The Pediatric Surgery Milestone Project

A Joint Initiative of
The Accreditation Council for Graduate Medical Education,

and

The American Board of Surgery

July 2015
 The Pediatric Surgery 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 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.

i
 Pediatric Surgery Milestones
Chair: Ron Hirschl, MD

Working Group Advisory Group

Kenneth S. Azarow, MD, FACS, FAAP Timothy P. Brigham, MDiv, PhD
Mary Brandt, MD James C. Herbert, MD
Laura Edgar, EdD, CAE John R. Potts III, MD
J. Ted Gerstle, MD, FRCSC, FACS, FAAP
Kurt Heiss, MD
Whit Holcomb, MD
Max R. Langham Jr., MD
Grace Z. Mak, MD
Mark V. Mazziotti, MD
Benedict C. Nwomeh, MD
David Powell, MD
Peggy Simpson, EdD
John Waldhausen, 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 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.

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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 to 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 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 Selecting a response box on the line in between levels
level implies that milestones in that level and indicates that milestones in lower levels have been
in lower levels have been substantially substantially demonstrated as well as some milestones
demonstrated. in the higher level(s).

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 01/2014 THE PEDIATRIC SURGERY MILESTONES: ACGME REPORT WORKSHEET

Bronchoscopy/Esophagoscopy — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Serves as first assistant for Equipment Functional knowledge Independent ability to Develops innovative operative
the majority of the Limited ability to assemble adequate, but suboptimal assemble scope and technique, approach, or
procedure scope and troubleshoot assembly of equipment or troubleshoot problems significant improvement in
functional problems ability to troubleshoot bronchoscopy/esophagoscopy
problems Consistently optimal
Technique understanding and exposure
Limited exposure of Adequate but suboptimal of tracheobronchial tree and
tracheobronchial tree and understanding and exposure esophagus; optimal
esophagus; poor utilization of tracheobronchial tree and utilization of scope
of scope esophagus; adequate
utilization of scope Expedient and safe
Foreign body/biopsy identification of foreign
Limited ability to identify Adequate but inefficient body/tumor and/or retrieval
foreign body/tumor or to identification of foreign of foreign body/biopsy of
retrieve foreign body/biopsy body/tumor and/or retrieval tumor
tumor of foreign body/biopsy of
tumor

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 1
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Esophageal atresia/Tracheoesophageal Fistula (TEF) Repair — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Serves as first assistant for Incision Functional, but suboptimal Consistently appropriate Develops innovative
the majority of the Limited ability to identify incision or port placement placement of incision or operative technique,
procedure appropriate incision or port ports approach, or significant
placement improvement in the
established technique for
Dissection esophageal atresia/TEF
Limited ability to dissect TEF Adequate but suboptimal Expedient dissection, safe repair
dissection of TEF isolation of TEF
Fistula ligation
Limited ability to Successful, but suboptimal Consistently appropriate
ligate/divide fistula; concern ligation/division of fistula and ligation/division of fistula;
for tracheal narrowing tracheal dissection maintained appropriate cuff
of membranous trachea
Anastomosis
Limited ability to Occasional lapses in Consistently appropriate
appropriately space and appropriate spacing and spacing of sutures, tissue
place anastomotic sutures depth of anastomotic approximation, and
and approximate tissue sutures, or occasional lapse in consistent bites into
tissue approximation submucosa

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 2
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Inguinal hernia repair on a child less than six months of age — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Serves as first assistant for Incision Functional but suboptimal Consistently appropriate Develops innovative
the majority of the Limited ability to identify placement of incision/port(s) placement of incision/port(s) operative technique,
procedure appropriate incision or port approach, or significant
placement improvement in established
technique for inguinal hernia
Exposure repair
Limited ability to expose key Adequate establishment and Consistently optimizes
structures maintenance of retraction exposure of inguinal
but with occasional loss of anatomy; efficiently directs
exposure of key structures wound retraction to
Hernia sac maintain exposure
dissection/ligation
Limited ability to perform Successful, but suboptimal Consistently appropriate
hernia sac dissection/ligation dissection/ligation of hernia dissection/ligation of hernia
or vas/vessel/fallopian tube sac; vas/vessels/fallopian sac and consistently safe
dissection tube preserved with minor mobilization of
traumatic injury vas/vessels/fallopian tube

