ACGME proposing changes to EM residency requirements

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DocEspana said:
One of the two sites my residency trains at has a real wild West philosophy to education and a LOT of head trauma (people jump off buildings a lot I guess). Almost on principle they ask us to crich most of those head/face traumas. I know I graduated with over 20 crichs, likely over 30 (I don't think over 40. That seems like too many). I know that plenty of them were definitely optional, but I assumed the educational decision was to always opt in. Always assumed that's a normal thing in residency to finish with 20-30 of them. Maybe we were more wild west than I thought.

I've even done a few as an attending because I got a reputation as the airway guy (not because of the crichs!) and if my partner taps me on the shoulder and says he can't get the airway and then I can't get it on my first try, I'm criching because there have probably been too many attempts already with my one extra.
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We always just intubated facial trauma the normal way.
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TooMuchResearch said:
We always just intubated facial trauma the normal way.
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Yeah we didn't get an option. We were told that we had to do a crich to practice it by our attendings (obviously some of them were " put the tube where the bloody bubbles are").We would get told what kind of intubation we had to do on every intubation. It was whatever the attending wanted you to do, so we would get told to use different tools and different approaches whenever the attending felt bored.
 
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I was ready by 3 but after being in the real world for a while it’s clear a lot aren’t.
 
I think the argument is not that you can't be ready in 3 or are more ready in 4. It's that you are doing essentially 34 months of EM and required outside rotations (and a tiny bit of vacation) just to accomplish the requirements for the current 3 year program. I am not versed in other specialties specifically but my impression (and what I've heard from reliably but technically not ACGME sources) is thats unheard of in other fields. To leave zero room for any electives or broadening/personalizing of your education. Technically I think there are 6-8 total weeks unaccounted for in the 36 month version and most places feel that toxicology, anesthesiology +/- labor and delivery are worthwhile and make them mandatory at their program.

The four year version allows for the requirements to 1. Be less rushed with no room for error, illness, or pregnancy 2. Actually add in some of those "electives" that should be required and 3. Allow time for legitimate and real electives to actually broaden your knowledge base by going to another department and working with them. I know i took 2 weeks with plastics and it was a massive benefit for me.

It's not like electives are make or break , but they're a benefit. The fact that there is just zeeeeeeero room for anything but the requirements in 36 month curriculum is (so I hear) an oddity for EM.
 
DocEspana said:
I think the argument is not that you can't be ready in 3 or are more ready in 4. It's that you are doing essentially 34 months of EM and required outside rotations (and a tiny bit of vacation) just to accomplish the requirements for the current 3 year program. I am not versed in other specialties specifically but my impression (and what I've heard from reliably but technically not ACGME sources) is thats unheard of in other fields. To leave zero room for any electives or broadening/personalizing of your education. Technically I think there are 6-8 total weeks unaccounted for in the 36 month version and most places feel that toxicology, anesthesiology +/- labor and delivery are worthwhile and make them mandatory at their program.

The four year version allows for the requirements to 1. Be less rushed with no room for error, illness, or pregnancy 2. Actually add in some of those "electives" that should be required and 3. Allow time for legitimate and real electives to actually broaden your knowledge base by going to another department and working with them. I know i took 2 weeks with plastics and it was a massive benefit for me.

It's not like electives are make or break , but they're a benefit. The fact that there is just zeeeeeeero room for anything but the requirements in 36 month curriculum is (so I hear) an oddity for EM.
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it may be an oddity but the vast majority of programs 89% I believe) in the era when em was widely respected and knowledgeable attracting some of the brightest and highest step score earners were 3 year programs. So clearly it works. The recent drop in pass rates and quality candidates has more to do with over saturation with a new abundance of crappy programs where they can only teach moving the meat with medium acuity sites where metrics are taught as the primary standard.
 
Rendar5 said:
it may be an oddity but the vast majority of programs 89% I believe) in the era when em was widely respected and knowledgeable attracting some of the brightest and highest step score earners were 3 year programs. So clearly it works. The recent drop in pass rates and quality candidates has more to do with over saturation with a new abundance of crappy programs where they can only teach moving the meat with medium acuity sites where metrics are taught as the primary standard.
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Oh it's definitely more than 75%, so 89% doesn't surprise me. I'm not a fan of 4 years for the sake of being 4 years. I went 3 years because it was the best option for me. I'm a fan of four years as a mechanism to go "oh no! How unexpected!" When it closes a bunch of bad residencies. I'm just sitting here trying to talk/type out some good aspects of the 4 year shift (and echoing some of the arguments ACEP or some other org made a few years ago about the same topic).
 
