The Neurology Milestone Project: A Joint Initiative of

The Neurology Milestone Project
A Joint Initiative of
The Accreditation Council for Graduate Medical Education
and
The American Board of Psychiatry and Neurology
July 2015
The Neurology Milestone Project
The milestones are designed only for use in evaluation of resident physicians 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 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.
i
Neurology Milestones
Chair: Steven L. Lewis, MD
Working Group Advisory Group

Colum Amory, MD, MPH Timothy P. Brigham, MDiv, PhD
Amar Dhand, MD, DPhil Patricia Crumrine, MD
Laura Edgar, EdD, CAE John W. Engstrom, MD
Jonathan P. Hosey, MD, FAAN Larry Faulkner, MD
Ralph Jozefowicz, MD Mary Lieh-Lai, MD
Joseph Kass, MD Janice M. Massey, MD
Chaouki Khoury, MD Meredith Runke, MD
Shannon M. Kilgore, MD
Octavia Kincaid, MD
Louise King, MS
Tracey Milligan, MD
Noor Pirzada, MD
Sonja Potrebic, MD, PhD
Patrick Reynolds, MD
David Spencer, MD
ii
Milestone Reporting
This document presents milestones designed for programs to use in semi-annual review of resident 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 resident performance as a resident
moves from entry into residency through graduation. In the initial years of implementation, the Review Committee will examine
milestone performance data for each program’s residents as one element in the Next Accreditation System (NAS) to determine
whether residents overall are progressing.
For each period, review and reporting will involve selecting milestone levels that best describe a resident’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. These levels do not correspond with post-graduate year of education.
Selection of a level implies that the resident substantially demonstrates the milestones in that level, as well as those in lower levels
(see the diagram on page v).
Level 1: The resident demonstrates milestones expected of a resident who has completed his or her first post-graduate year of
education.
Level 2: The resident is advancing and demonstrates additional milestones, but is not yet performing at a mid-residency level.
Level 3: The resident continues to advance and demonstrate additional milestones, consistently including the majority of
milestones targeted for residency.
Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency.
This level is designed as the graduation target.
Level 5: The resident has advanced beyond performance targets set for residency 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 residents will reach this level.
iii
Additional Notes
Level 4 is designed as the graduation target and does not represent a graduation requirement. Making decisions about readiness for graduation
is the purview of the residency 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.
Some milestone descriptions include statements about performing independently. These activities must conform to ACGME supervision
guidelines, as well as institutional and program policies. For example, a resident who performs a procedure independently must, at a minimum,
be supervised through oversight.
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.
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 milestone report
worksheet. For each reporting period, a resident’s performance on the milestones for each sub-competency will be indicated by:
 selecting the level of milestones that best describes that resident’s performance in relation to the milestones
or
 for Patient Care and Medical Knowledge milestones, selecting the option that says the resident has “Not yet rotated”
or
 for Interpersonal and Communication Skills, Practice-based Learning and Improvement, Professionalism, and Systems-based
Practice milestones, selecting the option that says the resident has “Not yet achieved Level 1”
Selecting a response box in the middle of a

level implies that milestones in that level and Selecting a response box on the line in between levels
in lower levels have been substantially indicates that milestones in lower levels have been
demonstrated. substantially demonstrated as well as some milestones
in the higher level(s).
v
Version 07/13 Neurology Milestones, ACGME Report Worksheet
History — Patient Care
Level 1 Level 2 Level 3 Level 4 Level 5

 Obtains a neurologic  Obtains a complete and  Obtains a complete,  Efficiently obtains a  Efficiently obtains a
history relevant neurologic relevant, and organized complete, relevant, and complete, relevant, and
history neurologic history organized neurologic organized neurologic
history history incorporating
subtle verbal and non-
verbal cues
Comments: Not yet rotated
Neurological Exam — Patient Care

 Performs complete  Performs complete  Performs a relevant  Efficiently performs a  Consistently
neurological exam neurological exam neurological exam relevant neurological demonstrates mastery in
accurately incorporating some exam accurately performing a complete,
additional appropriate incorporating all relevant, and organized
maneuvers additional appropriate neurological exam
 Visualizes papilledema maneuvers
 Accurately performs a  Accurately performs a
neurological exam on brain death examination
the comatose patient
The milestones are a product of the Neurology Milestone Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the
American Board of Psychiatry and Neurology. 1
Management/Treatment — Patient Care

