4-year programs on the way out?

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Has anyone heard any speculation concerning the chance that ACGME mandating the EM curriculum to be complete in three years, leaving four year programs to foot the bill for the last year or phase it out? Also, is it true that 4yr programs were only given 3 years accreditation at last review compared to the standard 5 years received by 3 yr programs?

Thanks,

MT

 

[pseudoknot]

I haven't heard this, and don't believe it for a second. New four year programs are being started. Several academic programs have or are about to switch from three to four.

I have heard that the ACGME was becoming interested in why there were three formats for EM, but it sounds like they haven't even officially started to look into the issue. Indeed, two PDs I asked about this said they thought that either the 2-4 programs might go away, or that eventually they would all be four.

Given that the trend is for medical training to get longer and longer at every stage, I think you can bet on the latter. In fact, within our lifetimes EM residencies will probably be at least five years...

 

[shookwell]

Has anyone heard any speculation concerning the chance that ACGME mandating the EM curriculum to be complete in three years, leaving four year programs to foot the bill for the last year or phase it out? Also, is it true that 4yr programs were only given 3 years accreditation at last review compared to the standard 5 years received by 3 yr programs?

Thanks,

MT

4 year programs are already footing the bill for the last year, that's probably the main reason that most programs are 3 year.

Also, I think that if one format is mandated there's a good chance it will be 4 years.

 

[Xerxes1729]

4 year programs are already footing the bill for the last year, that's probably the main reason that most programs are 3 year.

Also, I think that if one format is mandated there's a good chance it will be 4 years.

Currently, Medicare only pays for three years of EM training. I was told this is on the basis of a position paper in the 1980s that said three years was an appropriate length of training, but at the time this was three years after a one-year internship.

 

[alwaysaangel]

Currently, Medicare only pays for three years of EM training. I was told this is on the basis of a position paper in the 1980s that said three years was an appropriate length of training, but at the time this was three years after a one-year internship.

Yup. A program I interviewed explained why there are some 3 and some 4 and this was a big part of the basis.

Basically in the 90s RRC said EM had to be 3 years. Then medicare started only paying for 3 years.

The programs that stuck with 4 years apparently are the ones that already didn't really depend on medicare funding (eg county hospitals that receive few medicare patients). So it has no effect on them because medicare wasn't their primary source of funding anyway so they decided to maintain their 4 year training.

I have a feeling there won't be agreement between all programs anytime soon.

 

[pcarlson05]

Yup. A program I interviewed explained why there are some 3 and some 4 and this was a big part of the basis.

Basically in the 90s RRC said EM had to be 3 years. Then medicare started only paying for 3 years.

The programs that stuck with 4 years apparently are the ones that already didn't really depend on medicare funding (eg county hospitals that receive few medicare patients). So it has no effect on them because medicare wasn't their primary source of funding anyway so they decided to maintain their 4 year training.

I have a feeling there won't be agreement between all programs anytime soon.

On the interview trail I spoke with someone connected in the national leadership that they were going to need to provide a convincing argument about why there should exist two models of EM training. Specifically, they were going to need to argue why a fourth year should be necessary when three year programs have already proven so successful. Take that for what it's worth..

 

[EctopicFetus]

Honestly, even if they have to pay for a 4th yr resident it would be a big money maker for them.

Consider this.. if an EM doc makes $175/hr nationwide plus benefits paying a resident less than 20% of that isnt a bad deal right? Also consider how many more hours the resident works compared to an attending. Sure the volume is less (I believe papers show residents see 1.2-1.5 pph) but still the economics are simple.

 

[shookwell]

Honestly, even if they have to pay for a 4th yr resident it would be a big money maker for them.

Consider this.. if an EM doc makes $175/hr nationwide plus benefits paying a resident less than 20% of that isnt a bad deal right? Also consider how many more hours the resident works compared to an attending. Sure the volume is less (I believe papers show residents see 1.2-1.5 pph) but still the economics are simple.

Not so simple, because you could just hire more subsidized PGY 1-3 residents if your only objective was having bodies in the ED.

