: Pediatric Radiology

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Milestones Supplemental Guide
This document provides additional guidance and examples for the Pediatric Radiology Milestones.This is not designed to indicate any specific requirements for each level, but to provide insight into the thinking of the Milestone Work Group.
Included in this document is the intent of each Milestone and examples of what a Clinical Competency Committee (CCC) might expect to be observed/assessed at each level.Also included are suggested assessment models and tools for each subcompetency, references, and other useful information.
Review this guide with the CCC and faculty members.As the program develops a shared mental model of the Milestones, consider creating an individualized guide (Supplemental Guide Template available) with institution/program-specific examples, assessment tools used by the program, and curricular components.
Additional tools and references, including the Milestones Guidebook, Clinical Competency Committee Guidebook, and Milestones Guidebook for Residents and Fellows, are available on the Resources page of the Milestones section of the ACGME website.

Milestones
Examples Level 1 Uses electronic health records (EHRs) to obtain relevant clinical information; contacts referring physician when reason for exam is unclear • A primary care physician has a teen with cirrhosis and a liver mass on ultrasound; the fellow provides consultation with attending radiologist guidance to address the next step in imaging • Provides consultation to the primary care physician regarding a patient with a pacemaker who the primary care physician would like assessed via magnetic resonance imaging (MRI) Level 4 Manages consultations independently, taking into consideration cost effectiveness and risk-benefit analysis • Independently consults about advanced MRI techniques and sequences in preparation for brain tumor analysis Level 5 Provides comprehensive consultations at the expert level • Independently recommends preliminary scrotal ultrasound and tumor marker analysis first on consultation for a lung biopsy on an 18-year-old male patient who presents with multiple lung masses on x-ray and a retroperitoneal mass on CT Assessment Models or Tools • Case conferences

Demonstrates knowledge of pathophysiology of common pediatric disease processes
• Identifies pulmonary lobar anatomy • Describes explanation for findings evaluated by common genitourinary fluoroscopic studies, such as vesicoureteral reflux, duplex collecting systems • Understands and can discuss the spectrum of pathologic processes that commonly affect pediatric patients • Demonstrates an understanding of neonatal pulmonary processes evaluated by chest radiography Level 2 Applies knowledge of anatomy to make imaging diagnoses of common pediatric conditions

Applies knowledge of pathophysiology to make imaging diagnoses of common pediatric conditions
• Accurately identifies lobar pneumonia • Distinguish abdominal neuroblastoma from lymphoma • Discusses and uses nuclear medicine examinations in the evaluation of commonly encountered pediatric diseases including vesicoureteral reflux, hepatobiliary diseases, and bone lesions • Accurately identifies a thyroid nodule on ultrasound, raises the possibility of toxic adenoma in a patient with a thyroid nodule and hyperthyroidism, uses I-123 uptake and scan to identify a hyperfunctioning thyroid adenoma Level 3 Applies knowledge of anatomy to make imaging diagnoses of less common pediatric conditions

Applies knowledge of pathophysiology to make imaging diagnoses of less common pediatric conditions
• Accurately identifies pediatric pulmonary diseases with CT imaging • Accurately identifies less commonly encountered pediatric intra-abdominal and intrapelvic diseases with cross-sectional imaging, such as benign and malignant liver neoplasms • Properly uses nuclear medicine examinations to diagnosis less commonly encountered pediatric diseases, including positron emission tomography (PET)-CT or PET-MRI, such as lymphoma, germ cell tumor, sarcoma, Wilms tumors, and metastatic neuroblastoma

