Do ACGME Milestones Predict General Surgery Performance?
by Anthony Rabe, BA; Sarah C. Gaston, D.O.; Peter Muscarella II, M.D. | April 28, 2026
Article Citation: Sun T, Zheng B, Yamazaki K, Smith BK, Hamstra SJ. Association of ACGME Milestones With Other Performance Measures in General Surgery: A Meta-Analytic Study. Acad Med. 2025 Nov 1;100(11):1337-1344. doi: 10.1097/ACM.0000000000006142.
What is this article about?
This study is a meta-analysis that examines Accreditation Council for Graduate Medical Education (ACGME) Milestone ratings in general surgery residency in comparison to other commonly used performance measures. The authors synthesized data from 16 studies to assess how Milestone ratings correlate with Entrustable Professional Activities (EPAs), the American Board of Surgery In-Training Examination (ABSITE), social-emotional outcomes, patient outcomes, United States Medical Licensing Examination (USMLE) scores and residency application factors. The analysis found a strong positive correlation between Milestones and EPAs; moderate correlation with ABSITE scores; little to no association with USMLE scores, application metrics, social-emotional outcomes; and slightly negative association with patient outcomes.
Why should you read the article?
These findings provide important evidence regarding the validity and application of ACGME Milestones in surgical training. Milestone data are widely used for formative feedback, promotion decisions and program evaluation, but the validity of these measures has not been largely examined. This study clarifies that Milestones align well with clinical knowledge-based assessments such as EPAs and medical knowledge-based exams like the ABSITE, but are poor predictors of professionalism, interpersonal skills and patient outcomes. Additionally, certain selection criteria in the residency interview process, such as USMLE scores, may be poor indicators of residents who will perform well in accordance with the ACGME milestones. For educators involved in assessment of trainees, this article provides critical evidence to guide appropriate interpretation and use of ACGME Milestone data in conjunction with EPAs.
How can you use this article?
Educators can use this article to better understand competency-based assessment in graduate medical education and reflect on how these concepts may inform their own teaching and evaluation practices. Milestones, EPAs, and direct observation tools offer insights that can help clinical educators think more critically about the strength and weaknesses of assessment frameworks and how they can inform their own assessments. Educators may also use these findings to refine the evaluation process and enhance feedback quality, to better develop competent trainees. This review underscores the need for further research examining how Milestones and other performance metrics function in different settings and how they should be integrated into medical assessment systems. Finally, the information here may help inform decision-making for medical students who are potentially interested in pursuing surgical careers.
Review Authors: Anthony Rabe BA, third year medical student at Ohio University Heritage College of Osteopathic Medicine, Portsmouth, OH (Co-authors: Sarah C. Gaston, D.O., and Peter Muscarella II, M.D.). Organization: Association for Surgical Education