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 3
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Intestinal/duodenal atresia (DA) repair — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Serves as first assistant Incision/port placement Functional but suboptimal Consistently appropriate Develops innovative
for the majority of the Limited ability to identify placement of incision/port(s) placement of incision/port(s) operative technique,
procedure appropriate incision or port approach, or significant
placement improvement in
established technique for
Abdominal exploration intestinal/DA repair
Limited ability to perform Adequate, but suboptimal Consistently performs
abdominal exploration that performance of abdominal complete, efficient, and
should include evaluation for exploration that should include systematic abdominal
additional abnormalities (e.g., evaluation for additional exploration that identifies
atresias, malrotation) anomalies (e.g., atresias, additional abnormalities (e.g.,
malrotation) atresias, malrotation)
Intestinal resection (atresia)
Limited ability to perform Adequate, but suboptimal Consistently appropriate
intestinal resection or failure to performance of intestinal understanding and
consider need for resection and/or tapering/STEP performance of intestinal
tapering/Serial Transverse resection and/or tapering/STEP
Enteroplasty (STEP)

Anastomosis Occasional lapses in spacing Consistently appropriate

Limited ability to appropriately and depth of anastomotic spacing of sutures, tissue
space and place anastomotic sutures, or occasional lapse in approximation, and consistent
sutures and approximate tissue tissue approximation (in DA, bites into submucosa (in DA,
(in DA, often unaware of occasional lapse in awareness continually aware of Sphincter
Sphincter of Oddi) of Sphincter of Oddi) of Oddi)

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 4
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Hirschsprung pull-through — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Serves as first assistant for Incision/port placement Functional but suboptimal Consistently appropriate Develops innovative
the majority of the Limited ability to identify placement of incision/port(s) placement of incision/port(s) operative technique,
procedure appropriate incision or port approach, or significant
placement improvement in established
technique for Hirschsprung
Abdominal exploration pull-through
Limited ability to perform Adequate, but suboptimal Consistently performs
abdominal exploration or to performance of abdominal complete, efficient, and
identify transition zone exploration, identification of systematic abdominal
and/or perform biopsy transition zone, and/or exploration with appropriate
performance of biopsy identification of transition
zone and biopsy
Rectal dissection/resection
Limited ability to perform Adequate, but suboptimal Consistently appropriate
pull-through performance of pull-through performance of pull-through

Suture placement
Limited ability to Occasional lapses in spacing Consistently appropriate
appropriately space and and depth of anastomotic spacing of sutures, tissue
place anastomotic sutures, or sutures, or lapses in tissue approximation, and bites
to approximate tissue; approximation; occasional into submucosa; consistently
limited ability to orient pull- lapses in pull-through aware of pull-through
through segment orientation segment orientation

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 5
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Wilms/Neuroblastoma Resection — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Serves as first assistant for Incision/port placement (as Functional but suboptimal Consistently appropriate Develops innovative
the majority of the appropriate) placement of incision/port(s) placement of incision/port(s) operative technique,
procedure Limited ability to identify approach, or significant
appropriate incision or port improvement in established
placement technique for
Wilms/neuroblastoma
Abdominal exploration resection
Limited ability to perform Adequate, but suboptimal Consistently performs
abdominal exploration/tumor performance of abdominal complete, efficient, and
exposure exploration/tumor exposure systematic abdominal
exploration/tumor exposure
Vascular control
Limited ability to identify and Adequate, but suboptimal Consistently appropriate
control vascular structures in performance of control of performance of control of
either tumor, and/or to assess vascular structures in either vascular structures in either
for tumor thrombus in Wilms tumor, and/or assessment for tumor, and assessment for
tumor thrombus in Wilms tumor thrombus in Wilms
Excision of tumor
Limited ability to safely Adequate, but suboptimal Consistently appropriate
manipulate tumor (e.g., ability to safely manipulate technique with tumor
without rupture in Wilms) tumor (e.g., without rupture manipulation and intra-
and/or to make decisions in Wilms) and/or to make operative decision-making
regarding resectability decisions regarding
resectability

