Geriatric Medicine Milestones: The Accreditation Council For Graduate Medical Education

Geriatric Medicine Milestones
The Accreditation Council for Graduate Medical Education
Implementation Date: July 1, 2021

Second Revision: April 2021
First Revision: October 2014
©2021 Accreditation Council for Graduate Medical Education (ACGME)

All rights reserved except the copyright owners grant third parties the right to use the Geriatric Medicine Milestones on a non-exclusive basis for educational purposes.
The Milestones are designed only for use in evaluation of fellows in the context of their participation in ACGME-
accredited fellowship programs. The Milestones provide a framework for the assessment of the development of the
fellow in key dimensions of the elements of physician competency in a specialty or subspecialty. They neither
represent the entirety of the dimensions of the six domains of physician competency, nor are they designed to be
relevant in any other context.

i
Work Group
Steven Barczi, MD, FAASM Kevin Foley, MD
Katherine Bennett, MD Rachelle Gajadhar, MD
Min Ho Cho, MD Jennie Kirby, MPA
Ryan DeLong, MD Aubrey Knight, MD
Laura Edgar, EdD, CAE Shoshana Streiter, MD
Kathryn Eubank, MD Eric Widera, MD
Helen Fernandez, MD, MPH
The ACGME would like to thank the following organizations for their continued support in the
development of the Milestones:
American Board of Internal Medicine
American Geriatrics Society
ACGME Review Committee for Internal Medicine

ii
Understanding Milestone Levels and Reporting
This document presents the Milestones, which programs use in a semi-annual review of fellow performance, and then report to the
ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME Competencies organized in a
developmental framework. The narrative descriptions are targets for fellow performance throughout their educational program.
Milestones are arranged into levels. Tracking from Level 1 to Level 5 is synonymous with moving from novice to expert fellow in the
specialty or subspecialty. For each reporting period, the Clinical Competency Committee will review the completed evaluations to select
the milestone levels that best describe each learner’s current performance, abilities, and attributes for each subcompetency.
These levels do not correspond with post-graduate year of education. Depending on previous experience, a junior fellow may achieve
higher levels early in his/her educational program just as a senior fellow may be at a lower level later in his/her educational program.
There is no predetermined timing for a fellow to attain any particular level. Fellows may also regress in achievement of their milestones.
This may happen for many reasons, such as over scoring in a previous review, a disjointed experience in a particular procedure, or a
significant act by the fellow.
Selection of a level implies the fellow substantially demonstrates the milestones in that level, as well as those in lower levels (see the
diagram on page vi).

iii
Additional Notes
Level 4 is designed as a graduation goal but does not represent a graduation requirement. Making decisions about readiness for
graduation and unsupervised practice is the purview of the program director. Furthermore, Milestones 2.0 include revisions and
changes that preclude using Milestones as a sole assessment in high-stakes decisions (i.e., determination of eligibility for certification
or credentialing). Level 5 is designed to represent an expert fellow whose achievements in a subcompetency are greater than the
expectation. Milestones are primarily designed for formative, developmental purposes to support continuous quality improvement for
individual learners, education programs, and the specialty. The ACGME and its partners will continue to evaluate and perform research
on the Milestones to assess their impact and value.
Some milestone descriptions include statements about performing independently. These activities must occur in conformity to ACGME
supervision guidelines as described in the Program Requirements, as well as to institutional and program policies. For example, a
fellow who performs a procedure independently must, at a minimum, be supervised through oversight.
A Supplemental Guide is also available to provide the intent of each subcompetency, examples for each level, assessment methods or
tools, and other available resources. The Supplemental Guide, is designed only to assist the program director and Clinical Competency
Committee, and is not meant to demonstrate any required element or outcome.
Supplemental Guides and other resources are available on the Milestones page of each specialty section of the ACGME website. On
www.acgme.org, choose the applicable specialty under the “Specialties” menu, then select the “Milestones” link in the lower navigation
bar.

