A lot of posts, danced around the topic and didn't drop real names or rationale. I hope this helps.
With all due respect Traumadok, your post is quite incorrect on several points.
1) If you're going to such a hot shot place with amazing experience, you simply don't NEED a fourth year. If your in-house population doesn't cut it, and you need some away rotations (or simply more time) to buff up your skills & experience, or, you wanna become the chair or PD of some big fancy program, yea, you probably need a 4 year program. Otherwise, it's overkill, and unnecessary. If you're THAT intent in becoming the best ER doc you can, even at the expense of an extra year, start your residency with a General Surgery internship. Yea, I said it. You'll learn SO MUCH (but in the MOST PAINFUL WAY) on post-op complications, and become MUCH more skilled & aggressive with procedures than your EM counterparts. The experience definitely carries on in the ED.
2) Some of the programs you list by name under "Huge program, lots of research, and extremely respected" have not only had their EM residency on probation, but have lost it altogether within this decade. And are frankly behind and inept when it comes to up-to-date equipment found in the modern ER, and the availability of all subspecialties.
3) Also on that list are some programs that may have a huge trauma program, but the ED itself sees NO significant trauma. Case & point: Shock Trauma. ALL serious traumas go to the TRU, which is run by Surgery ONLY. If you're not on Surgery, you don't see it, ALL RESIDENCY LONG. NO interaction at all, not even airway. And even IF you're on Surgery in the TRU, forget about seeing kids, cuz that subpopulation (that's critical for your education) is directed to Hopkins before it ever hits your door. So from the ED's perspective, you simply miss out. A lot. See my last point for more.
4) Just cuz you have a flight program doesn't mean you become flight doc. How do I know? I'm AT a program that has a flight program. We don't have that opportunity for residents, save for their EMS month. I know some programs actually allow you to moonlight as a flight doc (lesser pay, but still beats the daily grind in the ED), but not all flight programs are created equally. If you REALLY want good experience prehospitally, go to a program that has an established and active (read: physician field response) EMS Fellowship. That way, you likely have a chance at becoming an assistant medical director to one of their services when you're a 3rd year, and can get REAL hands-on administrative as well as clinical practice outside the hospital - which will not only improve & augment your existing EMS service, but it will also make you a better and more well-rounded (and well-respected) doc.
5) You failed to mention that many fancy schmancy big name places:
- Still make you do floor months. That's USELESS. You should look at the curriculum, and the more useless crap is on their curriculum, the less interested you should be. The program I went to had ZERO floor months. If you were off-service, if it wasn't Anesthesia, EMS, or Admin, it was an ICU month. Medical, surgical, tox, whatever. But no floors, no wasting time rounding. Show me how to treat the sickies. The not sick, we see those EVERY DAY from day ONE in the ED.
- Have big overbearing fellowship programs whose fellows swoop in and take your procedures. Your your program is simply lacks backbone, and consults for all procedures. If Ortho does all your reductions, and Pulm takes your lines and sometimes even airways, Surgery takes all your chest tubes, etc, look elsewhere, no matter HOW good the reputation. You're only as good as YOUR personal experience. And if it's being stolen from ya from other residents, that's not an ideal learning environment.
- Catch up with the times. If you can't use Propofol (its restricted to Anesthesia only), look elsewhere. I cannot STRESS just how important being VERY skilled & comfortable with Propofol sedations is to the flow of your Dept, as well as its safety and ease of use in experienced hands. Children & adults alike
- If you REALLY wanna be a good ED doc, you wanna be a whiz with the population we are the most hesitant with: Peds. So don't waste your time going to a residency with a HUGE population, only to find out it's got a separate Peds ED you only rotate through for 3-5 months out of your entire 36 month residency. Yea, then there's a reason why you're uncomfortable with Peds. Cuz you barely did any of it. You want a high volume OPEN ED that sees peds and adults in the same setting, so its a linear - and constant - progression throughout your education. And you get experience doing their reductions & sedations as mentioned above as well. At my program, I logged over 60 Propofol sedations on children 1 year and BELOW. Yep, the population no one wants to touch.
Anyway, I think that's enough. I appreciate you taking the time to make your post, but I don't think you did a lot of first-hand research and fact-checking before posting it. Or perhaps it was merely your opinion, which we all have, but shouldn't necessarily readily share...