 Demonstrates basic  Discusses general  Individualizes treatment  Adapts treatment based  Demonstrates
knowledge of approach to initial for specific patients on patient response sophisticated knowledge
management of patients treatment of common  Initiates management  Identifies and manages of treatment subtleties
with neurologic disease neurologic disorders, for neurologic complications of therapy and controversies
including risks and emergencies and triages  Independently directs
benefits of treatment patient to appropriate management of patients
 Identifies neurologic level of care with neurologic
emergencies  Appropriately requests emergencies
consultations from non-  Appropriately requests
neurologic care consultations from a
providers for additional neurologic subspecialist
evaluation and for additional evaluation
management or management
Comments:
Not yet rotated
Movement Disorders — Patient Care

 Recognizes when a  Identifies movement  Diagnoses and manages  Diagnoses uncommon  Manages uncommon
patient may have a disorder common movement movement disorders movement disorders
movement disorder phenomenology and disorders  Appropriately refers a  Engages in scholarly
categories (hypokinetic  Identifies movement movement disorder activity in movement
and hyperkinetic) disorder emergencies patient for a surgical disorders (e.g., teaching,
evaluation or other research)
interventional therapies
 Manages movement
disorders emergencies
Neuromuscular Disorders — Patient Care

 Recognizes when a  Identifies patterns of  Diagnoses and manages  Diagnoses uncommon  Manages uncommon
patient may have a neuromuscular disease common neuromuscular neuromuscular disorders neuromuscular disorders
neuromuscular disorder (e.g., anterior horn cell disorders  Recognizes when tissue  Engages in scholarly
disease, nerve root,  Manages neuromuscular biopsy is warranted activity in
plexus, peripheral nerve, disorder emergencies neuromuscular disorders
neuromuscular junction,  Interprets results of (e.g., teaching, research)
muscle) NCS/EMG testing in
 Identifies neuromuscular context of clinical
disorder emergencies presentation
 Orders NCS (nerve
conductive study)/EMG
(electromyography)
testing appropriately
Cerebrovascular Disorders — Patient Care

 Recognizes when a  Describes stroke  Identifies specific  Diagnoses uncommon  Manages uncommon
patient may have a syndromes and etiologic mechanism of patient’s cerebrovascular cerebrovascular
cerebrovascular disorder subtypes cerebrovascular disorder disorders disorders
 Identifies  Appropriately refers for  Engages in scholarly
cerebrovascular interventional or surgical activity in
emergencies evaluation cerebrovascular
 Lists indications and  Manages common disorders (e.g., teaching,
contraindications for cerebrovascular research)
intravenous disorders including
thrombolytic therapy appropriate use of
thrombolytics
Comments:
Not yet rotated
Cognitive/Behavioral Disorders — Patient Care

 Recognizes when a  Identifies common  Diagnoses and manages  Diagnoses and manages  Engages in scholarly
patient may have a cognitive/behavioral common uncommon activity in
cognitive/behavioral disorders cognitive/behavioral cognitive/behavioral cognitive/behavioral
disorder disorders, including disorders disorders (e.g., teaching,
cognitive effects of research)
traumatic brain injury  Demonstrates
 Manages behavioral sophisticated knowledge
complications of of advanced diagnostic
cognitive/behavioral testing and
disorders controversies
 Appropriately refers for
neuropsychological
testing in evaluating
patients with
cognitive/behavioral
disorders
Demyelinating Disorders — Patient Care

 Recognizes when a  Diagnoses and manages  Recognizes uncommon  Diagnoses uncommon  Manages uncommon
patient may have a common demyelinating demyelinating disorders demyelinating disorders demyelinating disorders
demyelinating disorder disorders  Manages acute  Engages in scholarly
presentations of activity in demyelinating
demyelinating disorders disorders (e.g., teaching,
research)
Epilepsy — Patient Care

