or with outpatient clinic complicated medical/ psychiatric illness) PC2—Integrated patient care: performing, coordinating, and supervising care in multidisciplinary settings, inpatient or outpatient, and including liaison and educational roles Provides basic psychiatric Provides basic psychiatric Provides comprehensive Provides effective care, Leads the psychosocial assessment and treatment information and integrated care for patients guidance, and education in a component of a recommendations, requiring recommendations to through collaboration with other multidisciplinary medical multidisciplinary medical indirect supervision with direct multidisciplinary medical providers treatment team, including treatment team supervision available treatment team managing complex dynamics affecting the patient and treatment team (e.g., patient who splits treatment team)
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Medical Knowledge MK1—Knowledge regarding psychiatric illnesses in the medically ill: assessment and management of major psychiatric disorders, substance use disorders, somatic symptom disorders, adjustment disorders, and psychologic factors affecting medical conditions Demonstrates limited knowledge Demonstrates basic knowledge Demonstrates comprehensive Demonstrates comprehensive Develops, synthesizes, or regarding common psychiatric regarding epidemiology, knowledge regarding the knowledge regarding the presents new knowledge illnesses and their treatments in etiology, phenomenology, assessment and management of presentation and assessment regarding psychiatric the medically ill prognosis, and treatment of psychiatric illnesses in the of complex/atypical illnesses and their treatments common psychiatric illnesses medically ill, including detailed psychiatric illnesses in the in the medically ill in the medically ill, including knowledge of adverse effects and medically ill, including common adverse effects and drug-drug interactions advanced knowledge in drug-drug interactions specific medical populations (e.g., cancer, transplant, or OB-GYN) MK2—Knowledge regarding psychiatric manifestations of medical illnesses: assessment and management of physical and psychologic reactions to medical illness and its treatment Demonstrates basic knowledge Demonstrates comprehensive Demonstrates comprehensive Develops, synthesizes, or Demonstrates limited knowledge regarding common psychiatric regarding the presentation knowledge regarding the knowledge regarding the presents new knowledge manifestations of medical and treatment of psychiatric assessment and management of assessment and management regarding psychiatric illnesses and their treatments symptoms caused by psychiatric symptoms caused by of psychiatric symptoms symptoms caused by medical (e.g., delirium or syndromes and common medical illnesses common medical illnesses and caused by complex/ illnesses and their treatments symptoms secondary to medical and their treatments their treatments uncommon medical illnesses conditions) and their treatments
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TABLE 3.
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MK3—Practice of psychosomatic medicine: A. Ethics and legal issues B. Models of consultation and collaborative care C. Issues in diverse populations (e.g., cultural, ethnic, developmental, gender, and sexual orientation) 1A. Demonstrates limited knowledge of clinically relevant legal and ethical issues in medical settings (e.g., capacity evaluations)
2A. Demonstrates knowledge of essential ethical and legal issues
3A. Demonstrates comprehensive knowledge of clinically relevant legal and ethical issues in medical settings (e.g., capacity evaluations)
1B. Demonstrates limited knowledge of consultation and collaborative care models
2B. Demonstrates basic knowledge of common consultation and collaborative care models
3B. Demonstrates comprehensive knowledge of consultation and collaborative care models
1C. Recognizes importance of delivering culturally competent care
2C. Demonstrates recognition of issues in delivering culturally competent care
3C. Consistently demonstrates awareness and skill regarding the effect of cultural differences in patient care
4A. Demonstrates advanced knowledge of clinically relevant legal and ethical issues in medical settings, including in difficult and challenging situations 4B. Demonstrates advanced knowledge of consultation and collaborative care models, including emerging new modes of clinical care 4C. Anticipates the effect of diversity on patient care and serves as role model in provision of care in diverse groups
5A. Functions as leader or expert in institutional ethical or legal processes
5B. Explores new forms of care models or performs health services research in consultation and collaborative care 5C. Generates new understanding of diversity issues
Systems-Based Practice SBP1—Patient safety and the health care team A. Medical errors and quality improvement activities B. Communication and patient safety C. Regulatory and educational activities related to patient safety 1A/B. Describes the common system causes for errors (e.g., communication failures, equipment failures, and other failures of the health care delivery system)
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3A. Understands and consistently uses safety procedures
2B. Effectively and regularly uses all appropriate forms of communication to ensure accurate transitions of care
3B. Displays effective communication with colleagues and recognizes special circumstances that will affect safety
2C. Follows regulatory requirements related to reporting requirements and prescribing practices
3C. Effectively communicates safety procedures and requirements to trainees and other audiences
4C. Develops content for and/ or facilitates patient safety presentations/conferences focusing on systems-based errors in patient care
Consistently provides costeffective care, using a variety of resources, including the electronic medical record (EMR)
Practices efficient, costeffective, high-value clinical care, using a full range of resources, in routine and complex cases
