What Should We Take Away?

The lack of differences in the observed outcomes do not suggest one EM training length is superior. Yet, neither study really examined robust markers of care quality or strong measures of competence. There are many ways in which an additional year of training may benefit trainees (i.e., elective time, additional mentorship) that were not directly studied. The additional year may improve career trajectory or longevity, entrance into fellowship or academic practice, or other longer-term outcomes, including successful development of a niche in the specialty. Importantly, the opportunity cost of delaying an attending salary by one year was not addressed in either study.

Given there are no large differences in clinical care or test scores, four-year EM programs should work to demonstrate the value of the additional year of training by expanding goals beyond basic academic and clinical achievement. This justification is required by the Accreditation Council for Graduate Medical Education (ACGME). For example, four-year programs could offer formal research training or niche clinical experiences such as aeromedical or telemedicine, which a three-year curriculum cannot feasibly accommodate. Additionally, four-year programs should consider (and ideally study) the value of these experiences to the career path of their graduates, and how these educational opportunities supplement or compare to dedicated fellowships. For example, an emergency medical services scholarly track may not provide trainees with equal qualifications to a fellowship.

Furthermore, while the ACGME and ABEM directly govern EM training length, external pressures may drive programs toward one program length.

Applicant interest in a particular EM format may also incentivize programs toward one training length. Furthermore, graduate medical education is funded by Medicare, and additional goals for longer training programs may not align with the funding goals of the U.S. government.¹² On the contrary, hospitals may operationally and financially benefit from longer training lengths thus indirectly influencing curricula decisions. Therefore, applicant, funding, and operational factors may influence programs to offer a particular curriculum length.

Emergency medicine’s body of knowledge as reflected by the Model of the Clinical Practice of EM is ever-expanding.¹³ Some of these training opportunities previously considered unique (i.e., ultrasound and resuscitation procedures) may become a new standard for programs and require a longer training period.¹³ Therefore, the results of this current research should be seen as a point-in-time evaluation and should be reexamined regularly to decide what is required to practice as an emergency physician. Arguably, the right answer lies with the resident who chooses to train for a specific length of time or the residency programs that choose to offer specific curricula.