Blake R. Denley , 2025-05-09 08:30:00
Less than two years ago, I completed a three-year emergency medicine residency and, after passing written and oral board exams, became a board-certified emergency physician. Now, the Accreditation Council for Graduate Medical Education is claiming that three years of personal and financial sacrifice are not enough.
The ACGME reviews each specialty’s program requirements every 10 years, and it recently released their proposed updates for emergency medicine. Their most notable change? Eliminating the three-year pathway that roughly 80% of programs currently use and mandating an unjustified four-year model. By my math, the change could cost each class of future emergency physicians over $2 billion in cumulative financial loss — including missed income, lost investment growth, and increased debt — and result in a $7.5 billion increase in government payments to hospitals over the next decade.
The proposal threatens to burden future residents while failing to meaningfully improve the quality of their education. I support raising training standards — but through improved educational quality, not additional time.
In its defense of the four-year mandate, the ACGME typically cites three factors: decreased work hours and patient encounters, decreased efficiency upon graduation, and downtrending board scores. Let’s take them each individually.
Downtrending board scores. Primarily driven by patient safety concerns, the ACGME has changed its duty hours policies over the years, which has led to residents working fewer hours overall. And while it notes that the educational impact of decreased work hours is “unclear,” it also highlights downtrending board pass rates and subsequently concludes we need to mandate four years of training.
But this approach fails to accept the evidence. Though published data is limited, a 2023 American Board of Emergency Medicine study showed that three-year graduates had higher mean scores and pass rates on their written board exam compared with four-year graduates. To cite board score concerns as justification for its four-year mandate flies in the face of the available evidence.
Decreased work hours and patient encounters. The ACGME says that many emergency medicine residents are not getting enough patient encounters, so they need an extra year. I agree that some residents need more patient encounters, but I disagree it’s a work hours problem. The expansion of existing emergency medicine residencies and growing presence of physician assistants and nurse practitioners in the emergency department both contribute to having fewer patients available per resident. ED boarding — that is, keeping admitted patients physically in the ED because there are no inpatient beds available — also negatively impacts residents’ productivity and education. The most logical solution would be to mandate a minimum number of patient encounters, much like surgeons must have a specific number of cases, and rightsize residency programs to optimize educational value. But that’s not what the ACGME has done.
Instead, the ACGME has chosen to not set a standard relative to volume of experience. The proposal does include a formula to determine how many residents a program may have, but it is flawed and easily manipulable. The formula is based on annual emergency department volume and number of weeks residents spend in the ED. It ignores critical factors that affect patient availability, such as the presence of physician assistants, nurse practitioners, or off-service residents and areas of the ED where residents don’t work. It also doesn’t consider the actual number of hours worked.
It really is a missed opportunity — one that fails to recognize how advantageous it would be to raise the standard by defining a required number of encounters. By not setting a bar and using the manipulable formula, the ACGME is erring on the side of convenience for hospitals, not educational quality or resident experience.
Decreased efficiency upon graduation. ACGME claims that new graduates often provide inefficient patient care (i.e. too few patients per hour). By sharing this belief in their defense of the four-year mandate, the ACGME reveals their assumption that four-year grads are more prepared than three-year grads. Unfortunately, that belief is not only unsupported, but it’s actually been disproven. A 2023 study that analyzed over 1 million patient encounters showed no difference in metrics related to efficiency, safety and flow between three- and four-year graduates. It also showed no difference in these metrics between new graduates and experienced new hires.
Even if we accept their assumptions for the sake of analysis, their proposal isn’t structured in a way that would increase residents’ efficiency. To come up with their recommendation for 124 weeks of ED time, the ACGME assumed residents would see 1.0 patients per hour and work 40 hours per week, on average.
First, I don’t know many residents working just 40 hours per week. And second, basing the standard off of a below-expectations patients per hour will not increase efficiency of graduates. If it’s efficiency we want to improve, why not utilize a higher standard than 1.0 patients per hour? I support the Emergency Medicine Residents’ Association’s (EMRA) recommendation to mandate a minimum of 5,000 patient encounters and at least 94 weeks of ED time. Still assuming 40 hours per week, residents would have to average 1.33 patients per hour — a very manageable metric that would improve efficiency more than the current proposal. And I bet programs with learning environments that enable residents to reach 5,000 encounters in three years will produce more efficient physicians than those utilizing four years to reach the same benchmark.
Without being provided with a logical rationale for the four-year mandate, I’m left wondering what the real reason for this proposed change may be. I worry about two potential reasons: workforce concerns and financial incentives.
A 2021 workforce study projected a surplus of nearly 8,000 emergency physicians by 2030. In response, many stakeholders called on the ACGME to limit the expansion of existing programs and halt the creation of new ones. One idea proposed during that time was to mandate four years of training, and the idea was (or is?) that mandating a four-year model would force certain programs to decrease their class size or potentially even close.
The potential financial motivations are also real. As emergency physician Leon Adelman explains in a recent newsletter, “the proposed changes would bring billions of federal funding to training institutions. Under the new mandate the Centers for Medicare and Medicaid Services, which funds most resident training, would now fund the 3,000-plus new fourth-year positions, as well as more than 750 existing fourth-year positions that are currently subsidized by the institutions. That’s at least $750 million in new government funding each year, or $7.5 billion over a decade. Residents, on the other hand, would lose big. Based on average medical school debt and emergency physician salaries, each resident could lose over $700,000 in lifetime personal wealth due to increased interest, delayed earnings and lost investment growth. Multiply that by the 3,000-plus residents who would newly have to complete a fourth year, and each entering class could collectively lose more than $2.1 billion in lifetime personal wealth.
Now, I am not claiming that the ACGME is explicitly motivated by workforce manipulation or financial pressures. And I do believe that appropriate, evidence-based changes should be adopted regardless of the financial impact on individuals. But by refusing to engage with questions about these topics, they have invited scrutiny and suspicion. The truth is, both the workforce and financial arguments make more sense than any justification the ACGME has offered to date.
If the ACGME is truly committed to transparency, accountability and evidence-based decision-making, they should withdraw the proposed EM program requirements from consideration, re-engage stakeholders with genuine opportunities for influence, and commit to future changes that prioritize what is best for both patients and trainees.
Blake R. Denley, M.D., is a board-certified emergency physician and faculty at Ochsner Health in New Orleans. He is also the immediate past president of the Emergency Medicine Residents’ Association, the largest and oldest resident organization in the world.
