The Clinical Neurophysiology Milestone Project
The Clinical NeurophysiologyMilestone ProjectA Joint Initiative ofThe Accreditation Council for Graduate Medical EducationandThe American Board of Psychiatry and NeurologyJuly 2015
The Clinical Neurophysiology Milestone ProjectThe Milestones are designed only for use in evaluation of the fellow in the context of their participation inACGME-accredited residency or fellowship programs. The Milestones provide a framework for assessment of thedevelopment of the fellow in key dimensions of the elements of physician competency in a specialty orsubspecialty. They neither represent the entirety of the dimensions of the six domains of physician competency,nor are they designed to be relevant in any other context.i
Clinical Neurophysiology MilestonesChair: Ralph Józefowicz, MDWorking GroupAdvisory GroupImran Ali, MDLaura Edgar, EdD, CAELaurie Gutmann, MDLouise King, MSNoor Pirzada, MDLarry Faulkner, MDEric Holmboe, MDSteven Lewis, MD*Mary Lieh-Lai, MD*Acknowledgement: Special thanks to Steven Lewis, MD, who was an active member of both the Working and Advisory Groups.ii
Milestone ReportingThis document presents Milestones designed for programs to use in semi-annual review of fellow performance and reporting to theACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in adevelopmental framework from less to more advanced. They are descriptors and targets for fellow performance as a fellow movesfrom entry into fellowship through graduation. In the initial years of implementation, the Review Committee will examine Milestoneperformance data for each program’s fellows as one element in the Next Accreditation System (NAS) to determine whether fellowsoverall are progressing.For each period, review and reporting will involve selecting milestone levels that best describe a fellow’s current performance andattributes. Milestones are arranged into numbered levels. Tracking from Level 1 to Level 5 is synonymous with moving from noviceto expert in the subspecialty.Selection of a level implies that the fellow substantially demonstrates the milestones in that level, as well as those in lower levels(see the diagram on page v).Level 1: The fellow demonstrates milestones expected of an incoming fellow.Level 2: The fellow is advancing and demonstrates additional milestones, but is not yet performing at a mid-fellowship level.Level 3: The fellow continues to advance and demonstrate additional milestones, consistently including the majority ofmilestones targeted for fellowship.Level 4: The fellow has advanced so that he or she now substantially demonstrates the milestones targeted for fellowship. Thislevel is designed as the graduation target.Level 5: The fellow has advanced beyond performance targets set for fellowship and is demonstrating “aspirational” goalswhich might describe the performance of someone who has been in practice for several years. It is expected that onlya few exceptional fellows will reach this level.iii
Additional NotesLevel 4 is designed as the graduation target and does not represent a graduation requirement. Making decisions about readiness forgraduation is the purview of the fellowship program director. Study of Milestone performance data will be required before theACGME and its partners will be able to determine whether milestones in the first four levels appropriately represent thedevelopmental framework, and whether Milestone data are of sufficient quality to be used for high-stakes decisions.Examples are provided with some milestones. Please note that the examples are not the required element or outcome; they areprovided as a way to share the intent of the element.Some milestone descriptions include statements about performing independently. These activities must occur in conformity to theACGME supervision guidelines, as well as institutional and program policies. For example, a fellow who performs a procedureindependently must, at a minimum, be supervised through oversight.Patient Care milestones have a “Not Applicable” option. This option should only be used for those areas in which the fellow willreceive no education/experience. For example, a fellow who is completing an EEG/NCS track with no exposure to EMG should havethe EMG milestone set marked at “Not Applicable.” If the fellow has some exposure, an evaluation should be indicated. It is notexpected that the fellow with limited exposure will receive a Level 4.Answers to Frequently Asked Questions about Milestones are available on the Milestones web tonesFAQ.pdf.iv