DocEspana said:
It's not like electives are make or break , but they're a benefit. The fact that there is just zeeeeeeero room for anything but the requirements in 36 month curriculum is (so I hear) an oddity for EM.
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I did my elective in legal medicine. I spent a month working in a med mal defense firm. I primarily worked with attorneys to write their defences, but I got to sit in on a deposition and trial. That month was extremely helpful for later on.
 
Prehealth1011 said:
Would love to hear med students thoughts on this, if the extra year sways their passion away from procedures, seeing the undifferentiated and what not.
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Still early on so time will tell, but it definitely gives some pause. With the difference in 3-4 year programs being explained as just an extra year of free labour (unless the 4th year had actual extra experiences, not just additional medicine rotations or something), it's a bit disheartening. The noted suggestion on getting more experience in lower acuity settings is interesting (unsure if I'm reading that correctly). Anesthesia is certainly looking like a nicer option for the same length. I'm still EM-pilled, for now.
 
ablanco said:
I'm still EM-pilled, for now.
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Honestly that probably matters more than Step scores. That a significant percentage of med students that match in EM don’t want to practice EM has been a problem for our specialty for a long time. Attracting failed surgical specialty applicants boosted our competitiveness and (maybe) our prestige. It’s also meant that too many EPs identify as future med spa owners or real estate moguls and don’t feel any sense of obligation to the profession itself.
 
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DocEspana said:
I think the argument is not that you can't be ready in 3 or are more ready in 4. It's that you are doing essentially 34 months of EM and required outside rotations (and a tiny bit of vacation) just to accomplish the requirements for the current 3 year program. I am not versed in other specialties specifically but my impression (and what I've heard from reliably but technically not ACGME sources) is thats unheard of in other fields. To leave zero room for any electives or broadening/personalizing of your education. Technically I think there are 6-8 total weeks unaccounted for in the 36 month version and most places feel that toxicology, anesthesiology +/- labor and delivery are worthwhile and make them mandatory at their program.
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I can speak specifically to IM in this regard. I was a research pathway resident who completed IM in 2 years before moving on to fellowship. I was able to complete all of my RRC mandated rotations in 20 months. It meant I had almost as many inpatient rotations (wards, ICU and ED) as an R2 as I did as an intern, while the typical setup (at least at my program) was to split those about 2/3 in the R2 year and 1/3 in the R3. I got only 3 months of electives (2 of which I did in my sub-specialty, the other was research in the lab I joined during my post-doc). The other month was vacation. So yeah, you can cram 3 years of an IM residency into 2 years, but you're basically just setting yourself up to either be a hospitalist or checking the boxes you need to do to be a sub-specialist. If I had wanted to be a well rounded internist, or wanted to explore anything other than the sub-specialty I went in thinking I wanted to do, there's no way I could have done it in that short period of time.
 
EMdoc254 said:
I’ll admit I’ve never done a cric on a real patient. And I trained at a trauma heavy hospital where my colleagues had multiple crics. Just never had to. I’ve also never done a perimortem c section. I don’t think I’ll ever feel comfortable doing a thoracotomy even though I’ve done 3. Don’t think an extra year would fix any of that.
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I don't work anywhere that a patient survives transport after a thoracotomy anyway. Bilateral chest tubes and endotracheal tube is the best I can offer.
 
I can see IM doing it electives because of specialties however, what specialty are you doing in EM? You could make a month of specialties by adding another shift to the EM months to make it more “hardcore” three years already does a lot of ICU.

You could also do 2 week electives some of the electives with one less EM month

The things like legal medicine should be built in to the conference. Or Sim lab should be doing plastic and ENT procedures.

EM can only do critical care and you’re less expensive than IM we can go into specialties that everyone else can go into, but take a year longer. The reason why they aren’t electives in EM is because the field is very narrow in your career.

Ultrasound Fellowship! Leadership fellowship! Simulation Fellowship!

