The Brain Injury Medicine Milestone Project

A Joint Initiative of
The Accreditation Council for Graduate Medical Education
The American Board of Physical Medicine and Rehabilitation
The American Board of Psychiatry and Neurology

July 2015

The Brain Injury Medicine Milestone Project

The Milestones are designed only for use in evaluation of the fellow in the context of their participation in
ACGME-accredited residency or fellowship programs. The Milestones provide a framework for assessment of the
development of the fellow in key dimensions of the elements of physician competency in a specialty or
subspecialty. They neither represent the entirety of the dimensions of the six domains of physician competency,
nor are they designed to be relevant in any other context.

Brain Injury Medicine Milestones

Chair: Gerard Francisco, MD
Working Group

Advisory Group

David Baron, DO
AM Barrett, MD
Laura Edgar, EdD, CAE
Samuel Gandy, MD
Louise King, MS
Steven Lewis, MD
Lisa Lombard, MD

Jim McDeavitt, MD
Mary Lieh-Lai, MD
Teresa Massagli, MD

ii

Milestone Reporting
This document presents Milestones designed for programs to use in semi-annual review of fellow performance and reporting to the
ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a
developmental framework from less to more advanced. They are descriptors and targets for fellow performance as a fellow moves
from entry into fellowship through graduation. In the initial years of implementation, the Review Committee will examine Milestone
performance data for each programs fellows as one element in the Next Accreditation System (NAS) to determine whether fellows
overall are progressing.
For each period, review and reporting will involve selecting milestone levels that best describe a fellows current performance and
attributes. Milestones are arranged into numbered levels. Tracking from Level 1 to Level 5 is synonymous with moving from novice
to expert in the subspecialty.
Selection of a level implies that the fellow substantially demonstrates the milestones in that level, as well as those in lower levels
(see the diagram on page v).
Level 1: The fellow demonstrates milestones expected of an incoming fellow.
Level 2: The fellow is advancing and demonstrates additional milestones, but is not yet performing at a mid-fellowship level.
Level 3: The fellow continues to advance and demonstrate additional milestones, consistently including the majority of
milestones targeted for fellowship.
Level 4: The fellow has advanced so that he or she now substantially demonstrates the milestones targeted for fellowship. This
level is designed as the graduation target.
Level 5: The fellow has advanced beyond performance targets set for fellowship and is demonstrating aspirational goals
which might describe the performance of someone who has been in practice for several years. It is expected that only
a few exceptional fellows will reach this level.

iii

Additional Notes

Level 4 is designed as the graduation target and does not represent a graduation requirement. Making decisions about readiness for
graduation is the purview of the fellowship program director. Study of Milestone performance data will be required before the
ACGME and its partners will be able to determine whether milestones in the first four levels appropriately represent the
developmental framework, and whether Milestone data are of sufficient quality to be used for high-stakes decisions.
Examples are provided with some milestones. Please note that the examples are not the required element or outcome; they are
provided as a way to share the intent of the element.
Some milestone descriptions include statements about performing independently. These activities must occur in conformity to the
ACGME supervision guidelines, as well as institutional and program policies. For example, a fellow who performs a procedure
independently must, at a minimum, be supervised through oversight.

Answers to Frequently Asked Questions about Milestones are available on the Milestones web page:
http://www.acgme.org/acgmeweb/Portals/0/MilestonesFAQ.pdf.

iv

The diagram below presents an example set of milestones for one sub-competency in the same format as the ACGME Report
Worksheet. For each reporting period, a fellows performance on the milestones for each sub-competency will be indicated
by selecting the level of milestones that best describes that fellows performance in relation to those milestones.

Selecting a response box in the middle of a

level implies that milestones in that level and
in lower levels have been substantially
demonstrated.

Selecting a response box on the line in between levels

indicates that milestones in lower levels have been
substantially demonstrated as well as some milestones
in the higher level(s).

