Letter of Concern from the Association of Academic Chairs of Emergency Medicine Regarding ACGME Proposed Changes

Abstract

This letter, signed by over 50 academic chairs of emergency medicine, urges the ACGME to reconsider a proposed mandate requiring all emergency medicine residency programs to adopt a four-year training model. The authors argue that current three-year programs are supported by data demonstrating equivalent educational and clinical outcomes compared to four-year formats. They criticize the flawed survey methodology underpinning the proposal, note the loss of milestone-based training flexibility, and highlight the lack of added scholarly or clinical value in the fourth year. The letter also outlines negative consequences for fellowship participation, workforce development, trainee debt, and diversity. The signatories advocate for maintaining the current flexible training model to preserve excellence, equity, and innovation in emergency medicine education.

To: Accreditation Council for Graduate Medical Education

401 North Michigan Avenue, Suite 2000

Chicago, IL 60611

May 1, 2025

Dear Members of the Accreditation Council for Graduate Medical Education,

We, the undersigned academic chairs of emergency medicine departments are writing to express our deep concerns regarding the recent proposal to mandate a transition from the current 3- or 4-year training format to a compulsory 4-year residency requirement in Emergency Medicine. This decision would impact 80% of all Emergency Medicine training programs and is of utmost concern to us.

Our objections to this decision are as follows:

Data from the American Board of Emergency Medicine and other reputable sources does not support the necessity of lengthening training to four years to achieve the knowledge thresholds sought. In fact, existing data supports the quality and competency of residents graduating from well-established 3-year programs. Mandating an additional year of training without clear empirical evidence undermines the proven efficacy of current training models. For example, studies by Beeson et al.1, Hayden et al.2, and Nikolla et al.3 demonstrate that there are no significant differences in board examination performance or clinical competence between graduates of 3-year and 4-year programs.

The decision to implement this change appears to have been based on survey data that is fundamentally flawed. The survey methodology obscured the true intent behind the questions and included leading questions that biased the results. Such flawed data cannot serve as a reliable basis for making substantial changes to residency training requirements.

By mandating a 4-year training period, the new policy negates the milestone-based curriculum that has been a cornerstone of Emergency Medicine residency training. Program Directors currently have the discretion to graduate residents after 3 years upon achievement of all required milestones or to add individualized training as needed. This flexibility allows for tailored educational experiences that align with individual resident capabilities and career goals. A one-size-fits-all approach would erode this effective, individualized training model.

Moreover, the addition of a fourth year fails to introduce meaningful enhancements to scholarly activity or research requirements that would substantively advance our specialty. While we recognize that extended training may benefit select individuals, mandating a 4-year format for all residents should be accompanied by corresponding scholarly expectations and justifications—not just additional service time.

While Emergency Medicine physicians are well-prepared for careers beyond direct clinical emergency department care through the current 3-year format, mandating a fourth year is less efficient for learners, the specialty, and the healthcare workforce. Residents seeking non-clinical pathways typically pursue fellowships, and a streamlined 3-year residency followed by focused fellowship training offers the most efficient trajectory. A study by Ehmann et al.4 revealed that transitioning from a 3-year to a 4-year Emergency Medicine residency format led to a reduction in the number of graduates pursuing fellowship training. This suggests that extended base training may dissuade residents from subspecializing, potentially diminishing the future pipeline of EM experts in critical areas such as toxicology, ultrasound, and critical care. Imposing a fourth generalized year risks discouraging fellowship participation and contradicts ongoing efforts to reduce unnecessary burdens on trainees. Maintaining the 3-year model supports individualized training, fosters lifelong learning and career satisfaction, and sustains a diverse and dynamic pipeline for future Emergency Medicine leadership.

The financial impact of transitioning to a mandatory 4-year model is also significant. For hospitals, adding an incompletely funded fourth year would further strain already thin margins threatened by reimbursement cuts. Arguments suggesting that increased low-acuity clinical time and reduced advanced practitioner staffing would offset these costs conflate service needs with educational priorities, undermining the true mission of graduate medical education. For trainees, the additional year would exacerbate their already considerable six-figure educational debt—a burden that disproportionately affects URiM (Underrepresented in Medicine) students and risks dissuading them from entering the specialty altogether.

In conclusion, we urge the ACGME to reconsider this decision in light of these concerns. Flexibility in residency training duration, grounded in evidence-based practices and responsive to the diverse needs of our trainees and specialty, is essential to advancing Emergency Medicine education and maintaining excellence in patient care.

Thank you for considering our perspectives on this critical matter. We remain committed to working collaboratively with the ACGME to ensure that any changes to Emergency Medicine residency requirements uphold the highest standards of medical education and service to our communities.

Sincerely,