SBP2—Resource management: costs of care and resource selection Recognizes disparities in health Coordinates patient access to care at individual and community and system community levels resources
4A. Skillfully participates and contributes in a multidisciplinary context in quality improvement and patient safety projects (e.g., morbidity and mortality conference, root cause analysis meeting) 4B. Takes a leadership role in ensuring coordinated patient care, including accurate transitions of care
5A/B/C. Provides organizational leadership or consultation to improve care quality and patient safety
5A/B/C. Implements innovative systems to improve care quality and patient safety 5A/B/C. Develops new curricula and approaches to education in safety and quality issues 5A/B/C. Contributes on a regulatory level to safety and quality improvement
Designs new approaches to provide efficient care to monitor and educate regarding health care resource use
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1C. Follows institutional safety policies, including reporting of problematic behaviors and processes, errors, and near misses
2A. Describes systems and procedures that promote patient safety
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Level 2
Knows the relative cost of care (e.g., medications, diagnostics, levels of care, and procedures)
Understands health care funding and regulations related to organization of health care services
Level 3
Level 4
Level 5 Advocates for improved access to and additional resources within systems of care
SBP3—Community-based care: community-based programs; self-help groups, including 12-step approaches; medical, psychiatric, and substance abuse recovery/rehabilitation programs Has a basic knowledge of local Has a basic knowledge of Incorporates community Skillfully uses a wide range of Develops new care programs health care delivery systems community resources; resources, self-help groups community-based resources and new approaches to link coordinates care with (including 12-step approaches), for rehabilitation and medical and communitycommunity mental health and social networks in clinical recovery, including in based programs agencies, schools, and other care; appropriately refers to challenging cases of agencies; recognizes rehabilitation and recovery co-morbid chronic medical importance of self-help programs and psychiatric illnesses groups, and recovery and rehabilitation approaches SBP4—Consultation to health care systems Describes how systems issues Identifies systems issues in affect clinical care clinical care and clarifies required interactions and communication
Communicates with other providers and provides effective recommendations regarding systems issues in clinical care
Provides expert advanced recommendations to address systems issues in clinical care, including challenging and complex situations requiring novel management
Measures outcomes of systems-based interventions, contributes to improvement of existing service delivery systems, or develops new modes of health care delivery
4A. Identifies and meets selfdirected learning goals with little external guidance; keeps up with relevant changes in medical knowledge using a system or process2; recognizes limits of own knowledge 4B. Consistently makes informed, evidence-based clinical decisions; demonstrates a recognized mastery of the knowledge base of psychosomatic medicine
5A/B. Synthesizes and presents new findings; develops educational methodology to communicate new medical knowledge
Practice-Based Learning and Improvement PBLI1—Lifelong learning A. Self-assessment and self-improvement B. Use of evidence-based medical knowledge
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1A. Regularly seeks and incorporates feedback to improve performance; identifies self-directed learning goals, and periodically reviews them with supervisory guidance
2A. Demonstrates a balanced and accurate self-assessment of own competence, using clinical outcomes to identify areas for continued improvement
3A. Demonstrates improvement in clinical practice based on continual self-assessment and evidence-based information
1B. Formulates a searchable question from a clinical question
2B. Selects an appropriate, evidence-based information tool1 to meet self-identified learning goals
3B. Efficiently searches and uses medical literature to answer clinical questions; critically appraises different types of research, including randomized controlled trials, systematic reviews, meta-analyses, and practice guidelines
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PBLI2—Teaching A. Development as a teacher B. Observable teaching skills 1A. Assumes a role in the clinical teaching of trainees and assists faculty members in providing supervision to these learners
1B. Recognizes the role of physician as teacher
2A. Participates in activities designed to develop and improve teaching skills and assists faculty members in providing supervision to trainees (e.g., medical students and residents) in psychosomatic medicine settings 2B. Evaluates and provides feedback to trainees, and communicates goals and objectives for instruction of trainees
3A. Actively participates in didactic presentations on psychosomatic medicine topics to groups (e.g., grand rounds, case conference, and journal club)
4A. Independently develops and provides consistently effective presentations on psychosomatic medicine to groups, including to health professionals in nonpsychiatric disciplines
5A. Is recognized as an educator of colleagues, the broader professional community, and/or the public
3B. Effectively teaches individual trainees in clinical settings; effectively uses feedback on teaching to improve teaching methods and approaches
4B. Demonstrates recognized skill in the education of trainees, including those in nonpsychiatric disciplines
5B. Organizes and develops curriculum materials relevant to psychosomatic medicine
4A. Consistently displays compassion, integrity, and sensitivity, including in the more challenging areas of medical practice
5A. Serves as a role model and teacher of compassion, integrity, respect for others, and sensitivity to diverse patient populations
