3 yr or 4 yr EM Residency?

[NYYk9005]

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Hello smart people of emergency medicine.

I am a third year medical student wanting to go into emergency medicine. Love it.

My question is regarding residencies. What are the pros and cons of selecting a 3 yr residency vs a 4 yr residency?

I live in NY where there seem to be quite a few prestigious four yr programs but was wondering if I should go with three.

One year earlier, attending salary faster, attendings experience (or fellowship) quicker.

What do you people suggest?

 

[RustedFox]

3 years and GTFO.

 

[@JackShephard]

The simple answer is, the 3 year grads like 3 years and the 4 year grads like 4 years. The 4 year grads usually say they feel better trained. Obviously, you get more elective time also.

I think it's better to look at the programs you'd like to apply to in the geographic region you prefer, then after interviews, make that decision. I guess one could knock off all the 4 year programs out of their application, but I'd probably refrain from doing that until I had all the interviews I wanted.

 

[Hercules]

3 years and GTFO.

I did a 4 year program because I liked it and geography was a huge factor. It was great but I would recommend 3 years for all the reasons listed throughout this forum. As a side note my former program has now converted to a 3 year format.

 

[@JackShephard]

I did a 4 year program because I liked it and geography was a huge factor. It was great but I would recommend 3 years for all the reasons listed throughout this forum. As a side note my former program has now converted to a 3 year format.

Wow, I guess some 4 year grads recommend 3 years...

 

[littlejuan]

The simple answer is, the 3 year grads like 3 years and the 4 year grads like 4 years. The 4 year grads usually say they feel better trained. Obviously, you get more elective time also.

I think it's better to look at the programs you'd like to apply to in the geographic region you prefer, then after interviews, make that decision. I guess one could knock off all the 4 year programs out of their application, but I'd probably refrain from doing that until I had all the interviews I wanted.

That is what I did. I actually had a few 4 year programs at the top of my list, but I ultimately matched at a 3 year program. I haven't started quite yet, but I am incredibly happy. The program fits me well... it has everything I was looking for.

 

[BoardingDoc]

I think it's better to look at the programs you'd like to apply to in the geographic region you prefer, then after interviews, make that decision.

Can't echo this enough. I just matched into residency in EM and I went into application season thinking I was going to lean heavily towards 3 year programs because I couldn't justify the 4th year in my head.

By the end of interview season, my rank list (in terms of length) was 3, 4, 4, 3, 3, 4 etc....

The point is, I'd recommend ranking programs based on whether or not you want to live there and train there. If you need to flip a coin between two "equally good" programs in your head, then I'd go with the 3 year one.

 

[namethatsmell]

Search

 

[DocEspana]

5 year. Never grow up.

 

[swamprat]

I rotated at a 4 year program and I loved it but ended up ranking it 7 because I couldn't justify an extra year. Knowing myself i would be very bitter that last year working like a resident when I could be an attending.

 

[Cerberus]

There are probably hundreds of threads on this but here's my experience. I ranked 4,4,3,3... ranked a 3 and happy I did because I loved the program. I did a fellowship and now am a director.

 

[TheERdr]

I'm a 4th year resident and not at all bitter about it. Yes, I have friends who are attendings, BUT... I am also getting an awesome education, I am training at a program where I LOVE the people, I have had opportunities to do everything I have wanted in residency, will be starting my dream job in a few months!
Go with your gut...If you go to a 4 and you love it, jump in the water is great. If you fall in love with a 3, go to a 3

 

[gman33]

Look at how the program is structured and think about your interests and goals.
Some 4 year programs are great.
Some just have you wasting a bunch of months that will contribute little to your education.
A solid 3 year program will train you well.
The extra year isn't that big of a deal. Just look for the program that seems like the best fit.

 

[mybubbles14]

Agree with everyone above... I applied geographically regardless of program length. Prior to my interviews I figured all of the 4s would be at the bottom. At the end of the day the top of my ROL was 3 4 4 3 3. When it came down to making my decision I really didn't factor in length of the program with the exception of #11. It might have been about 2 spots higher had it been a 3 year.

 

[Dr.CCM]

It comes down to this. If it's a place you like more than any other OR you wouldn't be happy at any of the 3 year places you receive interviews , then obviously do the 4th year place. More than likely, you'll find excellent 3 year programs at great locations.

