In a retrospective observational cohort study Using national milestone data from 2478 neurosurgery residents across 120 U.S. programs (2018–2022), with descriptive statistical analysis Khalid et al.evaluate the progression of neurosurgical residents across the 6 ACGME core competencies and 20 subcompetencies, specifically: Assessing how many residents reach level 4 proficiency by the final year (PGY-7). Identifying patterns of co-occurring deficiencies in competencies. They conclude that neurosurgery residents demonstrate substantial milestone progression throughout training, but gaps remain—particularly in specialized clinical skills and self-assessment (Reflective Practice). Nearly 45% fail to reach level 4 in at least one subcompetency by PGY-7. These deficiencies are concentrated in areas often covered during fellowship training (e.g., epilepsy, pain, peripheral nerve). Therefore, residency programs may need to enhance exposure to these areas or redefine competency expectations. The authors recommend: Targeted educational interventions
Specialized procedural training To ensure that all residents achieve the necessary competencies for independent practice 1)
🧠 1. Conceptual Overreach: Competency as a Bureaucratic Fantasy
This study mistakes numerical progression in a checklist for actual neurosurgical maturity. “Milestones” are treated as objective truths, when in reality they are administrative fictions imposed top-down by ACGME to simulate accountability. The implicit assumption—that every resident must hit an arbitrary “level 4” to be considered competent—is never questioned. The authors do not interrogate what level 4 means, who defines it, or whether it maps to meaningful clinical outcomes. Instead, they deliver descriptive statistics masquerading as insights.