Professionalism PROF1—Compassion, integrity, and respect A. Compassion for others, self-reflection, and sensitivity to diverse patient populations B. Adherence to ethical principles 2A. Routinely displays empathy, compassion, and sensitivity to diversity in psychiatric evaluation and treatment
1B. Recognizes ethical conflicts in practice and seeks supervision to manage them
2B. Analyzes and manages ethical issues in common clinical situations in the psychosomatic medicine setting
3A. Facilitates positive communication and develops a mutually agreeable care plan in the context of conflicting physician, patient, and/or family values and beliefs 3A. Discusses own cultural background and beliefs and the ways in which these affect interactions with patients 3B. Manages ethical issues in a wide range of clinical situations in the psychosomatic medicine setting
4A. Displays recognized expertise in and leads educational activities regarding ethical and practice issues 4B. Systematically analyzes and manages complex ethical issues in psychosomatic medicine (e.g., end-of-life decisions)
5B. Identifies emerging ethical issues within subspecialty practice and can discuss opposing viewpoints
PROF2—Accountability to self, patients, colleagues, and profession A. Work balance and fatigue management B. Professional behavior and participation in professional community
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1A. Notifies team and enlists appropriate coverage for clinical and nonclinical responsibilities when fatigued or ill
2A. Identifies and manages situations in which maintaining personal health is challenged and seeks assistance when needed
3A. Demonstrates healthy and responsible work style; takes steps to address impairment in self and in colleagues if present
4A. Effectively prioritizes and balances conflicting interests of self, family, and others to optimize medical care and practice of profession
5A. Participates as an active member on committees or in organizations that address physician wellness
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1A. Demonstrates capacity for self-reflection, empathy, openness to different beliefs, and respect for diversity; provides examples of the importance of attention to diversity in psychiatric evaluation and treatment
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Level 1
Level 2
Level 3
Level 4
Level 5
1B. Follows institutional policies for physician conduct and responsibility
2B. Recognizes the importance of participating in one’s professional community
3B. Displays professionalism in work, collaborates effectively with colleagues, maintains skills (e.g., prepares for obtaining and maintaining board certification), and consistently displays responsibility for ensuring that patients receive the best possible care
4B. Participates in the primary specialty and subspecialty professional community (e.g., professional societies, patient advocacy groups, and community service organizations); displays exemplary professionalism and serves as role model in ensuring that patients receive best possible care
5B. Develops organizational policies, programs, or curricula for professionalism
4A/B. Sustains therapeutic and working relationships in complex and challenging contexts, including in situations with significant differences of opinion among care providers, families, and patients
5A/B. Develops approaches to managing difficult situations and communications in the psychosomatic medicine setting 5A/B. Effectively mentors other health care providers in leadership, communication skills, and conflict management 5A/B. Engages in scholarly activity (e.g., teaching or research) regarding teamwork and conflict management
4A. Demonstrates communication that is appropriate, efficient, concise, and pertinent in challenging situations (e.g., significant differences of opinion, with patients with limited communication and/ or cognitive abilities)
5A/B. Develops new modes of system organization to facilitate communication and maintenance of professional relationships
Interpersonal and Communication Skills ICS1—Relationship development and conflict management A. Relationship with patients B. Conflict management with patients, families, colleagues, and members of the health care team 1A. Develops therapeutic relationship with patients and their families and is aware of cultural diversity in communicating with people of different backgrounds
2A. Develops therapeutic relationships with patients and is respectful of cultural diversity in discussions with patients and their families
3A. Skillfully forms therapeutic relationship with a wide range of patients in the psychosomatic medicine setting
1B. Recognizes communication conflicts in work relationships
2B. Develops working relationships across specialties and systems of care in uncomplicated situations
3B. Appropriately sustains working relationships in the face of conflict or differences in opinions with other services or colleagues and is able to efficiently resolve routinely encountered conflicts
ICS2—Information sharing and record keeping A. Accurate documentation and effective communication with health care team and patients B. Maintaining professional boundaries 1A. Ensures transitions of care are accurately documented and that the written record is accurate and timely, with attention to preventing confusion and error, consistent with institutional policies
2A. Provides complete, timely, and accurate documentation
3A. Demonstrates effective verbal and written communication with patients, families, colleagues, and other health care providers that is appropriate, efficient, concise, and pertinent
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TABLE 3. Continued
4B. Uses discretion and judgment in the inclusion of sensitive patient material in the medical record and in all communication with patients, families, and colleagues 3B. Consistently maintains professional boundaries and respect for confidentiality 1B. Maintains appropriate boundaries in sharing information by electronic communication and in the use of social media
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OB-GYN ¼ obstetrics and gynecology; ICS ¼ Interpersonal and Communication Skills; MK ¼ Medical Knowledge; PBL ¼ Practice-Based Learning and Improvement; PC ¼ Patient Care; PROF ¼ Professionalism; SBP ¼ Systems-Based Practice.