These are the EM fellowships. Yes the five EM programs where the ICU is run by the ED but in the most part IM pulm and anesthesia CC give way more flexibility

All the others are run by different specialties
 
You may review the changes and comment here:
www.acgme.org

Review and Comment

The ACGME invites comments from the community of interest regarding the proposed Requirements listed below.
www.acgme.org www.acgme.org

Here is a summary of the changes from my interpretation of them:
  • Extend training from 3 years to 4 years
    • Total 124 weeks of ED time
      • Minimum 62 weeks in a high-resource ED (i.e., tertiary care facility)
      • Minimum 4 weeks in a low-resource ED (i.e., smaller community shop)
        • Time in low-resource ED not supervised by board-certified EP does NOT count
    • 3,000 patients seen for every resident
      • Combines numbers from all sites as a percentage of time spent at each site
    • Recommended patient volume
      • 1 PPH average
      • 40 hours/week max
      • Expected volume is approximately 5,000 ED patients seen during residency
  • Increased ICU time
    • 2 months in the adult ICU
    • 4 months total ICU time
    • Can't remember specifics, but certain percentage must be PGY-2 or above
  • Changes in procedure numbers
    • Adult intubations increased from 35 to 75
    • Chest tubes include pigtails now
    • Surgical airways include trachs in addition to crics
    • Lumbar puncture numbers decreased to 10
    • Minimum 10 each dislocation/fracture reductions (now separated)
    • Simulation allowed for a lot more procedures
  • I think they dropped required numbers for ultrasound
  • Residents must present their scholarly activity (disseminate -- publish, poster, blog, whatever but it has to be shared somehow)
  • Required rotation/experience in administration (2 weeks) including quality improvement project
  • Required ophthalmology core experience (IIRC doesn't need to be a dedicated rotation)
  • Requirement that other residency/fellowship programs and APPs cannot "negatively impact" ED resident education
  • Specific requirements for didactics/individual education
    • 5 hours per week minimum (averaged)
    • So many hours per year
    • Resident required to attend so many hours (approximately 70% of didactics)
    • Now have an individual education component -- didn't spend much time reading details
  • Requirements to have so much staff support per number of residents based on FTEs
I'm sure I missed a few things, but that's the gist of what I saw. The low-resource ER concerns me that they are increasing the residency time only to place residents in lower-volume EDs. Can't help but think of how the for-profits will benefit from this.

EDIT: Changed the low-resource requirement.
 
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This "specialty" can eff all the way off.
For REAL for real.
I just worked a 1-11 at our mothership for the first time in 3-4 months.
It's an unmitigated disaster.
Thank Christ I got paid a fat bonus to do so.
CTs were getting five hours to even get done.
Children (RNs) with green hair and doorknocker nose piercings were puttering about clueless.
They looked like farm animals.
Literally nothing was getting done.
This is our future.
 
RustedFox said:
This "specialty" can eff all the way off.
For REAL for real.
I just worked a 1-11 at our mothership for the first time in 3-4 months.
It's an unmitigated disaster.
Thank Christ I got paid a fat bonus to do so.
CTs were getting five hours to even get done.
Children (RNs) with green hair and doorknocker nose piercings were puttering about clueless.
They looked like farm animals.
Literally nothing was getting done.
This is our future.
Click to expand...
Just saying.. i love this.. all of it.. i feel this..
 
Brigade4Radiant said:
Low resource and low acuity like a critical access for 62 weeks lol
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Yeah, they mention something about a facility without a lot of ancillary services, competing residencies, and places that need to transfer patients.

I'm really concerned about a PGY-3 or 4 seeing 1 PPH.
 
southerndoc said:
  • Required ophthalmology core experience (IIRC doesn't need to be a dedicated rotation)
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At first I figured this would be an easy way to shut some places down, but it’s pretty minimal. Slit lamp, intraocular pressure, foreign body removal, and canthotomy/cantholysis.

If you throw in ocular vitals, how to open difficult lids, red eye, and minor POCUS, you’ve covered almost everything you need. Outside of c/c since that honestly needs a little hands on experience (and is rare), that’s probably under 2 hours of education. A lot of ophtho residencies sucker some poor PGY2s or APDs into doing a crash course, or the EM residents hang out with the consult resident for a few days.