Systems-Based Practice 1: Patient Safety Overall Intent:
To engage in the analysis and management of patient safety events, including relevant communication with patients, families, and health care professionals Milestones Examples Level 1 Demonstrates knowledge of common pediatric patient safety events Demonstrates knowledge of how to report pediatric patient safety events • Is aware that extravasation of contrast is a safety event and knows where and how to report Level 2 Identifies system factors that lead to pediatric patient safety events Reports pediatric patient safety events through institutional reporting systems (simulated or actual) • Identifies that poor communications and poor patient hand-offs contribute to patient safety events • Has identified and reported a patient safety issue (real or simulated), along with system factors contributing to that issue Level 3 Participates in analysis of pediatric patient safety events (simulated or actual) Participates in disclosure of pediatric patient safety events to patients and families (simulated or actual) • Reviews a patient safety event (e.g., preparing for M and M presentations, preparing for departmental meeting on reading discrepancies), joining a root cause analysis group and has communicated with patients/families about such an event Level 4 Conducts analysis of pediatric patient safety events and offers error prevention strategies (simulated or actual) Discloses pediatric patient safety events to patients and families (simulated or actual) • Participates in a root cause analysis group or M and M conference or quality assurance (QA) radiation safety conference of a patient safety event and develops an action plan where appropriate • Collaborates with a team to lead the analysis of a patient safety event and can competently communicate with patients/families about those events Level 5 Actively engages teams and processes to modify systems to prevent pediatric patient safety events Role models or mentors others in the disclosure of pediatric patient safety events • Competently assumes a leadership role at the departmental or institutional level for patient safety, possibly even being the person to initiate action or call attention to the need for action • Chairs an M and M committee or a QA/discrepancy committee meeting Assessment Models or Tools  • Identifies the members of the interprofessional imaging team and describes their roles • Describes an effective sign-out to the covering radiology team members • Knows that non-English-speaking patients without insurance are at risk for receiving a lesser degree of care than English-speaking patients • Knows that income disparities may impact pre exam prep or appearance of patient at an appointment and takes precautions to avoid missed/no show exams Level 2 Coordinates care of patients in routine pediatric radiology imaging/procedures effectively using the roles of interprofessional teams Performs safe and effective transitions of care/hand-offs in routine clinical situations

Identifies specific population and community health needs and inequities for the local population
• Works with other members of the radiology team (nurses, technologists) to coordinate patient imaging, but requires supervision to ensure all necessary imaging is performed • Requests Child Life assistance when needed • Requests the help of Child Life Specialists when working with an upset, anxious child • Effectively performs sign-outs between shifts to ensure that pending studies and their clinical implications are known to incoming team • Identifies that underrepresented minority patients from a community clinic may need additional levels of assistance to obtain proper follow-up following imaging • Identifies that sickle cell patients may require transcranial US as a screening exam for determination of need for transfusions to prevent stroke Level 3 Coordinates care of patients in complex pediatric radiology imaging/procedures effectively using the roles of interprofessional teams Performs safe and effective transitions of care/hand-offs in complex clinical situations

Identifies local resources available to meet the needs of a patient population and community
• Coordinates the imaging sequencing for complex patients such as multi-injured trauma patients • Prioritizes urgent patients from the intensive care unit (ICU), trauma, and emergency department for imaging/procedures and hands off the plan to the team on the next shift • Identifies a special-needs outreach program in the community to assist children with complex care • Works with child advocacy team in cases of non-accidental trauma Level 4 Role models effective coordination of pediatric patient-and family-centered care among different disciplines and specialties Role models safe and effective transitions of care/hand-offs Participates in adapting the practice to provide for the needs of specific populations (actual or simulated) • Serves as a role model and educator for students and more junior team members regarding the engagement of the radiology team as needed for each patient, and ensures the necessary resources have been arranged • Provides efficient hand-offs to ICU team at the end of a rapid-response event that occurred in radiology • Coordinates and prioritizes consultant input for a new high-risk diagnosis (e.g., malignancy) to ensure the patient gets appropriate follow-up • Guides more junior residents in an effective post-procedure hand-off to the referring service • Participates in workflow improvement project to improve access of interpretation services within the radiology department for non-English-speaking immigrants and refugees To understand the physician's role in the complex health care system and how to optimize the system to improve patient care and the health system's performance Milestones Examples Level 1 Identifies key components of the complex health care system (e.g., hospital, finance, personnel, technology) Describes the mechanisms for reimbursement, including types of payors • Recognizes that multiple components exist in a health care system, including various practice settings, reimbursement models, and types of insurance

