Assessing Residency Readiness: Patterns of “Not Yet Level 1” Milestone Ratings in Emergency Medicine Interns

The Accreditation Council for Graduate Medical Education (ACGME) Milestones define competency expectations for graduate medical education trainees. A designation of “Not Yet Level 1” (NYL1) indicates failure to meet minimum competency expected of incoming interns and can reflect a lack of preparedness for residency. The objective of this study was to evaluate NYL1 milestone ratings among U.S. MD–graduated Emergency Medicine (EM) interns at mid-year and end-of-year.

We performed a national retrospective analysis of ACGME milestone evaluations for EM PGY-1 residents graduated from US medical schools from 2021-2024. NYL1 percentages at mid-year and end-of-year evaluations identified areas of lesser preparation (top quartile of EM subcompetencies). Descriptive statistics summarized distributions and comparisons.

A total of 6,893 EM PGY-1 residents were analyzed. At mid-year, the mean proportion of NYL1 ratings across subcompetencies was 2.5% (range 1.8%–3.3%), decreasing by end-of-year to a mean of 0.4% with a narrower range (0.2%–1.0%). Subcompetencies related to pharmacotherapy and medication safety (Patient Care 5 [PC5]), quality improvement (Systems-Based Practice 2 [SBP2]), and accountability and conscientiousness (Professionalism 2 [PROF2]) exhibited higher relative NYL1 percentages at both evaluation periods. In contrast, patient safety knowledge (Systems-Based Practice 1 [SBP1]), system navigation for patient-centered care (Systems-Based Practice 3 [SBP3]), and understanding the physician’s role within health care systems (Systems-Based Practice 4 [SBP4]) demonstrated elevated mid-year NYL1 percentages but improved to average or below-average levels by year’s end. Scientific knowledge of common presentations (Medical Knowledge 1 [MK1]) demonstrated a below-average mid-year NYL1 percentage but a relatively higher proportion at end-of-year.

Nationally, the proportion of PGY1 EM residents whose milestone assessments are NYL1 is low (below 5%) at both mid-year and end-of-year evaluations, suggesting overall strong readiness for residency. Patterns of NYL1 highlight potential targets for medical schools and residency programs. Next steps involve determining which training level should address each target.