I suspect the many places without a residency will just throw together a PowerPoint and have the residents attest to having clicked through it. Most low acuity places won’t have a slit lamp anyway.
 
eyeeye_captain said:
At first I figured this would be an easy way to shut some places down, but it’s pretty minimal. Slit lamp, intraocular pressure, foreign body removal, and canthotomy/cantholysis.
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The first, and most important, thing to teach is to wander around the department trying to find the slit lamp. Once you find it you realize it doesn’t work so you forego it and just give them close follow up as an outpatient like 99.98% of other eye complaints.
 
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JacobMcCandles said:
The first, and most important, thing to teach is to wonder around the department trying to find the slit lamp. Once you find it you realize it doesn’t work so you forego it and just give them close follow up as an outpatient like 99.98% of other eye complaints.
Click to expand...

Honestly; I would really like someone just to show me where it is and how to turn the effing thing on.
 
JacobMcCandles said:
The first, and most important, thing to teach is to wonder around the department trying to find the slit lamp. Once you find it you realize it doesn’t work so you forego it and just give them close follow up as an outpatient like 99.98% of other eye complaints.
Click to expand...
That hit me in the old feelings. Try having to wheel one from the other end of the hospital and back for every ED consult because the department got sick of losing them. Even the ortho bros in the trauma bays were complimenting how swole I looked.
 
RustedFox said:
how to turn the effing thing on.
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Switch is in a different place on every. Effing. Model. And there are a bare minimum of 3 electrical connections that can be effed. That’s not even counting the specialty light bulb that might be blown. I worked counties and VAs from med school through fellowship, happy to come to your shop with some duct tape and a prayer.
 
RustedFox said:
This "specialty" can eff all the way off.
For REAL for real.
I just worked a 1-11 at our mothership for the first time in 3-4 months.
It's an unmitigated disaster.
Thank Christ I got paid a fat bonus to do so.
CTs were getting five hours to even get done.
Children (RNs) with green hair and doorknocker nose piercings were puttering about clueless.
They looked like farm animals.
Literally nothing was getting done.
This is our future.
Click to expand...

The specialty is toast.

It should have stayed in the model where you split the ED into "medical" and "surgical" and had rotating IM docs see all the chest pains and surgeons see all the belly pains, where if you're not sick you wait 12 hours or self diurese home.

Instead we pretended that you needed "training" to work in the ED, and it morphed into the bastardization we see today that is part pill mill, part psychiatric somatization institute, part gomer day care, part disaster mitigation center, all while you are pushed to be 100% perfect every time, satisfy the "customer," and not piss off anyone.

EM suffers from the problem where you're often the smartest person in the room, but have to placate all sorts of immature childish personalities. Whether it's the nurse that doesn't want to do the right thing because "protocol," a CT tech that won't give contrast for Cr 1.5 or a medic that brings in body that's been dead for 12 hours; you have to pretend that all these fools deserve a voice, and not be immediately fired.

It should be the best specialty, and at its core it is. We are the ones people turn to when they really need a doctor. But society decided that there's more value in replacing a 90 year olds hip than saving a child's life.
 
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southerndoc said:
You may review the changes and comment here:
www.acgme.org

Review and Comment

The ACGME invites comments from the community of interest regarding the proposed Requirements listed below.
www.acgme.org www.acgme.org

Here is a summary of the changes from my interpretation of them:

  • Total 124 weeks of ED time
    • 62 weeks in a high-resource ED (i.e., tertiary care facility)
    • 62 weeks in a low-resource ED (i.e., smaller community shop)
      • Required -- I can't remember, but I think it specifies that minimums of 62 weeks spent in low-resource ED
      • Time in low-resource ED not supervised by board-certified EP does NOT count
I'm sure I missed a few things, but that's the gist of what I saw. The low-resource ER concerns me that they are increasing the residency time only to place residents in lower-volume EDs. Can't help but think of how the for-profits will benefit from this.
Click to expand...

I didn't se a 62-week minimum in the low-resource ED (or 62-week in the high-resource, for that matter).

I may have misinterpreted something, but here are the relevant bullet points from the proposed program requirements:
  • At least 62 weeks of the resident’s emergency medicine clinical experience should occur at the primary clinical site. (Detail)
  • At least four weeks of this clinical experience must be at a low- resource emergency department and four weeks at a high- resource emergency department. (Core)
  • Residents should have no less than eight weeks of experience in a practice setting designated for low-acuity patients, such as an emergency department fast track or urgent care center. Time spent in a low-resource emergency department does not count toward this experience. (Detail)
 
I took a look at the proposed 3,000 pts/yr requirement and this is an even worse threshold than people hoped.