iv
The diagram below presents an example set of milestones for one sub-competency in the same format as the ACGME Report
Worksheet. For each reporting period, a fellow’s performance on the milestones for each sub-competency will be indicated by
selecting the level of milestones that best describes that fellow’s performance in relation to those milestones.
Selecting a response box in the Selecting a response box on the line in

middle of a level implies that between levels indicates that milestones
milestones in that level and in lower in lower levels have been substantially
levels have been substantially demonstrated as well as some
demonstrated. milestones in the higher level(s).

v
Version 2 Geriatric Medicine, ACGME Report Worksheet
Patient Care 1: Comprehensive Geriatric Assessment
Level 1 Level 2 Level 3 Level 4 Level 5

Identifies domains of a Performs a Formulates a care plan Implements a unified, Implements a
comprehensive geriatric comprehensive geriatric that integrates findings patient-centered care comprehensive geriatric
assessment, including assessment, eliciting from a comprehensive plan that integrates all assessment methodology
medical, psychosocial, information from ancillary geriatric assessment domains of the for use with innovative
and functional elements sources, including the focused on optimizing comprehensive geriatric models of care delivery,
patient, family, caregivers, physical, psychosocial, assessment in new care settings, and/or
and interdisciplinary team and functional health collaboration with the unique patient
interdisciplinary team populations
and community partners
Comments:
Not Yet Completed Level 1
Not Yet Assessable

1
Patient Care 2: Patient and Family/Caregiver Support

Describes formal and Identifies potential Collaborates with the Develops a Innovates or advocates to
informal support systems stressors and support interdisciplinary team to comprehensive plan in enhance caregiver
for older adults options for individual use available resources to partnership with the support and programming
patients educate and support patient, patient’s family, within communities or
patients and interdisciplinary systems of care
team to optimize
Describes the roles of Employs approaches or Collaborates with the support of the patient
caregiver(s) and the tools to assess interdisciplinary team to and patient’s
risks and benefits of family/caregiver burden use available resources family/caregiver(s)
caregiving and identify potential and support for
stressors and support family/caregiver(s)
options
Comments:
Not Yet Assessable

2
Patient Care 3: Assessing and Optimizing of Pharmacotherapy

Identifies common Recognizes age-related Modifies medications Optimizes medication Works within larger health
medications that should changes in the based on principles of management of patients care systems and
be avoided or used with metabolism of and polypharmacy, risks and with multi-morbidity by community-based
caution in older adults response to medications benefits, and identification synthesizing evidence, organizations to minimize
of barriers to adherence, patient preferences, life harms from over and
and monitors response to expectancy, functional under prescribing
de-prescribing trajectory, and clinical
feasibility
Performs a medication Identifies patients at risk Effectively communicates
reconciliation, including for negative outcomes medication changes to
both prescribed and over due to polypharmacy and patients, families,
the counter medications overprescribing or under caregivers, and health
prescribing care professionals across
health settings
Comments:
Not Yet Assessable

3
Patient Care 4: Assessing and Optimizing Physical and Cognitive Function

Identifies tools to assess Performs functional Interprets findings from a Effectively integrates Promotes assessment
physical function assessment of an functional assessment, findings from and optimization of
individual patient considering strengths and functional and cognitive physical and cognitive
limitations of the assessments into care functioning for patients
assessment plans, including referral across care systems
for rehabilitative
therapies as indicated
Identifies tools to assess Performs cognitive Interprets findings from a
cognition assessment of an cognitive assessment,
individual patient considering strengths and
limitations of the
assessment
Comments:
Not Yet Assessable

