Association of ACGME Milestones With Other Performance Measures in General Surgery: A Meta-Analytic Study

Purpose The Accreditation Council for Graduate Medical Education (ACGME) Milestone ratings in general surgery have the potential to be used as formative feedback to enhance trainee performance. This assumption rests on validity evidence, such as correlations with learning outcomes and early-career outcomes. This meta-analysis aims to estimate the effect size of the association between Milestone ratings and other performance measures in general surgery. Method The authors conducted electronic database (search dates: August 9, 2023, March 25, 2024, and February 20, 2025) and forward and backward reference searching. A 3-level meta-analysis was performed to account for clustering and dependency of effect sizes. Overall effect size and heterogeneity statistics were estimated. Moderated analyses were conducted to examine whether any observed heterogeneity could be accounted for by training level, Milestones competency category, outcomes, and Milestones version. Results The authors extracted 445 effect sizes from 16 studies. Milestone ratings were statistically significantly correlated with Entrustable Professional Activities (r = 0.59, P < .001) and American Board of Surgery In-Training Examination (r = 0.39, P < .001) but not with United States Medical Licensing Examination (r = 0.11, P = .20), social-emotional outcomes (r = 0.14, P = .25), patient outcomes (r = −0.08, P = .41), and residency application factors (r = 0.07, P = .42). Training level, Milestones competency category, and Milestones version did not moderate effect size estimates. Conclusions The ACGME Milestone ratings in general surgery correlate strongly with some indicators of performance, including Entrustable Professional Activity assessments and the American Board of Surgery In-Training Examination, but not for other outcomes, such as United States Medical Licensing Examination, social-emotional outcomes, residency application factors, or patient outcomes.