A National Study of Neurosurgical Residency Competency Development

Introduction: Achieving competency across Accreditation Council for Graduate Medical Education (ACGME)-defined milestones is essential for neurosurgery residents to ensure readiness for independent practice. Understanding areas where residents commonly struggle can inform targeted educational interventions. This study aims to evaluate milestone progression across six ACGME core competencies and 20 sub-competencies among neurosurgery residents, focusing on the attainment of Level 4 competency by the final postgraduate year (PGY 7) and to identify patterns of co-occurring deficiencies.

Methods: We conducted a retrospective cohort study analyzing national ACGME Milestone data from 2,478 neurosurgery residents across 120 accredited programs in the United States. Milestone assessments were included from PGY 1 to PGY 7, covering March 2018 to June 2022.

Results: All six core competencies demonstrated significant progression from PGY 1 to PGY 7, with mean scores increasing from approximately 1.2–1.7 in PGY 1 to 4.20–4.36 by PGY 7. Medical Knowledge attained the highest final mean score of 4.36 ± 0.46, followed by Systems-Based Practice (4.26 ± 0.50) and Professionalism(4.26 ± 0.49). Patient Care reached a mean score of 4.20 ± 0.49; however, certain sub-competencies within this domain, 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), showed comparatively lower scores. By PGY 7, 445 of 997 residents(44.6%) had not achieved Level 4 in at least one sub-competency. Patient Care had the highest proportion of residents below Level 4 (35.5%), particularly in specialized areas. Sub-competencies with the most significant number of residents below Level 4 included Reflective Practice and Commitment to Personal Growth (18.9%), Pain and Peripheral Nerve Disorders (18.7%), and Pediatric Neurological Surgery (16.7%). The pairwise analysis revealed significant co-occurrences of deficiencies, especially among specialized Patient Care sub-competencies and between Reflective Practice and technical competencies.

Conclusion : While neurosurgery residents demonstrate robust milestone progression overall, significant gaps persist in specific sub-competencies related to specialized clinical skills and self-assessment practices. The identified patterns of co-occurring deficiencies suggest that integrated educational strategies may be necessary to address these gaps.