Association of Surgical Resident Competency Ratings With Patient Outcomes

Daniel E. Kendrick, Angela E. Thelen, Xilin Chen, Tanvi Gupta, Kenji Yamazaki, Andrew E. Krumm, Hoda Bandeh-Ahmadi, Michael Clark, John Luckoscki, Zhaohui Fan, Greg M. Wnuk, Andrew M. Ryan, Bhramar Mukherjee, Stanley J. Hamstra, Justin B. Dimick, Eric S. Holmboe, Brian C. George

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Purpose: Accurate assessment of clinical performance is essential to ensure graduating residents are competent for unsupervised practice. The Accreditation Council for Graduate Medical Education milestones framework is the most widely used competency-based framework in the United States. However, the relationship between residents' milestones competency ratings and their subsequent early career clinical outcomes has not been established. It is important to examine the association between milestones competency ratings of U.S. general surgical residents and those surgeons' patient outcomes in early career practice. Method: A retrospective, cross-sectional study was conducted using a sample of national Medicare claims for 23 common, high-risk inpatient general surgical procedures performed between July 1, 2015, and November 30, 2018 (n = 12,400 cases) by nonfellowship-trained U.S. general surgeons. Milestone ratings collected during those surgeons' last year of residency (n = 701 residents) were compared with their risk-adjusted rates of mortality, any complication, or severe complication within 30 days of index operation during their first 2 years of practice. Results: There were no associations between mean milestone competency ratings of graduating general surgery residents and their subsequent early career patient outcomes, including any complication (23% proficient vs 22% not yet proficient; relative risk [RR], 0.97, [95% CI, 0.88-1.08]); severe complication (9% vs 9%, respectively; RR, 1.01, [95% CI, 0.86-1.19]); and mortality (5% vs 5%; RR, 1.07, [95% CI, 0.88-1.30]). Secondary analyses yielded no associations between patient outcomes and milestone ratings specific to technical performance, or between patient outcomes and composites of operative performance, professionalism, or leadership milestones ratings (P ranged.32-.97). Conclusions: Milestone ratings of graduating general surgery residents were not associated with the patient outcomes of those surgeons when they performed common, higher-risk procedures in a Medicare population. Efforts to improve how milestones ratings are generated might strengthen their association with early career outcomes.

Original languageEnglish (US)
Pages (from-to)813-820
Number of pages8
JournalAcademic Medicine
Issue number7
StatePublished - Jul 1 2023

Bibliographical note

Funding Information:
Funding/Support: This project was possible through ongoing grant support from the Agency for Healthcare Research and Quality via Grant # AHRQ K08 HS027653.

Funding Information:
The authors acknowledge contributions to this work from the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Surgery (ABS) and the Fellowship Council (FC). The ACGME shared the milestones data, and the ABS and FC provided certification data that made it possible to exclude fellowship-trained surgeons from our analyses.

Publisher Copyright:
Copyright © 2023 by the Association of American Medical Colleges.

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