• Describes various practice models
Level 2 Describes how components of a complex health care system are interrelated, and how this impacts patient care

States relative cost of common procedures
• Understands that pre-authorization may impact patient care and remuneration to the health system • States relative costs of chest x-ray versus chest CT Level 3 Discusses how individual practice affects the broader system (e.g., length of stay, readmission rates, clinical efficiency)

Describes the technical and professional components of imaging costs
• Understands that turnaround times and dictation errors may affect patient care, e.g., length of stay, which impacts the broader system • Differentiates between the technical and professional costs of a head CT Level 4 Manages various components of the complex health care system to provide efficient and effective pediatric patient care and transition of care Describes the pediatric radiology revenue cycle and measurements of productivity (e.g., relative value units) • Works collaboratively with pertinent stakeholders to improve procedural start times • Works collaboratively to improve informed consent for non-English-speaking patients requiring interpreter services

Analyzes, reflects on, and institutes behavioral change(s) to narrow the gap(s) between expectations and actual performance
Independently designs and implements a learning plan • Takes input from technologists, peers, and supervisors to gain insight into personal strengths and areas to improve • Follows up on the outcomes of patient for which they have dictated reports, with prompting • Changes daily practice habits to increase efficiency • Independently develops method to document goals in a specific and achievable manner, such that attaining them is measurable Level 4 Consistently seeks performance data and feedback with humility and adaptability

Analyzes effectiveness of behavioral changes where appropriate, and considers alternatives in
• Independently follows up on the outcomes of patients for which they have dictated reports

• Consistently identifies learning gaps and addresses areas to work on narrowing the gap(s) between expectations and actual performance
Uses performance data to measure the effectiveness of the learning plan and improves it when necessary

Coaches others on reflective practice
Facilitates the design and implements learning plans for others • Actively discusses learning goals with supervisors and colleagues; may encourage other learners on the team to consider how their behavior affects the rest of the team • Provides constructive feedback to peers for improvement • Identifies and describes potential triggers for professionalism lapses, describes when and how to appropriately report professionalism lapses, and outlines strategies for addressing common barriers to reporting • Discusses the basic ethical principles (beneficence, nonmaleficence, justice, autonomy) and professionalism (professional values and commitments), and how they apply in various situations (e.g., informed consent process) • Obtains informed consent for procedures

Level 2 Demonstrates insight into professional behavior in routine situations and takes responsibility for one's own professionalism lapses
Analyzes straightforward situations using ethical principles • Acknowledges and takes responsibility for lapse • Apologizes and takes corrective action for the lapse(s) if necessary • Articulates strategies for preventing similar lapses in the future • Demonstrates professional behavior in routine situations and uses ethical principles to analyze straightforward situations, such as those where: o there are no or few conflicts (between values or patients) o the resident may be tired or hungry, but is not excessively fatigued, overwhelmed, or otherwise distressed o workload is not unusually high, and there is no significant time pressure to make decisions Level 3 Demonstrates professional behavior in complex or stressful situations Recognizes the need to seek help in managing and resolving complex ethical situations • Analyzes complex situations, such as how the clinical situation evokes strong emotions, conflicts (or perceived conflicts) between patients or between professional values; the learner navigates a situation while not at personal best (due to fatigue, hunger, stress, etc.), or the system poses barriers to professional behavior (e.g., inefficient workflow, inadequate staffing, conflicting policies) • Recognizes own limitations and seeks resources to help manage and resolve complex ethical situations • Analyzes difficult (real or hypothetical) ethical dilemmas and situations, or professional case scenarios • Recognizes own limitations, and consistently demonstrates professional behavior Professionalism 2: Accountability/Conscientiousness Overall Intent: To take responsibility for one's own actions and the impact on patients and other members of the health care team

Milestones
Examples Level 1 Responds promptly to requests or reminders to complete tasks and responsibilities  Independently uses shared decision making to align patient goals, and preferences with treatment options to make a personalized care plan • Independently communicates with a patient and their family members diagnoses at the bedside while performing imaging examinations; involves the patient, their family, and the referring clinician(s) in formulating a plan for subsequent clinical steps

