Race and Gender Differences in Pediatric Milestone Levels: A Multi-institutional Study

Background: Pediatric programs assess residents using the Accreditation Council for Graduate Medical Education (ACGME) milestone system. Despite milestones being a numerical system based on specific written criteria, evidence exists showing that there are differences in milestones based solely on demographic factors in other specialties. We aimed to assess differences in milestone levels amongst pediatric residents based on race and gender.

Methods: This retrospective, cross-sectional, multi-institutional study included milestone levels over six years from three mid-sized university-affiliated pediatric residency programs based at urban, tertiary care teaching hospitals. Per the ACGME, milestones are rated from 1.0 to 5.0 across six core competencies: patient care (PC), medical knowledge (MK), systems-based practice (SBP), practice-based learning and improvement (PBLI), professionalism (PROF), and interpersonal and communication skills (ICS). All institutions demonstrated a similar method of assigning milestones. Faculty and peer evaluations of residents were used to assign an initial level. Afterwards, the institutions’ Clinical Competency Committees, composed of the program leadership and medical education faculty, used expert opinion and consensus to adjust milestones as needed. For the core competencies that included multiple sub-competencies, milestones were averaged to create a composite score. Self-reported gender and race were collected from the Electronic Residency Application Service.

Results: Data included 1446 composite scores from 316 residents. Most residents were female (71%) and self-identified as white (African American 11%, Asian 25%, Hispanic 11%, White 53%). For race, African American residents had the lowest composite scores in five of six core competencies: PC (p = .030), MK (p=.005), PBLI (p =.003), PROF (p <.001), and ICS (p=.005) This finding was particularly pronounced in PROF (African American mean 3.35 (SD .75) versus Asian 3.51 (.66), Hispanic 3.58 (.66), White 3.59 (.67)). When examined across postgraduate year (PGY) levels, scores for African American residents were lower than other racial groups in all core competencies across all years. Female residents had statistically significantly higher scores than male residents in two competencies: PC (3.38 (.75) versus 3.24 (.82), p = .002) and SBP (3.32 (.74) vs. 3.23 (.80), p = .049). When examined across PGY levels, in MK female residents had had significantly higher scores than male residents as PGY-1s (2.53 (.44) versus 2.48 (0.48), p = .044) but lower scores than male residents as PGY-3s (4.00 (.43) versus 4.14 (.45), p = .03.).

Conclusion: Race and gender are significantly associated with milestones in pediatric residencies. This study reveals racial disparities in the assessment of trainees in residency programs. Pediatric training programs should take steps to ensure that assessments of trainees are without bias.