 

[Arcan57]

On the interview trail I spoke with someone connected in the national leadership that they were going to need to provide a convincing argument about why there should exist two models of EM training. Specifically, they were going to need to argue why a fourth year should be necessary when three year programs have already proven so successful. Take that for what it's worth..

This sounds like an epic troll job. There are numerous surgical and surgical subspecialty programs that require research years thus creating multiple lengths for their residency programs. And I'd argue that there are multiple reasons to have both 3 and 4 year programs (which has been exhaustively discussed in other threads). The only argument I could see for forcing standardization was if 3 yr programs didn't produce competent attendings, which is manifestly not the case.

 

[NEATOMD]

It's not that anyone ever mandated that Emergency Medicine or any other residency be 3 years, but that a cap was put into place regarding how many residents Medicare would pay for at each institution. If they were over the cap, then Medicare wouldn't pay for any additional residents. To accomodate, residencies including others besides even Emergency Medicine became shorter. Many residencies choose to get around this by just paying for additional residents themselves.

I agree with others above in saying that if the time of EM was to change, it would probably increase since new RRC rules have placed all of these new work hour restrictions. However, I have a hard time seeing it happen for most programs since no one wants to have open slots on match day.

 

[Arcan57]

Not so simple, because you could just hire more subsidized PGY 1-3 residents if your only objective was having bodies in the ED.

Not so. The amount of funding from Medicare for residents within a particular hospital system is fixed. Adding new residency spots means coming up with funds independently, or cannibalizing from other programs at the institution.

 

[Arcan57]

Honestly, even if they have to pay for a 4th yr resident it would be a big money maker for them.

Consider this.. if an EM doc makes $175/hr nationwide plus benefits paying a resident less than 20% of that isnt a bad deal right? Also consider how many more hours the resident works compared to an attending. Sure the volume is less (I believe papers show residents see 1.2-1.5 pph) but still the economics are simple.

What about the hit in productivity you see for an attending in a supervisory role vs. doing primary patient care? Paying residents probably still comes out on top, but I bet not by as much as you'd expect.

 

[pseudoknot]

On the interview trail I spoke with someone connected in the national leadership that they were going to need to provide a convincing argument about why there should exist two models of EM training.

This sounds like an epic troll job. There are numerous surgical and surgical subspecialty programs that require research years thus creating multiple lengths for their residency programs. And I'd argue that there are multiple reasons to have both 3 and 4 year programs (which has been exhaustively discussed in other threads). The only argument I could see for forcing standardization was if 3 yr programs didn't produce competent attendings, which is manifestly not the case.

FWIW, I heard the same thing from three different PDs, so either I'm also a troll or this is something real people are saying. It may not come to anything, but there it is.

I don't think the surgical analogy is necessarily applicable because the research years don't count as clinical training and are essentially like time off from residency, more or less.

I agree there are reasons why there are 3 and 4 year programs, but I also think 3 + fellowship could address most of them. As I said, I would be surprised if it went that way, unfortunately.

 

[EMRocksmyworld]

FWIW, I heard the same thing from three different PDs, so either I'm also a troll or this is something real people are saying. It may not come to anything, but there it is.

I don't think the surgical analogy is necessarily applicable because the research years don't count as clinical training and are essentially like time off from residency, more or less.

I agree there are reasons why there are 3 and 4 year programs, but I also think 3 + fellowship could address most of them. As I said, I would be surprised if it went that way, unfortunately.

Agree with everything in this post. Research years definitely do not count as clinical training so that's irrelevant.

I have heard the same thing from multiple PDs too, although I also doubt it will happen.

I do understand the arguments for 4 years (and actually favor 4 year programs for myself) especially if one is interested in academics, but agree completely that 3+1 is perhaps the best of both worlds.

 

[pcarlson05]

This sounds like an epic troll job. There are numerous surgical and surgical subspecialty programs that require research years thus creating multiple lengths for their residency programs. And I'd argue that there are multiple reasons to have both 3 and 4 year programs (which has been exhaustively discussed in other threads). The only argument I could see for forcing standardization was if 3 yr programs didn't produce competent attendings, which is manifestly not the case.