 Recognizes when a  Identifies epilepsy  Diagnoses and manages  Diagnoses uncommon  Manages uncommon
patient may have had a phenomenology, and common seizure seizure disorders seizure disorders
seizure classification of seizures disorders and provides  Appropriately refers an  Engages in scholarly
and epilepsies antiepileptic drug epilepsy patient for activity in epilepsy (e.g.,
 Diagnoses convulsive treatment surgical evaluation or teaching, research)
status epilepticus  Diagnoses non- other interventional
convulsive status therapies
epilepticus
 Manages convulsive and
non-convulsive status
epilepticus
Headache Syndromes — Patient Care

 Recognizes common  Diagnoses and manages  Recognizes uncommon  Diagnoses and manages  Engages in scholarly
headache syndromes common headache headache syndromes uncommon headache activity in headache
syndromes  Diagnoses and manages syndromes syndromes (e.g.,
 Identifies headache headache emergencies teaching, research)
emergencies
Comments:
Not yet rotated
Neurologic Manifestations of Systemic Disease — Patient Care

 Recognizes when a  Diagnoses and manages  Recognizes uncommon  Diagnoses and manages  Engages in scholarly
patient’s neurologic common neurologic neurologic uncommon neurologic activity in neurologic
symptoms may be due manifestations of manifestations of manifestations of manifestations of
to systemic illness systemic diseases systemic disease systemic disease systemic disease (e.g.,
 Identifies neurologic  Diagnoses and manages teaching, research)
emergencies due to neurologic emergencies
systemic disease due to systemic disease
Child Neurology for the Adult Neurologist — Patient Care

 Obtains basic neurologic  Lists the elements of a  Obtains a complete and  Initiates management of  Diagnoses uncommon
history of infants and neurological age-appropriate common childhood childhood neurologic
children examination of infants neurologic history of neurologic disorders disorders
and children infants and children  Initiates management of
 Recognizes broad  Performs a complete common neurologic
patterns of neurologic and age-appropriate emergencies in infants
disease in infants and neurological and children
children examination of infants
 Lists normal and children
developmental  Diagnoses common child
milestones neurologic disorders
Comments:
Not yet rotated
Neuro-Oncology — Patient Care

 Recognizes common  Identifies neuro-  Provides differential  Appropriately refers for  Engages in scholarly
clinical presentations of oncological emergencies diagnosis of brain or advanced testing, activity in neuro-
a brain or spine mass and initiates spine mass including biopsy oncology (e.g., teaching,
management  Identifies neurologic  Manages neurologic research)
complications due to complications due to
cancer or the treatment cancer or the treatment
of cancer of cancer
Psychiatry for the Adult Neurologist — Patient Care

 Recognizes when a  Identifies common  Recognizes when a  Diagnoses common  Engages in scholarly
patient may have a psychiatric disorders patient’s neurological psychiatric disorders activity in psychiatric
psychiatric disorder  Identifies psychiatric co- symptoms are of  Initiates management of disorders (e.g., teaching,
 Obtains an appropriate morbidities in patients psychiatric origin psychiatric co- research)
psychiatric history with a neurologic  Recognizes when a morbidities in patients
disease patient’s psychiatric with a neurologic
symptoms are of disease
neurologic origin
 Identifies major side
effects of psychiatric
medications
Neuroimaging — Patient Care

 Identifies basic  Recognizes emergent  Describes abnormalities  Interprets MR and CT  Identifies subtle
neuroanatomy on brain imaging findings on of the brain and spine neuroimaging of brain abnormalities on
magnetic brain MR and CT on MR and CT and spine angiography
resonance (MR) and  Identifies basic  Identifies major  Interprets carotid and
computerized neuroanatomy on spine abnormalities on transcranial ultrasound
tomography (CT) MR and CT angiography
 Identifies major vascular
anatomy on angiography
Comments:
Not yet rotated
Electroencephalogram (EEG) — Patient Care
 Explains an EEG  Uses appropriate  Describes normal EEG  Interprets common EEG  Interprets uncommon
procedure in non- terminology related to features of wake and abnormalities and EEG abnormalities
technical terms EEG (e.g., montage, sleep states creates a report  Describes normal and
amplitude, frequency)  Recognizes EEG patterns  Recognizes normal EEG some abnormal EEG
of status epilepticus variants features of wake and
 Recognizes common EEG sleep states in children
artifacts
Comments:
Not yet rotated
Nerve Conduction Studies (NCS)/Electromyography (EMG) — Patient Care