The diagram below presents an example set of milestones for one sub-competency in the same format as the ACGME ReportWorksheet. For each reporting period, a fellow’s performance on the milestones for each sub-competency will be indicatedby selecting the level of milestones that best describes that fellow’s performance in relation to those milestones.Selecting a response box in the middle of alevel implies that milestones in that level andin lower levels have been substantiallydemonstrated.Selecting a response box on the line in between levelsindicates that milestones in lower levels have beensubstantially demonstrated as well as some milestonesin the higher level(s).v
Version 04/2014Clinical Neurophysiology Milestones, ACGME Report WorksheetHistory — Patient CareLevel 1Obtains a relevant andorganized neurologichistoryLevel 2Obtains a relevant andorganized historyincorporating subtle verbaland non-verbal cuesLevel 3Obtains a focused historysufficient to guidesubsequentneurophysiologicinvestigationLevel 4Consistently obtains afocused history sufficientto guide vel 5Serves as a role model toother learners for focusedhistory taking regardingneurophysiologicinvestigationNot ApplicableNeurological Exam — Patient CareLevel 1Performs a relevantneurological examincorporating someadditional appropriatemaneuversLevel 2Performs a relevantneurological examaccurately incorporatingall additional appropriatemaneuversLevel 3Performs a focusedneurological examinationsufficient to guidesubsequentneurophysiologicinvestigationLevel 4Consistently performs afocused neurologicalexamination sufficient toguide subsequentneurophysiologicinvestigationLevel 5Serves as a role model toother learners forperforming a focusedexamination regardingneurophysiologicinvestigationComments:Not ApplicableCopyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology. All rightsreserved. The copyright owners grant third parties the right to use the Clinical Neurophysiology Milestones on a non-exclusive basis foreducational purposes.1
Version 04/2014Clinical Neurophysiology Milestones, ACGME Report WorksheetElectroencephalogram (EEG) — Patient CareLevel 1Describes normal EEGfeatures of awake andsleep statesLevel 2Interprets common EEGabnormalities and createsa reportRecognizes common EEGartifactsRecognizes normal EEGvariantsRecognizes common EEGpatterns associated withstatus epilepticusRecognizes uncommonEEG patterns associatedwith status epilepticusRecognizes the indicationsand contraindications foruse of activationprocedures (e.g., sleepdeprivation, photicstimulation,hyperventilation)Recognizes the indicationsfor prolonged video EEGmonitoringLevel 3Applies basic knowledge ofelectrical safety, filters,artifacts, montages,electrodes, signal analysis,and other relevanttechnical aspects to theperformance andinterpretation of EEGstudiesLevel 4Applies advancedknowledge of electricalsafety, filters, artifacts,montages, electrodes,signal analysis, and otherrelevant technical aspectsto the performance andinterpretation of EEGstudiesUtilizes appropriatetechnical standards fordetermining and reportingelectrocerebral inactivityin brain deathAccurately interprets andreports EEG findings inchildren and adults,including normal variantsand abnormal EEGpatternsInterprets and reports EEGfindings in children andadults, including normalvariants and abnormal EEGpatternsLevel 5Plans, supervises, andinterprets pre-surgicalevaluation of patients withepilepsy (e.g., intracranialEEG monitoring andcortical mapping)Accurately interprets andreports findings ofprolonged video EEGmonitoringInterprets and reportsfindings of prolongedvideo EEG monitoringComments:Not ApplicableCopyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology. All rightsreserved. The copyright owners grant third parties the right to use the Clinical Neurophysiology Milestones on a non-exclusive basis foreducational purposes.2
