Assessment Of Milestones Research Articles

P.117 Quantitative evaluation in competency-based medical education – a nationwide survey of the spinal surgical training landscape

Background: The competency-based medical education (CBME) model has been recently implemented in spinal neurosurgical and orthopedic residencies. This model is grounded on entrustable professional activities (EPAs) that allow the assessment of clinical milestones. Integrating quantitative metrics to evaluate procedural competencies could refine the assessment’s scope. This survey, administered to program directors (PDs), aims to evaluate the current state and anticipated needs for quantitative evaluation to develop innovative assessment techniques. Methods: We surveyed 32 PDs of neurosurgical (N=14) and orthopedics (N=16) programs with a spine service via RedCap. We collected information on the programs’ characteristics. We inquired about existing assessment methods and the perceived values of developing quantitative metrics to assess spinal technical competencies using thirteen questions. Results: The response rate was 53%. All programs use EPAs to assess procedural competencies through direct observation in the operation room. One surgical program employed quantitative metrics for examination. Four PD valued the profitability of quantitative evaluation methods in a clinical or simulatory context. Conclusions: The use of quantitative metrics to assess spinal surgical competencies in Canadian neurosurgical and orthopedic residency programs is seldom. Despite its underutilization, PDs acknowledge the potential for quantitation to improve the accuracy and reliability of CBME assessments in both simulated and clinical settings.

A study on the effects of three game intervention programs on executive functions of preschool autistic children

Executive dysfunction has been widely reported in children with autism spectrum disorder (ASD). Although studies have demonstrated the intervention effect of sports game and pretend play on children’s executive function, few studies have examined the effect of Comprehensive games, and similar studies in children with ASD are scarce. In order to investigate the effect of different games on the executive functions of preschool children with ASD, 24 preschool children with ASD were selected in this study. According to the results in the executive function Pre-test, measured by the autistic children’s behavior scale and in the verbal behavior milestone assessment, the subjects were divided into three groups, and received 8 wk’ sports games, pretend play and comprehensive games interventions respectively. After the first 4 wk’ intervention, their executive functions undertook a mid-test, and the final assessment was done at the end the following 4 wk. The results showed that: (1) sports games significantly improved the working memory and cognitive flexibility of preschool children with ASD. The early stage could see the intervention effect on their working memory, while the effect on cognitive flexibility was shown in the late stage; (2) Pretend play effectively improved the working memory and cognitive flexibility of preschool children with ASD, and the intervention effect emerged in the late stage; (3) comprehensive game effectively improved the working memory and cognitive flexibility of preschoolers with ASD both before and after the intervention, and the improvement of inhibitory control has reached a marginal significant level. The intervention effect of comprehensive game was better than that of single sports games or pretends play. The results of this study have both theoretical and practical significance for the intervention of ASD children’s cognitive development.

Resident Self-assessment and Clinical Competency Committee Evaluations in Family Medicine: A Single-Institution Study.

We sought to describe the process of integrating resident self-assessments into milestone assessments at the University of Texas Medical Branch Family Medicine Residency Program in Galveston, Texas. We compared resident self-assessments across milestones to Clinical Competency Committee (CCC) assessments across terms (fall versus spring) and by postgraduate year (PGY). In fall 2020, the milestone assessment process was updated to include a resident milestone self-assessment, which was used as the starting point for CCC assessment. We calculated mean and standard deviation of average milestone scores for both self-assessment and CCC for each PGY. We used repeated measure analysis of variance to examine within- and between-subject effects. Self-assessment and CCC assessments were completed for 30 postgraduate trainees for spring 2020 and fall 2021 terms, for a total of 60 self- and 60 CCC assessments. CCC score was similar to self-assessment. There were larger variations in the resident self-assessment scores than CCC scores. Self-assessment scores increased by PGY, but were not different between fall and spring terms. We found a significant three-way interaction of assessors, terms, and PGYs. Resident milestone self-assessment enables residents to participate in the assessment process, and when differences exist between self- and CCC assessments, specific feedback can be given based on individual milestone skills. Our study showed progression between PGY regardless of the assessor, but only CCC assessment showed significant differences between terms.

