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.

Increasing Role in Health Care

Emergency medicine is a dynamic and continuously evolving specialty. To suggest that emergency medicine practice remains unchanged since my residency graduation nearly a decade ago, or even since the last significant discussion regarding training length, would be a profound misrepresentation. The scope of our responsibilities and the depth of expert-level knowledge expected of us are constantly expanding. How do we effectively incorporate the necessary experiences and dedicated learning time to prepare our residents for this increasingly complex role? Standardizing training to an appropriate length offers the opportunity to better equip them for the present and future demands of emergency medicine practice.

Stripping away the understandable emotional responses surrounding the proposed increase in training length reveals a fundamental truth. The practice of emergency medicine today, and undoubtedly in the future, bears little resemblance to its iteration in years past. Therefore, a proposal to adjust the length of training should not be met with surprise but rather with thoughtful consideration and, frankly, a degree of advocacy.

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Dr. Little is the residency program director at AdventHealth in Orlando.

CON: The Four-Year Mandate: Where’s the Data?

by Megan Healy, MD, FAAEM

A large group of emergency medicine program directors (PDs) convened in March 2025 to discuss major concerns about a proposed mandate to extend emergency medicine residency training to four years, established by the Program Requirements Writing Group (PRWG) of the Accreditation Council for Graduate Medical Education (ACGME).

The experienced PDs who assembled represent three-year programs, which account for about 80 percent of all emergency medicine programs. This group is troubled by the methods used by the PRWG to develop the proposed changes, concerned about the lack of evidence to support the proposal, and frustrated by the absence of broader stakeholder engagement in this disruptive and consequential change.

The PRWG explains that their directive was to create a residency curriculum for the future of 2050. We all agree on the need to set and maintain high standards for emergency medicine training.

However, a time-dependent format change is not the clear way to achieve this. Among other conclusions, the group cited 5,000 patient contacts throughout the course of training as a benchmark for competency and 124 weeks of emergency medicine time as the interval necessary to meet this goal, without supporting data. Many current three-year programs can achieve these numbers within current formats.

The PRWG also identified a set of new experiences necessary for emergency medicine training and claimed these cannot be achieved in a three-year format. The writing group included few three-year PDs—educators who know best what can be accomplished within existing structures.

The PRWG also leaned heavily on a survey where PDs were asked to build an imagined program without constraints, with the individual components adding up to more than could be covered in 36 months.¹ This survey was not conducted in a transparent fashion and is not sufficient for claiming PD consensus on training length. The rationale for the format change is lacking, and alternative measures could be used to ensure high training standards.

The PRWG has not provided convincing evidence of a problem with emergency medicine graduate competency on a scale that requires this level of disruption. Nor have they demonstrated that a time-dependent format change would make meaningful change to improve graduate competency. Our public letter to the ACGME cites current literature, including a study that shows no difference in performance of three- and four-year graduates, and higher qualifying exam pass rates for three-year program graduates.^2,3 In addition, the PRWG proposed a time-dependent format change, even as the ACGME itself moves towards competency-based education as the model of the future. The writing group has failed to present measures that will be used to evaluate whether this intervention is meeting its goals. We need more data to support this change.

This proposal is being pushed through without responsible engagement with current education leaders and without addressing major concerns about the burden on institutions, programs, and trainees.

Why? There are serious potential unintended consequences on the workforce, non-physician providers and departmental staffing, resident debt, student recruitment, fellowship training, and more. The ACGME should, of course, maintain their focus on the education of our future physicians, but they do not operate in a vacuum, as the last few years have demonstrated.

As a specialty, we need time and data to understand the effects of this change and to prepare if this course of action is indeed supported by evidence. The internal ACGME comment form is insufficient to address these concerns and the Council of Residency Directors in Emergency Medicine (CORD), as the organization that represents PDs, has also been disappointingly silent since the PRWG presentation, declining to create a forum for membership input on the proposal.

The PRWG cannot simply bulldoze the many experienced PDs, chairs, and other education leaders who have serious concerns about the rationale, feasibility, and effects of this mandate.

Emergency medicine educators are highly invested in ensuring the competency of our residency graduates. We also believe in raising the minimum standards for emergency medicine training programs. However, the PRWG has not yet done the work to demonstrate that a significant problem with graduate competency exists, and to show that a time-dependent format change would be the appropriate evidence-based intervention to improve training standards.

To be effective in managing a change of this magnitude, you must engage the people affected and provide robust evidence and rationale before pushing ahead with a burdensome and risky change. The ask is simple: The ACGME and PRWG should pause this mandate, seek more data, and engage the broader group of emergency medicine educators who are rightfully concerned.

We all want to ensure excellent emergency medicine education for the future, so let’s work together to get it right.

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Dr. Healy is a professor of clinical emergency medicine and residency program director at the Lewis Katz School of Medicine at Temple University.

References

1. Regan L, McGee D, Davis F, Murano T. Building the future curriculum for emergency medicine residency training. J Grad Med Educ. 2025;17(2):248-253.
2. Nikolla DA, Zocchi MS, Pines JM, et al. Four- and three-year emergency medicine residency graduates perform similarly in their first year of practice compared to experienced physicians. Am J Emerg Med. 2023;69:100-107.
3. Beeson MS, Barton MA, Reisdorff EJ, et al. Comparison of performance data between emergency medicine 1-3 and 1-4 program formats. J Am Coll Emerg Physicians Open. 2023;4(3):e12991.