ASH TPD Symposium Training Milestones 12/6/13 Elaine A Muchmore, MD

Conflicts of Interest Serve as H/O representative on RRC-Internal Medicine (term ) Serve as ASH representative to AAIM/ABIM/ACGME Subspecialty Milestones Working Group

Goals of session Time-line for roll-out of reporting milestones for specialties Changes required to collate and submit fellow- specific information to ACGME Status and rationale for curricular milestones for Hematology/Oncology

Time-line for NAS/IM reporting milestones 1999: introduction of 6 areas of competence 2009: restructuring of accreditation based on training outcomes 2012: lengthening of accreditation cycles; identification of NAS “phase 1” and “phase 2” specialties : annual data input into webads by programs Early 2013: IM (reporting) specialty milestones posted for residencies 6/2013: formation of Clinical Competency Committees for phase 1 residencies 5/2014: First annual submission of evaluations of all residents in each of 22 subcompetencies; then twice yearly

Annual Data Review Elements ( aka “Dashboard”) for Fellowships RRC-IM will annually review: 1)Program Attrition 2)Program Changes 3)Scholarly Activity 4)Board Pass Rate 5)Clinical Experience 6)Resident Survey 7)Faculty Survey 8)Reporting Milestones Collected now as part of the program’s annual ADS update. ADS streamlined 2012: 33 fewer questions & more multiple choice or Y/N To be generated via annual administration of survey of graduating fellows Starting fall, 2013, will be self reported First conducted 2013 Annual survey of >70% of fellows in program

If only one part of dashboard, why all the angst about reporting milestones? Incremental increase in complexity of evaluations Require a “sea change” in training interactions with residents/fellows Require more time to complete No data regarding outcomes has been shared Compressed implementation time-line

Time-line for subspecialty reporting milestones 2/13: AAIM/ACGME/ABIM summit of specialty society representatives 5/13: Second summit. Decision: to add milestone for scholarship (MK3), and to split into writing groups to revise IM document 11/13: Third summit. Decision: – 1) add PC4a (non-invasive procedures), but not to combine ANY of the IM milestones (new total 24) – 2) all specialty fellowships will share same reporting milestones 12/3/13: final document sent to specialty societies 12/20/13: deadline for approval/disapproval 11/2014: first data will be submitted to ACGME for fellows, according to 24 reporting milestones

SUBSPECIALTY MILESTONES – ACGME Report Worksheet 1. Gathers and synthesizes essential and accurate information to define each patient’s clinical problem(s). (PC1) Not Yet Assessable Critical Deficiencies Ready for unsupervised practice Aspirational Comments:

23. (INTERNAL MEDICINE) Appropriate utilization and completion of health records. (ICS3) Not Yet Assessable Critical Deficiencies Ready for unsupervised practice Aspirational Health records are absent or missing significant portions of important clinical data Health records are disorganized and inaccurate Health records are organized and accurate but are superficial and miss key data or fail to communicate clinical reasoning Health records are organized, accurate, comprehensive, and effectively communicate clinical reasoning Health records are succinct, relevant, and patient specific Role models and teaches importance of organized, accurate and comprehensive health records that are succinct and patient specific

23. (SPECIALTIES) Appropriate utilization and completion of health records. (ICS3) Not Yet Assessable Critical Deficiencies Ready for unsupervised practice Aspirational Health records are absent or missing significant portions of important clinical data Does not enter medical information and test results/ interpretation into health record Health records are disorganized and inaccurate Inconsistently enters medical information and test results/ interpretation into health record Health records are organized and accurate but are superficial and miss key data or fail to communicate clinical reasoning Consistently enters medical information and test results/ interpretation into health records Patient specific hHealth records are organized, timely, accurate, comprehensive, and effectively communicate clinical reasoning Health records are succinct, relevant, and patient specific Medical information and test results/ interpretation are effectively and promptly provided to physicians and patients Role models and teaches importance of organized, accurate and comprehensive health records that are succinct and patient specific

23. Appropriate utilization and completion of health records. (ICS3) Not Yet Assessable Critical Deficiencies Ready for unsupervised practice Aspirational Health records are absent or missing significant portions of important clinical data Does not enter medical information and test results/ interpretation into health record. Health records are disorganized and inaccurate Inconsistently enters medical information and test results/ interpretation into health record. Health records are organized and accurate but are superficial and miss key data or fail to communicate clinical reasoning Consistently enters medical information and test results/ interpretation into health records. Patient specific health records are organized, timely, accurate, comprehensive, and effectively communicate clinical reasoning Medical information and test results/ interpretation are effectively and promptly provided to physicians and patients Role models and teaches importance of organized, accurate and comprehensive health records that are succinct and patient specific