Treatments and Outcomes for Patients with Spinal Muscular Atrophy Type 2: Findings from RESTORE Registry (P7-9.010)

Treatments and Outcomes for Patients with Spinal Muscular Atrophy Type 2: Findings from RESTORE Registry (P7-9.010)

A Longitudinal Experience and Annual “Check-Ins” to Increase Resident EEG and EMG Milestone Attainment and Improve Milestone Rating Accuracy (P1-2.002)

<h3>Objective:</h3> To determine if a longitudinal approach to EEG and EMG education with annual individual formative “check-ins” resulted in meaningful changes in quality and quantity of resident Milestone assessments. <h3>Background:</h3> By graduation, neurology residents are expected to achieve Level 4 ACGME Milestone proficiency at EEG and EMG interpretation. Surveys on EEG/EMG education in neurology residency reveal a wide range of exposure to these topics, approaches to assessment, and discrepancies between programs’ assessments of competence versus residents’ confidence in these skills. <h3>Design/Methods:</h3> Starting in 2020, residents in our program underwent annual individual “check-ins” with faculty to review a standard set of EEG and EMG studies. Anonymized semi-annual Milestone scores from 2014 to 2022 were reviewed, and scores were compared before and after initiation of the “check-ins.” Outcomes included the number of assessment points submitted (an indicator of how often these Milestones were recorded earlier in residency) and the proportion of graduating residents attaining the Level 4 Milestone. <h3>Results:</h3> Before the initiation of “check-ins,” there were missing Milestone scores for 17% (49/290) and 21% (60/290) of assessment points in EEG and EMG, respectively, mainly from PGY2 reports. Post-intervention, this significantly decreased to 1% (1/150, p&lt;0.001) for EEG, but not for EMG (20% [30/150], p = 0.865). Pre-intervention, resident Milestone achievement of at least Level 4 by graduation was 63% (26/41) for EEG and 17% (7/41) for EMG; this increased to 81% (25/31) for EEG (p = 0.111), and 52% (16/31) for EMG (p = 0.002). <h3>Conclusions:</h3> A longitudinal curriculum with annual “check-ins” significantly improved ability to track EEG Milestone progress. The proportion of graduating residents achieving Milestone goals for EMG increased significantly, and there was a trend toward higher attainment levels for EEG. We propose that these “check-ins” provide residents and programs with more accurate individualized feedback to better target future learning and program improvement. <b>Disclosure:</b> Dr. Sutherland has received personal compensation in the range of $0-$499 for serving as a Consultant for McGraw-Hill. Dr. Bower has nothing to disclose. Dr. Zuchowski has nothing to disclose. Dr. Dewey has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for United States. Dr. Moeller has received publishing royalties from a publication relating to health care.

Outcomes in Patients with Spinal Muscular Atrophy and Four or More SMN2 Copies Treated with Onasemnogene Abeparvovec: Findings from RESTORE (P7-9.007)

Outcomes in Patients with Spinal Muscular Atrophy and Four or More SMN2 Copies Treated with Onasemnogene Abeparvovec: Findings from RESTORE (P7-9.007)

Cold Spray Coatings of Complex Concentrated Alloys: Critical Assessment of Milestones, Challenges, and Opportunities

Complex concentrated alloys (CCAs) are structural and functional materials of the future with excellent mechanical, physical, and chemical properties. Due to the equiatomic compositions of these alloys, cost can hinder scalability. Thus, the development of CCA-based coatings is critical for low-cost applications. The application of cold spray technology to CCAs is in its infancy with emphasis on transition elements of the periodic table. Current CCA-based cold spray coating systems showed better adhesion, cohesion, and mechanical properties than conventional one-principal element-based alloys. Comprehensive mechanical behavior, microstructural evolution, deformation, and cracking of cold spray CC-based coatings on the same and different substrates are reviewed. Techniques such as analytical models, finite element analysis, and molecular dynamic simulations are reviewed. The implications of the core effects (high configurational entropy and enthalpy of mixing, sluggish diffusion, severe lattice distortion, and cocktail behavior) and interfacial nanoscale oxides on the structural integrity of cold spray CCA-based coatings are discussed. The mechanisms of adiabatic heating, jetting, and mechanical interlocking, characteristics of cold spray, and areas for future research are highlighted.