"Epic troll"? I was just posting my experiences. Doesn't seem that far-fetched to me...

 

[xaelia]

Difficult to make the argument that 4 years is required to adequately train an emergency physician considering the predominance of 3-year programs generates board certified EM physicians successfully year after year. 4 years may be better, but 3 years is sufficient.

The 3+1 model - such as at BIDMC - is probably ideal. Pay increase, junior attending in a system you're familiar with, protected time to finish your academic projects - great way to ensure you're interested in academics and buff your CV. Or, you go off and do a fellowship, or go off into the community, etc.

Hardly impossible to go into academics straight out of a 3-year program, but I'm sure you'd be better prepared with another year.

 

[Cerberus]

Most of the people commenting on how EM is headed towards 4year programs are medical students, who probably heard it while interviewing at 4year programs. I have heard nothing about this and I seriously doubt it will happen. The majority of programs are 3 year programs and the people coming out of those programs are not having a difficult time passing their boards or finding work. I don't see much push for this or benefit to it.

 

[Arcan57]

"Epic troll"? I was just posting my experiences. Doesn't seem that far-fetched to me...

Not that you personally are a troll, more in that there is extraordinarily little chance that there will be any legislated changes in EM training length. Anyone saying it is likely to happen is looking for the listener's reaction, which is quite similar to trolling.

 

[iceman77_7]

Most of the people commenting on how EM is headed towards 4year programs are medical students, who probably heard it while interviewing at 4year programs. I have heard nothing about this and I seriously doubt it will happen. The majority of programs are 3 year programs and the people coming out of those programs are not having a difficult time passing their boards or finding work. I don't see much push for this or benefit to it.

There is a big push in CA to go to 4 years. Harbor is going to 4 after this year's incoming class, Highland, USC and UCSD all went from 2-4 to 1-4 in recent years. Of the 12 EM residencies in CA, the only remaining 3 year programs will be UCI, Stanford, UC Davis and Loma Linda. 2/3 of CA's programs will be 4 year programs next year. I'm applying to and ranking both types of programs highly, but in looking at the CA programs, it seems to be that the push here is to go to 4.

 

[alwaysaangel]

There is a big push in CA to go to 4 years. Harbor is going to 4 after this year's incoming class, Highland, USC and UCSD all went from 2-4 to 1-4 in recent years. Of the 12 EM residencies in CA, the only remaining 3 year programs will be UCI, Stanford, UC Davis and Loma Linda. 2/3 of CA's programs will be 4 year programs next year. I'm applying to and ranking both types of programs highly, but in looking at the CA programs, it seems to be that the push here is to go to 4.

For highland, USC and UCSD all they did was incorporate the intern year (probably because fewer people were willing to apply for prelims when so many other programs didn't require it). They didn't really change from 3 to 4. Just from 4 to 4 all in one place.

Harbor switching over is the only true 3 to 4 year switch.

So I disagree that there is a "push" to go to 4 years. A lot of California were already 4 years and have been for ages. California has a huge population of uninsured patients: Medicare doesn't pay for uninsured patients. So California programs being 4 years has more to do with having a bunch of true county programs that don't really depend on Medicare funding than anything else - so when the government stopped paying for the fourth year a bunch of California programs didn't HAVE to switch over to 3 years.

85% of the rest of the country is 3 years...us Californians are just weird 😛

 

[Cerberus]

There is a big push in CA to go to 4 years. Harbor is going to 4 after this year's incoming class, Highland, USC and UCSD all went from 2-4 to 1-4 in recent years. Of the 12 EM residencies in CA, the only remaining 3 year programs will be UCI, Stanford, UC Davis and Loma Linda. 2/3 of CA's programs will be 4 year programs next year. I'm applying to and ranking both types of programs highly, but in looking at the CA programs, it seems to be that the push here is to go to 4.

It's not really a "push to go to 4 years" if only 1 program has switched from 3 to 4 years of training. The other programs mentioned were just a variation of the 4 year program that switched to the better, 1-4, format.

 

[Cerberus]

For highland, USC and UCSD all they did was incorporate the intern year (probably because fewer people were willing to apply for prelims when so many other programs didn't require it). They didn't really change from 3 to 4. Just from 4 to 4 all in one place.