Version 07/2014

Brain Injury Medicine Milestones, ACGME Report Worksheet

Patient Care History and Physical Examination of Individuals with Brain Injury
Level 1
Level 2
Level 3
Acquires a basic history,
Utilizes knowledge of
Acquires a history, and
including medical,
brain injury medicine to
performs a physical exam
functional, and
acquire a history and
and functional evaluation
psychosocial elements
perform a physical and
in patients with complex
neurologic exam and
conditions and
Performs a basic physical
functional evaluation
comorbidities, including
and neurologic exam that
psychiatric
identifies impairments and Interprets the neurologic
functional abilities
exam to accurately assess Modifies history and exam
brain injury and its
to accommodate the
sequelae
patients impairments,
optimize assessment,
minimize discomfort, and
preserve patient dignity

Comments:

Level 4
Efficiently acquires a
relevant history, and
performs a targeted
physical exam across a
spectrum of ages,
impairments, and clinical
settings

Level 5
Serves as a role model for
gathering subtle and
difficult information
Serves as a role model for
physical exam skills in
complex brain injury
patients

Elicits subtleties and

information that may not
be readily volunteered by
the patient
Identifies and correctly
interprets subtle or
atypical physical and
neurologic findings from
the brain injury

Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, The American Board of Physical Medicine and Rehabilitation, and The
American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Brain Injury Medicine Milestones
on a non-exclusive basis for educational purposes.

Version 07/2014

Brain Injury Medicine Milestones, ACGME Report Worksheet

Patient Care Spasticity Interventions (e.g., Chemodenervation, Neurolytic Procedures, Intrathecal Baclofen Pump)
Level 1
Level 2
Level 3
Level 4
Level 5
Complies with safety
Demonstrates basic
Makes appropriate choices Assesses outcomes of
Skillfully performs a wide
protocols regarding
understanding of which
regarding medication
spasticity interventions
variety of procedures and
procedures
spasticity intervention
options, dosing, and
and manages
teaches others in the safe
should be used to treat
guidance methods (e.g.,
complications
performance of these
Provides basic education
specific conditions
baclofen pump
procedures
to patients and families
programming, botulinum
Independently performs
regarding procedureObtains informed consent, toxin injection)
procedures
specific information and
confirming patient and
treatment options
family understanding and
Modifies procedure to
inviting questions
accommodate the
patients impairment and
Performs procedures with minimize discomfort (e.g.,
direct supervision; may
sedation)
need attending
intervention during
procedures

Comments:

Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, The American Board of Physical Medicine and Rehabilitation, and The
American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Brain Injury Medicine Milestones
on a non-exclusive basis for educational purposes.

Version 07/2014

Brain Injury Medicine Milestones, ACGME Report Worksheet

Patient Care Evaluation and Diagnosis of Individuals with Brain Injury across the Entire Spectrum of Severity
Level 1
Level 2
Level 3
Level 4
Produces a differential
Generates a differential
Develops a comprehensive Synthesizes clinical
diagnosis for common
diagnosis that considers
differential diagnosis,
information and results of
presentations
atypical presentations and including for less common diagnostic studies in the
conditions commonly seen conditions
development of a
Orders appropriate
in brain injury
comprehensive differential
diagnostic studies for
Appropriately prioritizes
diagnosis
common presentations
Orders appropriate
the sequence and urgency
diagnostic studies for
of diagnostic testing
Orders diagnostic testing
conditions commonly seen
based on costin brain injury
Correctly interprets
effectiveness and
diagnostic study results
likelihood that results will
and appropriately pursues influence clinical
further testing or specialist management
input

Comments:

Level 5
Efficiently produces a
focused and prioritized
differential diagnosis
accounting for rare
conditions
Streamlines diagnostic
evaluation for maximal
cost-effectiveness and
minimal patient burden

Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, The American Board of Physical Medicine and Rehabilitation, and The
American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Brain Injury Medicine Milestones
on a non-exclusive basis for educational purposes.

Version 07/2014

Brain Injury Medicine Milestones, ACGME Report Worksheet

Patient Care Medical/Neuropsychiatric Management of Individuals with Brain Injury across the Entire Spectrum of Severity
This includes inpatient, outpatient, and consultative management of:
Current comorbidities
Secondary conditions
Potential complications
Level 1
Level 2
Level 3
Level 4
Level 5
Evaluates general medical Identifies and manages
Manages patients with
Develops and implements Evaluates and
problems and initiates
common comorbidities
complex comorbidities
a comprehensive
appropriately applies
and secondary conditions
treatment plan that
emerging treatments in
treatment
and secondary conditions
associated with brain
identifies and addresses all individual patients
Identifies common
Identifies individual risk
pertinent comorbidities,
injury
neurobehavioral
factors for complications
secondary conditions, and Critically evaluates
consequences of brain
Identifies level of medical
and institutes preventive
emerging treatments for
potential complications
acuity and triages
efficacy and scientific
injury
care
appropriately
validity
Counsels patients
Initiates pharmacologic
regarding treatment risks
Performs initial diagnostic and non-pharmacologic
and benefits, outcomes,
evaluation of
treatment of
and prognosis
neurobehavioral
neurobehavioral
consequences
symptoms
Adjusts management
appropriate to the care
Uses appropriate
Provides consultations to
consultations to guide
patients under the care of setting
treatment plan
other services
Individualizes and adjusts
ongoing treatment of
neurobehavioral
symptoms