Have a look at section 1.8.h (page 8) in the proposed program requirements document: https://www.acgme.org/globalassets/...nt/2025/110_emergencymedicine_rc_02122025.pdf

In the worked example, a program with 24 total residents works 100 weeks over 4 years at a hospital with 45,000 visits per year and 28 weeks at a hospital with 30,000 visits per year. Their formula leads to a calculated patient volume of 4,276 patients per resident per year.

Using this same formula, a program of 24 residents could work 124 total weeks at a hospital with 30,194 visits/yr and meet the 3,000 pts/yr requirement.

The minimum program size of 16 (a decrease from 18) could satisfy the requirements by doing all their shifts at a hospital with 20,130 pts/yr.
 
Prehealth1011 said:
Would love to hear med students thoughts on this, if the extra year sways their passion away from procedures, seeing the undifferentiated and what not.
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If this change goes through, EM is going to be a no from me unless they can get the critical care fellowship down to 1 year in length. For me the big advantage to EM was the fast training and relative availability of cool and interesting fellowships that still allowed one to practice the primary specialty but with less overall time in the ER (pain, crit care, EMS, hyperbarics, tox, sports, palliative, addiction, etc).

My opinion is this change has the potential to silo EM grads more and more to the ED, which is not what many practicing emergency docs seem to want long-term. More and more critical access or urgent care jobs will go to IM/GP/FM docs or midlevels. Pay in larger facilities likely will increase a bit, but only working in these places will lead to burnout for many over time.
 
WhatJobDoIPick said:
The specialty is toast.

It should have stayed in the model where you split the ED into "medical" and "surgical" and had rotating IM docs see all the chest pains and surgeons see all the belly pains, where if you're not sick you wait 12 hours or self diurese home.

Instead we pretended that you needed "training" to work in the ED, and it morphed into the bastardization we see today that is part pill mill, part psychiatric somatization institute, part gomer day care, part disaster mitigation center, all while you are pushed to be 100% perfect every time, satisfy the "customer," and not piss off anyone.

EM suffers from the problem where you're often the smartest person in the room, but have to placate all sorts of immature childish personalities. Whether it's the nurse that doesn't want to do the right thing because "protocol," a CT tech that won't give contrast for Cr 1.5 or a medic that brings in body that's been dead for 12 hours; you have to pretend that all these fools deserve a voice, and not be immediately fired.

It should be the best specialty, and at its core it is. We are the ones people turn to when they really need a doctor. But society decided that there's more value in replacing a 90 year olds hip than saving a child's life.
Click to expand...
QFT.
 
Franzd'Epinay said:
I didn't se a 62-week minimum in the low-resource ED (or 62-week in the high-resource, for that matter).

I may have misinterpreted something, but here are the relevant bullet points from the proposed program requirements:
  • At least 62 weeks of the resident’s emergency medicine clinical experience should occur at the primary clinical site. (Detail)
  • At least four weeks of this clinical experience must be at a low- resource emergency department and four weeks at a high- resource emergency department. (Core)
  • Residents should have no less than eight weeks of experience in a practice setting designated for low-acuity patients, such as an emergency department fast track or urgent care center. Time spent in a low-resource emergency department does not count toward this experience. (Detail)
Click to expand...
I must've misread that. It's at least 62 weeks ED time at primary site. The remainder can be at a secondary site, but minimum 4 weeks required at low-resource ED.
 