Version 04/2014Clinical Neurophysiology Milestones, ACGME Report WorksheetNerve Conduction Studies (NCS) — Patient CareLevel 1Applies knowledge ofperipheral nerve anatomyin the performance of NCSLevel 2Performs and interpretscommon motor andsensory NCSApplies principles ofelectrical safety to theperformance of NCSPerforms and interpretslate response studies (e.g.,F waves, H reflexes)Formulates basic NCS planfor specific, commonclinical presentationsRecognizes commonanatomical variants in theinterpretation of NCSIdentifies technicalartifacts in theinterpretation of NCSCreates a report for NCSLevel 3Performs and interpretsneuromuscular junctiontesting (e.g., repetitivestimulation study)Performs and interpretsuncommon motor andsensory NCSPerforms and interpretscranial nerve testing (e.g.,blink reflex, facial nerve)Level 4Accurately interprets andprovides a detailed reportof common anduncommon nerveconduction study findingsin conjunction with theelectromyography (EMG)Level 5Performs and interpretsspecial NCS procedures(e.g., autonomic testing)Recognizes uncommonanatomical variants in theinterpretation of NCSComments:Not ApplicableCopyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology. All rightsreserved. The copyright owners grant third parties the right to use the Clinical Neurophysiology Milestones on a non-exclusive basis foreducational purposes.3
Version 04/2014Clinical Neurophysiology Milestones, ACGME Report WorksheetEMG — Patient CareLevel 1Applies knowledge ofnerve and muscle anatomyin the performance ofEMGApplies principles ofelectrical safety to theperformance of EMGFormulates basic EMGplan for specific, commonclinical presentationsLevel 2Performs and interpretsEMG of commonlysampled musclesLevel 3Performs and interpretsEMG of uncommonlysampled musclesRecognizes common EMGfindingsPerforms and interpretsEMG of cranial nerveinnervated musclesCreates a report for anEMG study in conjunctionwith NCSLevel 4Recognizes uncommonEMG findingsAccurately interprets andprovides a detailed reportof common anduncommon EMG findingsin conjunction with NCSLevel 5Performs and interpretsspecial EMG procedures(e.g., single fiber EMG,quantitative EMG studies)Identifies technicalartifacts in theinterpretation of EMGComments:Not ApplicableCopyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology. All rightsreserved. The copyright owners grant third parties the right to use the Clinical Neurophysiology Milestones on a non-exclusive basis foreducational purposes.4
Version 04/2014Clinical Neurophysiology Milestones, ACGME Report WorksheetEvoked Potential (EP)/ Intra-operative Monitoring (IOM) — Patient CareLevel 1Describes normalwaveforms related tocommonly performed EPstudiesLevel 2Correlates commonabnormalities associatedwith EP studies in variousdisease statesCorrelates normalwaveforms withassociated anatomicstructures and physiologicphenomenaOrders and utilizesappropriate basicprocedures in patientsundergoing IOM (e.g.,brainstem auditoryresponses, transcranialmagnetic stimulation)Comments:Level 3Applies basic knowledge oftechnical aspects ofEP/IOM studiesUtilizes appropriate IOMstudies (SSEPs, MEP)associated with thesurgical proceduresProvides appropriatefeedback to surgeonsduring routine IOMprocedures withsupervisionLevel 4Applies detailedknowledge of the technicalaspects of EP/IOM studiesand provides guidance totechnologists and othersLevel 5Interprets uncommonfindings of clinicalsignificance during IOMand with EP studiesAccurately interpretscommon findings ofclinical significance duringIOM, and provides timelyfeedback to surgeonsindependentlyAccurately interpretscommon findings ofclinical significanceassociated with EP studiesNot yet achieved Level 1Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology. All rightsreserved. The copyright owners grant third parties the right to use the Clinical Neurophysiology Milestones on a non-exclusive basis foreducational purposes.5