MK3
-Awareness and Help-Seeking ICS1: Effective Communication with Patients, Families, and Caregivers ICS1: Patient-and Family-Centered Care ICS2: Effective Communication with Members of the Health Care Team (Written and Oral) ICS2: Interprofessional and Team Communication ICS3: Communication within Health Care Systems ICS3: Effective Teaching No match

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Reviews relevant history and laboratory results for a patient being assessed for abdominal pain • Notes patient's glomerular filtration rate prior to protocolling a study with intravenous contrast Level 2 With assistance, delineates the clinical question, obtains appropriate clinical information, uses evidence-based imaging guidelines, and recommends next steps for emergent and routine consultations • Determines that patient has right lower quadrant pain, refers to American College of Radiology (ACR) Appropriateness Criteria and suggests appropriate imaging exam • Determines that an 8-year-old boy has right lower quadrant pain, refers to ACR Appropriateness Criteria and suggests appropriate imaging exam

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Consultations can be over the phone, in the reading room, at tumor boards, etc.Routine consultation is defined as clinical concerns in which the patient has a routine clinical history/presentation • Image Gently.Pediatric Radiology and Imaging.http://www.Imagegently.org.2021.• Institutional policies

Patient Care 2: Competence in Procedures Overall Intent:
To proficiently and independently perform procedures; to anticipate and manage complications of procedures

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Performs joint aspiration with ultrasound • Performs joint injection with ultrasound or fluoroscopic guidance

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Recognizes potentially complex patients and the need for surgical consultation prior to exam being performed, for example, bowel obstruction in intussusception

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Participates in annual review of fluoroscopic examination protocols • Helps initiate a musculoskeletal ultrasound program

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Develops on-call manual to aide learners and others to recognize complications The care of patients is undertaken with appropriate faculty supervision and conditional independence, allowing fellows to attain the knowledge, skills, attitudes, and empathy required for autonomous practice.•Background and Intent: The ACGME Glossary of Terms defines conditional independence as "graded, progressive responsibility for patient care with defined oversight."• Invasive procedures expected of a general radiologist may include: paracentesis, thoracentesis, thyroid biopsy, superficial lymph node, lumbar puncture, and/or abscess drainage.• The New England Journal of Medicine.Videos in Clinical Medicine.

Medical Knowledge 1: Protocol Selection and Optimization of Images Overall Intent:
To apply knowledge of protocol selection to optimize imaging

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Correctly describes appropriate department protocols for pediatric imaging

Medical Knowledge 3: Knowledge of Basic and Clinical Science Overall Intent: To
apply knowledge of anatomy, pathophysiology, and cellular and molecular systems to generate a differential diagnosis

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Uses somatostatin receptor imaging to diagnose neuroendocrine tumor Level 4 Proficiently integrates knowledge of anatomic and molecular imaging with pathophysiology to formulate a diagnosis• Suggests sarcoidosis over malignancy on patient with metabolically active mediastinal and hilar lymphadenopathy and appropriately distributed pulmonary nodules • Correctly uses and describes the use of molecular imaging, MR angiographic, and interventional radiologic examinations in the diagnosis and treatment of less-commonly encountered disease processes such as neuroendocrine tumors as well as lymphovascular diseases such as Parkes-Weber and Klippel-Trenaunay syndromes

