PRO: Move to Mandated Four-Year Residency a Crucial Step

by Andrew Garrett Little, DO, FACEP

The recent proposal by the Accreditation Council for Graduate Medical Education (ACGME) to extend all emergency medicine residency training from three to four years has ignited a fervent debate within the emergency medicine community. Having attended the ACGME update webinar in early February 2025 alongside fellow emergency medicine educators, the proposition initially sparked a sense of relief within me.

As a program director at a three-year institution who trained in a four-year program, I viewed this as a crucial step toward equipping our graduates for enduring and successful emergency medicine careers, alleviating the constant pressure of deciding what essential knowledge and skills might be left for them to acquire independently.

However, the subsequent reaction from the broader emergency medicine community has been disheartening. Regardless of the ACGME’s ultimate decision, the often public and sometimes contentious discourse surrounding this proposal will undoubtedly leave a lasting impact. Like all commentary preceding this, whether from individuals or organizations, this article reflects my personal perspective on the matter. As I’ve observed, listened to, and read the diverse opinions regarding the proposed changes, particularly the training length adjustment, I must admit to being taken aback by the intensity and nature of some responses. Although other proposed modifications might warrant greater collective attention, I’ve been asked to focus on the training duration. For me, the logical progression from a three-year to a four-year format boils down to three fundamental considerations: time, knowledge, and the evolving role of emergency medicine in health care.

Time

The current landscape of resident work hours is significantly different from years past. The informal shift toward a 60-hour work week, coupled with a greater emphasis on wellness initiatives that often prioritize time off, means our trainees are potentially accumulating more than 1,000 fewer clinical hours per year compared with their counterparts just five years ago. Over a three-year program, this translates to a substantial deficit of 3,000 hours—a significant loss of crucial patient encounters, procedural opportunities, and invaluable learning experiences. How do we effectively compensate for this erosion of clinical time? Do we attempt to compress more into the existing three-year framework? Or do we revert to the unsustainable 80-hour work week? Standardizing training to an appropriate length of four years offers a straightforward solution to recapture some of this lost time.

Knowledge

Although the commonly cited studies focusing on board pass rates are demonstrably flawed and their conclusions have been selectively employed by both proponents and opponents of the change, a broader trend is concerning. In-Training Examination (ITE) and board scores have generally decreased over the past five to 10 years, a period that has simultaneously witnessed an exponential expansion in the knowledge base required for competent and comprehensive emergency medicine practice. The well-intentioned notion that residents would use their reduced work hours for independent study has, regrettably, not materialized universally. Therefore, how do we effectively address these evolving knowledge demands? How can we introduce new and increasingly complex concepts while ensuring mastery of foundational principles? A fourth year provides programs with the appropriate opportunities to adequately teach the expanding curriculum and cultivate the skills essential for both exam success and a deeper understanding of the multifaceted practice of emergency medicine.