Harbor switching over is the only true 3 to 4 year switch.

So I disagree that there is a "push" to go to 4 years. A lot of California were already 4 years and have been for ages. California has a huge population of uninsured patients: Medicare doesn't pay for uninsured patients. So California programs being 4 years has more to do with having a bunch of true county programs that don't really depend on Medicare funding than anything else - so when the government stopped paying for the fourth year a bunch of California programs didn't HAVE to switch over to 3 years.

85% of the rest of the country is 3 years...us Californians are just weird 😛

This.

 

[pseudoknot]

The new programs at UCSF and UW are also 4 years.

 

[Docuronium]

Talking to our Program Director the other day, he stated fairly specifically that the country was moving toward 4 years, and that ours would be transitioning to 4 years soon.

 

[pcarlson05]

Not that you personally are a troll, more in that there is extraordinarily little chance that there will be any legislated changes in EM training length. Anyone saying it is likely to happen is looking for the listener's reaction, which is quite similar to trolling.

Reach.

 

[jbar]

I just wish they would standardize the residencies a bit more. It was crazy how different the programs were. Some had 5 months ICU time, others 2. Some had 4 months of non-ICU floor time, others 0. I think programs should clearly still have some flexibility because they see different populations and pathology in different EDs, but things are pretty scattered right now. There should be a bit more consensus .

 

[gutonc]

I just wish they would standardize the residencies a bit more. It was crazy how different the programs were. Some had 5 months ICU time, others 2. Some had 4 months of non-ICU floor time, others 0. I think programs should clearly still have some flexibility because they see different populations and pathology in different EDs, but things are pretty scattered right now. There should be a bit more consensus .

Some of that will depend on the "deal" the program has with other departments whose residencies require ED time. Ours basically has parity between EM doing IM months and IM doing EM months (over the course of residency). What this works out to here is that the EM interns do 2 MICU months, one IM floor month a cards consult month (although that sometimes gets pushed to R2).

 

[RustedFox]

Hate to sound like a jerk, but this 'lets all do more years' thing makes me turbo-mad.

Sure, make all EM residencies five years, medical school tuition can cost a half-million dollars... and we'll never be out of debt.

Meanwhile, the PA and NP crowds are pushing for a bigger scope of practice/larger billing....

So just what DOES all that time and money that I invested get me, exactly?

 

[Arcan57]

Hate to sound like a jerk, but this 'lets all do more years' thing makes me turbo-mad.

Sure, make all EM residencies five years, medical school tuition can cost a half-million dollars... and we'll never be out of debt.

Meanwhile, the PA and NP crowds are pushing for a bigger scope of practice/larger billing....

So just what DOES all that time and money that I invested get me, exactly?

Clinical competence.

 

[pseudoknot]

Clinical competence.

Absolutely. More time will always equate to more clinical competence. If a little basic science is good, a whole lot is better. Six weeks of neuroanatomy? Why not six months? That'll really show those midlevels who's boss.

 

[RustedFox]

Clinical competence.

Ah, I see what I was missing... the more time I spend as an underpaid, indebted resident... the better doctor I'll be someday ! Shoot, sign me up for another TWO years.

To quote Credence Clearwater Revival - "Someday Never Comes".

 

[JackBauERfan]

this debate goes on all the time.

My thoughts are : (and I'm biased, did a 4 year)

We do emergency medicine, which is a mixed medical/surgical specialty

we are required to learn a good number of procedures as well as critical/complex medical pathologies/emergencies.

medicine does 3 years with a bunch of fellowships
surgery does 5 years (ENt, ortho, urology, optho, gen surg)
Anesthesia which is almost close to our speciality does 4 years.

It doesnt' seem unreasonable that in order to learn the whole breadth in training 4 years would be a better suit for the field.

will you lose money doing , yes but that should not be a determinant of training.

Will you be a competent physician after 3 years in EM? yes, a lot would, but from my experience, I'm not so sure that we are not graduating some folks that are questionable.