4
Patient Care 5: Framing Clinical Management Decisions within the Context of Prognosis

Lists common methods Describes strengths and Applies an individual Integrates prognosis Incorporates prognosis in
and tools for estimating weaknesses of various patient’s prognosis and and goals of care into local and national
prognosis methods and tools for “lag time to benefit” as shared clinical decision guidelines and
assessing prognosis in part of a framework to making, in collaboration performance metrics to
patient populations determine risks and with patients, families/ avoid overtreatment and
benefits of preventative caregivers, and the undertreatment of
Describes common Describes how the and therapeutic interdisciplinary team preventive interventions
patterns of disease interplay between multi- interventions
trajectories morbidity, functional
impairment, and frailty
affects disease
trajectories
Comments:
Not Yet Assessable

5
Patient Care 6: Consultative Care

Respectfully responds to Identifies and clarifies the Seeks and integrates Provides Leads the health care
a consultation request goals of the consultation input from different comprehensive and team in the provision of
and conveys and conveys members of the health prioritized effective consultative
recommendations, with recommendations care team and provides recommendations, services across the
supervision recommendations to the including assessment spectrum of disease
primary team in a clear and rationale, to all complexity and acuity
and timely manner necessary health care
team members
Recognizes consult Independently recognizes Prioritizes workflow in Mobilizes resources to

acuity and urgency, with consult acuity and response to consult acuity provide care in an
supervision urgency and urgency urgent situation
Comments:
Not Yet Assessable
Patient Care
The fellow is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training program. He
or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of
safe, effective, patient-centered, timely, efficient, and equitable care.
_____ Yes _____ No _____ Conditional on Improvement

6
Medical Knowledge 1: Geriatric Syndromes

Lists common geriatric Describes the Demonstrates knowledge Synthesizes risk factors, Advances knowledge
syndromes pathophysiology of of diagnostic tests and pathophysiology, about the basic science,
geriatric syndromes tools applicable to scientific knowledge, prevention, and clinical
geriatric syndromes, diagnostic testing, and management of geriatric
recognizing their utility patient and caregiver syndromes through
and limitations factors to prevent and education, research, or
manage geriatric other scholarly activity
syndromes
Communicates and
Recognizes risks and Describes the interplay Recognizes clinical and
predisposing factors in between medications, co- community resources, works with
the development of morbidities, evidence-based practices, interprofessional teams
geriatric syndromes socioeconomic factors, and models of care useful and community
and geriatric syndromes in the prevention and resources to implement
management of geriatric geriatric syndrome
syndromes prevention and
management plans
Comments:
Not Yet Assessable

7
Medical Knowledge 2: Principles of Aging

Describes age-related Describes theories of Describes how aging Applies knowledge of Advances knowledge of
changes to organs and aging affects the presentation of the biology and the principles of aging
their system functions diseases physiology of aging to through education,
promote healthy aging research, or other
scholarly activity
Describes the Differentiates between Describes how aging Integrates knowledge of

heterogeneity of aging normal aging and disease impacts homeostasis, normal aging into
and its relationship to physiologic reserve, disease diagnosis and
gender, socioeconomic function, cognition, and treatment
factors, education, pharmacology
lifestyle, and disease
Comments:
Not Yet Assessable
Medical Knowledge
____ Yes ____ No ____ Conditional on Improvement

8
Systems-Based Practice 1: Patient Safety and Quality Improvement

Demonstrates Recognizes health care Participates in analysis of Conducts analysis Actively engages teams
knowledge of common system issues that patient safety events of patient safety events and processes to modify
patient safety events negatively impact the care (simulated or actual) and offers error systems to prevent
of older adults prevention strategies patient safety events
(simulated or actual)
Demonstrates Reports patient safety Participates in disclosure Discloses patient safety Role models or mentors
knowledge of how to events through of patient safety events to events to patients and others in the disclosure of
report patient safety institutional reporting patients and families families (simulated or patient safety events
events systems (simulated or (simulated or actual) actual)
actual)
Demonstrates Describes local quality Participates in local Demonstrates the skills Creates, implements, and
knowledge of basic improvement initiatives quality improvement required to identify, assesses quality
quality improvement initiatives develop, implement, improvement initiatives
methodologies and and analyze a quality at the institutional or
metrics improvement project community level
Comments:

9
Systems-Based Practice 2: System Navigation for Patient-Centered Care

Identifies key elements Coordinates care of Coordinates care of Role models effective Analyzes the process of
of care coordination patients in routine clinical patients with multi- coordination of patient- care coordination and
situations, effectively morbidities, effectively centered care among leads in the design and
utilizing the roles of the utilizing the roles of their different disciplines and implementation of
interprofessional team interprofessional team specialties improvements
members members
Identifies key elements Performs safe and Performs safe and Role models and Improves quality of
for safe and effective effective transitions of effective transitions of advocates for safe and transitions of care within
transitions of care and care/hand-offs in routine care/hand-offs in complex effective transitions of and across health care
hand-offs clinical situations clinical situations care/hand-offs within delivery systems to
and across health care optimize patient outcomes
delivery systems
Comments:

10
Systems-Based Practice 3: Physician Role in Health Care Systems

Identifies key Describes how the Discusses how individual Engages with various Advocates for or leads
components of the relationship between the practice affects the components of the systems change that
continuum of care health care system, broader system health care system to enhances high value,
community health needs, provide effective patient efficient, and effective
and health disparities care patient care
impact patient care
Describes common Delivers care with Engages with Advocates for patient Participates in health
health payment models consideration of the patients/caregivers in care needs with policy advocacy activities
patient’s health payment shared decision making, consideration of each for populations and
model informed by each patient’s health communities, outside of
patient’s health payment payment model the home institution
model
Comments:

11
Systems-Based Practice 4: Models and Systems of Care

Identifies evidence- Describes potential Assesses evidence-based Applies evidence-based Develops systems-based
based models of care for reasons why evidence- models of care for models of care to initiatives using evidence-
older adults based models of care individual patients improve patient care based models of care
improve outcomes for
older adults
Comments:
Systems-Based Practice

12
Practice-Based Learning and Improvement 1: Evidence-Based and Informed Practice

Demonstrates how to Articulates clinical Locates and applies the Critically appraises and Coaches others to
access, categorize, and questions and elicits best available evidence, applies evidence, even critically appraise and
analyze clinical evidence patient preferences and integrated with patient in the face of apply evidence for
values to guide evidence- preference, to care for uncertainty and complex patients, and/or
based care patients conflicting evidence, to participates in the
guide care tailored to development of guidelines
the individual patient
Comments:

13
Practice-Based Learning and Improvement 2: Reflective Practice and Commitment to Personal Growth

Accepts responsibility for Demonstrates openness Seeks performance data Intentionally seeks Consistently role models
personal and to performance data episodically, with performance data seeking performance data
professional (feedback and other adaptability and humility consistently, with with adaptability and
development by input) to inform goals adaptability and humility humility
establishing goals
Identifies factors that Analyzes and reflects on Analyzes, reflects on, and Challenges Coaches others on
contribute to gap(s) the factors that contribute institutes behavioral assumptions and reflective practice
between expectations to gap(s) between change(s) to narrow the considers alternatives in
and actual performance expectations and actual gap(s) between narrowing the gap(s)
performance expectations and actual between expectations
performance and actual performance
Actively seeks Designs and implements Independently creates Uses performance data Facilitates the design and
opportunities to improve a learning plan, with and implements a to measure the implementation of
prompting learning plan effectiveness of the learning plans for others
learning plan, and
improves it when
necessary
Comments:
Practice-Based Learning and Improvement


14
Professionalism 1: Professional Behavior

Demonstrates Identifies potential risk Demonstrates Recognizes situations Coaches others when
professional behavior in factors for professional behavior in that may lead to their behavior fails to
routine situations professionalism lapses complex or stressful professionalism lapses meet professional
situations and takes and intervenes to expectations
responsibility for one’s prevent lapses in
own professionalism oneself and others
lapses
Comments:

