Extending Emergency Medicine residency to 4 years is a premature and untested idea
This could be the nail in the coffin to a much-needed primary care specialty suffering from declining interest
If you have the privilege of not being familiar with medical school/resident Reddit, I do not suggest starting now. To quote Seinfeld, reading through some of these pages is like looking at the sun. You don’t stare at it; it’s too risky. You get a sense of it, and then you look away.
However, I have Reddit to thank for recently informing me about a report released by the ACGME outlining proposed changes to emergency medicine (EM) residency programs - one of which was to change the length of all programs to 4 years. Currently, most EM programs follow a 3 year schedule. This represents a very large shift in the training landscape for aspiring EM docs.
This undoubtedly sparked massive outrage and debate online, with many calling this additional hurdle unjustified in a field with declining popularity. Before I give my two cents, it is important to acknowledge where these changes came from and the rationale of the ACGME, which is provided in their report. I have summarized them here:
EM shifts are decreasing in length nationwide, reducing the number of total clinical encounters of a resident over time.
There has been a downward trend of pass rates for the board licensing exam.
In a survey of EM residency program directors (PDs), most felt that the number of months needed to train competent EM physicians exceeded the length of their programs - with 3 year PDs reporting 41.58 months and 4 year PDs reporting 50.65 months.
Ironically like the EM stereotype, I think whoever wrote this report did a good job of diagnosing valid problems, but may have been too quick to jump to this particular solution.
Generally, my philosophy is that if you want to make a big change to medical education, study it rigorously first. The report cites no peer-reviewed studies comparing any of their outcomes of interest (board pass rates, residency training hours, trainee and PD satisfaction etc) between 3 vs 4 year residency programs. It has not even been attempted. This is perhaps the best specialty to do this type of research as there already exist a mix of 3 and 4 year programs. Even if this were not the case and all EM programs were 3 years long, I would encourage the ACGME to conduct cluster randomized trials where some programs train for 3 years and others train for 4 years and compare outcomes for at least 3-4 cohorts of graduating residents. It is way too premature to make such large decisions that affect the lives of thousands of trainees and millions of dollars in terms of salaries and taxpayer-funded residency seats without first researching beforehand.
In the case of EM residency - there could be a multitude of reasons behind the drop in board pass rates. These factors include the baseline competence of graduating medical students who pursue EM, the recent COVID-19 pandemic which put a disparate burden on EM docs, and fluxes in EM provider staffing. Many of these factors have an element of time variation where their significance can ebb and flow as time goes on.
For example, the competitiveness of EM residencies has changed widely over time - in the 90s, programs had historically low residency fill rates but then shifted to become moderately competitive through the 2010s, during which few matches went with unfilled seats. But in the 2020s, EM has experienced a decline in the number of applicants and an uptick in the number of unfilled seats. It may be the case that this field is no longer attracting the best and brightest out of medical school - resulting in lower board pass rates among residents. I could just as easily make an alternate theory that the disproportionate burden on EM residents during the COVID pandemic resulted in less study time and worse pass rates for cohorts who trained in that era.
Instead of fixating on one possible cause such as program length, we need to explore all possible root causes of the issues that the ACGME clearly define. I myself have several questions about these phenomena. Is the decline in interest in EM and subsequent board pass rates seasonal or a permanent issue? Is this something that necessitates a permanent fix like changing the length of the residency? Are there other ways we could go about this issue? The answers to these can have large policy implications but can only be elucidated with strong research.
We preach evidence-based medicine in routine clinical practice but fail to apply this standard when it comes to education. I have written about similar pitfalls of current methodologies in the medical school pre-clerkship curriculum as well as the pre-med curriculum. In each of those cases, tradition and unwillingness to change takes precedence over any real evidence of efficacy.
For researchers interested in medical education, this is clearly a pressing need in the literature and we should allocate grant money and research support accordingly. If it is found that a 4 year residency does in fact solve these issues to a significant degree, I will be the first one to support this ACGME change.
I think this proposed change also contains another negative effect - it may continue to disincentivize applicants from pursuing EM, a critical primary care specialty currently in a shortage and already facing threats of further decline.
As I mentioned earlier, fewer applicants to the tune of thousands are applying EM in recent years, leaving 555 unfilled spots in 2023, an all-time high in the 21st century. With an ever-increasing burden of ED visits, many hospitals have also resorted to expanding the scope of nurse practitioners and physician assistants to bridge the gap. This so-called “mid-level creep” is a band-aid solution that serves mainly to cut costs with little evidence to support good patient outcomes. Combine this with corporatization of hospitals and the burnout wreaked by the recent pandemic and the outlook for a fulfilling career in EM is looking bleak among medical students. This is rather sad given the massive importance of EM physicians in the overall health system, serving as medicine’s first line of defense 24/7, 365 days a year.
Increasing the years of training will only serve to kick the specialty while it’s down. Let me be clear - we should never lower standards for a profession due to lack of interest, but it is hard to justify increasing the standards for a profession suffering from lack of interest, especially if we have no data to back it up. EM is one of several specialties that can only benefit from higher standards in training. But this does not only come in the form of increasing program length.
This is especially true as while the ACGME states that 3 years is not enough to train a competent EM doctor, the scope of practice of mid-level providers in the ED has only increased while their reduced load of training compared to residents has stayed the same. Does the ED value extra years of training or not? We have to pick one.
I also could not escape the sinister feeling that there may be an uglier motive for this - that extending training helps hospitals and health care systems squeeze 1 more year of cheap resident labor. If that is the case, then this sets quite the precedent and the EM specialty may be doomed.
Overall, I think this decision is a major inflection point on the future of the EM career. Changes like this one will affect our ability to meet the significant demands of the emergency department as well as ensure that interest in the field remains strong with future trainees. Therefore, any proposed changes to the residency training process should not be taken lightly and should be tested with stringent methodology first.