The associations between stunting and wasting at 12 months of age and developmental milestones delays in a cohort of Cambodian children

Worldwide, over 250 million children under 5 years do not reach their developmental potential due to several causes, including malnutrition. In Cambodia, the prevalence of stunting and wasting among children remains high. This prospective cohort study aimed to assess acquisition of motor and cognitive developmental milestones in early childhood and their associations with stunting and wasting. Children aged from 0 to 24 months were recruited from three provinces in Cambodia and followed up to seven times from March 2016 to June 2019, until their 5 years. Data collection included anthropometry and developmental milestones. Seven motor and seven cognitive milestones were evaluated using the Cambodian Development Milestone Assessment Tool. Associations were assessed with parametric survival models. Hazard ratios (HR) below 1 stood for lower probabilities for achieving developmental milestones. Data were available for 7394 children. At 12 months, the prevalence of stunting and wasting were 23.7% and 9.6% respectively. Both were consistently associated with delays in most motor and cognitive milestones. Stunting was strongly associated with delays in gross motor milestones (HR < 0.85; p < 0.001). Wasting was more strongly associated with delays in fine motor development and most cognitive milestones (HR < 0.75; p < 0.001). Promoting nutritional programs in the first 1000 days to prevent malnutrition is essential to further the optimal growth and motor and cognitive development of Cambodian children.

P.105 Safety and effectiveness of onasemnogene abeparvovec (OA) alone or with other disease-modifying therapies (DMTs): Findings from RESTORE

We aimed to describe real-world safety and effectiveness of OA alone or in combination with other DMTs for patients with SMA. RESTORE is an ongoing, prospective, multicenter, multinational, observational SMA patient registry. We evaluated patients with 2 or 3 SMN2 gene copies receiving OA alone or with any other DMTs. As of Nov. 23, 2021, data were available for 247 patients who received OA: 121 (49.0%) received OA alone (group 1); 48 (19.4%) received OA before (group 2); and 78 (31.6%) received OA after (group 3) another DMT. All patients in group 3 received nusinersen, and none received risdiplam. Of patients with ≥2 milestone assessments (≥1 post-OA administration; n=112), 71 (63.4%) achieved new milestones: 35 (49.3%) in group 1, 15 (21.1%) in group 2, and 21 (29.6%) in group 3. There was no significant difference in time to first milestone achievement after OA administration among groups (p=0.2). Median changes in CHOP INTEND scores for Groups 1, 2, and 3 were 11 (n=43; 38 [88.4%] achieved increase of ≥4 points), 11 (n=19; 16 [84.2%] achieved increase of ≥4 points), and 4 (n=33; 20 [60.6%] achieved increase of ≥4 points), respectively. Median changes in HFMSE scores for groups 1, 2, and 3 were 13.5 (n=12; 10 [83.3%] achieved increase of ≥3 points), 5 (n=9; 6 [66.7%] achieved increase of ≥3 points), and 4 (n=10; 7 [70%] achieved increase of ≥3 points), respectively. Median changes in HINE scores for groups 1, 2, and 3 were 6.5 (n=14), 6.5 (n=6), and 3.5 (n=8), respectively. Any-grade treatment-emergent AEs were recorded in groups 1, 2, and 3 for 51 (42.2%; 23 [19.0%] with grade ≥3), 28 (58.3%; 15 [31.3%] with grade ≥3), and 49 (62.8%; 26 [33.3%] with grade ≥3) patients, respectively. No new safety signals were identified. Real-world effectiveness was observed for patients receiving OA monotherapy and in patients who switched from nusinersen or who received subsequent DMTs. Patients who received nusinersen experienced more frequent and severe AEs.