Comments: Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 6
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Congenital Diaphragmatic Hernia Repair — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Serves as first Extracorporeal membrane Adequate, but suboptimal Consistently appropriate Develops innovative
assistant for the oxygenation (ECMO) cannulation (if decision-making for instituting decision-making for instituting operative technique,
majority of the performed) decision making ECMO and discriminating ECMO and discriminating approach, or significant
procedure Limited ability to make appropriate between venovenous and between venovenous and improvement in
decision for instituting ECMO and venoarterial options venoarterial options established technique
discriminating between venovenous for congenital
and venoarterial options Adequate, but suboptimal Consistently appropriate ability diaphragmatic hernia
ability to identify and control to identify and control neck repair
Cannulation neck vascular structures; vascular structures; consistent
Limited ability to identify and control adequate, but suboptimal ability to safely insert cannulas
cervical vascular structures; limited ability to safely insert cannulas
ability to safely insert cannulas
Functional but suboptimal Consistently appropriate
Incision/port placement placement of incision/port(s ) placement of incision/port(s)
Limited ability to identify appropriate
placement of incision/port(s)

Diaphragm repair Adequate, but suboptimal Consistently demonstrates the

Limited ability to safely and ability to effectively reduce appropriate ability to
effectively reduce hernia contents hernia contents and/or close effectively reduce hernia
and/or close diaphragmatic defect diaphragmatic defect with contents and/or close
with appropriately spaced/placed appropriately spaced/placed diaphragmatic defect with
sutures sutures appropriately spaced/placed
sutures

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 7
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General Procedure Assessment — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Serves as first assistant for Instrument handling Adequate, but suboptimal Consistently appropriate use Develops innovative
the majority of the Limited ability to choose and use and choice of and choice of instruments operative technique,
procedure use instruments instruments instrumentation, operative
appropriately approach, or significant
improvement in established
Respect for tissue technique
Limited ability to handle Adequate, but suboptimal Consistently appropriate
tissues carefully; moderate tissue handling; occasional handling of tissues; minimal
tissue damage tissue damage tissue damage

Time and motion

Frequent tentative, awkward, Efficient time and motion, Clear economy of motion
unnecessary movements occasional awkward or and maximum efficiency
unnecessary movements
Operation flow
Frequent lack of forward Some forward planning of Obviously has planned
progression; frequently stops operation; reasonable course of operation and
operating and seems unsure procedure progression anticipated next steps
of next move

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 8
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General Patient Care Assessment — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Performs a basic physical Performs a comprehensive Provides the pre- and post- Directs the multidisciplinary Appropriately and
exam and understands the physical exam, recognizes operative management of a pre- and post-operative independently counsels
management and imaging associated anomalies, and complicated newborn, or management of a complex families for prenatal surgical
in a newborn or child; provides the pre- and post- multiple injured child, newborn with multiple conditions
performs primary operative management of an including ICU care (ventilator anomalies, or multiple
assessment and initiates uncomplicated newborn or management, parenteral injured child, including ICU Directs and leads
resuscitation of an injured single-system injured child, nutrition, fluids and care (ventilator multidisciplinary team in
child including intensive care unit electrolytes) management, parenteral quality improvement
(ICU) care (ventilator nutrition, fluids and focused on patient
Diagnoses common management, parenteral Manages complex post- electrolytes) outcomes
complications nutrition, fluids and operative complications
electrolytes) Independently anticipates, Coordinates/leads a
Recognizes normal growth, Evaluates and manages diagnoses, and proficiently multidisciplinary team in
development, and Manages common post- variances from expected manages interventions and providing comprehensive
expected outcome after operative complications outcomes in the late post- complications, and care of the child
treatment operative course in the appropriately involves the transitioning to adulthood
Recognizes variances in outpatient setting multidisciplinary team
growth, development, and
expected outcome after Independently provides
treatment comprehensive long-term
care in the outpatient
setting

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 9
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Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5

Through discussion in Through discussion in didactic Through discussion in Through discussion in Demonstrates expertise
didactic and clinical settings, and clinical settings, this didactic and clinical didactic and clinical in specific area(s) of
this fellow demonstrates fellow demonstrates settings, this fellow settings, this fellow pediatric surgery, and/or
thorough knowledge of the thorough knowledge of the demonstrates thorough demonstrates thorough contributes substantially
basic pediatric surgery topics intermediate pediatric knowledge of the advanced knowledge of the complex to the literature
below: surgery topics below: pediatric surgery topics pediatric surgery topics
below: below:
 Appendicitis  Branchial cleft
 Inguinal hernia cyst/sinus/remnant  DA  Anorectal
 Intussusception  Gastroesophageal reflux  ECMO malformation
 Malrotation  Gastroschisis  Hirschsprung disease  Biliary atresia
 Pyloric stenosis  Lung physiology  Intestinal atresia  Choledochal cyst
 Thoracic/abdominal  Omphalocele  Neuroblastoma  Congenital
trauma  Ovarian/adnexal diseases  Wilms tumor diaphragmatic hernia
 Undescended testis  Cystic pulmonary
airway malformation
 Esophageal atresia
with or without TEF