Version 04/2014Clinical Neurophysiology Milestones, ACGME Report WorksheetSleep Disorders — Patient CareLevel 1Obtains a relevant andfocused history andperforms a focused andrelevant examination in apatient with suspectedsleep disorderLevel 2Orders and utilizesappropriate sleep studymodalities (e.g.,polysomnography,multiple sleep latencytesting)Level 3Interpretspolysomnographicfeatures of common sleepdisordersLevel 4Accurately interpretsclinical andneurophysiologicalfeatures of common sleepdisordersApplies detailedknowledge of the technical Manages common sleepApplies basic knowledge of Applies basic knowledge of aspects ofdisorders utilizingcommon sleep disordersthe technical aspects ofpolysomnographypharmacologic and nonto evaluation of patientspolysomnographypharmacologic modalitiesLevel 5Interprets and reportspolysomnography findingsin children and adultsInterprets clinical andneurophysiologicalfeatures of uncommonsleep disordersComments:Not yet achieved Level 1Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology. All rightsreserved. The copyright owners grant third parties the right to use the Clinical Neurophysiology Milestones on a non-exclusive basis foreducational purposes.6
Version 04/2014Clinical Neurophysiology Milestones, ACGME Report WorksheetLocalization — Medical KnowledgeLevel 1Accurately localizes lesionsto specific regions of thenervous systemLevel 2Demonstrates basicknowledge ofneuroanatomy andneurophysiology relevantto performing andinterpretingneurophysiologic studiesLevel 3Demonstrates detailedknowledge ofneuroanatomy andneurophysiology relevantto performing andinterpretingneurophysiologic studiesComments:Level 4Consistently demonstratessophisticated and detailedknowledge ofneuroanatomy andneurophysiology relevantto performing andinterpretingneurophysiologic studiesLevel 5Teaches other learnersneuroanatomy relevant toperforming andinterpretingneurophysiologic studiesNot yet achieved Level 1Planning Neurophysiologic Testing — Medical KnowledgeLevel 1Knows the indications forordering neurophysiologictestingLevel 2Knows the indications forordering specific subtypesof neurophysiologictesting (e.g., single fiberEMG, multiple sleeplatency test, inpatientvideo EEG monitoring)Level 3Plans basicneurophysiologic testingrelevant to the underlyingdisorderLevel 4Plans detailedneurophysiologic testingrelevant to the underlyingdisorderLevel 5Guides other learners inplanning neurophysiologictesting relevant to theunderlying disorderComments:Not yet achieved Level 1Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology. All rightsreserved. The copyright owners grant third parties the right to use the Clinical Neurophysiology Milestones on a non-exclusive basis foreducational purposes.7
Version 04/2014Clinical Neurophysiology Milestones, ACGME Report WorksheetNeuromuscular Disorders — Medical KnowledgeLevel 1Demonstrates knowledgeof common patterns ofneuromuscular disordersLevel 2Demonstrates knowledgeof uncommon patterns ofneuromuscular disordersLevel 3Demonstrates basicknowledge ofneurophysiologic findingsin common anduncommonneuromuscular disordersLevel 4Demonstrates detailedknowledge ofneurophysiologic findingsin common anduncommonneuromuscular disordersLevel 5Engages in scholarlyactivity related toneurophysiologic findingsin neuromusculardisordersComments:Not yet achieved Level 1Epilepsy — Medical KnowledgeLevel 1Demonstrates knowledgeof common types ofseizures and epilepsy,including epilepsysyndromesLevel 2Demonstrates knowledgeof uncommon types ofseizures and epilepsy,including epilepsysyndromesLevel 3Demonstrates basicknowledge of clinical andEEG findings in commonand uncommon seizuresand epilepsyLevel 4Demonstrates detailedknowledge of clinical andEEG findings in commonand uncommon seizuresand epilepsyLevel 5Engages in scholarlyactivity related to clinicaland EEG findings inseizures and epilepsyComments:Not yet achieved Level 1Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology. All rightsreserved. The copyright owners grant third parties the right to use the Clinical Neurophysiology Milestones on a non-exclusive basis foreducational purposes.8
Version 04/2014Clinical Neurophysiology Milestones, ACGME Report WorksheetSleep Disorders — Medical KnowledgeLevel 1Describes normalneurophysiologic featuresof sleep stagesRecognizes clinicalfeatures of common sleepdisordersLevel 2Recognizes the indicationsfor use of different sleepstudy modalities (e.g.,polysomnography,multiple sleep latencytesting)Level 3Describespolysomnographicfeatures of sleep disordersDemonstrates knowledgeof the technical aspects ofpolysomnographyLevel 4Recognizes clinical andneurophysiologicalfeatures of common sleepdisordersLevel 5Interprets and reportspolysomnography findingsin children and adultsRecognizes clinical andneurophysiologicalfeatures of uncommonsleep disordersComments:Not yet achieved Level 1Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology. All rightsreserved. The copyright owners grant third parties the right to use the Clinical Neurophysiology Milestones on a non-exclusive basis foreducational purposes.9