P.37 Outcomes in patients with spinal muscular atrophy and four or more SMN2 copies treated with onasemnogene abeparvovec: Findings from RESTORE

Onasemnogene abeparvovec (OA) is a one-time gene replacement therapy for spinal muscular atrophy (SMA). While clinical trials of OA included patients with two or three SMN2 gene copies, patients with four or more copies may be treated in clinical practice. Natural history and outcomes following SMA treatment have not been well-characterized for these patients. We sought to describe clinical outcomes after OA monotherapy for patients with four or more SMN2 copies in RESTORE, a prospective SMA registry. We evaluated baseline characteristics, and post-treatment motor function, motor milestone achievement, use of ventilatory/nutritional support, and adverse events (AEs). Patients evaluable for motor function or milestone achievement had ≥2 assessments, with ≥1 after OA. Seven children with four SMN2 copies and five with more than four copies were included. All 12 cases were identified by newborn screening in the United States and treated presymptomatically. Median age at OA was 3 months (range, 1–11). Two of three children with evaluable motor milestone assessments achieved new milestones. All three children evaluable for CHOP INTEND maintained or achieved the maximum score of 64 points. One child was evaluable for HINE and achieved a 6-point increase. Five children with recorded AE data had ≥1 treatment-emergent AE (mainly Grade 1 LFT and/or troponin elevations without relevant clinical signs). Two children reported AEs ≥Grade 3 (one had otitis media and one with history of fetal stroke had seizure ∼3.5 months post-OA). No deaths or use of ventilatory/nutritional support were reported. Patients with four or more SMN2 gene copies attained improvements in motor function and achieved new milestones after treatment with OA. Presentation of SMA with four or more SMN2 copies is heterogeneous, and laboratory determination of SMN2 copy number may be unreliable, highlighting the importance of early identification and intervention to optimize outcomes for all SMA patients.

P.104 Treatments and outcomes for patients with spinal muscular atrophy (SMA) type 2: Findings from RESTORE registry

We aimed to describe real-world treatment patterns/outcomes for patients with SMA type 2 (SMA2). RESTORE is an ongoing SMA patient registry. We analyzed changes in motor milestones and disability scores and assessed treatment-emergent adverse events (TEAEs) for patients who received ≥1 disease-modifying therapy (DMT; gene therapy [onasemnogene abeparvovec (OA)] or SMN2 modulator [nusinersen/risdiplam]). As of Nov. 23, 2021, RESTORE included 48 patients with SMA2, and 29 (60.4%) were female. Eight (16.7%), 37 (77.1%), 2 (4.2%) and 1 (2.1%) had 2, 3, 4 and ≥4 SMN2 gene copies, respectively. Median age at SMA diagnosis was 14.0 months and at first DMT administration, 16.0 months. Median interval between diagnosis and first DMT was 1 month. Median age at first DMT differed between groups (p=0.0033): OA monotherapy, 16.5 months (n=24); nusinersen monotherapy, 25 months (n=10); risdiplam monotherapy, 8 months (n=1); switching from other DMT to OA, 12 months (n=11); and receiving add-on therapy to OA, 15.5 months (n=2). Of 26 patients with ≥2 motor milestone assessments (≥1 post-DMT administration), all but 4 (OA only [n=3], nusinersen only [n=1]) maintained or achieved new milestones: 13 (59.1%) received OA monotherapy; 6 (27.3%) switched from nusinersen to OA; 1 (4.5%) received add-on to OA; and 2 (9.1%) received nusinersen only. Median HFMSE score change was 5.5 (n=10), with median monthly change of 0.6 (n=10) for all patients, and 11.0 (n=5), with median monthly change of 0.7 (n=6) for patients receiving OA monotherapy. Any-grade TEAEs were recorded for 12/24 (50%) patients who received OA monotherapy, 7/11 (63.6%) who switched from nusinersen to OA, and 1/2 (50%) who received add-on treatment to OA. Of patients who received OA, 3 required non-oral feeding support and 2 required BiPAP ventilation. AEs in RESTORE are consistent with OA experience. No new safety signals were identified. OA is effective and has an acceptable safety profile for patients with SMA2.