19. (INTERNAL MEDICINE) Responds to each patient’s unique characteristics and needs. (PROF3) Not Yet Assessable Critical Deficiencies Ready for unsupervised practice Aspirational Is insensitive to differences related to culture, ethnicity, sexual orientation, gender, gender identity, race, age, and religion in the patient/caregiver encounter Is unwilling to modify care plan to account for a patient’s unique characteristics and needs Is sensitive to and has basic awareness of differences related to culture, ethnicity, sexual orientation, gender, gender identity race, age and religion in the patient/caregiver encounter Requires assistance to modify care plan to account for a patient’s unique characteristics and needs Seeks to fully understand each patient’s unique characteristics and needs based upon culture, ethnicity, sexual orientation, gend er identity gender, religion, and personal preference Modifies care plan to account for a patient’s unique characteristics and needs with partial success Recognizes and accounts for the unique characteristics and needs of the patient/ caregiver Appropriately modifies care plan to account for a patient’s unique characteristics and needs Role models professional interactions to navigate and negotiate differences related to a patient’s unique characteristics or needs Role models consistent respect for patient’s unique characteristics and needs

19. (SPECIALTIES) Responds to each patient’s unique characteristics and needs. (PROF3) Not Yet Assessable Critical Deficiencies Ready for unsupervised practice Aspirational Is insensitive to differences related to personal characteristics and needs culture, ethnicity, sexual orientation, gender, gender identity, race, age, and religion in the patient/caregiver encounter Is unwilling to modify care plan to account for a patient’s unique characteristics and needs Is sensitive to and has basic awareness of differences related to personal characteristics and needs to culture, ethnicity, sexual orientation, gender, gender identity race, age and religion in the patient/caregiver encounter Requires assistance to modify care plan to account for a patient’s unique characteristics and needs Seeks to fully understand each patient’s unique personal characteristics and needs based upon culture, ethnicity, sexual orientation, gend er identity gender, religion, and personal preference Modifies care plan to account for a patient’s unique characteristics and needs with partial success Recognizes and accounts for the unique personal characteristics and needs of the patient/ caregiver Appropriately modifies care plan to account for a patient’s unique characteristics and needs Role models professional interactions to navigate and negotiate differences related to a patient’s unique characteristics or needs Role models consistent respect for patient’s unique characteristics and needs

19. Responds to each patient’s unique characteristics and needs. (PROF3) Not Yet Assessable Critical Deficiencies Ready for unsupervised practice Aspirational Is insensitive to differences related to personal characteristics and needs in the patient/caregiver encounter Is unwilling to modify care plan to account for a patient’s unique characteristics and needs Is sensitive to and has basic awareness of differences related to personal characteristics and needs the patient/caregiver encounter Requires assistance to modify care plan to account for a patient’s unique characteristics and needs Seeks to fully understand each patient’s personal characteristics and needs Modifies care plan to account for a patient’s unique characteristics and needs with partial success Recognizes and accounts for the personal characteristics and needs of the patient/ caregiver Appropriately modifies care plan to account for a patient’s unique characteristics and needs Role models professional interactions to navigate and negotiate differences related to a patient’s unique characteristics or needs Role models consistent respect for patient’s unique characteristics and needs

Summary of reporting milestones Context-free CCC and PD will make a determination about “substantial compliance” with milestones in each column for each fellow Fellows are not required to achieve “ready for unsupervised practice” in every subcompetency

Additional issues regarding reporting milestones Pending: guidance from ACGME regarding whether “not applicable” category will be specific to sub-competencies or competencies Plan will be to revisit text of reporting milestones 2 years after implementation

What are curricular milestones? Essential elements of the specialty NOT required by ACGME! For Hematology/Oncology most are in “patient care” Linked to entrustable professional activities (EPAs) Can be used as rotation specific evaluations, thus providing direct input into reporting milestones

2. (CURRICULAR MILESTONE) Develops and achieves comprehensive management plan for each patient. (PC2) Not Yet Assessable Critical Deficiencies Ready for unsupervised practice Aspirational Does not understand basic principles of transfusion medicine Understands the basic principles of transfusion medicine and orders appropriate blood products with supervision Appropriately orders blood products for common indications Appropriately orders blood products for complex indications, including apheresis and specialized products Teaches and role models the principles of transfusion medicine and the appropriate ordering of all blood products

4b. (CURRICULAR MILESTONE) Skill in performing and interpreting noninvasive procedures and/or testing. (PC4b): Demonstrates ability to perform and interpret peripheral blood smears Not Yet Assessable Critical Deficiencies Ready for unsupervised practice Aspirational Unable to interpret a normal peripheral blood smear Consistently able to read a normal peripheral blood smear and identify normal features in all three cell lines Consistently able to read normal and common abnormal peripheral blood smears and identifies abnormal features of all three cell lines; able to appropriately order bone marrow testing for common disorders Consistently able to read uncommon abnormal peripheral blood smears; cons istently able to appropriately order bone marrow testing for uncommon disorders Teaches and role models the ability to diagnose rare diseases on peripheral blood smear and to explain the peripheral and bone marrow smear findings to others

Curricular milestones development: status ASH and ASCO have working groups ASCO modified the ASH product (from meeting 10/14) ASCO-ASH meeting on 11/25 resulted in “substantive consensus” ASCO will collate changes and send back to ASH. Areas of discussion: – Word-smithing – Subcompetency placement – “oncology-only” training exceptions Plan is for draft to be circulated to H/O PDs by late January – This would allow time to revise evaluation tools, if desired, before AY14-15