Is it also not an inevitable conclusion to extend residency training when duty hours have continued to shrink over the past 20 years?
You can only reduce experience so far at the same length of residency before the product diminishes in quality.
 
southerndoc said:
You may review the changes and comment here:
www.acgme.org

Review and Comment

The ACGME invites comments from the community of interest regarding the proposed Requirements listed below.
www.acgme.org www.acgme.org

Here is a summary of the changes from my interpretation of them:
  • Extend training from 3 years to 4 years
    • Total 124 weeks of ED time
      • Minimum 62 weeks in a high-resource ED (i.e., tertiary care facility)
      • Minimum 4 weeks in a low-resource ED (i.e., smaller community shop)
        • Time in low-resource ED not supervised by board-certified EP does NOT count
    • 3,000 patients seen for every resident
      • Combines numbers from all sites as a percentage of time spent at each site
    • Recommended patient volume
      • 1 PPH average
      • 40 hours/week max
      • Expected volume is approximately 5,000 ED patients seen during residency
  • Increased ICU time
    • 2 months in the adult ICU
    • 4 months total ICU time
    • Can't remember specifics, but certain percentage must be PGY-2 or above
  • Changes in procedure numbers
    • Adult intubations increased from 35 to 75
    • Chest tubes include pigtails now
    • Surgical airways include trachs in addition to crics
    • Lumbar puncture numbers decreased to 10
    • Minimum 10 each dislocation/fracture reductions (now separated)
    • Simulation allowed for a lot more procedures
  • I think they dropped required numbers for ultrasound
  • Residents must present their scholarly activity (disseminate -- publish, poster, blog, whatever but it has to be shared somehow)
  • Required rotation/experience in administration (2 weeks) including quality improvement project
  • Required ophthalmology core experience (IIRC doesn't need to be a dedicated rotation)
  • Requirement that other residency/fellowship programs and APPs cannot "negatively impact" ED resident education
  • Specific requirements for didactics/individual education
    • 5 hours per week minimum (averaged)
    • So many hours per year
    • Resident required to attend so many hours (approximately 70% of didactics)
    • Now have an individual education component -- didn't spend much time reading details
  • Requirements to have so much staff support per number of residents based on FTEs
I'm sure I missed a few things, but that's the gist of what I saw. The low-resource ER concerns me that they are increasing the residency time only to place residents in lower-volume EDs. Can't help but think of how the for-profits will benefit from this.

EDIT: Changed the low-resource requirement.
Click to expand...
We met all these in three years, pretty sure.
 
eyeeye_captain said:
At first I figured this would be an easy way to shut some places down, but it’s pretty minimal. Slit lamp, intraocular pressure, foreign body removal, and canthotomy/cantholysis.

If you throw in ocular vitals, how to open difficult lids, red eye, and minor POCUS, you’ve covered almost everything you need. Outside of c/c since that honestly needs a little hands on experience (and is rare), that’s probably under 2 hours of education. A lot of ophtho residencies sucker some poor PGY2s or APDs into doing a crash course, or the EM residents hang out with the consult resident for a few days.

I suspect the many places without a residency will just throw together a PowerPoint and have the residents attest to having clicked through it. Most low acuity places won’t have a slit lamp anyway.
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Really? I work at a place that sees under 5k patients per year give or take and we have a slit lamp.
 
eyeeye_captain said:
Switch is in a different place on every. Effing. Model. And there are a bare minimum of 3 electrical connections that can be effed. That’s not even counting the specialty light bulb that might be blown. I worked counties and VAs from med school through fellowship, happy to come to your shop with some duct tape and a prayer.
Click to expand...
We have a different model at every hospital. There is one that has two power switches and I can never remember which hospital it is. Our best one was actually gifted to us by our favorite local ophthalmologist.
 
JacobMcCandles said:
The first, and most important, thing to teach is to wander around the department trying to find the slit lamp. Once you find it you realize it doesn’t work so you forego it and just give them close follow up as an outpatient like 99.98% of other eye complaints.
Click to expand...

Ophthalmic Equipment | Haag-Streit BA 904C Portable Slit Lamp | Veatch Ophthalmic Instruments

Complete high-quality exams while ensuring patient comfort with the Haag-Streit BA 904C Portable Slit Lamp. Lightweight, ideal for hospital rooms.
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Had an optometrist where I did my residency who used this for nursing home consults.
 
I think overall its a step in the right direction. Especially the new procedure number minimums. From what I've heard the 3 to 4 transition was mostly because of the fact that many EDs are by in large a ****show now with lots of hallway and waiting room medicine. The big problem with this is it leads to less patients being seen and procedures being done in residencies. While the 3 years was fine back in the day with high acuity high functioning EDs its quite rare to have those nowadays. Having worked as EM faculty at multiple programs there's been a steep drop in the numbers since covid and i'm not exaggerating that many places are graduating residents seeing under 2 PPH and doing under 20 ED intubations. While 4 years is not technically needed the extra rotations needed would mean there would be no off service or elective rotations based on the current schedules at most residency programs. The sad truth is that even academics has become a disaster in most emergency departments.