Predicting Performance at Graduation From Early ACGME Milestone Ratings: Longitudinal Learning Analytics in Professionalism and Communication in Vascular Surgery

Program directors in surgical disciplines need more tools from the ACGME to help them use Milestone ratings to improve trainees' performance. This is especially true in competencies that are notoriously difficult to measure, such as professionalism (PROF) and interpersonal and communication skills (ICS). It is now widely understood that skills in these two areas have direct impact on patient care outcomes. This study investigated the potential for generating early predictors of final Milestone ratings within the PROF and ICS competency categories. This retrospective cohort study utilized Milestone ratings from all ACGME-accredited vascular surgery training programs, covering residents and fellows who completed training in June 2019. The outcome measure studied was the rate of achieving the recommended graduation target of Milestone Level 4 (possible range: 1-5), while the predictors were the Milestone ratings attained at earlier stages of training. Predictive probability values (PPVs) were calculated for each of the 3 PROF and two ICS sub-competencies to estimate the probability of trainees not reaching the recommended graduation target based on their previous Milestone ratings. All ACGME-accredited vascular surgery training programs within the United States. All trainees completing a 2 year vascular surgery fellowship (VSF) in June 2019 (n = 119) or a 5 year integrated vascular surgery residency (IVSR) in June 2019 (n = 52) were included in the analyses. The overall rate of failing to achieve the recommended graduation target across all PROF and ICS sub-competencies ranged from 7.7% to 21.8% of all trainees. For trainees with a Milestone rating at ≤ 2.5 with 1 year remaining in their training program, the predictive probability of not achieving the recommended graduation target ranged from 37.0% to 71.5% across sub-competencies, with the highest risks observed under PROF for "Administrative Tasks" (71.5%) and under ICS for "Communication with the Healthcare Team" (56.7%). As many as 1 in 4 vascular surgery trainees did not achieve the ACGME vascular surgery Milestones targets for graduation in at least one of the PROF and ICS sub-competencies. Biannual ACGME Milestone assessment ratings of PROF and ICS during early training can be used to predict achievement of competency targets at time of graduation. Early clues to problems in PROF and ICS enable programs to address potential deficits early in training to ensure competency in these essential non-technical skills prior to entering unsupervised practice.

Teaching Self-directed Learning Skills Through a Resident-Led Milestones Process.

The Accreditation Council for Graduate Medical Education allows flexibility for resident roles in the Milestone assessment process. The University of Utah Family Medicine Residency implemented a resident-led Milestones process to cultivate the skill of self-assessment and promote resident ownership of their learning. Residents were provided comprehensive evaluation data and asked to self-assess their competency on each Milestone, with input from their advisor. Residents presented their self-assessment to the Clinical Competency Committee, who then determined the final score for each Milestone. A 10-question survey examined perceptions of the resident-led Milestones process by residents and faculty. We calculated means and standard deviations (SD). A total of 16 of 24 residents (67% response rate) and 12 of 14 faculty (86% response rate) completed the survey. Residents agreed most highly with the following statements: "I have good support from my advisor in being prepared to lead my Milestones meeting," "I am actively engaged in guiding the development of my own Milestones ratings," and "Leading my Milestones meeting assists me in accurately self-assessing my progress." Residents showed high agreement that "My final Milestones scores accurately reflect my behavior and level of knowledge." Residents rated the stress as low, in response to the statement, "My Milestones meeting is stressful for me." Faculty responses were similar but tended toward lower scores than residents. The resident-led Milestones process engages residents actively in self-assessment. Residents and faculty believe the process provides accurate assessment results without undue stress; this process potentially increases residents' ability to understand their own learning needs and direct their own learning process.

Assessment of neurosurgical resident milestone evaluation reporting and feedback processes.

