Patient Volume Requirements: Evaluation of the 2025 ACGME Proposal for Emergency Medicine Residency Programs

ABSTRACT

Objectives

The 2025 ACGME proposed that all EM residency programs must be 4 years and achieve a minimum of 3000 patients per resident. We characterize the current residency program patient volume per resident based on the proposed requirements. Secondarily, we describe the number of programs that meet the proposed visit volume requirement and the estimated impact of the 4‐year length mandate.

Methods

We conducted a cross‐sectional analysis utilizing a linked dataset of the 2023 American Hospital Association Annual Survey and 2025 EM program information from ACGME's website. Hospital zip codes were linked with Rural‐Urban Commuting Area Codes. We calculated the estimated residency program patient volume per resident as proposed by ACGME. Secondarily, we calculated the estimated change in patient volume if 3‐year programs converted to 4 years.

Results

Of 286 programs, the median program patient volume was 7300 (IQR: 5190–10,207). Among the 232 (81%) 3‐year programs, the median volume was 7616 (IQR: 5292–10,639), while the 54 (19%) 4‐year programs demonstrated a median of 6520 (IQR: 4930–9304). Rural programs (3%) had a median patient volume of 7744 (IQR: 5453–13,209), compared to 7300 (IQR: 5190–10,207) for urban programs (97%). Nine programs (3%) were below the 3000‐patient volume threshold; 7 of these were 3‐year programs, and transitioning to 4 years could bring 6 above the threshold.

Conclusions

Currently, 97% of EM programs meet the proposed 3000‐patient volume threshold, with a median volume well over double this value and similar volumes across program lengths and rurality. Transitioning from 3 to 4 years may enable all but one current 3‐year program to meet the new volume requirement. Therefore, the proposed ACGME changes may not increase the minimum required clinical exposure for EM residents as originally intended and should prompt re‐examination.

1. Introduction

As the most significant change to graduate medical education requirements in decades, the 2025 Accreditation Council for Graduate Medical Education (ACGME) recently proposed new residency accreditation requirements to increase minimum clinical training standards. Most visibly, all emergency medicine (EM) residency programs must include 4 years of clinical training. Among the new requirements, but to date the subject of less attention, ACGME also proposed that all programs must achieve a minimum volume of 3000 EM patients per resident. This threshold was determined from a survey of EM residency program directors asked to estimate the necessary emergency department (ED) patient encounters required for residents to acquire adequate clinical skills [1, 2].

Historically, the ACGME requirement for ED clinical volume was a minimum of 30,000 annual visits at the primary residency teaching site, indirectly implying a minimum volume exposure requirement of 1667 annual visits per resident given the minimum program size requirement of 18 residents per program. This requirement was first introduced in 1995, determined through consensus, and similar to the 2025 requirement, lacking in empiric validation based on national ED visit volumes [3]. The 1995 requirement has been criticized as failing to capture the clinical experience of residency programs utilizing multiple teaching sites. It has also failed to adjust for the increase in national ED visit volume, which rose from 96.5 million in 1995 to 155 million in 2022 [4, 5]. Furthermore, it has not adapted to the growing complexity of patients or the availability of more advanced treatment modalities and technologies since 1995 [6].

While an updated ACGME EM patient volume requirement is likely warranted, concern exists among stakeholders that the proposed 2025 requirements may result in broad loss of accreditation, particularly among programs that include low volume or rural training sites. Despite mixed evidence predicting a future emergency physician workforce surplus, sustaining training programs may be important to ensure an adequate workforce amidst increased attrition rates and to address long‐standing gaps in staffing rural EDs [6, 7, 8, 9, 10, 11].

Accordingly, to investigate the implications of ACGME's proposed volume requirement, we characterize the current estimated EM residency program patient volume per resident, with stratification by program length and rurality. Secondarily, we describe the number of programs that meet the proposed 2025 ED visit volume requirement and the estimated impact of the 4‐year program mandate.

2. Methods

2.1. Study Design

We conducted a cross‐sectional analysis utilizing a linked dataset of the 2023 American Hospital Association (AHA) Annual Survey and 2025 EM program information from ACGME's website. The AHA annual survey included hospital zip codes and annual ED volumes. The ACGME website directory included the name, length, number of filled positions, and hospital rotation sites of EM residency programs [12]. CR abstracted residency information from ACGME's website, and CR and CEWT linked hospital and EM residency program data based on probabilistic matching of hospital characteristics such as name and location. Rotation sites were not included if the name indicated a non‐EM or nonhospital rotation (e.g., poison center, emergency medical services, orthopedic, ophthalmologic, etc.). The AHA hospital zip codes were linked with the Rural–Urban Commuting Area (RUCA) Codes dataset. We categorized programs' primary sites in metropolitan areas (RUCA code 1–3) as urban and programs in micropolitan and nonmetropolitan areas (RUCA code 4–10) as rural.

2.2. Outcomes

Our primary outcome was the estimated residency program patient volume per resident, calculated as proposed by the ACGME [2]. Briefly, the ACGME calculation estimates the patient volume at each rotation site by multiplying the estimated number of weeks spent at each site by the estimated site ED weekly visit volume. This value is then added to the remaining ED rotation site visit volume estimations and is finally divided by the number of residents per program (Supporting Information S1). We report the residency program patient volume per resident based on program length and rurality of the program's primary site.

