A national study of neurosurgical residency competency development

The aim of this study was to evaluate milestone progression across 6 Accreditation Council for Graduate Medical Education (ACGME) core competencies and 20 subcompetencies among neurosurgery residents, focusing on the attainment of level 4 proficiency by the final postgraduate year (PGY 7), and to identify patterns of co-occurring deficiencies.

A retrospective cohort analysis was conducted using national ACGME Milestone data from 2478 neurosurgery residents across 120 programs in the United States, covering 2018 to June 2022 evaluations. Semiannual milestone scores were analyzed using mean, standard deviation, median, and interquartile range. The proportion of residents not achieving level 4 by PGY 7 was assessed, and co-occurring deficiencies were identified through pairwise analysis and the variance-to-mean ratio (VMR).

Residents demonstrated significant progression from PGY 1 to PGY 7, with mean scores increasing from 1.2-1.7 in PGY 1 to 4.20-4.36 by PGY 7. By PGY 7, 445 of 997 residents (44.6%) had not achieved level 4 in at least one subcompetency. Patient Care (PC) had the highest proportion below level 4 (35.5%), particularly in specialized areas such as Surgical Treatment of Epilepsy and Movement Disorders (mean 4.08 ± 0.48) and Pain and Peripheral Nerve Disorders (mean 4.05 ± 0.49). Pairwise analysis revealed co-occurrences among specialized PC subcompetencies and between Reflective Practice and technical competencies. VMR analysis showed substantial variability in subcompetency attainment across programs.

Neurosurgery residents show robust milestone progression, yet gaps persist in specialized clinical skills and self-assessment practices, often aligning with subspecialties where fellowship training is common. Residency programs might need to enhance exposure or adjust competency expectations. Integrated educational strategies, including targeted interventions and specialized procedural training, are recommended to ensure all residents achieve level 4 competency, preparing them for independent practice.