July Milestones of the Month--PC1 and PROF2

Each month I'm planning to bring one or two of our twenty-two Milestones forward for emphasis.
For July, I chose The Basics:  Psychiatric Evaluation and Accountability to Self, Patients, Colleagues, and the Profession.

Like all of the Milestones, these are organized around a developmental course, from Novice to Expert.  At Level 1, you exhibit the skills and abilities expected of a beginning intern, and by Level 5 you are beginning to exemplify the qualities of experienced attendings.  It should be emphasized that the levels do not correspond to training year, and that they do not represent requirements for program completion. Indeed, we should view Level 5 as aspirational goals--many of us as attendings have to honestly admit that we might not consistently be at that level on all milestones. Instead, these are mostly objective standards that will help us evaluate our own progress in training and practice.  You'll also notice that each Milestone is further subdivided into Threads along which the development occurs and can be more or less objectively observed.  You can visit all of our Milestones at the ACGME, or on New Innovations.

For PC1, Evaluation, there are a couple of things I'd emphasize: First is the paramount importance of patient safety and risk assessment--especially assessing suicidal and homicidal ideation. I'm struck that there is no Level 3, 4, or 5 on this thread. It is foundational to the work of a psychiatrist. Back in the "old days", we were told that a sure way to fail the oral board exam was to fail to complete this task in our patient interview. This is still the most important task we perform, so practice, practice, practice!

The second interesting item is Thread D--the use of our own emotional responses to the patient for their diagnostic value. Whether you call it counter-transference or gut instinct, how it feels to be with a particular patient is often a very important clue to understanding how they relate to the world, or how their symptoms are manifesting themselves. I can't claim to have read all of the Internal Medicine or General Surgery Milestones, but I would not expect to find this Thread there. It is a unique province of our discipline, one to be observed, nurtured, and discussed in supervision. Also, as in the "House of God", where the third law is "At a cardiac arrest, the first procedure is to take your own pulse", it is important that we check ourselves emotionally and are attentive to our inner state when dealing with the extreme levels of emotional disturbance that we encounter in our our patients. I would encourage all of us to avail ourselves of opportunities to learn Mindfulness as a vital skill to build resilience and sustain ourselves for a long career, topics which are addressed further in the next Milestone, Accountability to Self, Patients, Colleagues, and the Profession. 

Again with PROF2, you'll notice the gradual development of Professionalism from beginner to leader--which starts with two foundational items in Thread B: Core Professional Behaviors and Openness to Feedback.  Much has been written about what constitutes "core professional behaviors", and some of this will be included in this month's Virtual Journal Club selections.  The footnotes in the ACGME Milestones refer to overall values of compassion, integrity, responsibility, accountability, and respect for others. The behaviors that manifest these values will include timeliness, reliability, listening, and public behavior, among others. We have assembled some of these in our Program's Compact, which we will discuss in the very near future.  In the meantime, commit yourselves today, at the beginning of this academic year, to adopt the professional character of a psychiatrist in all of your encounters with patients, colleagues, and the community, and to seek to further develop that character in yourself and others.