Regarding just increasing requirements and closing programs I'd be all in favor but that would likely mean closing 50%+ residency programs which ACGME would realistically never let happen even if it did survive all the backlash from emergency faculty and hospital leadership.
 
AES256 said:
My opinion is this change has the potential to silo EM grads more and more to the ED
Click to expand...
How?

If anything, the additional rotations and electives will expose people to more things outside of the ED.
 
alpinism said:
I think overall its a step in the right direction. Especially the new procedure number minimums. From what I've heard the 3 to 4 transition was mostly because of the fact that many EDs are by in large a ****show now with lots of hallway and waiting room medicine. The big problem with this is it leads to less patients being seen and procedures being done in residencies. While the 3 years was fine back in the day with high acuity high functioning EDs its quite rare to have those nowadays. Having worked as EM faculty at multiple programs there's been a steep drop in the numbers since covid and i'm not exaggerating that many places are graduating residents seeing under 2 PPH and doing under 20 ED intubations. While 4 years is not technically needed the extra rotations needed would mean there would be no off service or elective rotations based on the current schedules at most residency programs. The sad truth is that even academics has become a disaster in most emergency departments.

Regarding just increasing requirements and closing programs I'd be all in favor but that would likely mean closing 50%+ residency programs which ACGME would realistically never let happen even if it did survive all the backlash from emergency faculty and hospital leadership.
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Why should we punish good 3 year programs?

Cut the trash programs instead of of playing this ridiculous game w training length.

You don't think the CMGs will adapt to this?
 
Franzd'Epinay said:
How?

If anything, the additional rotations and electives will expose people to more things outside of the ED.
Click to expand...

An additional year of required, unnecessary training.

You get a finite number of years. Why waste one.

Those interested in CC etc will just choose IM or anesthesia (or anything else) instead
 
Franzd'Epinay said:
How?

If anything, the additional rotations and electives will expose people to more things outside of the ED.
Click to expand...
The main way to get out of the ED seems to be fellowships, but it seems to me making the residency longer would disincentive folks from doing one. Right now, there's a huge explosion in pain medicine interest and there's even a petition to allow sleep fellowship from EM that's circulating around the internet. I'm not so sure these movements will be as strong when people are graduating from a residency that is roughly 30% longer and have loans to pay.

There's also the fact that there will probably be an increase in compensation from this move for two reasons.

1) The market is accustomed to seeing something shy of 3,000 graduates hit the market every year. If this proposal goes through, that number will be in the hundreds for the year 2030.

2) There will likely be programs that shut down from the increased requirements which further reduce the amount of graduates every year beyond 2030.

These two factors would lead to decreased supply, leading to increased demand. This would likely lead to some type of an increase in compensation in hospitals that can afford it (depending on the market of course).

When you have increased compensation, lots of people pursue that compensation. This will probably lead to less EM physicians working urgent care or in rural CAHs, as they often can't afford to increase compensation as much as the big boys. These facilities may then start to target EM physicians less in their hiring, leading to less of these types of opportunities. This last part is much less likely than the above, but definitely a possibility depending on how many residencies close down.
 
There is such a myriad of variables at play here that precisely no one can accurately predict what the actual ramifications of these changes would be. Recognizing that, I'll simplify things and say that I'm all for tightening training requirements. If in doing that they streamline all programs to 4 years, so be it.
 
I really think it depends on the program/training. I'll be honest I felt ready about 1/3 into PGY3. I also remember my first attending shift and how nervous I was - the FIRST patient brought in by EMS, old, dizzy lady. F***! Edit- I don't think an extra year would have changed it - at some point you gotta take the training wheels off.

But yeah my program was a busy 3 years with not a lot of fluff, 8 months of ICU time, 4 intern year 2 pgy2 and 2 pgy3, 3-4 hospitals from community to level 1. I guess YMMV
 
AES256 said:
The main way to get out of the ED seems to be fellowships, but it seems to me making the residency longer would disincentive folks from doing one. Right now, there's a huge explosion in pain medicine interest and there's even a petition to allow sleep fellowship from EM that's circulating around the internet. I'm not so sure these movements will be as strong when people are graduating from a residency that is roughly 30% longer and have loans to pay.
Click to expand...
There are people actively trying to leave EM 10+ years into being an attending (some on this very forum). A residency that is "30% longer" (one year) isn't going to be the thing that stops people from jumping ship. If you're burned out, you're burned out. Plenty of people do fellowships after four-year programs right now as it is.