Big negatives of that 4th year are: a year of lost income, a year of loans accruing interest, an extra year if doing a fellowship, an additional year of work before you can retire. Most programs don't offer anything special with their 4th year other than an additional year of work. Wouldn't it be better to be paid like an attending that 4th year staffing the department vs a resident salary?

Most specialities that offer an additional year in their curriculum typically do so for a reason-- a year off for research at medicine or surgery residency, critical care fellowship if doing general surgery, etc. Our 4 year programs in EM don't do that.

 

[@JackShephard]

It comes down to this. If it's a place you like more than any other OR you wouldn't be happy at any of the 3 year places you receive interviews , then obviously do the 4th year place. More than likely, you'll find excellent 3 year programs at great locations.

Big negatives of that 4th year are: a year of lost income, a year of loans accruing interest, an extra year if doing a fellowship, an additional year of work before you can retire. Most programs don't offer anything special with their 4th year other than an additional year of work. Wouldn't it be better to be paid like an attending that 4th year staffing the department vs a resident salary?

Most specialities that offer an additional year in their curriculum typically do so for a reason-- a year off for research at medicine or surgery residency, critical care fellowship if doing general surgery, etc. Our 4 year programs in EM don't do that.

Good post, although I don't think a 3 vs 4 year residency is going to be the limiting factor in deciding when one retires.

 

[Dr.CCM]

Good post, although I don't think a 3 vs 4 year residency is going to be the limiting factor in deciding when one retires.

All other things being equal, it will have an impact. It could have a significant impact in when you are ABLE to retire. It's a year for your loans to increase, a year with a significantly reduced pay, and a year before you can really start saving and that's the kicker. If you were to assume to have the same financial responsibility, how does a 200k+ reduction in income over a year not have an impact on when you could financially retire?

 

[The Buff]

All other things being equal, it will have an impact. It could have a significant impact in when you are ABLE to retire. It's a year for your loans to increase, a year with a significantly reduced pay, and a year before you can really start saving and that's the kicker. If you were to assume to have the same financial responsibility, how does a 200k+ reduction in income over a year not have an impact on when you could financially retire?

Yes, all other things being equal. I think Dr Shepard's point is that it is extremely hard to predict you financial course over 20-30 years. Maybe you will have large medical bills, maybe your rich uncle will will die, maybe you'll make good investment decisions, maybe you wont. So, yes, you do gain a year of financial viability by going to a three year program, but there are so many other variables in life I dont think you can predict that you will retire earlier just because you went to a three year program.

 

[@JackShephard]

All other things being equal, it will have an impact. It could have a significant impact in when you are ABLE to retire. It's a year for your loans to increase, a year with a significantly reduced pay, and a year before you can really start saving and that's the kicker. If you were to assume to have the same financial responsibility, how does a 200k+ reduction in income over a year not have an impact on when you could financially retire?

Yes, all other things being equal. I think Dr Shepard's point is that it is extremely hard to predict you financial course over 20-30 years. Maybe you will have large medical bills, maybe your rich uncle will will die, maybe you'll make good investment decisions, maybe you wont. So, yes, you do gain a year of financial viability by going to a three year program, but there are so many other variables in life I dont think you can predict that you will retire earlier just because you went to a three year program.

Exactly. 200k sounds like a lot and it is. But it's not the limiting factor. Just like when people are trying to get into an exercise program and they are focused on which gym to go to and what gear they need to buy. Those are factors, but not LIMITING factors. Everything is a factor.

What could be more important?

- Ability to negotiate income levels
- Business sense an entrepreneurship
- Spending habits! (literally there are people who are broke who have quadruple the income of some multimillionaires. Furthermore, look at many professional athletes who earn hundreds of millions and are broke. Income rarely determines how wealthy a person becomes, how they spend/invest does).
- Investing skills. You could earn 50% more than a good investor, and still have less than he does after 30 years.
- etc. I'm sure there are more. Ability to shelter from taxes and other things.

There are other financial savvy people on this site (like WhiteCoatInvestor). I'm sure he'd tell you the same. Anyone who has seen a lot of financial cases (financial advisers or professionals) could tell you what I'm saying is true. So yeah, a 3 or 4 year residency will not be the limiting factor in deciding when one retires.

 

[The White Coat Investor]

I didn't apply to four year programs at all. Great docs come out of both types of programs. A 4 year graduate IS better trained than a 3 year graduate. Why wouldn't they be? Whether they are better trained than a 3 year graduate one year out, or a three year graduate who has completed a fellowship, is another discussion. There is no doubt that FINANCIALLY, the right move is 3 year then straight to a community practice. But life is about a lot more than finances.