As a secondary analysis, we calculated the estimated change of patient volume if 3‐year programs converted to a 4‐year format. This was accomplished by multiplying the estimated patient volume from the initial ACGME equation by 4/3, an approximation of the increase of patient volume if 1 year of residency were added. This estimation is consistent with the 2025 ACGME proposal, which indicates 3‐year programs that adopt a fourth year will add 31 weeks of EM rotations for a program total requirement of 124 weeks, representing a 4/3 ratio [1].

3. Results

Out of 1266 ACGME rotation sites, we linked 1192 (94%) with AHA data. A total of 149 linked hospitals (13%) were not individually listed in the AHA but instead reported as part of a larger hospital included in the AHA. Of the 286 programs with complete program data, the median program patient volume was 7300 (IQR: 5190–10,207). The 232 (81%) current 3‐year programs demonstrated a median patient volume of 7616 (IQR: 5292–10,639), and the 54 (19%) current 4‐year programs demonstrated a median patient volume of 6520 (IQR: 4930–9304). Geographically, the eight programs (3%) with primary rotation hospitals in rural areas had a median patient volume of 7744 (IQR: 5453–13,209), and the 278 (97%) programs with primary rotation hospitals in urban areas had a median patient volume of 7300 (IQR: 5190–10,207).

Nine (3%) programs had an estimated program patient volume per resident below the 3000‐patient volume threshold (Figure 1). Of these, seven were 3‐year programs and none were primarily located in rural designations. If these seven programs transitioned to 4‐year programs, six would newly have a patient volume per resident above the 3000‐patient threshold.

FIGURE 1.

Distribution of estimated residency program patient volume per resident. (A) Based on current program lengths. (B) If 3‐year programs became 4.

4. Discussion

Our findings reveal that 97% of EM residency programs currently meet the proposed 3000‐patient volume requirement, with a median volume well over double the proposed requirement threshold. Thus, if the intent of the ACGME proposal was to elevate resident clinical experience through higher minimum ED visit volumes among training programs, that objective is not likely to be met by their proposal. While the exact rationale for this proposed volume threshold may be multifactorial and limited based on its survey‐based provenance, accreditation bodies may need to consider a higher threshold to ensure adequate clinical volume and training. Alternatively, these data may also reassure some stakeholders that this threshold will not result in widespread loss of accreditation for programs, especially in rural areas.

Our findings indicate that patient volume was similar between 3 and 4‐year programs and between rural and urban programs. If 3‐year programs were extended to 4 years, all but one current 3‐year program would meet the new volume requirement. While meeting this threshold may not have been the primary reason for increasing program length, accreditation bodies and residency programs should be reassured that the proposal to extend training duration supports meeting the proposed visit volume requirement.

5. Limitations

This study was subject to limitations. As ED visit volume is manually reported to AHA, minor and random errors may exist. However, as no standardized federal or regulatory body data collection of ED visit volume currently exists, the AHA survey remains the most widely available data source for research and policy [13]. Some hospitals reported ED volumes in affiliation with larger hospitals. While this may overestimate the ED volume at these sites, the effect was limited to a small subset of data. Our calculation to assess an added fourth year of residency assumed that the additional year added an average patient volume from the preceding 3 years. Given that the fourth year commonly includes a large majority of EM rotations, our calculations may have underestimated the anticipated volume.

There are limitations to the proposed ACGME patient volume calculation [1]. The methodology does not account for hospital off‐service rotations; ACGME currently reports total months at each hospital site without information on which months are spent in the ED. Therefore, all ACGME hospital rotations are assumed to be ED rotations, potentially overestimating patient visit volumes. Additionally, the proposed methodology does not account for visits evaluated by nonphysician practitioners or visits independently evaluated by attending physicians, both of which may result in overestimation. Future analyses may benefit from including the exact number of ED rotations at each site and a granular site‐specific adjustment for nonphysician practitioners or the exclusion of units not staffed by residents.

Finally, the proposed ACGME methodology assumes that all rotation blocks are 4 weeks in length, even though some programs report in calendar months [14]. This results in an underestimation of visit volumes at such programs, as there are on average 4.35 weeks per month. If ACGME proceeds with the 3000‐patient volume threshold, requirements could include standardization of rotation lengths for accurate program patient volume calculation.

6. Conclusions

Our findings demonstrate that 97% of existing programs already exceed the ACGME proposed volume threshold, with a median estimated visit volume per resident well over double the proposed minimum requirement. These findings not only underscore the importance of establishing a standardized, accurate, and transparent methodology for estimating patient volume but should also prompt re‐examination of the 3000‐patient threshold if accreditation bodies desire to broadly increase resident clinical experience. These steps will both ensure the integrity of accreditation compliance and promote training standards that support the future emergency care workforce.

Author Contributions

C.E.W.T. and A.K.V., study concept and design; C.E.W.T., drafting of manuscript; C.E.W.T. and C.R., acquisition of data, analysis, and interpretation; C.R., statistical expertise; C.J.G., R.B.S., K.G., A.U., P.A., D.M.C., and A.K.V., critical revisions of the manuscript for important intellectual content.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1.

Topping C. E. W., Rothenberg C., Gettel C. J., et al., “Patient Volume Requirements: Evaluation of the 2025 ACGME Proposal for Emergency Medicine Residency Programs,” AEM Education and Training 9, no. 3 (2025): e70071, 10.1002/aet2.70071.

Data Availability Statement

The data that support the findings will be available in American Hospital Association at https://www.ahadata.com/aha‐annual‐survey‐database following an embargo from the date of publication to allow for commercialization of research findings.