Structured performance evaluations are important for the professional development and personal growth of resident learners. This process is formalized by the Accreditation Council for Graduate Medical Education milestones assessment system. The primary aim of this study was to understand the current feedback delivery mechanism by exploring the culture of feedback, the mechanics of delivery, and the evaluation of the feedback itself. Face-to-face interviews were conducted with 10 neurosurgery residents exploring their perceptions of summative feedback. Coded data were analyzed qualitatively for overriding themes using the matrix framework method. A priori themes of definition of feedback, feedback delivery, and impact of feedback were combined with de novo themes discovered during analysis. Trainees prioritized formative over summative feedback. Summative and milestone feedback were criticized as being vague, misaligned with practice, and often perceived as erroneous. Barriers to implementation of summative feedback included perceived veracity of feedback, high interrater variability, and the inconstant adoption of a developmental progression model. Gender bias was noted in degree of feedback provided and language used. Trainee perception of feedback provided multiple areas of improvement. This paper can serve as a baseline to study improvements in the milestone feedback process and optimize learning.

Improving Recognition of Treatable Rare Neuromuscular Disorders in Primary Care: A Pilot Feasibility Study.

Innovative targeted treatments for neuromuscular disorders (NMDs) can dramatically improve the course of illness. Diagnostic delay, however, is a major impediment. Here, we present a pilot project aimed at assessing the feasibility of a screening program to identify children at high risk for NMDs within the first 30 months of life. The Promoting Early Diagnosis for Neuromuscular Disorders (PEDINE) project implemented a three-step sequential screening in an area of about 300,000 people with (1) an assessment of the motor development milestones to identify “red flags” for NMDs by primary care pediatricians (PCPs) as part of the routine Health Status Check visits; (2) for the children who screened positive, a community neuropsychiatric assessment, with further referral of suspected NMD cases to (3) a hospital-based specialized tertiary care center. In the first-year feasibility study, a total of 10,032 PCP visits were conducted, and twenty children (0.2% of the total Health Status Check visits) screened positive and were referred to the community neuropsychiatrist. Of these, four had elevated creatine kinase (CK) serum levels. This pilot study shows that screening for NMDs in primary care settings is feasible and allows children at high risk for muscular disorder to be promptly identified.

Biomarkers and neuromonitoring for prognosis of development after perinatal brain damage

Das sich entwickelnde Gehirn ist in der Perinatalperiode besonders empfindlich für eine Vielzahl von Insulten, wie z. B. Extremfrühgeburtlichkeit und perinatale Asphyxie. Ihre Komplikationen können zu lebenslangen neurokognitiven, sensorischen und psychosozialen Einschränkungen führen; deren Vorhersage bleibt eine Herausforderung. Eine Schlüsselfunktion kommt der möglichst exakten Identifikation von Hirnläsionen und funktionellen Störungen zu. Die Prädiktion stützt sich auf frühe diagnostische Verfahren und die klinische Erfassung der Meilensteine der Entwicklung. Zur klinischen Diagnostik und zum Neuromonitoring in der Neonatal- und frühen Säuglingsperiode stehen bildgebende Verfahren zur Verfügung. Hierzu zählen zerebrale Sonographie, MRT am errechneten Termin, amplitudenintegriertes (a)EEG und/oder klassisches EEG, Nah-Infrarot-Spektroskopie, General Movements Assessment und die frühe klinische Nachuntersuchung z. B. mithilfe der Hammersmith Neonatal/Infant Neurological Examination. Innovative Biomarker und -muster (Omics) sowie (epi)genetische Prädispositionen sind Gegenstand wissenschaftlicher Untersuchungen. Neben der Erfassung klinischer Risiken kommt psychosozialen Faktoren im Umfeld des Kindes eine entscheidende Rolle zu. Eine möglichst akkurate Prognose ist mit hohem Aufwand verbunden, jedoch zur gezielten Beratung der Familien und der Einleitung von frühen Interventionen, insbesondere vor dem Hintergrund der hohen Plastizität des sich entwickelnden Gehirns, von großer Bedeutung. Diese Übersichtsarbeit fokussiert die Charakterisierung der oben genannten Verfahren und ihrer Kombinationsmöglichkeiten. Zudem wird ein Ausblick gegeben, wie innovative Techniken in Zukunft die Prädiktion der Entwicklung und Nachsorge dieser Kinder vereinfachen können.