Comments:

Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, The American Board of Physical Medicine and Rehabilitation, and The
American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Brain Injury Medicine Milestones
on a non-exclusive basis for educational purposes.

Version 07/2014

Brain Injury Medicine Milestones, ACGME Report Worksheet

Patient Care Rehabilitation Management of Individuals with Brain Injury

Level 1
Level 2
Level 3
Prescribes rehabilitation
Prescribes commonly-used Provides therapy
therapies by discipline,
adaptive devices in
prescriptions with
based on functional need
partnership with the
appropriate precautions
interprofessional team
Prescribes commonly-used
Recognizes the indications orthoses
for basic orthoses and
mobility aids
Establishes short- and
long-term rehabilitation
goals

Comments:

Level 4
Provides detailed therapy
prescription for specific
conditions

Level 5
Serves as a resource to
orthotists, therapists, and
other health care
professionals for problemsolving unusual clinical
and functional challenges

Prescribes assistive
technologies and mobility
devices in partnership with
the interprofessional team Serves as an expert
resource to other
Evaluates and adjusts
stakeholders (e.g.,
short- and long-term
insurance companies) for
patient-specific
the appropriateness of
rehabilitation goals
durable medical
equipment and assistive
technologies

Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, The American Board of Physical Medicine and Rehabilitation, and The
American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Brain Injury Medicine Milestones
on a non-exclusive basis for educational purposes.

Version 07/2014

Brain Injury Medicine Milestones, ACGME Report Worksheet

Medical Knowledge Traumatic and Non-traumatic Brain Injury

This includes:
Epidemiology and etiology
Anatomy and pathophysiology
Secondary conditions and complications
Therapeutic and diagnostic options
Level 1
Level 2
Level 3
Describes basic brain
Demonstrates knowledge
Describes prevention and
anatomy and the effects of of pathophysiology, risk
management of secondary
insult to specific brain
factors, secondary
conditions and
regions
conditions, treatment
complications, including
options, and complications expected effects, side
Demonstrates basic
across a spectrum of
effects, and
knowledge of common
impairments
contraindications of
brain injuries
treatment
Demonstrates knowledge
Describes comorbidities
of differing levels of
Demonstrates knowledge
and complications of brain consciousness after a
of the continuum of brain
injury
brain injury
injury care
Demonstrates knowledge
of the objective measures
for evaluating level of
consciousness after brain
injury

Comments:

Level 4
Demonstrates the
knowledge required to
successfully diagnose and
treat complex brain injury
conditions and
complications

Level 5
Serves as an expert
resource to health care
professionals regarding
brain injury

Delineates a brain injuryspecific health

maintenance and
management program
across the lifespan
Demonstrates knowledge
of the key prognostic
indicators in different
levels of consciousness

Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, The American Board of Physical Medicine and Rehabilitation, and The
American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Brain Injury Medicine Milestones
on a non-exclusive basis for educational purposes.

Version 07/2014

Brain Injury Medicine Milestones, ACGME Report Worksheet

Medical Knowledge Functional Outcomes and Assessment across the Entire Spectrum of Brain Injury Severity
Level 1
Level 2
Level 3
Level 4
Demonstrates basic
Demonstrates advanced
Demonstrates knowledge
Demonstrates knowledge
knowledge of functional
knowledge of functional
of appropriate use and
of limitations of
impairment associated
impairment associated
interpretation of
assessment tools
with brain injury
with brain injury
assessment tools
Demonstrates knowledge
Demonstrates knowledge
Integrates knowledge of
of controversial and
of commonly-used
functional goals and
emerging evaluations and
assessment tools in brain
prognosis into an
interventions for
injury medicine
individualized treatment
functional outcome
plan
Demonstrates knowledge
of functional outcome and
prognosis based on
impairment

Comments:

Level 5
Serves as an expert
resource regarding
functional outcomes and
interventions in brain
injury

Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, The American Board of Physical Medicine and Rehabilitation, and The
American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Brain Injury Medicine Milestones
on a non-exclusive basis for educational purposes.