Frankly, being in residency for another year was pretty unappealing to me. While residency might have been my favorite job ever, I certainly wouldn't ever want to do it for another year that I didn't have to. It is painful to work 60 hours a week in an ED (80 when off-service). It is painful to have to present your patients to someone else. It is painful to have to rebuild the relationships that were put on the backburner for 3 years.

If you are absolutely in love with one geographic area, or one program in particular, and don't mind making less and spending more time in residency, then go for it. But if you just want 4 years of training, I think you'd be better off with a fellowship.

All that said, I'd go to a great 4 year program over a mediocre 3 year program. Luckily, that wasn't a decision I had to make. In fact, I don't get the impression that 4 year programs are any less competitive than 3 year programs. If you can go to a great 4 year program, you can go to a great 3 year program.

 

[Hercules]

There is no doubt that FINANCIALLY, the right move is 3 year then straight to a community practice. .

You can't argue with that. I would say (as a 4 year grad) that you can ease the financial hit by going to a moonlighting friendly program. Several of us added $100k-150k moonlighting in our 4th year. Of course if all you're really interested in is making money during your 4th year than you should probably just do a 3 year program and be an attending during that 4th year.

 

[GTP]

You can't argue with that. I would say (as a 4 year grad) that you can ease the financial hit by going to a moonlighting friendly program. Several of us added $100k-150k moonlighting in our 4th year. Of course if all you're really interested in is making money during your 4th year than you should probably just do a 3 year program and be an attending during that 4th year.

Added? As In 100-150 K on top of your 55 k PGY4 paycheck?

 

[Hercules]

Added? As In 100-150 K on top of your 55 k PGY4 paycheck?

Yes added. We would routinely pick up 2-4 twenty-fours a month at a few rural low volume EDs around us. You could count on a good 4-6 hrs of sleep most nights and the pay we negotiated was good.

 

[GTP]

Yes added. We would routinely pick up 2-4 twenty-fours a month at a few rural low volume EDs around us. You could count on a good 4-6 hrs of sleep most nights and the pay we negotiated was good.

Wow. That's pretty insane. And you could do this right from second year or just the last year?

 

[Hercules]

Wow. That's pretty insane. And you could do this right from second year or just the last year?

Depends on your program. This was single coverage and many programs frown on single coverage until your final year. I wouldn't necessarily plug my scenario into your future budgeting plans. Our situation does not seem to be the norm from talking with others. Our work hours in residency were pretty reasonable and we had some good opportunities within an hour or two of our program.

 

[GTP]

Depends on your program. This was single coverage and many programs frown on single coverage until your final year. I wouldn't necessarily plug my scenario into your future budgeting plans. Our situation does not seem to be the norm from talking with others. Our work hours in residency were pretty reasonable and we had some good opportunities within an hour or two of our program.

Here I was allocating my future income.

 

[Dr.CCM]

Exactly. 200k sounds like a lot and it is. But it's not the limiting factor. Just like when people are trying to get into an exercise program and they are focused on which gym to go to and what gear they need to buy. Those are factors, but not LIMITING factors. Everything is a factor.

What could be more important?

- Ability to negotiate income levels
- Business sense an entrepreneurship
- Spending habits! (literally there are people who are broke who have quadruple the income of some multimillionaires. Furthermore, look at many professional athletes who earn hundreds of millions and are broke. Income rarely determines how wealthy a person becomes, how they spend/invest does).
- Investing skills. You could earn 50% more than a good investor, and still have less than he does after 30 years.
- etc. I'm sure there are more. Ability to shelter from taxes and other things.

There are other financial savvy people on this site (like WhiteCoatInvestor). I'm sure he'd tell you the same. Anyone who has seen a lot of financial cases (financial advisers or professionals) could tell you what I'm saying is true. So yeah, a 3 or 4 year residency will not be the limiting factor in deciding when one retires.

Exactly. 200k sounds like a lot and it is. But it's not the limiting factor. Just like when people are trying to get into an exercise program and they are focused on which gym to go to and what gear they need to buy. Those are factors, but not LIMITING factors. Everything is a factor.

What could be more important?

- Ability to negotiate income levels
- Business sense an entrepreneurship
- Spending habits! (literally there are people who are broke who have quadruple the income of some multimillionaires. Furthermore, look at many professional athletes who earn hundreds of millions and are broke. Income rarely determines how wealthy a person becomes, how they spend/invest does).
- Investing skills. You could earn 50% more than a good investor, and still have less than he does after 30 years.
- etc. I'm sure there are more. Ability to shelter from taxes and other things.

