This is a perpetual question facing medical students going into EM. Three- and four-year residency? The first thing you should know is that there are really three types:

  • PGY 1-4: A four-year program that begins with the first postgraduate year of training
  • PGY 1-3: A three-year program that begins with the first postgraduate year of training
  • PGY 2-4: A three-year program that begins following completion of a first postgraduate year of training. These programs are rapidly being phased out and no longer exist.

Actually, Emergency Medicine started in July 1970 at the University of Cincinnati as a 2 year program. In time many then grew to four years in length. Residencies are supported by federal funding via Medicare. Eventually the feds decided that three years were all you needed and so they started fully funding only three years. Many four year programs consolidated down. The ones that remained took a hit financially on that fourth year.

So why do four years?

Those in favor of it feel that EM is so broad a field there is no way you can learn enough in three years. The more time you spend with the knowledge, the better you’ll get. There’s more lectures to attend and more procedures to potentially do.

Also, if you’re going into academics, four-year programs may not want a three-year graduate teaching their seniors. Technically, they have the same level of training. If you’re going into the community, that extra fourth-year of knowledge will help you when you’re by yourself (without the support of many specialties to back you up).

Peter Rosen noted at Denver Health that his 3-year graduates, while smart enough, had an inferiority complex. They knew what to do, but were able to be talked out of doing it by other specialties. Yet, the residents that had completed an additional year of fellowship were much more comfortable in their management plans. The fourth-year graduates were “smoother in personal interactions, in understanding how to compromise while being firm in the interfaces that are so key to the successful practice of emergency medicine…To be respected, one must be respectable. This starts with self-respect.”

So why do three years?

A new graduate of a three-year program could be making $200,000 more than her buddy toiling away at a fourth-year resident’s salary. This is often called the “$200,000 mistake.” Some feel that the 4th year senior residents just serve to make it easier for the faculty so actually do the program more good than they do the residents. The ABEM In-Training Exam shows that residents in both 3-year and 4-year programs scores about the same. So do malpractice cases. So why waste your time? Especially when there is a lack of board certified, residency trained EM physicians out there.

So, I graduated from a 2-3-4 program. I would say that EM is so broad, you definitely cannot learn it in three years. You can’t learn it in 4. Or 5. Or 6. Or 10. This requires a dedication to lifelong learning. My advice would be to find a program you like, with faculty you respect and residents you enjoy in a city you would be happy in. Unless you have real financial concerns, don’t worry about the length of the program.

Annotated References:

  2. (list of ACGME accredited residencies)
  3. (great advice from David Overton)
  4. Peter Rosen and Glenn C. Hamilton. “Three year verses Four year Residency.” (for and against debate by Drs. Rosen and Hamilton)
  6. Lori Weichenthal. “Advantages of a Four-Year Residency.” The California Journal of Emergency Medicine V:1,Jan-Mar 2004.

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