Comments: Not yet achieved Level 1

Demonstration of knowledge of topics can be evaluated through tools such as: 1) PedScore modules; 2) multiple choice questions; and 3)
discussion of open-ended questions with faculty members.

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 10
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General Knowledge Assessment — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5

Demonstrates knowledge of Demonstrates knowledge of Demonstrates knowledge of Demonstrates knowledge of Demonstrates significant
embryology, anatomy, and embryology, anatomy, and embryology, anatomy, and embryology, anatomy, and command of the literature,
physiology of basic topics physiology of intermediate physiology of advanced topics physiology of complex topics including novel therapeutic
topics interventions and
Discusses initial diagnostic Discusses initial diagnostic Discusses initial diagnostic outcomes
and treatment Discusses initial diagnostic and treatment and treatment
recommendations for basic and treatment recommendations for recommendations for
topics, including those that recommendations for advanced topics, including complex topics, including
require urgent management intermediate topics, including those that require urgent those that require urgent
those that require urgent management management
Discusses potential management
complications and their Discusses potential Discusses potential
management, as well as Discusses potential complications and their complications and their
expected outcomes for complications and their management, as well as management, as well as
basic topics management, as well as expected outcomes for expected outcomes for
expected outcomes for advanced topics complex topics
intermediate topics

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 11
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Healthcare Delivery and Cost – Systems Based Practice

Level 1 Level 2 Level 3 Level 4 Level 5

Understands cost Articulates risk-benefit Incorporates cost Leads efforts to reduce costs Develops or institutes a cost
implications of clinical analysis, including cost to considerations into clinical by reducing variations in efficient clinical pathway
decisions patient decisions care which reduces cost of
patient care
Understands how to Incorporates risk Understands the principles of Understands the concept of
appropriately utilize mid- management in pediatric insurance coverage and work relative value units Advocates on a national or
level and other health care surgery access to care for children (RVUs) and physician regional level for health care
providers to optimize the compensation policy
delivery of care to children
(inpatient, outpatient, on
call, rounding)

Comments:

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 12
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Patient Safety — Systems-based Practice

Level 1 Level 2 Level 3 Level 4 Level 5

Demonstrates an Recognizes medical errors Suggests improvements to Leads multidisciplinary Participates as an advocate
understanding of the as systemic events and reduce medical errors efforts to improve patient on a regional or national
importance of patient facilitates reporting in a safety at the division and/or level for pediatric patient
safety and the occurrence blame-free environment Anticipates potentially hospital level safety
of medical errors in dangerous situations and
pediatric surgery patients Anticipates the inherent risk intervenes Designs evidence-based
of medical errors as a result clinical pathway to
Participates in an effective of inadequate patient hand- decrease medical errors
patient hand-off and off and surgical time-out
surgical time-out process

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 13
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Systems-based Documentation — Systems-based Practice

Level 1 Level 2 Level 3 Level 4 Level 5

Demonstrates commitment Accurately and promptly Effectively uses medical Effectively uses medical Works with the electronic
to maintaining medical documents daily patient care record system to synthesize record system to answer a medical record professional
records within the institutional complex patient information clinical research question or team to solve problems in
documentation system complete a quality the medical record system
improvement project

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 14
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Evidence-based Medicine — Practice-based Learning and Improvement

Level 1 Level 2 Level 3 Level 4 Level 5

Incorporates evidence- Understands the quality and Synthesizes a clinical plan Demonstrates utilization of Formulates an outcomes-
based guidelines into limitations of available from multiple sources of evidence derived from a based quality improvement
clinical decisions literature and data evidence database or registry in project to answer a clinical
changing his or her practice question
pattern

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 15
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Self-directed Learning — Practice-based Learning and Improvement