Longitudinal assessment of milestone development among internal medicine residents in Taiwan

The Accreditation Council for Graduate Medical Education (ACGME) milestones have been implemented in residency training worldwide. We investigated the development of individual competency in first-year residents (R1) and second-year postgraduate students (PGY2) who received internal medicine training in Taiwan. A multicenter observational cohort study was conducted to evaluate the competency-based milestone evaluation designed by the Taiwan Society of Internal Medicine in 2019. The evaluation was based on the ACGME-accredited milestone ratings. Periodic evaluation of milestone achievements of R1 and PGY2, who entered the internal medicine residency training at six medical centers, was performed. Each resident was evaluated every 3 months. Among the 98 R1 enrolled in 2019, substantial improvement in sub-competencies, including skill in performing procedures (Patient Care 4), clinical knowledge (Medical Knowledge 1), knowledge of diagnostic testing and procedures (Medical Knowledge 2), and identify impact the cost of health care and practices cost-effective care (Systems Based Practice 3) during the two years of training. Among the 107 R1 and 46 PGY2 enrolled in 2020, no significant difference in baseline milestone ratings was observed. However, the milestone assessments of R1 in 2020 showed improvement in nearly all sub-competencies compared with the stationary status of PGY2 in 2020. We demonstrate the application of ACGME-based accredited milestone ratings to target the educational goals of internal medicine residency training in Taiwan. Differences in milestone ratings between different PGY training systems exist. The long-term impact of performance among different PGY training systems requires further investigation.

Qualitative Study of Orthopedic Surgery Milestones 1.0: Burdens and Benefits

The purpose of this study was to explore the context and mechanisms by which the first set of Milestones impacted the processes of the Clinical Competency Committee, how programs have incorporated the Milestones into their program, and to understand more about the resident perspective in order to improve Orthopedic Surgery Milestones. In 2020 all 201 accredited orthopedic surgery residency programs were invited to participate in qualitative telephone interviews to assess their experience with the Milestones and complete a supplemental online survey about their Clinical Competency Committee. Participants were comprised of a self-selected sample and complemented by a purposeful sample to ensure a breadth of perspectives. Interview data were analyzed using template analysis. Survey data were analyzed with descriptive statistics. Interviews were completed with 101 individuals from 47 programs (23% of all programs). The two overarching themes were implementation and impact of Milestones. Subthemes within implementation were substantial variability in approaches to Milestone use in curriculum and assessment, faculty development, and methods to introduce residents to the Milestones assessment framework. The large number of subcompetencies created a significant burden for almost all programs. The structure of the Milestones was also viewed as poorly aligned with the variable design of rotation schedules across programs. Milestones have the potential to offer valuable feedback for trainees and programs overall. While some benefits were noted and most programs appreciated the intent, the structure and design of the initial set of orthopedic surgery Milestones created substantial challenges for these programs. The results of this study helped guide a revision of the Orthopedic Surgery Milestones. These results can also be used by program leadership to encourage reflection around past, current, and future utilization of the Milestones framework. Further research will be needed to determine the impact of the revision on programs.