15
Professionalism 2: Ethical Principles

Demonstrates Applies basic principles to Analyzes complex Analyzes complex Identifies and seeks to
knowledge of basic address straightforward situations using ethical situations and engages address system-level
ethical principles ethical situations principles and identifies with resources for factors that induce or
the need to seek help in managing and exacerbate ethical
addressing complex addressing ethical problems or impede their
ethical situations dilemmas as needed resolution
Comments:

16
Professionalism 3: Accountability/Conscientiousness

Performs clinical and Performs clinical and non- Performs clinical and non- Proactively implements Creates strategies to
non-clinical clinical responsibilities in clinical responsibilities in strategies to ensure the enhance others’ ability to
responsibilities with a timely manner in routine a timely manner in needs of patients, efficiently complete
prompting situations complex or stressful teams, and systems are clinical and non-clinical
situations met responsibilities
Comments:

17
Professionalism 4: Well-Being

Recognizes the Identifies methods and Creates a plan for Reflects on how plans Promotes system
importance of resources for maintaining maintaining personal and for maintaining personal changes to enhance the
addressing personal and personal and professional professional well-being and professional well- well-being of others
professional well-being well-being being may change over
time and circumstance
Comments:
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 well-being, the mechanisms by which those factors affect well-being, and available resources and tools to improve
well-being.
Professionalism

18
Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication

Uses language and non- Establishes a therapeutic Establishes a therapeutic Establishes and Mentors others in
verbal behavior to relationship with the relationship in the setting maintains therapeutic situational awareness and
demonstrate respect and patient and patient’s of complex patient and relationships using critical self-reflection to
establish rapport family/caregiver, using family/caregiver dynamics shared decision making develop positive
active listening and clear therapeutic relationships
language
Identifies barriers to Recognizes how barriers Recognizes personal Modifies strategies to

effective communication to effective biases and attitudes minimize barriers to
communication apply to affecting communication effective communication
specific patients
Comments:

19
Interpersonal and Communication Skills 2: Interprofessional and Team Communication

Identifies the role and Solicits insights from and Integrates contributions Prevents and mediates Promotes a culture of
function of uses language that values from interdisciplinary conflict and distress open communication and
interdisciplinary team all interdisciplinary team team members into the among interdisciplinary effective teamwork within
members members care plan team members the interdisciplinary team
Comments:

20
Interpersonal and Communication Skills 3: Communication within Health Care Systems

Accurately documents Documents patient Demonstrates organized Concisely reports Provides feedback to
information in the patient encounters in an and timely diagnostic and diagnostic and improve others’ written
record organized manner therapeutic reasoning therapeutic reasoning, communication
through notes in the including anticipatory
patient record guidance, in the patient
record
Safeguards patient Facilitates communication Appropriately selects the Demonstrates written or Guides departmental or
personal health across the continuum of method of communication verbal communication institutional
information across the care based on context that serves as an communication around
continuum of care example for others to policies and procedures
follow across the
continuum of care
Comments:

21
Interpersonal and Communication Skills 4: Complex Communication around Serious Illness

Identifies prognosis as a Assesses the patient’s Delivers prognosis and Tailors communication Coaches others in the
key element for shared family’s/caregiver’s attends to emotional of prognosis according communication of
decision making prognostic awareness responses of patients and to patient consent, prognosis
and identifies preferences patients’ patient’s
for receiving prognostic families/caregivers family’s/caregiver’s
information needs, and medical
uncertainty, and is able
to address emotional
responses
Identifies the need to Facilitates communication Sensitively and Independently uses Coaches shared decision
assess patient and with the patient and the compassionately delivers shared decision making making in patient and
patient family/caregiver patient’s family/caregiver medical information; to align the patient’s patient’s family/caregiver
expectations and by setting the agenda, elicits the patient’s and and the patient’s communications
understanding of their clarifying expectations, the patient’s family’s/caregiver’s
health status and and verifying an family’s/caregiver’s values, goals, and
treatment options understanding of the values, goals, and preferences with
clinical situation preferences; and treatment options to
acknowledges uncertainty make a personalized
and conflict, with care plan in situations
guidance with a high degree of
uncertainty and conflict
Comments:

22
Interpersonal and Communication Skills

Overall Clinical Competence
This rating represents the assessment of the fellow's development of overall clinical competence during this year of training:
____Superior: Far exceeds the expected level of development for this year of training
____Satisfactory: Always meets and occasionally exceeds the expected level of development for this year of training
____Conditional on Improvement: Meets some developmental milestones but occasionally falls short of the expected level of development for this
year of training. An improvement plan is in place to facilitate achievement of competence appropriate to the level of trainin g.
____Unsatisfactory: Consistently falls short of the expected level of development for this year of training.

23

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Geriatric Medicine Milestones

The Accreditation Council for Graduate Medical Education

Implementation Date: July 1, 2021

©2021 Accreditation Council for Graduate Medical Education (ACGME)

©2021 Accreditation Council for Graduate Medical Education (ACGME)

©2021 Accreditation Council for Graduate Medical Education (ACGME)

©2021 Accreditation Council for Graduate Medical Education (ACGME)

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Selecting a response box in the Selecting a response box on the line in

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Patient Care 1: Comprehensive Geriatric Assessment

Level 1 Level 2 Level 3 Level 4 Level 5

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Patient Care 2: Patient and Family/Caregiver Support

Level 1 Level 2 Level 3 Level 4 Level 5

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Patient Care 3: Assessing and Optimizing of Pharmacotherapy

Level 1 Level 2 Level 3 Level 4 Level 5

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Patient Care 4: Assessing and Optimizing Physical and Cognitive Function

Level 1 Level 2 Level 3 Level 4 Level 5

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Level 1 Level 2 Level 3 Level 4 Level 5

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Patient Care 6: Consultative Care

Level 1 Level 2 Level 3 Level 4 Level 5

Recognizes consult Independently recognizes Prioritizes workflow in Mobilizes resources to

_____ Yes _____ No _____ Conditional on Improvement

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Medical Knowledge 1: Geriatric Syndromes

Level 1 Level 2 Level 3 Level 4 Level 5

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Medical Knowledge 2: Principles of Aging

Level 1 Level 2 Level 3 Level 4 Level 5

Describes the Differentiates between Describes how aging Integrates knowledge of

____ Yes ____ No ____ Conditional on Improvement

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Systems-Based Practice 1: Patient Safety and Quality Improvement

Level 1 Level 2 Level 3 Level 4 Level 5

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Systems-Based Practice 2: System Navigation for Patient-Centered Care

Level 1 Level 2 Level 3 Level 4 Level 5

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Systems-Based Practice 3: Physician Role in Health Care Systems

Level 1 Level 2 Level 3 Level 4 Level 5

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Systems-Based Practice 4: Models and Systems of Care

Level 1 Level 2 Level 3 Level 4 Level 5

_____ Yes _____ No _____ Conditional on Improvement

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Practice-Based Learning and Improvement 1: Evidence-Based and Informed Practice

Level 1 Level 2 Level 3 Level 4 Level 5

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Level 1 Level 2 Level 3 Level 4 Level 5

Practice-Based Learning and Improvement

_____ Yes _____ No _____ Conditional on Improvement

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Professionalism 1: Professional Behavior

Level 1 Level 2 Level 3 Level 4 Level 5

©2021 Accreditation Council for Graduate Medical Education (ACGME)

Professionalism 2: Ethical Principles

Level 1 Level 2 Level 3 Level 4 Level 5

©2021 Accreditation Council for Graduate Medical Education (ACGME)

___ Yes _ No ___ Conditional on Improvement

Yes No Conditional on Improvement

___ Yes _ No ___ Conditional on Improvement

___ Yes _ No ___ Conditional on Improvement

___ Yes _ No ___ Conditional on Improvement

___ Yes _ No ___ Conditional on Improvement