Version 07/2014

Brain Injury Medicine Milestones, ACGME Report Worksheet

Systems-based Practice Systems Thinking, including Cost- and Risk-effective Practice

Level 1
Level 2
Level 3
Level 4
Describes basic cost and
Describes cost- and riskMakes clinical decisions
Consistently makes clinical
risk implications of care
benefit ratios in patient
that balance cost- and risk- decisions that balance
care
benefit ratios
cost- and risk-benefit
ratios

Comments:

Level 5
Engages in scholarly
activity regarding costand risk-effective practice
in brain injury medicine

Not yet achieved Level 1

Systems-based Practice Work In Interprofessional Teams to Enhance Patient Safety and Patient Care
Level 1
Level 2
Level 3
Level 4
Identifies and reports
Describes team members Describes potential
Participates in a teamerrors and near-misses
roles in maintaining
sources of system failure
based approach to medical
patient safety
in clinical care such as
error analysis
minor, major, and sentinel
Understands the role of
events
Demonstrates knowledge
the interprofessional care
of the institutional and
team for patients with
Participates in the
national quality measures
brain injury
interprofessional care
used by members of the
team for patients with
interprofessional care
brain injury
team

Level 5
Engages in scholarly
activity regarding error
analysis and patient safety
in brain injury medicine
Leads an interprofessional
care team for patients
with brain injury

Comments:
Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, The American Board of Physical Medicine and Rehabilitation, and The
American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Brain Injury Medicine Milestones
on a non-exclusive basis for educational purposes.

Version 07/2014

Brain Injury Medicine Milestones, ACGME Report Worksheet

Systems-based Practice Coordination and Transitions in Care

Level 1
Level 2
Level 3
Describes and
Coordinates care within
Demonstrates knowledge
differentiates between the health care systems (e.g.,
of eligibility criteria and
various settings and
inpatient, outpatient,
mechanisms to access
systems of care
consultative)
commonly-used
community and
Demonstrates knowledge
governmental programs
of commonly-used
community resources and Facilitates effective, safe,
governmental programs
well-coordinated, patientavailable that provide
centered care within and
support and services (e.g., across health care systems
Supplemental Security
Income [SSI], Department
of Veteran Affairs [VA],
vocational rehabilitation)

Level 4
Efficiently manages and
coordinates safe and
effective patient
transitions between
various settings

Level 5
Serves as an expert
resource in care
coordination and advocacy
for improved systems of
care

Demonstrates knowledge
of regulatory compliance,
including accurate coding
and billing

Actively participates in
national and communitybased advocacy groups
relevant to brain injury

Organizes appeals for

coverage, and advocates
for patients in complex
situations

Demonstrates knowledge
of national and
community-based
advocacy groups relevant
to brain injury

Comments:

Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, The American Board of Physical Medicine and Rehabilitation, and The
American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Brain Injury Medicine Milestones
on a non-exclusive basis for educational purposes.

Version 07/2014

Brain Injury Medicine Milestones, ACGME Report Worksheet

Practice-based Learning and Improvement Self-directed Learning

Identify strengths, deficiencies, and limits in ones knowledge and expertise
Set learning and improvement goals
Identify and perform appropriate learning activities
Use information technology to optimize learning
Level 1
Level 2
Level 3
Acknowledges gaps in
Elicits feedback from other Develops an appropriate
knowledge and expertise
members of the
learning plan based upon
in brain injury medicine
interprofessional team
clinical experience and
feedback

Level 4
Completes an appropriate
learning plan based upon
clinical experience and
feedback

Level 5
Engages in scholarly
activity regarding practicebased learning and
improvement in brain
injury medicine

Comments:
Not yet achieved Level 1

Practice-based Learning and Improvement Location, Appraisal, and Assimilation of Evidence from Scientific Studies related to the Patients
Health Problems
Level 1
Level 2
Level 3
Level 4
Level 5
Uses information
Uses scholarly articles and Critically evaluates
Incorporates appropriate
Engages in scholarly
technology to search and
guidelines to answer
scientific literature
evidence-based
activity regarding
access relevant medical
patient care issues
information into patient
evidence-based care in
information
care
brain injury medicine
Understands the limits of
evidence-based medicine
in patient care

Comments:

Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, The American Board of Physical Medicine and Rehabilitation, and The
American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Brain Injury Medicine Milestones
on a non-exclusive basis for educational purposes.