Self injuries in adolescence, an unusual clinical presentation of autism

IntroductionAlthough autism is only twice more common in men than women in general population, in clinical samples women are underrepresented. This difference may be due to a poor sensitivity of current diagnostic criteria of autism related to females. We present a 13-year-old woman referred to the adolescent psychiatric unit for anxiety, self injuries and suicidal ideation. After careful assessment of current symptoms and neurodevelopmental milestones, deficits in emotional-comunicational reciprocity, nonverbal comunication and relationships emerged, as well as inflexible adherence to routines and restricted interests. The diagnose of autism spectrum disorder was made and the patient started a specific treatment.ObjectivesTo review the clinical features of autism spectrum disorders in adolescent females and its differential diagnosis.MethodsReview of the literature on autism spectrum disorders in female and its specific features.ResultsThe “Female Autism Phenotype” is a group features that are more common in autistic women, as opposed to the classic symptoms of autism in men. Some of these differential characteristics are: fewer social impairments and higher levels of social motivation; more age and gender appropriate restricted and repetitive interests; more internalizing rather than externalizing symptoms; and a tendency towards camouflagingConclusions- Autism in women is frequently underdiagnosed. - Females express autism in ways that not allways meet the current diagnostic criteria. - The “Female Autism Phenotype” has been proposed as an specific way of expression of autism in females.DisclosureNo significant relationships.

Using a Milestone Framework for Assessing Resident, Fellow, and Faculty Competence in Diversity, Equity, and Inclusion.

Graduating residents and fellows who can competently provide equitable and inclusive care to a diverse patient population requires data to monitor progress and outcomes. This data must be continuously gathered and used to guide improvements at the individual program level and at the sponsoring institution level for trainee and faculty growth and development. Recognizing the need for data, the Accreditation Council for Graduate Medical Education (ACGME) updated its 2021 annual Resident/Fellow and Faculty Surveys to include items related to equity and inclusion. Yet, accessible data on the structural competency level of our residents and faculty specific to the areas of health equity, social responsibility, diversity, inclusion, and social determinants of health is limited.1Our aim was to develop and implement a quick, evidence-based, structural competency tool to monitor trainee and faculty proficiency over time. A literature review was completed to identify key competency elements. To facilitate implementation, we framed our assessment to parallel the structure and format of the ACGME's core competency milestone model. Literature-identified elements were plotted in each of the core competency domains with progression delineated across 5 levels resulting in a comprehensive 8-page milestone document. The milestone was then iteratively revised by multiple stakeholders (experts in diversity, equity, and inclusion, ethics, and medical education; faculty; learners; program directors) to create an annotated and referenced 2-page master milestone and an abbreviated milestone with domain threads across levels (eg, Medical Knowledge) for inclusion within each graduate medical education (GME) program's required milestone assessment form and for faculty self-assessment. For example, an element in the domain of Patient Care level 3 (Identifies and incorporates mitigation strategies to address structural risks in patient care) progresses to level 4 (Develops and collaborates with patient on plan of care cognizant of patient's intersectionalites and its influences on their health care values, decisions…). In the Professionalism domain, level 3 (Reconciles personal beliefs and identities with professional role; develops strategies to mitigate own implicit biases; recognizes the contribution of bias to iatrogenic risk and health disparities) progresses to level 4 (Speaks up in the moment [allyship]; utilizes incident reporting mechanism to address microaggressions and/or lateral workplace violence).The milestone was approved by the Graduate Medical Education Committee (GMEC) for inclusion as a required formative trainee assessment in every program beginning in January 2021 and as a request for faculty to complete as a needs assessment. Data are not used for trainee progress (Clinical Competency Committee reviews) or annual faculty performance reviews. Trainee milestone data across programs revealed a consistent progression in the institutional average competence by year of training from 3.1 (postgraduate year [PGY]-1) to 4.4 (PGY-6). The same progression held within each residency and fellowship program. Faculty self-assessment (N&gt;100) revealed that, on average, greater than 50% of the faculty perceived themselves to be at level 4 or higher: range between domains of 53%–79% at or above level 3 by competency domain with SD 1.1 to 1.7. Programs utilize the data as part of their annual program evaluations outlining measurable action steps. At the GMEC level, the data guide GME-wide diversity, equity, and inclusion educational sessions for trainees and faculty.This structural milestone innovation meets our need for data to monitor our trainees' and faculty's competence to guide ongoing program improvements. Formatted like existing ACGME Milestones, implementation within existing trainee competency assessment systems and/or as a faculty self-assessment is seamless, enhancing its utility, feasibility, and transferability. That said, we recognize that milestones are not static; the specific domain inclusions will need to evolve as we do on our equity journey.