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Recognizes intracranial tumors and intraspinous tumors that may be part of a tumor syndrome Level 5 Proficiently integrates knowledge of anatomic and molecular imaging with pathophysiology to formulate a diagnosis at the expected level of a specialized pediatric radiologist • Optimizes cardiovascular imaging in the evaluation of individual patients with congenital cardiovascular anomalies • Optimizes central nervous system imaging in the evaluation of specific patients with multiple findings within the brain and spine • Optimizes MRI imaging of multifocal intra thoracic and intra-abdominal processes to facilitate diagnosis • Optimizes nuclear medicine and molecular imaging examinations in the evaluation of individual pediatric patients • Optimizes the use of interventional radiology examinations in the evaluation of individual • ACR.Practice Parameters and Technical Standards.https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards.2021.• Glastonbury CM, Mukherji SK, O'Sullivan B, Lydiatt WM.Setting the stage for 2018: How the changes in the American Joint Committee on Cancer/Union for International Cancer Control Cancer Staging Manual eighth edition impact radiologists.AJNR Am J Neuroradiol.2017;38(12):2231-2237.http://www.ajnr.org/content/38/12/2231.long.2021.• Louis DN, Perry A, Reifenberger G, et al.The 2016 World Health Organization classification of tumors of the central nervous system: A summary.Acta Neuropathol.2016;131(6):803-820. https://link.springer.com/article/10.1007%2Fs00401-016-1545-1. 2021.• Lydiatt WM, Patel SG, O'Sullivan B, et al.Head and neck cancers -major changes in the American Join Committee on cancer eighth edition cancer staging manual.CA Cancer J Clin. 2017;67(2):122-137.https://onlinelibrary.wiley.com/doi/full/10.3322/caac.21389.2021.

Based Practice 3: System Navigation for Patient-Centered Care Overall Intent:
Image Gently.https://www.imagegently.org/.2021.•Institute of Healthcare Improvement.http://www.ihi.org/Pages/default.aspx.2021.To demonstrate knowledge of core QI concepts and how they inform the modern practice of medicine, to demonstrate an ability to conduct a QI project To effectively navigate the health care system, including the interdisciplinary team and other care providers, to adapt care to a specific patient population to ensure high-quality patient outcomes • ACR.Radiology Safety.https://www.acr.org/Clinical-Resources/Radiology-Safety.2021.• Image Gently.https://www.imagegently.org/.2021.• Image Wisely.https://www.imagewisely.org/.2021.• Institute of Healthcare Improvement.http://www.ihi.org/Pages/default.aspx.2019.• Institutional resources Systems-

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Participates in screening outreach program for patients who may have nonaccidental trauma Level 5 Analyzes the process of care coordination and leads in the design and implementation of improvements

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Works with hospital or ambulatory site team members or leadership to analyze care coordination in that setting, and takes a leadership role in designing and implementing changes to improve the care coordination process Joint Commission Center for Transforming Healthcare.Hand-off Communications Targeted Solutions Tool.https://www.centerfortransforminghealthcare.org/tsthoc.aspx.2021.• Working with the local population the resident can participate in areas within or outside of radiology (e.g., open door clinics, diabetes screening)

Based Practice 5: Contrast Agent Safety Overall Intent:
Demonstrates competence in recognizing and managing contrast (iodinated and gadolinium) reactions • Understands the multiple components of the revenue cycle applied to an MRI exam • Understands the relative value units of the differing imaging exams and how

Practice-Based Learning and Improvement 2: Reflective Practice and Commitment to Professional Growth Overall Intent:
To seek clinical performance information with the intent to improve care; reflect on all domains of practice, personal interactions, and behaviors, and their impact on patients and colleagues (reflective mindfulness); develop clear objectives and goals for improvement in some form of a learning plan • Uses feedback to set goals to read more studies each day • Analyzes QA meeting information to provide more effective and correct readings • Reflects on factors contributing to lack of efficiency • With attending assistance, develops a learning plan to improve efficiency Level 3 Episodically seeks performance data and feedback, with humility and adaptability

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Uses scores from standardized assessments (e.g., RadExam, ACR In-Training) to create a learning plan

