Construct Validity Evidence for ACGME Milestones in Surgical Specialties: A Systematic Review

Background The Accreditation Council for Graduate Medical Education (ACGME) Milestones use has been formative and low-stakes to date, and transitioning to higher-stakes applications in a truly competency-based medical education (CBME) system requires extensive validity evidence. Surgical specialties, with their unique demands for procedural skills and operative experience, represent a critical context for evaluating the validity of Milestones. Objective To synthesize studies reporting validity evidence for the ACGME Milestones in surgical specialties. Methods This systematic review was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic literature search was conducted across 8 databases and references to identify studies that reported validity evidence for Milestones in surgical specialties. Literature was reviewed for inclusion using Covidence and coded based on Messick's framework. The quality of the studies was evaluated using the Medical Education Research Study Quality Instrument. Results A total of 114 studies were included from 2013 to 2023. The primary source of validity evidence (n=45, 39.5%) was relations to other variables (knowledge and skills, learner characteristics, patient/health care, social-emotional variables), followed by response processes (n=38, 33.3%: interrater reliability, rating processes, structure of Clinical Competency Committee, rater training, longitudinal reliability, straightlining) and consequences (n=29, 25.4%: value and utility, intended use, anticipated impact). Only 12 studies (10.5%) reported internal structure evidence. Conclusions This study provides insights into understanding what constitutes validity evidence within the context of ACGME Milestones in surgical specialties. This review highlights areas where further research is needed to support the moderate to high-stakes use of Milestones in a CBME system.