Level 1 Level 2 Level 3 Level 4 Level 5

Takes responsibility for Committed to self- Is self-reflective about own Analyzes and interprets own Displays a commitment to
actions and acknowledges improvement; responds well academic, professional, and experience, and uses the lifelong learning (e.g.,
errors to feedback personal needs, strengths, literature to alter practice routinely surveys literature,
and limitations pattern engages in continuing
Directs the discussion at medical education [CME]
morbidity and mortality activities, actively publishes)
conference with an
understanding of the
severity of the complication
presented (e.g., selects
cases to be presented,
performs appropriate
literature search)

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 16
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Integrity — Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5

Demonstrates an Thinks like a professional by Acts like a professional who Leads as a professional by Mentors others in areas of
understanding of the basic demonstrating behavioral recognizes limitations, managing him- or herself professionalism
cognitive and ethical and social components of accepts feedback, and is and his or her team and
components of professionalism effective at managing patients Mentors and teaches
professionalism difficult clinical situations integrity, altruism,
Demonstrates compassion Serves as a role model for individual responsibility,
Demonstrates and empathy for patients; Demonstrates integrity, honesty, integrity, and and professionalism
fundamental aspects of his or her work is noted for altruism, and individual professionalism; patient
medical professionalism, integrity, responsibility, responsibility to the needs supersede self- Understands the ethical
including confidentiality, commitment, and reliability patient, family, and team interest implications of
respect for patient choice, under most circumstances under all circumstances; incorporating new surgical
citizenship (e.g., medical serves as an advocate for skills and techniques into
record completeness, quality patient care practice
timeliness, arrives on time
for work, etc.), and
individual responsibility to
the team

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 17
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Recognition of Limits — Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5

Overestimates ability; Recognizes when Is self-aware of limitations; Never takes on tasks Mentors and educates
rarely asks for help when uncomfortable with tasks; anticipates situations that beyond own ability; reliably others in discovering and
needed asks for, and waits for help may be beyond his or her asks for help when needed acknowledging their
ability, and plans strengths and limitations
Organizes multidisciplinary
accordingly
teams to optimize patient
care

Comments:
Not yet achieved Level 1

Behavior and Respect — Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5

Few complaints related No complaints related to Consistently compassionate Serves as a role model for Mentors others in behavior
to behavior behavior; rarely displays and respectful of patients, respect and compassion which is respectful and
lapses in compassion and families, and other health towards patients, families, compassionate to patients,
respectfulness even in care workers even in and other health care families, and other health
difficult, stressful, and difficult, stressful, and workers care workers
highly demanding situations highly demanding situations

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 18
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Leadership — Professionalism

Level 1 Level 2 Level 3 Level 4 Level 5

Demonstrates an Organizes people and Demonstrates leadership Demonstrates advanced Models to and teaches
understanding of his or leads the pediatric surgery skills in adverse skills in leading a broad, others to be leaders, and
her role on team; works team environments; multidisciplinary team and develops the talents of
effectively with others on demonstrates best practices in managing the needs of others
the team for managing one’s team the team members;
motivates the team to high
performance

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 19
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Collaborator — Interpersonal and Communication Skills

Level 1 Level 2 Level 3 Level 4 Level 5

Demonstrates an Communicates effectively Resolves disagreements Negotiates and manages Is viewed as an exemplary
understanding of the with attending staff with other health care conflict among care communicator, problem
importance of effective members, peers, and other providers in a professional providers solver, and ambassador for
communication with other health care providers, manner the pediatric surgery service
providers including during transfer to Communicates effectively in the children’s hospital
other services and in times of crisis
multidisciplinary rounds

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 20
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Patient- and Family-centered Care — Interpersonal and Communication Skills

Level 1 Level 2 Level 3 Level 4 Level 5

Demonstrates an Communicates effectively Demonstrates effective Customizes emotionally Serves on local, regional, or
understanding of the value with patients and families in communication with difficult and ethically difficult national committees
of patient- and family- the inpatient and outpatient families information, such as addressing ethical or
centered care settings, including in palliative care discussions advocacy issues
obtaining informed consent
Demonstrates sensitivity in
caring for culturally diverse Uses translation services
patients appropriately

Comments:
Not yet achieved Level 1

The Milestones are a product of the Pediatric Surgery Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical
Education and the American Board of Surgery. 21