Emapp20177 said:
An additional year of required, unnecessary training.

You get a finite number of years. Why waste one.

Those interested in CC etc will just choose IM or anesthesia (or anything else) instead
Click to expand...

Yeah, this will probably decrease people who go into EM as a quick 3-year path to do something else (palliative, sports, etc.), but for the people who go into EM and genuinely develop an interest in a subspecialty, nothing in this plan prevents them from furthering their career. In fact, the extra elective/research time may make them stronger applicants.

I'm not sold on mandatory 4 years of training, but arguing against it because it "silos" EM grads just doesn't make sense to me.

AES256 said:
There's also the fact that there will probably be an increase in compensation from this move for two reasons.

1) The market is accustomed to seeing something shy of 3,000 graduates hit the market every year. If this proposal goes through, that number will be in the hundreds for the year 2030.

2) There will likely be programs that shut down from the increased requirements which further reduce the amount of graduates every year beyond 2030.

These two factors would lead to decreased supply, leading to increased demand. This would likely lead to some type of an increase in compensation in hospitals that can afford it (depending on the market of course).

When you have increased compensation, lots of people pursue that compensation. This will probably lead to less EM physicians working urgent care or in rural CAHs, as they often can't afford to increase compensation as much as the big boys. These facilities may then start to target EM physicians less in their hiring, leading to less of these types of opportunities. This last part is much less likely than the above, but definitely a possibility depending on how many residencies close down.
Click to expand...
If people are avoiding fellowships because they're well-compensated and happy in EM, that's a good thing. I wouldn't call that "siloing"; I would call that reducing burn out.
 
Anybody who thinks 4 years is a reasonable minimum, which it is not, needs to put their money where their mouth is.

Go to your admin tomorrow and tell them to fire every single NP and PA because we need more highly trained people in the ED, not lesser trained people. There are a lot of places who are perfectly content letting midlevels work with little to no oversight to help the bottom line... So which is it? Is it safe to have people caring for patients in the ED with such a low amount of training, or do we need even more training than the usual e year residency.

You can't have it both ways.

You can't continue to hire people with minimum education and training while simultaneously requiring 4 years of residency for physicians going forward.

In my opinion, it does not take 4 years to train an EM physician. This is a ridiculous idea.

I agree that this will drive down interest in EM and potentially result in some programs closing. That's great for supply and demand, but this is horrifically unfair to future residents.

The vast majority of attendings in this forum have claimed had significant consensus over the years that 3 years is plenty long enough. Look back at old posts. People claiming 4 years are needed were the traditionally the minority.

I would love to shut down the crappy programs opening over the last several years, but I cannot get behind the 4 year plan.
 
KGflyboy said:
Anybody who thinks 4 years is a reasonable minimum, which it is not, needs to put their money where their mouth is.

Go to your admin tomorrow and tell them to fire every single NP and PA because we need more highly trained people in the ED, not lesser trained people. There are a lot of places who are perfectly content letting midlevels work with little to no oversight to help the bottom line... So which is it? Is it safe to have people caring for patients in the ED with such a low amount of training, or do we need even more training than the usual e year residency.

You can't have it both ways.

You can't continue to hire people with minimum education and training while simultaneously requiring 4 years of residency for physicians going forward.

In my opinion, it does not take 4 years to train an EM physician. This is a ridiculous idea.

I agree that this will drive down interest in EM and potentially result in some programs closing. That's great for supply and demand, but this is horrifically unfair to future residents.

The vast majority of attendings in this forum have claimed had significant consensus over the years that 3 years is plenty long enough. Look back at old posts. People claiming 4 years are needed were the traditionally the minority.

I would love to shut down the crappy programs opening over the last several years, but I cannot get behind the 4 year plan.
Click to expand...
I don’t think comparing to midlevels is an accurate comparison. At least in our EDs, midlevels and physicians function in different capacities with oversight of the midlevels.
 
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