U.S. emergency medicine (EM) residency training length has been a decades-long dilemma: four versus three years. Two important questions befall educators and residents. First, is three years enough time to become an EM physician? Second, does an additional year add sufficient value to justify the time and expense? To date, the debate has been lively yet largely conceptual. Two recent studies have rekindled the discussion by adding more robust and objective results. The studies lend some evidence that three years of training may be the right number when considering knowledge and observed practice. But critical questions remain unanswered when it comes to specialization, career trajectory, and actual competence as an EM physician.

How Did Current Program Lengths Come About?

Residency length has varied since the inception of the specialty of EM.¹ Approved lengths have included postgraduate years (PGY) 1-3, 2-3, 2-4, and 1-4 over the last 30 years.¹ Curricula with non-EM internships (i.e., PGY 2-3 and 2-4) receded, giving way to categorical EM residencies with interns training under EM faculty (PGY 1-3 and 1-4).^2,3 In the 2021-2022 academic year, categorical (non-combined) EM residency lengths included 221 (80 percent) PGY 1-3 and 55 (20 percent) PGY 1-4 programs.¹

So, What Does the Additional Year Offer?

A fourth year of EM training offers additional supervised clinical and academic experience. This additional experience includes opportunities for elective rotations, scholarship, and niche development.^3,4 These opportunities are often incorporated into scholarly tracks designed to provide structured, specialized training.^5,6 Furthermore, this specialized training may facilitate the pursuit of fellowship programs and academic positions after graduation.^7,8 However, the additional year of training has an opportunity cost to the trainee.³ Furthermore, differences in clinical care between training lengths are mostly unknown. A study of 92 EM programs from 1999 observed similar counts for most procedures between training lengths.⁹ Overall, studies evaluating differences between trainees and graduates from varying EM training lengths are very limited in size and scope.

The Latest Research

One study was conducted by the American Board of Emergency Medicine (ABEM).^10,11 The ABEM study examined test scores in four- versus three-year programs and small differences in standardized test scores and pass rates were observed between trainees and graduates from three- and four-year curricula, including the qualifying and oral certifying examinations.¹⁰ For example, the qualifying examination pass rate was slightly higher for three-year graduates than four-year (93.1 percent versus 90.8 percent; P <0.001).¹⁰ However, these small differences are unlikely educationally meaningful. Another study conducted by US Acute Care Solutions examined 1,084,085 ED encounters by 70 new three-year graduates, 39 new four-year graduates, and 476 experienced new hires in their first year of practice within a large emergency medicine group. All three groups of physicians performed similarly across multiple measures of clinical care, including patients per hour, relative value units per hour, and 72-hour return visits with admission or transfer.¹¹