U.S. emergency medicine (EM) residency training length has been a decades-long dilemma: four vs. 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 emergency medicine.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 Additionally, 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

Two new studies have investigated academic and clinical performance between the two EM training lengths. ^10,11 One study, conducted by ABEM, examined test scores between trainees and graduates from four vs. three year programs.¹⁰Small differences in standardized test scores and pass rates were observed, 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 (93.1percent versus 90.8 percent; p < 0.001, ω = 0.08). ¹⁰ However,  these small differences are unlikely educationally meaningful. ¹⁰ The other study, conducted by US Acute Care Solutions (USACS), 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/transfer. ¹¹

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 test scores or clinical care, 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 3-year curriculum cannot not 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. For example, applicant interest in EM significantly declined after the EM workforce report was published resulting in a final count of 132 unfilled programs in 2023. ^12,13 This decline in interest has discouraged plans by programs and institutions to expand or open programs. 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 US government.¹⁴ 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.

Lastly, emergency medicine’s body of knowledge as reflected by the Model of the Clinical Practice of EM is ever-expanding.¹⁵ 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.¹⁵ Therefore, the results of this current research should be seen as a point-in-time evaluation and should be re-examined 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 a specific curricula.

References

1. Nelson LS, Calderon Y, Ankel FK, et al. American board of emergency medicine report on residency and fellowship training information (2021-2022). Ann Emerg Med. Jul 2022;80(1):74-83.e8. 
2. Nelson LS, Keim SM, Baren JM, et al. American board of emergency medicine report on residency and fellowship training information (2017-2018). Ann Emerg Med. May 2018;71(5):636-648.
3. Ross TM, Wolfe RE, Murano T, et al. Three- vs. four-year emergency medicine training programs. J Emerg Med. Nov 2019;57(5):e161-e165. 
4. Hopson L, Regan L, Gisondi MA, Cranford JA, Branzetti J. Program director opinion on the ideal length of residency training in emergency medicine. Acad Emerg Med. Jul 2016;23(7):823-7.
5. Jordan J, Hwang M, Coates WC. Academic career preparation for residents – are we on the right track? Prevalence of specialized tracks in emergency medicine training programs. BMC medical education. 2018;18(1):184-184. 
6. Jordan J, Hwang M, Kaji AH, Coates WC. Scholarly tracks in emergency medicine residency programs are associated with increased choice of academic career. West J Emerg Med. 2018;19(3):593-599. 
7. Ehmann MR, Klein EY, Kelen GD, Regan L. Emergency medicine career outcomes and scholarly pursuits: the impact of transitioning from a three-year to a four-year niche-based residency curriculum. AEM Educ Train. Jan 2021;5(1):43-51. 
8. Lubavin BV, Langdorf MI, Blasko BJ. The effect of emergency medicine residency format on pursuit of fellowship training and an academic career. Acad Emerg Med. Sep 2004;11(9):938-43. doi:10.1197/j.aem.2004.03.019
9. Hayden SR, Panacek EA. Procedural competency in emergency medicine: the current range of resident experience. Acad Emerg Med. Jul 1999;6(7):728-35. 
10. 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. Jun 2023;4(3):e12991. 
11. 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. Apr 15 2023;69:100-107. 
12. Marco CA, Courtney DM, Ling LJ, et al. The emergency medicine physician workforce: projections for 2030. Ann Emerg Med. Dec 2021;78(6):726-737. 
13. National Resident Matching Program. Advanced Data Tables 2023 Main Residency Match. National Resident Matching Program; 2023. https://www.nrmp.org/wp-content/uploads/2023/04/Advance-Data-Tables-2023_FINAL-2.pdf
14. Medicare payments for graduate medical education: what every medical student, resident, and advisor needs to know. Association of American Medical Colleges; 2019:1-12. Accessed 2022-03-26. https://www.aamc.org/data-reports/faculty-institutions/report/medicare-payments-graduate-medical-education-what-every-medical-student-resident-and-advisor-needs
15. Beeson MS, Ankel F, Bhat R, et al. The 2019 model of the clinical practice of emergency medicine. J Emerg Med. Jul 2020;59(1):96-120.