10

Version 07/2014

Brain Injury Medicine Milestones, ACGME Report Worksheet

Professionalism Compassion, Integrity, Accountability, and Respect for Self and Others
Level 1
Demonstrates compassion,
sensitivity, and
responsiveness to patients
and families

Level 2
Describes effects of sleep
deprivation and substance
abuse on a practitioners
performance

Demonstrates nondiscriminatory behavior in

all interactions, including
with diverse and
vulnerable populations

Demonstrates knowledge
of appropriate steps to
address impairment in self
Advocates for quality
patient care

Consistently demonstrates
professional behavior,
including appropriate
attire and timeliness

Comments:

Level 3
Demonstrates
compassionate practice of
medicine, even in the
context of disagreement
with patient beliefs

Level 4
Mentors others in the
compassionate practice of
medicine, even in the
context of disagreement
with patient beliefs

Incorporates patients
sociocultural needs and
beliefs into patient care

Mentors others in
sensitivity and
responsiveness to diverse
and vulnerable populations

Level 5
Engages in scholarly
activity regarding
professionalism in brain
injury medicine

Demonstrates knowledge
of appropriate steps to
address impairment in
colleagues

Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, The American Board of Physical Medicine and Rehabilitation, and The
American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Brain Injury Medicine Milestones
on a non-exclusive basis for educational purposes.

11

Version 07/2014

Brain Injury Medicine Milestones, ACGME Report Worksheet

Professionalism Medical Ethics

Level 1
Level 2
Describes basic ethical
Determines presence of
principles
ethical issues in practice

Level 3
Analyzes and manages
ethical issues in
straightforward clinical
situations

Level 4
Analyzes and manages
ethical issues in complex
clinical situations

Level 5
Demonstrates leadership
and mentorship in
applying ethical principles
in brain injury medicine
settings

Comments:
Not yet achieved Level 1

Interpersonal and Communication Skills Relationship Development, Teamwork, and Managing Conflict
Level 1
Level 2
Level 3
Level 4
Develops an empathic
Manages simple patient-/
Manages conflict in
Manages conflict across
relationship with patients
family-related conflicts
complex situations
systems of care
Actively participates in
team-based care

Engages patients in shared

decision making

Comments:

Uses easy-to-understand
language in all phases of
communication

Leads team-based patient

care activities

Level 5
Engages in scholarly
activity regarding
teamwork and conflict
management

Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, The American Board of Physical Medicine and Rehabilitation, and The
American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Brain Injury Medicine Milestones
on a non-exclusive basis for educational purposes.

12

Version 07/2014

Brain Injury Medicine Milestones, ACGME Report Worksheet

Interpersonal and Communication Skills Information Sharing, Gathering, and Technology

Level 1
Completes documentation
in a timely fashion

Level 2
Educates patients about
their diseases and their
management, including
risks and benefits of
treatment options
Completes all
documentation accurately,
including use of electronic
health records (EHR), to
promote patient safety
Participates in family and
team meetings addressing
continuum of care for
patients with brain injury

Level 3
Effectively communicates
the results of a brain injury
consultation in a timely
manner
Effectively gathers
information from
collateral sources
Demonstrates synthesis,
formulation, and thought
process in documentation
Utilizes adaptive
communication
techniques with patients
with brain injury

Level 4
Effectively and ethically
uses all forms of
communication

Level 5
Develops patient and
caregiver education
regarding brain injury
medicine

Mentors colleagues in
timely, accurate, and
efficient documentation

Proactively engages in
public outreach related to
brain injury

Leads family and team

meetings addressing
continuum of care for
patients with brain injury

Engages in scholarly
activity regarding
interpersonal
communication in brain
injury medicine

Demonstrates knowledge
of adaptive
communication
techniques for use with
patients with brain injury

Comments:
Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education, The American Board of Physical Medicine and Rehabilitation, and The
American Board of Psychiatry and Neurology. All rights reserved. The copyright owners grant third parties the right to use the Brain Injury Medicine Milestones
on a non-exclusive basis for educational purposes.

13