 Explains an NCS/EMG  Uses appropriate  Describes NCS/EMG  Interprets NCS/EMG  Performs, interprets,
procedure in terminology related to data data in common and creates a report for
nontechnical terms NCS/EMG  Lists NCS/EMG findings disorders NCS/EMG
in common disorders  Describes common
pitfalls of NCS/EMG
 Formulates basic
NCS/EMG plan for
specific, common clinical
presentations
Lumbar Puncture — Patient Care

 Lists the indications and  Lists the complications  Performs lumbar  Performs lumbar  Performs lumbar
contraindications for of lumbar puncture and puncture under direct puncture without direct puncture on patients
lumbar puncture their management supervision supervision with challenging
anatomy
Localization — Medical Knowledge

 Attempts to localize  Localizes lesions to  Accurately localizes  Efficiently and  Consistently
lesions within the general regions of the lesions to specific accurately localizes demonstrates
nervous system nervous system regions of the nervous lesions to specific sophisticated and
 Describes basic system regions of the nervous detailed knowledge of
neuroanatomy system neuroanatomy in
 Describes advanced localizing lesions
neuroanatomy
Comments:
Not yet rotated
Formulation — Medical Knowledge

 Summarizes history and  Summarizes key  Synthesizes information  Efficiently synthesizes  Consistently
exam findings elements of history and to focus and prioritize information to focus and demonstrates
exam findings diagnostic possibilities prioritize diagnostic sophisticated and
 Identifies relevant  Correlates the clinical possibilities detailed knowledge of
pathophysiologic presentation with basic  Accurately correlates pathophysiology in
categories to generate a anatomy of the disorder the clinical presentation diagnosis
broad differential with detailed anatomy  Effectively educates
diagnosis of the disorder others about diagnostic
 Continuously reasoning
reconsiders diagnostic
differential in response
to changes in clinical
circumstances
 Diagnoses brain death
Comments:
Not yet rotated
Diagnostic Investigation — Medical Knowledge

 Demonstrates general  Discusses general  Individualizes diagnostic  Explains diagnostic yield  Demonstrates
knowledge of diagnostic diagnostic approach approach to the specific and cost-effectiveness of sophisticated knowledge
tests in neurology appropriate to clinical patient testing of diagnostic testing and
presentation  Accurately interprets  Accurately interprets controversies
 Lists risks and benefits of results of common results of less common
tests to patient diagnostic tests diagnostic testing
 Recognizes indications
and implications of
genetic testing
 Recognizes indications
of advanced imaging and
other diagnostic studies
Systems thinking, including cost and risk effective practice — Systems-based Practice

 Describes basic cost and  Describes cost and risk  Makes clinical decisions  Incorporates available  Engages in scholarly
risk implications of care benefit ratios in patient that balance cost and quality measures in activity regarding cost-
care risk benefit ratios patient care and risk-effective
practice
Comments: Not yet achieved Level 1
Work in inter-professional teams to enhance patient safety — Systems-based Practice

 Describes team  Identifies and reports  Describes potential  Participates in a team-  Engages in scholarly
members’ roles in errors and near-misses sources of system failure based approach to activity regarding error
maintaining patient in clinical care such as medical error analysis analysis and patient
safety minor, major, and safety
sentinel events
Comments:
Not yet achieved Level 1
Self-directed learning — Practice-based Learning and Improvement

 Identify strengths, deficiencies, and limits in one’s knowledge and expertise
 Set learning and improvement goals
 Identify and perform appropriate learning activities
 Use information technology to optimize learning
 Acknowledges gaps in  Incorporates feedback  Develops an appropriate  Completes an  Engages in scholarly
knowledge and learning plan based appropriate learning activity regarding
expertise upon clinical experience plan based upon clinical practice-based learning
experience and improvement
Locate, appraise, and assimilate evidence from scientific studies related to the patient’s health problems – Practice-based Learning and
Improvement
 Uses information  Uses scholarly articles  Critically evaluates  Incorporates  Engages in scholarly
technology to search and guidelines to answer scientific literature appropriate evidence- activity regarding
and access relevant patient care issues based information into evidence-based
medical information patient care medicine
 Understands the limits
of evidence-based
medicine in patient care
Compassion, integrity, accountability, and respect for self and others — Professionalism

