National Study of Milestone Evaluation Differences by Gender and Race in Anesthesiology Residency Training

BACKGROUND: Competency-based medical education (CBME) relies on criterion-referenced assessments to track residents’ progression toward independent practice. The Accreditation Council for Graduate Medical Education (ACGME) Milestones serve as a structured framework to evaluate trainee performance, yet concerns have been raised about potential demographic differences in Milestone ratings. This study examined gender and race differences in Milestone ratings among anesthesiology residents. METHODS: We conducted a retrospective cohort study of 4997 residents from 141 anesthesiology programs graduating between 2017 and 2019. Milestone data from ACGME were linked with the Association of American Medical Colleges demographic data. Three-level mixed-effects models were conducted to estimate the differences in baseline Milestone ratings and growth trajectories, and predict marginal means of ratings at graduation by gender and race across 25 subcompetencies. RESULTS: At baseline, no significant differences in Milestone ratings were observed by gender or race. However, underrepresented minorities in medicine (URiM) residents demonstrated slower growth in ratings over time, resulting in significantly lower scores across all subcompetencies at graduation. Gender-based growth trajectories over time did not differ significantly between male and female residents, but by graduation, women received significantly lower ratings in 7 of 25 subcompetencies, primarily in patient care (PC) and medical knowledge (MK) competencies. The largest differences were observed in MK-1. Effect sizes for other subcompetencies were smaller, suggesting limited practical differences overall. CONCLUSIONS: These findings highlight that comparable Milestones ratings at baseline, yet modest but cumulative differences over time may lead to meaningful differences at graduation, particularly in MK-1 for URiM residents.