Title: Emergency Medicine at a Critical Juncture: Why Mandating a Fourth Year Could Be More Detrimental Than Beneficial
The domain of emergency medicine (EM) is at a crucial turning point. Long celebrated for its rapid pace, extensive scope of practice, and essential role in acute care, EM now confronts increasing internal and external hurdles. Among the most urgent are escalating burnout rates, changing healthcare economics, and a concerning rise in unfilled residency positions during the National Resident Matching Program (NRMP) Match process.
In this context, a new and contentious proposal has sparked renewed discussion: Should emergency medicine residencies be extended from three to four years as a compulsory standard?
The Accreditation Council for Graduate Medical Education (ACGME) is presently evaluating updates to the EM Program Requirements, which may include the establishment of a standardized 48-month residency curriculum. While the objective may be to bolster clinical expertise and improve readiness, this modification presents the risk of worsening existing issues without guaranteeing tangible enhancements in training outcomes.
No Proof of Improved Outcomes with Four-Year Programs
Despite the weighty implications of medical education reform, current evidence shows no significant clinical or educational advantage to prolonging EM residencies from three years to four years.
An increasing volume of research questions the belief that a longer training period yields better physicians. A 2021 study published in the Western Journal of Emergency Medicine demonstrated no statistically significant distinction in board pass rates between alumni of three-year and four-year programs. Furthermore, additional studies have indicated similar competencies in domains such as patient outcomes, procedural abilities, and job placements across both training avenues.
Indeed, findings from the American Board of Emergency Medicine (ABEM) strengthen this assertion. A 2023 review indicated that graduates from three-year programs slightly outperformed their four-year peers in board pass rates. At best, the suggested extension lacks a definitive evidence-based justification and risks conflating duration with depth, rather than tackling the fundamental issues — quality and relevance of training.
Economic and Workforce Implications
In addition to concerns about effectiveness, there are tangible economic and workforce ramifications to consider. For medical graduates in 2023, the average debt burden approached nearly $202,000, as reported by the Association of American Medical Colleges (AAMC). An additional year of residency implies another year at a resident physician’s salary — typically below $70,000 — compounded by delayed physician-level income, deferred loan repayment, and postponed retirement savings.
Nationally, mandating a fourth year may exacerbate an already precarious workforce, especially in rural or underserved regions. Although workforce modeling predicts a potential surplus of emergency physicians by 2030, these forecasts often overlook the uneven distribution of physicians throughout the U.S. and the ongoing closure of rural emergency departments. Delayed workforce entry may only amplify these disparities.
Recruitment Challenges in a Recovering Match Landscape
Most critically, an extended EM training period may undermine recent advancements in attracting new physicians to the specialty. Following a historic low in 2023 — when 555 EM residency positions remained unfilled during Match Week — 2025 showed signs of recovery, with only 65 unfilled positions and a national fill rate of 97.9%.
Nevertheless, medical students today are carefully considering multiple factors when choosing a specialty: lifestyle, salary potential, job stability, and increasingly, the duration of training and educational debt. A required fourth year may deter students, particularly those facing substantial financial burdens or familial responsibilities, siphoning off talent that EM is eager to retain.
In a field reliant on recruiting dedicated, resilient, and talented professionals, any factor that could reduce the applicant pool must be thoroughly examined.
Concentrate on the Right Issues
The obstacles facing emergency medicine do not stem from the length of residency training. Instead, they arise from systemic challenges within the post-residency work climate: burdensome administrative tasks, rising workplace violence, high patient loads, and increasing burnout.
What EM genuinely requires is investment in enhanced support systems for new graduates, initiatives that foster well-being and retention, and substantial interventions aimed at alleviating physician burnout and moral injury. Boosting resilience and job satisfaction will significantly enhance patient care and physician longevity far more effectively than extending training without solid evidence of benefit.
While advocates of the four-year requirement may operate with the best of intentions, enforcing an additional year risks diverting focus and resources from initiatives that could substantially impact the future strength of emergency medicine.
Conclusion
The future of emergency medicine ought to be guided by solid evidence, well-considered reforms, and an unwavering dedication to the welfare of both physicians and patients. Extending residency training to four years in the absence of data-driven justification undermines these objectives.
If the aim is to elevate EM and enhance community service, the way forward is not simply to increase duration — but to be more intelligent, supportive, and focused on solving the genuine challenges faced by today’s emergency physicians.
Authored by:
Polly Wiltz, D.O.
Anna Heffron, M.D.
Emergency Medicine Residents
References:
– ABEM