Self-Awareness and Help-Seeking Overall Intent:
Identifies issues that could impede others from completing tasks and provides demonstrates leadership when addressing to address those issues • On-call example: senior residents advise junior residents on how to manage their time, communicate effectively, and guide ordering providers and other members of the team including technologists on-call Level 5 Takes ownership of system outcomes• Sets up a meeting with the emergency medicine department to streamline patient flow To identify, use, manage, improve, and seek help for personal and professional well-being for self and others

and Communication Skills 1: Patient-and Family-Centered Communication Overall Intent:
This subcompetency is not intended to evaluate a fellow's well-being.Rather, the intent is to ensure that each fellow has the fundamental knowledge of factors that affect wellbeing, the mechanisms by which those factors affect well-being, and available resources and tools to improve well-being.•ACGME."Well-BeingToolsandResources."https://dl.acgme.org/pages/well-being-toolsresources.2021.•AmericanAcademy of Pediatrics.Resilience Curriculum: Resilience in the Face of Grief and Loss.https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/hospicepalliative-care/Pages/Resilience-Curriculum.aspx.2021.•Localresources,including Employee Assistance Program.•StanfordMedicine.WellMD.https://wellmd.stanford.edu/.2021.To deliberately use language and behaviors to form a therapeutic relationship with a patient and family members; to identify communication barriers, including self-reflection on personal biases, and minimize them in the doctor-patient relationship; to organize and lead communication around shared decision making Explains that they are a pediatric radiology fellow during patient and family interactions• Demonstrates an understanding that communication for a patient with unexpected and difficult diagnosis at the time of imaging, such as fetal demise while undergoing an ultrasound or finding suspicious for neoplasm, must be adapted for the situation • Understands that communication may need to be adjusted for children of different ages;and for families of variable educational backgrounds Identifies need for an interpreter; speaks in a manner at a level of understanding commensurate with education level of patient, and then realizes when the presence of a caregiver will be needed to aid in management decision making; asks patient their preferred pronouns • Before and/or after communication with patient/family members, closes the loop and asks them if they are clear about what is happening with their imaging care

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Independently communicates with a patient the presence of an imaging abnormality and if potential needs include other imaging exams for further work-up such as urinary tract infection Skills needed to Set the state, Elicit information, Give information, Understand the patient, and End the encounter (SEGUE) • Standardized patients or structured case discussions Curriculum Mapping • Notes or Resources • American Academy of Hospice and Palliative Medicine.Hospice and Palliative Medicine Competencies Project.http://aahpm.org/fellowships/competencies#competencies-toolkit.2021.• Laidlaw A, Hart J. Communication skills: An essential component of medical curricula.Part I: Assessment of clinical communication: AMEE Guide No. 51.Med Teach.2011;33(1):6-8.https://www.tandfonline.com/doi/full/10.3109/0142159X.2011.531170.2021.

and Communication Skills 2: Interprofessional and Team Communication Overall Intent:
To effectively communicate with the health care team, including with consultants, in both straightforward and complex situations Accepts a request to do perform a late afternoon procedure and offers to discuss with the attending without offering resistance • Documents communication of imaging findings to the health care team; uses time/date/person talked to Level 2 Clearly and concisely responds to a consultation request Communicates emergent findings according to institutional or national guidelines • Offers consulting service guidance to clinician on the necessity of the procedure and when it can be reasonably be performed after discussion with the radiology attending physician • Communicates urgent and emergent findings within 60 minutes of observing the critical result and then documents the communication in the report; uses time/date/person talked to/info repeated back Level 3 Checks understanding of recommendations when providing consultation Communicates non-emergent findings where failure to act may adversely affect patient outcome • Communicates identification of a suspicious pulmonary nodule on chest x-ray and recommends a chest CT • Communicates finding a corner fracture on plain film and suggests further imaging for possible non-accidental trauma Role models the resolution of conflict between neurosurgery and the emergency department for MRI scan prioritization while accepting input from MRI technology and radiology administration • Coaches more junior residents in subspecialty-level communications Assessment Models or Tools • Direct observation • End-of-rotation evaluationTo help programs transition to the new version of the Milestones, the ACGME has mapped the original Milestones 1.0 to the new Milestones 2.0.Indicated below are where the subcompetencies are similar between versions.These are not exact matches, but are areas that include similar elements.Not all subcompetencies map between versions.Inclusion or exclusion of any subcompetency does not change the educational value or impact on curriculum or assessment.