In this week’s simulation case, you will notice the addition of a table which is a description of ABEM Milestone #9 – General approach to Procedures (PC9). I created this table after attending a workshop from Dr. Danielle Hart (Assistant Residency Director and Director of Simulation at Hennepin County Medical Center). During the 2013 CORD assembly in Denver, Dr. Hart held a session in which she described a novel method by which to incorporate the ABEM milestones into simulation cases. This would accomplish two things:

  1. Provide an evaluation tool for the learners
  2. Easily incorporate milestones to evaluate residents

The key to using the milestones is to assign observable, identifiable behaviors that are specific to each learner level.

Performs the indicated procedure on all appropriate patients (including those who are uncooperative, at the extremes of age, hemodynamically unstable, and those who have multiple co-morbidities, poorly defined anatomy, high risk for pain or procedural complications, sedation requirement), takes steps to avoid potential complications, and recognizes the outcome and/or complications resulting from the procedure
Level 1Level 2Level 3Level 4Level 5

Identifies pertinent anatomy and physiology for a specific procedure

Uses appropriate Universal Precautions

Performs patient assessment, obtains informed consent and ensures monitoring equipment is in place in accordance with patient safety standards

Knows indications, contraindications, anatomic landmarks, equipment, anesthetic and procedural technique, and potental complications for common ED procedures

Performs the indicated common procedure on a patient with moderate urgency who has identifiable landmarks and a low-moderate risk for complications

Performs post-procedural assessment and identifies any potential complications

Determines a backup strategy if initial attempts to perform a procedure are unsuccessful

Correctly interprets the results of a diagnostic procedure

Performs indicated procedures on any patients with challenging features (e.g., poorly identifiable landmarks, at extremes of age or with co-morbid conditions)

Performs the indicated procedure, takes steps to avoid potential complications, and recognizes the outcome and/or complications resulting from the procedure

Teaches procedural competency and corrects mistakes
ABEM Milestone #9: General Approach to Procedures (PC9)
  • Level 1: The resident demonstrates milestones expected of an incoming resident.
  • 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; the resident demonstrates the majority of milestones targeted for residency in this sub-competency.
  • 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.

So for the perimortem c-section (CS) simulation case, I selected PC9 and assigned particular observable actions for each level. Not all the levels defined applied perfectly, and therefore some levels were excluded.

Incorporating ABEM milestones into the assessment process of simulation cases helps to standardize the evaluation process through observable actions and by using a common language.

Good luck using the tool!

Nikita Joshi, MD

Nikita Joshi, MD

ALiEM Chief People Officer and Associate Editor
Clinical Instructor
Department of Emergency Medicine
Stanford University
Nikita Joshi, MD


Emergency Medicine Doctor Associate Editor of ALiEM Gun Sense Advocate #FOAMed #Docs4GunSense #MomsDemandAction Tweets represent my own views and opinions