Version 04/2014Clinical Neurophysiology Milestones, ACGME Report WorksheetEP/ IOM — Medical KnowledgeLevel 1Describes fundamentalneurophysiologicprinciples of sensory andmotor EP studiesLevel 2Describes commonabnormalities associatedwith EP studies in variousdisease statesDescribes indications andlimitations of EP studiesDescribes basicprocedures utilized in IOM(e.g., brainstem auditoryresponses, transcranialmagnetic stimulation)Level 3Demonstrates basicknowledge of technicalaspects of EP/IOM studiesLevel 4Demonstrates detailedknowledge of the technicalaspects of EP/IOM studiesDescribes commonindications for IOM andappropriate studiesassociated with thesurgical proceduresDescribes commonfindings of clinicalsignificance during IOMLevel 5Describes uncommonfindings of clinicalsignificance during IOMand with EP studiesDescribes commonfindings of clinicalsignificance associatedwith EP studiesComments:Not yet achieved Level 1Systems thinking, including cost- and risk-effective practice — Systems-based PracticeLevel 1Describes basic cost andrisk implications of careLevel 2Describes cost- and riskbenefit ratios in patientcareLevel 3Makes clinical decisionsthat balance cost- and riskbenefit ratiosLevel 4Incorporates availablequality measures inpatient careLevel 5Engages in scholarlyactivity regarding costand risk-effective practicein clinical neurophysiologyComments:Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology. All rightsreserved. The copyright owners grant third parties the right to use the Clinical Neurophysiology Milestones on a non-exclusive basis foreducational purposes.10
Version 04/2014Clinical Neurophysiology Milestones, ACGME Report WorksheetWork in inter-professional teams to enhance patient safety — Systems-based PracticeLevel 1Describes team members’roles in maintainingpatient safetyLevel 2Identifies and reportserrors and near-missesLevel 3Describes potentialsources of system failurein clinical care such asminor, major, and sentineleventsLevel 4Participates in a teambased approach to medicalerror analysisLevel 5Engages in scholarlyactivity regarding erroranalysis and patient safetyin clinical neurophysiologyLevel 4Completes an appropriatelearning plan based uponclinical experienceLevel 5Engages in scholarlyactivity regarding practicebased learning andimprovement in clinicalneurophysiologyComments:Self-directed learning — Practice-based Learning and Improvement Identify strengths, deficiencies, and limits in one’s knowledge and expertise Set learning and improvement goals Identify and perform appropriate learning activities Use information technology to optimize learningLevel 1Level 2Level 3Acknowledges gaps inIncorporates feedbackDevelops an appropriateknowledge and expertiselearning plan based uponin clinical neurophysiologyclinical experienceComments:Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology. All rightsreserved. The copyright owners grant third parties the right to use the Clinical Neurophysiology Milestones on a non-exclusive basis foreducational purposes.11
Version 04/2014Clinical Neurophysiology Milestones, ACGME Report WorksheetLocate, appraise, and assimilate evidence from scientific studies related to the patient’s health problems – Practice-based Learning andImprovementLevel 1Level 2Level 3Level 4Level 5Uses informationUses scholarly articles and Critically evaluatesIncorporates appropriateEngages in scholarlytechnology to search andguidelines to answerscientific literatureevidence-basedactivity regardingaccess relevant medicalpatient care issuesinformation into patientevidence-based medicineinformationcarein clinical neurophysiologyUnderstands the limits ofevidence-based medicinein patient careComments:Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology. All rightsreserved. The copyright owners grant third parties the right to use the Clinical Neurophysiology Milestones on a non-exclusive basis foreducational purposes.12