How would a 4th year general surgery resident fair if they graduated...they would PROBABLY do ok, but they do 5 , because thats what they feel is necessary to train MOST residents. Obviously there is a limit to this logic, but do you see my point?

I just think if we want our field to be more respectable, it makes sense we should be 4...

Again I'm not saying someone from a 3 year residency is NEVER better than someone from 4 year, I've seen both ways, even were a 4 year resident may not be as good as someone from 3 years, but I'm talking about residency length for everyone.

 

[dotcb]

These are just my general thoughts (I did a 4 year program). If you just want to be a practicing emergency physician, 3 years is probably fine. If you want to do academics, 3+1, 4, or 4+1 are good ways to go.

 

[Arcan57]

Absolutely. More time will always equate to more clinical competence. If a little basic science is good, a whole lot is better. Six weeks of neuroanatomy? Why not six months? That'll really show those midlevels who's boss.

We were discussing residency training, not med school curriculum. If more residency training is not making you more clinically competent, than something is wrong with either you or the program.

 

[pseudoknot]

We were discussing residency training, not med school curriculum. If more residency training is not making you more clinically competent, than something is wrong with either you or the program.

It was the first example that came to mind, and I believe it's the same mentality. In general no one in medicine can conceive of the idea that there is any downside to increasing the length of training.

And, really? More residency training will always make you more clinically competent? Why, then, should EM residencies not be 6 or 10 years? Where do you draw the line? Isn't there a point of diminishing returns, especially when you're under the supervision of someone else? Isn't that why everyone says the first year out of residency is so scary and yet so educational? And likewise with moonlighting?

 

[roja]

Personally, I think this is the most ridiculous argument out there. three is not better than four. ALL residencies at some point, put out "questionable" grads. I have seen amazing people from threes and fours, average people from both, and weak from both.

Unless you, or whoever you are talking to, is sitting on either the ACGME or the EM RRC, everything is speculation.

And california is weird. It has a predominance of 4 year programs, because californians stay in california, and they all trained here so are more biased towards four years.

 

[Arcan57]

And, really? More residency training will always make you more clinically competent? Why, then, should EM residencies not be 6 or 10 years? Where do you draw the line? Isn't there a point of diminishing returns, especially when you're under the supervision of someone else? Isn't that why everyone says the first year out of residency is so scary and yet so educational? And likewise with moonlighting?

EM residencies aren't 6-10 years long because residency length is a compromise between creating clinical competence and outside factors. There definitely is an inflection point in the learning curve, and it's a plus if you reach that inflection point prior to leaving residency. Opportunities for constructive discussions to improve your quality of care are few and far between as an attending.

 

[bartleby]

Interesting discussion, but nobody in the 3 vs 4 year camps is ever going to agree that the others are right. You are biased based on how you trained.

There are perfectly reasoned thoughts about the advantages of 4 year programs including the ability to do more research and develop a "niche" if you are looking at academics.

I do not think you can make the case that the extra 6-7 months you spend in the emergency department in a 4 vs 3 year residency (when you consider the 5-6 months of elective time that 4 year programs offer) is going to make the difference between a competent vs non-competent doctor. If you are trying to establish basic competency rather than just "fine tuning" in the last 1-1.5 years of residency, you've got serious issues. A 3 vs 4 year residency isn't going to make a whit of difference in that situation.

 

[deleted109597]

I would argue that it isn't the extra months of training and elective (which are probably important as well), but the extra lecture time and extra supervision.
Unfortunately, as it is a good phrase, the "see one do one teach one" concept doesn't work. So you need extra practice.
However, since competency has been shown to be accomplished in 36 months, I can't argue that you need 48 months. You might be a little better, but your returns are likely diminished over time. You also earn less, and I bet more 4th year residents moonlight than third year residents at 3 year programs.

That being said, I will end up doing 4 years overall, so it's not that big of a difference in the scheme of life. As I've mentioned in other threads, go where you're happy at work and away from work.

 

[FutureCTDoc]

medicine does 3 years with a bunch of fellowships
surgery does 5 years (ENt, ortho, urology, optho, gen surg)

Ophthalmology is 1 + 3, not 5.