4A. Recruits appropriate assistance when cultural differences create barriers to patient care 1A. Organizes both written and oral information to be shared with patient, family, team, and others
2A. Consistently demonstrates communication strategies to ensure patient and family understanding, including use of easy-to-understand language, skillful use of interpreters, and face-to-face interaction while using EMR 2B. Demonstrates respect for patient confidentiality
3A. Consistently engages patients and families in shared decision making
Boland et al. from the different sources, and the PM working group convened to incorporate these critiques and finalize the milestones. The final draft contained a total of 15 subcompetencies and 24 threads, which was a substantial reduction from the original draft. DISSEMINATION AND IMPLEMENTATION Having completed a final draft, the milestones were posted by the ACGME in October 2014 (https://www. acgme.org/acgmeweb/tabid/147/ProgramandInstitution alAccreditation/MedicalSpecialties/Psychiatry.aspx) with a scheduled implementation in PM fellowship programs for July 2015. With this tight timeline, a pilot was not feasible and rapid dissemination and education about the milestones is now a priority. The working group introduced the rationale and plan for milestones in a summer 2014 APM newsletter and discussed the milestones with psychosomatic fellowship training directors at the 2014 annual APM meeting.16 Additional online communications (e.g., webinars) will be considered if there is need and interest. IMPLICATIONS OF THE MILESTONES ON FELLOWSHIP PROGRAMS AND RECOMMENDATIONS As with the general milestones, the PM milestones should improve the process of assessment and feedback in a fellowship program by providing objective, standardized criteria for evaluation.4 The milestones will help organize the semiannual feedback meetings between training directors and residents, allow for a clear description of the fellow’s progress, and identify areas of deficiencies as the fellow advances through fellowship training. The milestones will also encourage and, hopefully, improve self-assessment by fellows as they progress through their training. The milestones will also shape the evaluation process. The primary function of the CCC is to integrate the various trainee evaluations and identify which milestones have been achieved by each trainee. The CCC must meet at the midpoint and near the completion of the fellowship training year. With this relatively short timeline, it will be particularly important to have a well-organized CCC meeting at the midpoint of training so that the group can identify potential deficiencies and make corrective plans in time to have a meaningful influence on training. It is www.psychosomaticsjournal.org
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The Milestones for Psychosomatic Medicine Subspecialty Training FIGURE 2.
The 5 Developmental Levels for Fellowship Training.
recommended that the CCC also meet early in the program to provide the opportunity for earlier remediation, if needed. Such a process will only be as good as the information provided, and we expect that the implementation of milestones will require new and innovative methods of fellow assessment.17 Unlike the general psychiatry milestone working group, which produced sample assessment instruments, the subspecialty working groups have left it to each individual program to modify or create evaluation tools to map the milestones.18 Although each individual fellowship program is unique, many of the challenges for
milestone assessment are not. It is our hope that the implementation process be a group effort among PM training directors. There is no doubt that such an effort would be of enormous help, by standardizing assessment tools, limiting the administrative workload and improving the quality of assessments. We see this as an important role for the subspecialty organizations and expect that the APM will help lead this process. Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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Boland et al. 13. Heinrich TW, Schwartz AC, Zimbrean PC, et al: Recommendations for training psychiatry residents in psychosomatic medicine. Psychosomatics 2014; 55(5):438–449 14. Sollner W, Creed F: European guidelines for training in consultation-liaison psychiatry and psychosomatics: report of the EACLPP Workgroup on Training in ConsultationLiaison Psychiatry and Psychosomatics. J Psychosom Res 2007; 62(4):501–509 15. Worley LL, Levenson JL, Stern TA, et al: Core competencies for fellowship training in psychosomatic medicine: a collaborative effort by the APA Council on Psychosomatic Medicine, the ABPN Psychosomatic Committee, and the
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Academy of Psychosomatic Medicine. Psychosomatics 2009; 50(6):557–562 16. Boland R: Psychosomatic milestones update. Academy of Psychosomatic Medicine Newsletter. Available from: http://www.apm.org/newslett/14summer_APMnews.pdf. 2014 (Summer) 17. French JC, Dannefer EF, Colbert CY: A systematic approach toward building a fully operational clinical competency committee. J Surg Educ 2014; 71(6):e22–e27 18. Swing SR, Cowley DS, Bentman A: Assessing resident performance on the psychiatry milestones. Acad Psychiatry 2014; 38(3):294–302
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