 Demonstrates  Demonstrates  Demonstrates  Mentors others in the  Engages in scholarly
compassion, sensitivity, appropriate steps to compassionate practice compassionate practice activity regarding
and responsiveness to address impairment in of medicine, even in of medicine, even in professionalism
patients and families self context of disagreement context of disagreement
 Demonstrates non-  Consistently with patient beliefs with patient beliefs
discriminatory behavior demonstrates  Incorporates patients’  Mentors others in
in all interactions, professional behavior, socio-cultural needs and sensitivity and
including diverse and including dress and beliefs into patient care responsiveness to
vulnerable populations timeliness  Demonstrates diverse and vulnerable
 Describes effects of appropriate steps to populations
sleep deprivation and address impairment in  Advocates for quality
substance abuse on colleagues patient care
performance
Comments:
Knowledge about, respect for, and adherence to the ethical principles relevant to the practice of medicine, remembering in particular that
responsiveness to patients that supersedes self-interest is an essential aspect of medical practice — Professionalism

 Describes basic ethical  Determines presence of  Analyzes and manages  Analyzes and manages  Demonstrates
principles ethical issues in practice ethical issues in ethical issues in complex leadership and
straightforward clinical clinical situations mentorship on applying
situations ethical principles
Relationship development, teamwork, and managing conflict — Interpersonal and Communication Skills

 Develops a positive  Manages simple  Manages conflict in  Manages conflict across  Engages in scholarly
relationship with patient/family-related complex situations specialties and systems activity regarding
patients in conflicts  Uses easy-to-understand of care teamwork and conflict
uncomplicated  Engages patients in language in all phases of  Leads team-based management
situations shared decision-making communication patient care activities
 Actively participates in
team-based care
Comments:
Information sharing, gathering, and technology — Interpersonal and Communication Skills

 Effectively  Effectively  Effectively  Effectively leads family  Develops patient
communicates during communicates during communicates the meetings education materials
patient hand-overs using team meetings, results of a neurologic  Effectively and ethically  Engages in scholarly
a structured discharge planning, and consultation in a timely uses all forms of activity regarding
communication tool other transitions of care manner communication interpersonal
 Completes  Educates patients about  Effectively gathers  Mentors colleagues in communication
documentation in a their disease and information from timely, accurate, and
timely fashion management, including collateral sources when efficient documentation
 Accurately documents risks and benefits of necessary
transitions of care treatment options  Demonstrates synthesis,
 Completes all formulation, and
documentation thought process in
accurately, including use documentation
of EHR, to promote
patient safety
Comments:

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The Neurology Milestone Project

The American Board of Psychiatry and Neurology

Chair: Steven L. Lewis, MD

Working Group Advisory Group

Selecting a response box in the middle of a

History — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Comments: Not yet rotated

Neurological Exam — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Comments: Not yet rotated

Management/Treatment — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Movement Disorders — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Comments: Not yet rotated

Neuromuscular Disorders — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Comments: Not yet rotated

Cerebrovascular Disorders — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Cognitive/Behavioral Disorders — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Comments: Not yet rotated

Demyelinating Disorders — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Comments: Not yet rotated

Epilepsy — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Comments: Not yet rotated

Headache Syndromes — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Neurologic Manifestations of Systemic Disease — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Comments: Not yet rotated

Child Neurology for the Adult Neurologist — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Neuro-Oncology — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Comments: Not yet rotated

Psychiatry for the Adult Neurologist — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Comments: Not yet rotated

Neuroimaging — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Electroencephalogram (EEG) — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Nerve Conduction Studies (NCS)/Electromyography (EMG) — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Comments: Not yet rotated

Lumbar Puncture — Patient Care

Level 1 Level 2 Level 3 Level 4 Level 5

Comments: Not yet rotated

Localization — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5

Formulation — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5

Diagnostic Investigation — Medical Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5

Comments: Not yet rotated

Level 1 Level 2 Level 3 Level 4 Level 5

Comments: Not yet achieved Level 1