Version 04/2014Clinical Neurophysiology Milestones, ACGME Report WorksheetCompassion, integrity, accountability, and respect for self and others — ProfessionalismLevel 1Level 2Demonstrates compassion, Describes effects of sleepsensitivity, anddeprivation and substanceresponsiveness to patients abuse on performanceand familiesDemonstrates appropriateDemonstrates nonsteps to addressdiscriminatory behavior in impairment in selfall interactions, includingdiverse and vulnerablepopulationsConsistently demonstratesprofessional behavior,including dress andtimelinessLevel 3Demonstratescompassionate practice ofmedicine, even in contextof disagreement withpatient beliefsLevel 4Mentors others in thecompassionate practice ofmedicine, even in contextof disagreement withpatient beliefsIncorporates patients’sociocultural needs andbeliefs into patient careMentors others insensitivity andresponsiveness to diverseand vulnerable populationsDemonstrates appropriatesteps to addressimpairment in colleaguesLevel 5Engages in scholarlyactivity regardingprofessionalism in clinicalneurophysiologyAdvocates for qualitypatient careComments:Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology. All rightsreserved. The copyright owners grant third parties the right to use the Clinical Neurophysiology Milestones on a non-exclusive basis foreducational purposes.13
Version 04/2014Clinical Neurophysiology Milestones, ACGME Report WorksheetKnowledge about, respect for, and adherence to the ethical principles relevant to the practice of medicine, remembering in particular thatresponsiveness to patients that supersedes self-interest is an essential aspect of medical practice — ProfessionalismLevel 1Describes basic ethicalprinciplesLevel 2Determines presence ofethical issues in practiceLevel 3Analyzes and managesethical issues instraightforward clinicalsituationsLevel 4Analyzes and managesethical issues in complexclinical situationsLevel 5Demonstrates leadershipand mentorship inapplying ethical principlesin clinical neurophysiologysettingsComments:Relationship development, teamwork, and managing conflict — Interpersonal and Communication SkillsLevel 1Develops a positiverelationship with patientsin uncomplicatedsituationsActively participates inteam-based careLevel 2Manages simple patient/family-related conflictsLevel 3Manages conflict incomplex situationsEngages patients in shareddecision makingUses easy-to-understandlanguage in all phases ofcommunicationLevel 4Manages conflict acrossspecialties and systems ofcareLevel 5Engages in scholarlyactivity regardingteamwork and conflictmanagementLeads team-based patientcare activitiesComments:Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology. All rightsreserved. The copyright owners grant third parties the right to use the Clinical Neurophysiology Milestones on a non-exclusive basis foreducational purposes.14
Version 04/2014Clinical Neurophysiology Milestones, ACGME Report WorksheetInformation sharing, gathering, and technology — Interpersonal and Communication SkillsLevel 1Completes documentationin a timely fashionLevel 2Educates patients abouttheir diseases andmanagement, includingrisks and benefits oftreatment optionsCompletes alldocumentation accurately,including use of electronichealth records (EHR), topromote patient safetyLevel 3Effectively communicatesthe results of a neurologicconsultation in a timelymannerEffectively gathersinformation fromcollateral sources whennecessaryLevel 4Effectively and ethicallyuses all forms ofcommunicationMentors colleagues intimely, accurate, andefficient documentationLevel 5Develops patienteducation materialsregarding clinicalneurophysiologyEngages in scholarlyactivity regardinginterpersonalcommunication in clinicalneurophysiologyDemonstrates synthesis,formulation, and thoughtprocess in documentationComments:Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology. All rightsreserved. The copyright owners grant third parties the right to use the Clinical Neurophysiology Milestones on a non-exclusive basis foreducational purposes.15
interpretation of EEG studies Accurately interprets and reports EEG findings in children and adults, including normal variants and abnormal EEG patterns Accurately interprets and reports findings of prolonged video EEG monitoring Plans, supervises, and interprets pre-surgical evaluation of patients w
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