There are other financial savvy people on this site (like WhiteCoatInvestor). I'm sure he'd tell you the same. Anyone who has seen a lot of financial cases (financial advisers or professionals) could tell you what I'm saying is true. So yeah, a 3 or 4 year residency will not be the limiting factor in deciding when one retires.

I do read WhiteCoatInvestor. Got his book a few months ago. Best educational experience all of fourth year was reading that book. Highly recommended to everyone.

 

[emergentmd]

I applied to two programs that were 4 yrs and was last on my match list even though I liked them. Everyone has to prioritize but after being in college, med school for 7 yrs, an extra yr of residency didn't have any appeal to me.

I moonlighted alot when I was in my 2nd and 3rd year. I would say I doubled my pay back then. I know now that a resident could command $125-150/hr in texas.

I think moonlighting gave me more experience than in residency. In residency, I still had to check out pts with attendings and some were alittle overbearing. When I moonlighted, I made and lived wiht all of my decisions.

I know that money is not everything, but look at how much money you would throw away. As a 3rd yr resident, I did 18-12hr shifts. Plus didactic meetings which probably added another 4 days. So I was at work 22 days a month. On off shift, I was working 30 straight days back before all of the changes.

If I worked 22-12 hr shifts as an attending, I would make over 600K a year at a rate of $200/hr. I could find job in texas paying $250/hr in Houston tomorrow and I would make close to 800K with those hours.

Plus, a 4th yr would not add much b/c I was never going to go into academics. When I became an attending, It took me a month to get full speed.

 

[@JackShephard]

I applied to two programs that were 4 yrs and was last on my match list even though I liked them. Everyone has to prioritize but after being in college, med school for 7 yrs, an extra yr of residency didn't have any appeal to me.

I moonlighted alot when I was in my 2nd and 3rd year. I would say I doubled my pay back then. I know now that a resident could command $125-150/hr in texas.

I think moonlighting gave me more experience than in residency. In residency, I still had to check out pts with attendings and some were alittle overbearing. When I moonlighted, I made and lived wiht all of my decisions.

I know that money is not everything, but look at how much money you would throw away. As a 3rd yr resident, I did 18-12hr shifts. Plus didactic meetings which probably added another 4 days. So I was at work 22 days a month. On off shift, I was working 30 straight days back before all of the changes.

If I worked 22-12 hr shifts as an attending, I would make over 600K a year at a rate of $200/hr. I could find job in texas paying $250/hr in Houston tomorrow and I would make close to 800K with those hours.

Plus, a 4th yr would not add much b/c I was never going to go into academics. When I became an attending, It took me a month to get full speed.

Can anyone comment how common it is to moonlight during PGY-2/3?

For example, generally 1/3 or 2/3rds of programs permit this.

 

[deleted547339]

Can anyone comment how common it is to moonlight during PGY-2/3?

For example, generally 1/3 or 2/3rds of programs permit this.

Really depends on the program. I'm at a program where moonlighting is strongly encouraged by our administration. I'm pretty sure nearly 100% of our 3rd years moonlight at least some (there may be 1 or 2 that don't). They encourage it as a learning opportunity and it's nice to have a little extra cash. Plus, there are a lot of really good moonlighting opportunities within an hour or two.

I also interviewed where moonlighting was strictly forbidden. Some people think it's too dangerous with respect to liability. I believe there are some states that just don't allow it.

It seemed like the vast majority of the programs were somewhere in the middle. A lot had some in-house urgent care type moonlighting.

 

[@JackShephard]

Really depends on the program. I'm at a program where moonlighting is strongly encouraged by our administration. I'm pretty sure nearly 100% of our 3rd years moonlight at least some (there may be 1 or 2 that don't). They encourage it as a learning opportunity and it's nice to have a little extra cash. Plus, there are a lot of really good moonlighting opportunities within an hour or two.

I also interviewed where moonlighting was strictly forbidden. Some people think it's too dangerous with respect to liability. I believe there are some states that just don't allow it.

It seemed like the vast majority of the programs were somewhere in the middle. A lot had some in-house urgent care type moonlighting.

Is it appropriate to ask about moonlighting during an interview?

 

[GTP]

Is it appropriate to ask about moonlighting during an interview?

