The Nuclear Radiology Milestone Project - ACGME Home · The Nuclear Radiology Milestone Project The Milestones are designed only for use in evaluation of fellows in the context of

The Nuclear Radiology

Milestone Project

A Joint Initiative of

The Accreditation Council for Graduate Medical Education

and

The American Board of Radiology

February 2014

i

The Nuclear Radiology Milestone Project

The Milestones are designed only for use in evaluation of fellows in the context of their participation in ACGME-

accredited residency or fellowship programs. The Milestones provide a framework for the assessment of the

development of the resident physician 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.

ii

Nuclear Radiology Milestones

Chair: Lawrence P. Davis, MD

Working Group Advisory Group

Manuel L. Brown, MD Gary Becker, MD

Laura Edgar, EdD, CAE Louis Ling, MD

Milton J. Guiberteau, MD Kay H. Vydareny, MD

Petra J. Lewis, MD

M. Elizabeth Oates, MD

Umesh Oza, MD

iii

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 program’s 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 fellow’s 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.

iv

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 the Next Accreditation System and Milestones are posted on the Next Accreditation System section of the ACGME website.

Radiology Subspecialty Assessment tools:

End-of-Rotation Global Assessment

Direct observation and feedback

Reading out with resident

Review of reports

Rate of major discrepancies

Self-Assessment and Reflections/Portfolio

OSCE/simulation

Completion of institutional safety modules, BCLS/ACLS

Case/Procedure Logs, including complications

Multi-Source Evaluations

v

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 fellow’s performance on the milestones for each sub-competency will be indicated

by 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 a

level implies that milestones in that level and

in lower levels have been substantially

demonstrated.

Selecting a response box on the line in between levels

indicates that milestones in lower levels have been

demonstrated as well as some milestones in the higher

level(s).

Version 2/2014 THE NUCLEAR RADIOLOGY MILESTONES: ACGME REPORT WORKSHEET

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and the American Board of Radiology. All rights reserved. The copyright owners grant third parties the right to use the Nuclear Radiology Milestones on a non-exclusive basis for educational purposes. 1

Patient and Personnel Safety (Diagnostic and Procedural) — Patient Care 1

Level 1 Level 2 Level 3 Level 4 Level 5

Knows basic radiation

protection concepts (e.g., As

Low As Reasonably

Achievable [ALARA])

Knows basic considerations

for imaging females of

childbearing age, and those

who are pregnant/breast-

feeding

Safely handles and

administers

radiopharmaceuticals

Recognizes and manages

contrast reactions and

infiltrations

Uniformly practices ALARA

principles for self, staff

members, patients, families,

and public

Understands radiation dose

concerns as related to

radionuclide imaging, including

hybrid imaging, and can explain

risk/benefit

Ensures that each patient

receives the appropriate

examination or therapy

Treats common complications

from administered non-

radioactive pharmaceuticals

(e.g., furosemide, morphine

sulfate, captopril)

Manages minor radioactive

spills

Knows the comparative

radiation exposures received

by patients for common

nuclear radiology

examinations and procedures

Optimizes

radiopharmaceutical dosages

based on patient parameters

(e.g., age, size, comorbidities,

pregnancy, nursing)

Knows the relative and

absolute contraindications to

diagnostic and nuclear

radiology therapeutic

examinations (e.g., aortic

stenosis, exercise stress)

Understands and adopts the

concepts of Image Wisely ®

and Image Gently ®

Understands the management

of dose limit exceptions to

personnel or public from

nuclear radiology examinations

and therapeutic procedures

Knows the comparative

radiation exposures received

by patients for uncommon

nuclear radiology examinations

and procedures

Reduces patient radiation

exposure through choice of

examination and protocol

optimization (e.g., hydration/

voiding)

Understands the prevention

and management of

therapeutic

radiopharmaceutical

infiltrations

Teaches patient and

personnel radiation

safety

Implements new safety

procedures and quality

control measures

impacting patient care

Comments:

“Common” and “uncommon” to be defined by each program

Not yet achieved Level 1



Diagnostic Examinations: Patient Selection, Preparation, Examination Supervision, and Image Interpretation — Patient Care 2


Evaluates imaging requests

and patient information, and

reviews previous

examinations

Proposes appropriate

examinations for common

conditions/clinical

presentations

Accurately makes core

observations/interpretations

and formulates appropriate

differential diagnoses for

common findings on

common examinations

Is familiar with the range of

cardiac stress methods and

protocols

Selects and tailors protocols of

common examinations according to

patient information

Recommends appropriate patient

preparation (e.g., diet, medication)

Accurately makes core

observations/interpretations and

formulates appropriate differential

diagnoses for uncommon findings

on common examinations

Correlates nuclear imaging with

anatomical imaging, and compares

to previous examinations

Narrows the differential diagnosis

and describes management options

Recognizes the implications of the

adequacy of cardiac stress on

examination interpretation

Appropriately supervises

adequacy and

completeness of common

examinations

Makes accurate, efficient,

and focused

interpretations of

uncommon examinations,

including secondary

findings

Prioritizes differential

diagnoses and

recommends appropriate

management

Selects and tailors

protocols of uncommon

examinations according to

patient information

Appropriately supervises

adequacy and

completeness of

uncommon examinations

and complex cases

Makes subtle observations

and suggests a single

“best” diagnosis, when

appropriate, on all

examinations

Integrates current

literature and national

practice guidelines into

daily work

Teaches diagnostic

nuclear imaging to other

learners

Acts independently as a

consultant on

interdisciplinary teams

Presents or publishes

nuclear radiology

research in peer-

reviewed media

Comments:





Radionuclide Therapies: 131I for Benign and Malignant Disease, Parenteral Therapies – Patient Selection, Preparation, Evaluation,

Monitoring, and Follow-up — Patient Care 3


Knows indications/

contraindications for

radioiodine therapy of

benign and malignant

thyroid diseases

Is familiar with radiation

safety precautions and

restrictions (e.g., isolation)

Evaluates, selects, and

prepares patients for

radioiodine therapy, including

obtaining consent, and

performs the procedure

Communicates radiation

safety precautions to patient,

family, caregivers, and

hospital personnel

Knows the indications/

contraindications for common

parenteral

radiopharmaceutical therapies

Selects and applies

appropriate patient release

criteria, and follows up with

patient after radioiodine

therapy

Evaluates, selects, and

prepares patients for

common parenteral

radiopharmaceutical

therapies, including obtaining

consent

Plans and performs

radioiodine therapy in

complicated clinical situations

(e.g., renal failure, mentally

or physically challenged

patients)

Performs common parenteral

radiopharmaceutical

therapies

Demonstrates knowledge of

emerging therapeutic


Acts independently as a

consultant on

interdisciplinary teams

Teaches

radiopharmaceutical

therapy topics

Publishes or presents on a

radiopharmaceutical

therapy topic

Comments:





Anatomy, Physiology, and Pathophysiology — Medical Knowledge 1


Knows normal planar and

cross-sectional anatomy

Recognizes common

anatomic variants and

commonly-encountered

pathology

Knows normal physiology

of adults and children

Understands

pathophysiology of

common diseases

Understands physiologic

basis for patient preparation

protocols

Recognizes and explains

anatomic and functional

radiopharmaceutical imaging

findings of common diseases

in adults and children based

on knowledge of anatomy,

physiology, and

pathophysiology

Understands physiologic

basis for pharmacologic

interventions and

subsequent imaging findings


correlative and hybrid

imaging findings of common

disease in adults and children

based on knowledge of

anatomy, physiology, and

pathophysiology

Recognizes uncommon

anatomic variants


radiopharmaceutical,

correlative, and hybrid

imaging findings of complex

and uncommon diseases in

adults and children based on

knowledge of anatomy,

physiology, and

pathophysiology

Teaches planar and cross-

sectional anatomy,

physiology, and

pathophysiology

Comments:





Physics and Instrumentation — Medical Knowledge 2


Knows basic nuclear

radiology physics

Has knowledge of basic

instrumentation and

functions of non-imaging

devices (e.g., ionization

chambers, well counters,

survey meters, NaI probes)

and imaging devices (e.g.,

gamma cameras, positron

emission

tomography/computed

tomography (PET/CT)

scanners, and other hybrid

imaging systems)

Understands the

mathematical principles of

the use and measurement of

radioactivity

Understands basic image

acquisition and image

processing

Recognizes common imaging

artifacts and technical

problems


routine instrument quality

control tests

Processes simple nuclear

radiology examinations (e.g.,

renal scan)

Understands how to optimize

image acquisition

Understands image

reconstruction methods

Processes and optimizes

more complex nuclear

radiology examinations (e.g.,

multigated acquisition

cardiac)

Understands how to operate

a dose calibrator, survey

meter, and thyroid probe

Recognizes common

abnormal quality control test

results

Recognizes and resolves

common and uncommon

instrumentation artifacts

and other quality control

issues

Understands the

comparative advantages and

describes disadvantages of

routinely used nuclear

radiology instrumentation

Understands and describes

comparative advantages and

disadvantages of different

image reconstruction

methods

Teaches nuclear radiology

physics and instrumentation

Presents or publishes physics

or instrumentation-related

research in peer-reviewed

media

Develops new quality control

and/or imaging protocols

Comments:





Radiopharmaceuticals — Medical Knowledge 3


Understands the tracer

principle

Knows the indications,

physical properties, and

expected biodistributions of

commonly used diagnostic

(e.g., Tc-99m) and therapeutic

(e.g., I-131)


Knows basic radiopharmacy

operations and routine quality

control tests

Recognizes normal variant and

abnormal biodistributions of

commonly used diagnostic

and therapeutic


Recognizes

radiopharmaceutical quality

control problems on images

(e.g., free 99mTc)

Knows the indications,

physical properties, and

expected biodistributions of

uncommonly used diagnostic

(e.g., In-111 pentetreotide)

and therapeutic (e.g., I-131

MIBG) radiopharmaceuticals

Recognizes normal variant

and abnormal

biodistributions of

uncommonly used diagnostic

and therapeutic


Understands the implications

of radiopharmaceutical

quality control problems

Discusses emerging

radiopharmaceuticals and

other molecular imaging

agents

Resolves

radiopharmaceutical

quality control problems

Understands the elements

of a radiopharmaceutical

quality assurance program

Teaches

radiopharmaceutical

topics, including quality

control

Publishes or presents on a

radiopharmaceutical topic

Aids in the development of

new diagnostic and

therapeutic

radiopharmaceutical

protocols

Comments:





Regulatory Requirements — Systems-based Practice 1


Demonstrates awareness

of the Nuclear Regulatory

Commission (NRC),

pertinent state-specific

agencies, and methods of

accreditation

Knows the purpose and

functions of a nuclear

radiology radiation safety

program

Knows the basic NRC

regulations and state-specific

laws applying to radioactive

materials use, storage, and

disposal, the definition of

Authorized User, and

components of a written

directive

Understands the composition

and function of the Radiation

Safety Committee and the

responsibilities of the

Radiation Safety Officer

Knows how to disclose

reportable or recordable

incidents

Applies appropriate laws and

regulations to daily clinical

scenarios in the nuclear

radiology clinic/laboratory

(e.g., receives packages,

performs ambient surveys)

Performs basic

radiopharmaceutical quality

control testing

Understands the appropriate

rules and regulations

required to function as a

medical director of a nuclear

radiology unit

Is familiar with The Joint

Commission, NRC, and state

radiation safety inspection

processes

Is capable of participating in

a regulatory committee,

such as the Radiation Use

Committee (RUC) or

Radiation Safety Committee

(RSC)

Serves as the point person

during an inspection by The

Joint Commission, NRC, or

state radiation safety

inspection team

Comments:




Health Care Economics — Systems-based Practice 2


Describes the technical and

professional components of

imaging costs in nuclear

radiology

Has a basic understanding of

the advantages and

disadvantages of different

payment systems


departmental cost-savings

initiatives

Creates reports that contain

the elements necessary to

support examination coding

and billing compliance

Describes billing and coding

problems of specific nuclear

radiology examinations and

procedures; recognizes and

corrects incorrect coding

Develops understanding of

relative charges and

reimbursement for common

nuclear radiology

examinations and

procedures

Has a basic understanding

of the pre-certification

process, radiology benefits

managers, and structured

computer-based order entry

systems

Understands the concept of

national quality improvement

financial incentives (e.g.,

Physician Quality Reporting

System [PQRS])

Knows the current

reimbursement rules for high-

cost complex nuclear

radiology procedures (e.g.,

flurodeoxyglucose [FDG],

PET/CT, hybrid imaging)

Has an advanced practical

understanding of the pre-

certification process, radiology

benefits managers, and

structured computer-based

order entry systems

Has a basic understanding

of current state and

national health care

policies and their

implications

Comments:




Quality Improvement — Systems-based Practice 3


Describes the departmental

incident/occurrence

reporting system

Describes nuclear radiology

quality improvement

initiatives

Participates in the

departmental

incident/occurrence

reporting system

Incorporates nuclear

radiology quality

improvement into clinical

practice

Works in inter-professional

teams to enhance patient

safety and improve patient

care quality

Participates in identifying

institutional operational gaps

and implementing potential

solutions

Leads a team in the design

and implementation of a

quality improvement

project for the nuclear

radiology program

Routinely participates in

institutional root cause

analysis

Comments:




Self-directed Learning — Practice-based Learning and Improvement 1


Is aware of gaps in personal

knowledge and experience;

seeks help when

appropriate

Incorporates feedback

from teachers, colleagues,

and patients for self-

improvement

Develops a personal

learning plan

Selects evidence-based

information to answer

basic clinical questions

Seeks and incorporates

feedback to improve

performance

Assesses and provides

feedback to junior learners

Selects evidence-based

information to answer

advanced clinical questions

Demonstrates a balanced and

accurate professional self-

assessment

Investigates clinical

outcomes, and identifies

areas for continued

improvement

Shows evidence of reading

current literature related to

clinical topics

Develops an ongoing

personal continuing

education plan

Regularly incorporates

evidence-based information

and current research into

self-directed learning

Prepares and teaches

residents/student

conferences

Participates in a lifelong

continuing education plan in

the subspecialty

Develops an educational

curriculum and/or

assessment tools (e.g.,

resident evaluation tool)

Comments:




Scholarly Activity — Practice-based Learning and Improvement 2


Demonstrates

understanding of critical

thinking skills and research

design (e.g., journal club)


basic principles underlying

the ethical conduct of

research and the protection

of human subjects

Identifies a mentor and

proposes a scholarly activity

Critically reviews and

interprets the literature,

demonstrating the ability to

identify study aims,

hypotheses, design, and

biases

Initiates a focused scholarly

activity

Applies the principles of

ethics and good clinical

practice to the protection of

human subjects recruited to

participate in research

Maintains data safety and

patient monitoring to ensure

continued protection of

human subjects

Demonstrates

understanding of statistics

and epidemiology in data

analysis

Completes and presents

scholarly activity to peers

for review and critique at

the departmental or

local/regional/national

level

Independently plans and

executes research project

Applies for/obtains

extramural funding for

research study

Submits research to peer-

reviewed journal and/or

presents nationally

Comments:




Individual — Professionalism 1


Is an effective health care team

member, promoting primacy of

patient welfare, patient

autonomy, and social justice

Demonstrates the following

professional behaviors:

is truthful

recognizes personal

limitations and seeks help

when appropriate

recognizes personal

impairment and seeks help

when needed

responds appropriately to

constructive criticism

places needs of patients

before self

maintains appropriate

boundaries with patients,

colleagues, and others

exhibits tolerance and

acceptance of diverse

individuals and groups

Seeks and incorporates

feedback to improve

professional behavior

Discusses individual

professionalism issues

with students and

residents

Serves as a role model for

individual professional

behavior

Mentors others regarding

professionalism and ethics

Comments:

Levels 2-4: Maintains professional behavior as described in Level 1 Not yet achieved Level 1



Systems — Professionalism 2


Is an effective health care team

member who demonstrates the

following professional

behaviors:

fulfills work-related

responsibilities

recognizes the importance

and priority of patient care

and advocates for patient

interests

maintains patient

confidentiality

fulfills Institutional and

Program Requirements

related to professionalism

and ethics

prepares for and attends

required conferences

Identifies opportunities to

improve professionalism in

the workplace

Takes part in programs to

improve clinical care and

professional behavior

Discusses system

professionalism issues with

students and residents


system professionalism

Is an effective health care

team leader

Accepts leadership roles in

institutional, regional, and/or

national organizations to

advance professionalism

Comments:

Levels 2-4: Maintains professional behavior as described in Level 1




Effective Communication with Patients, Families, and Caregivers — Interpersonal and Communication Skills 1


Adheres to HIPAA and

institutional confidentiality

policies

Exhibits basic

communication skills and,

with indirect supervision,

can effectively

communicate in non-

stressful situations (e.g.,

normal results, acquiring

patient history)

Obtains informed consent

for diagnostic procedures

(e.g., pregnant patient,

sentinel node injections)

Communicates more

complex or difficult

information (e.g., abnormal

results, need for additional

imaging) in straightforward

cases

Communicates with more

challenging patients (e.g.,

cognitive impairment,

anxiety, cultural differences,

language barriers, low health

literacy) under indirect

supervision

Working with program faculty

members, oversees and

teaches more junior learners

on how to communicate

effectively with patients,

families, caregivers, and staff

members

Under direct supervision,

obtains informed consent for

therapeutic procedures


effective and compassionate

communication for more

junior learners

Seeks leadership

opportunities in the

department or institution

with regards to patient-

centered communication

Under direct supervision,

communicates medical

errors, complications, and

adverse events

Under indirect supervision,

obtains informed consent for

therapeutic procedures

Develops guidelines for

communication within the


Seeks leadership

opportunities in regional or

national professional

organizations with regards

to patient-centered

communication

Communicates medical

errors, complications, and

adverse events

Comments:




Effective Communication with Members of the Health Care Team (Written and Oral) — Interpersonal and Communication Skills 2


Adheres to HIPAA and

institutional confidentiality

policies

Efficiently generates clear,

accurate, and concise

reports that do not need

substantial faculty member

corrections in most cases

Communicates effectively

and professionally in non-

stressful situations

Understands the

institutional policy for

transitions of care and

hand-offs/hand-overs

Communicates urgent,

critical, and unexpected

findings according to

institutional policy, and in

compliance with ACR

guidelines

Efficiently generates clear,

accurate, and concise reports

that do not need substantial

faculty member corrections

in all cases


and professionally during

more stressful situations

(e.g., on call, busy day)

Effectively manages

transitions of care and hand-

offs/hand-overs

Generates tailored reports

meeting the specific needs of

the referring providers


and professionally in all

situations (e.g., during

interpersonal or

interdisciplinary conflicts)

Works with program faculty

members to oversee and

teach junior learners on how

to communicate effectively

and professionally

Actively participates in

departmental and

interdisciplinary teaching

and/or patient care

conferences


effective professional

communication

With faculty member

supervision, helps to

organize departmental and


and/or patient care

conferences

Seeks leadership

opportunities in the


with regards to health care

team-centered

communication

Develops and implements

standardized report templates

Resolves service issues

effectively and professionally

(e.g., delay in exam

scheduling)

Independently leads

departmental and


and/or patient care

conferences

Develops guidelines for

written and oral

communications for local or

national use

Seeks leadership

opportunities in regional or

national professional

organizations with regards to

health care team-centered

communication

Comments:


Documents

The Nuclear Radiology Milestone Project - ACGME Home · The Nuclear Radiology Milestone Project The Milestones are designed only for use in evaluation of fellows in the context of