I'm sure you can ask the residents during lunch or pre interview dinner

 

[Killa Beez MD]

Is it appropriate to ask about moonlighting during an interview?

I asked about moonlighting during every EM residency interview this past cycle and no one seemed to have a problem with it. If you're worried about asking during the interview then ask during the social event with the residents or at lunch.

 

[deleted547339]

Is it appropriate to ask about moonlighting during an interview?

I found it was something that usually came up without asking if it was common. Programs where it was a highlight brought it up at pre-interview dinners.

 

[emergentmd]

When i did residency, I was under the impression that moonlighting was either encouraged or they just turned the other way.

You could moonlight as much as you liked if it was on your off days. As seniors, we were off about 8 days a month. I usually did 36-48 hours a month moonlighting.

There was a resident I knew that worked literally every day she was off.

 

[pagemmapants]

Theoretically your moonlighting hours must still fall under the GME "duty hours" requirements. Where I trained this ended up being something like 4-6 shifts per month, need equivalent time off after a shift to rest before starting your new shift, no fewer than 8h between shifts, blah blah. Presumably this is enforced more or less stringently depending on your program.

I still managed to double my resident salary in my 3rd year.

I also seriously SERIOUSLY recommend it. Very confidence building. Much experience. Wow.

 

[The White Coat Investor]

I have mixed thoughts on moonlighting. Obviously the money is nice. There is a bit of an educational aspect (primarily being able to go out on your own and then going back into a supervised environment knowing what you're comfortable with and what you're not.) I did some very limited moonlighting (10 shifts total, all in the last 6 months of residency.) The last thing you want to do when you're already working 60 hours a week in the ED is work another shift or two, however.

My beef with moonlighting is more theoretical. If it's okay for a doctor with just a year or two of training to work in an ED, what's the point of completing an EM residency? Are we shooting ourselves in the foot saying our jobs don't require real residency training? That FPs, or docs with just an internship, or even mid-levels can do it?

We have a few PGY3s moonlight with us, but we only put them on double coverage shifts, so they're never there alone. Seems a good compromise.

 

[GTP]

I have mixed thoughts on moonlighting. Obviously the money is nice. There is a bit of an educational aspect (primarily being able to go out on your own and then going back into a supervised environment knowing what you're comfortable with and what you're not.) I did some very limited moonlighting (10 shifts total, all in the last 6 months of residency.) The last thing you want to do when you're already working 60 hours a week in the ED is work another shift or two, however.

My beef with moonlighting is more theoretical. If it's okay for a doctor with just a year or two of training to work in an ED, what's the point of completing an EM residency? Are we shooting ourselves in the foot saying our jobs don't require real residency training? That FPs, or docs with just an internship, or even mid-levels can do it?

We have a few PGY3s moonlight with us, but we only put them on double coverage shifts, so they're never there alone. Seems a good compromise.

This is a touchy subject. I did my third year electives at one hospital that only had FM residency. Whenever I told any resident I wanted to do EM, they went on and on about how it was horrible, and after training in EM I can only do EM. Whereas they can do EM, botox, scope people, OBgyn, etc. They talked about how EM is not special since anyone could do it. Hasn't changed my thoughts. I'm still EM all the way. I don't know why people always have to put down another specialty to elevate theirs.

 

[@JackShephard]

Just wanted to say thanks for all the input.

It appears moonlighting is much more common than I realized.

 

[deleted547339]

I have mixed thoughts on moonlighting. Obviously the money is nice. There is a bit of an educational aspect (primarily being able to go out on your own and then going back into a supervised environment knowing what you're comfortable with and what you're not.) I did some very limited moonlighting (10 shifts total, all in the last 6 months of residency.) The last thing you want to do when you're already working 60 hours a week in the ED is work another shift or two, however.

My beef with moonlighting is more theoretical. If it's okay for a doctor with just a year or two of training to work in an ED, what's the point of completing an EM residency? Are we shooting ourselves in the foot saying our jobs don't require real residency training? That FPs, or docs with just an internship, or even mid-levels can do it?

We have a few PGY3s moonlight with us, but we only put them on double coverage shifts, so they're never there alone. Seems a good compromise.

My take on it is not that you don't need residency training to be competent; very much the opposite. My take on it is that EM residency training is so valuable that as a PGY2 or PGY3 can likely provide better emergency care than the FP they currently have. I'm not moonlighting yet, but I hear some of the stories from our uppers about what some people are doing in the community and it is entirely terrifying.