the deal with 2-3-4 programs

[uclacrewdude]

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hey all,

i was looking at ucla's em website and it says that they're a 2-3-4 program. my question is, what happened to the intern year? did they do it at ucla as a transitional? did they do it at some other school? how is matching to a 2-3-4 program different than the regular match?

 

[Seaglass]

2-3-4 programs require a transitional/intern year in addition to the regular program. You may do the year there or elsewhere and typically it is a separate application process. When ranking you have a separate ROL for trans programs for EACH EM program you rank (although I assume you can just have 1 if you want). These programs are different than 1-4 programs which include the intern year at their program. The match process is the same except for having to apply for trans/intern spots additionally. You apply to them as a fourth year student the same as for other programs and the match is the same as well. You could mix 2-3-4, 1-4, and 1-3 programs in the same ROL if you wished.

Casey

 

[Coleman]

*Warning: completely personal opinion to follow.

2-3-4 programs are an amazing insult in my opinion. Here's the scoop as I have found out. The federal government states that only 3 years are necessary for EM training, so all they fund is 3 years. Programs that are 1-4 will fund the 4th year from their own budget. Not bad if you consider what it costs to pay an attending in the same role.

Now, a 2-3-4 program gets off easy. You have to interview and do a transitional year on someone else's tip, then arrive to their program nice and trained for 3 years of funding. Basically, you totally lose out.

If a program believes that 4 years are necessary for EM, which I am NOT arguing against, then I feel it is their responsibility to train you for the entire 4 years, not send you on some glorified 3rd year medical student rotation again.

Ok, done, thanks for reading.

 

[bcsmith]

I retort - if you choose a well designed transitional year program, prelim medicine, or prelim surgery, no one loses out. I don't know the numbers, but I've heard that the extra year of funding really taxes the sponsoring institution.

Ben

 

[DrQuinn]

Originally posted by bcsmith
I retort - if you choose a well designed transitional year program, prelim medicine, or prelim surgery, no one loses out. I don't know the numbers, but I've heard that the extra year of funding really taxes the sponsoring institution.

Ben

Taxes the sponsoring institution? They're paying 40k plus maybe 5-6k in benefits. Compare that to an attending EP who commands 180k+, not to mention only works 36-40 hours a week!

I do feel that going through a four year program would lead to better training... I mean, who couldn't use a few extra rotations in the ED or another month in the MICU perfecting line placement. But if the gov't and ACEP state that 3 years is sufficient, that's good enough for me!

Q, DO

 

[bcsmith]

Taxes the sponsoring institution? They're paying 40k plus maybe 5-6k in benefits. Compare that to an attending EP who commands 180k+, not to mention only works 36-40 hours a week!

I found the actual average PRA (per resident amount) here.

"According to AAMC estimates, the mean 2001 adjusted national average PRA (based on data from 1,096 teaching hospitals) will be $76,888 with a standard deviation of $6,323"

And when you multiply this times, say 10 resident-years, you get ~$750k. This might tax the sponsoring institution.

The 3 vs. 4 year argument is the subject of another thread. Different strokes for...

 

[margaritaboy]

I think the argument presented by Quinn above pits resident vs. attending compensation for the hours that would have to be covered in the ED.

In other words ~750K in resident compensation is practically nothing compared to what it would cost an institution to cover the ED hours with additional attendings.

 

[joaquin13]

I am really angry about the 2-3-4 programs as well, because you are basically screwed unless you match into a tracking internship where you are guaranteed a spot in their EM residency. What if your number one choice is a 234 program but you match at a lower on your list 1234 or 123 program? Does anyone have any similar experiences? I am third year student trying to narrow down my choices on where to do elective rotations, my #1 choices, etc....looking at LA County, and some other CA programs, which a lot seem to be 234.

 

[Seaglass]

I am really angry about the 2-3-4 programs as well, because you are basically screwed unless you match into a tracking internship where you are guaranteed a spot in their EM residency. What if your number one choice is a 234 program but you match at a lower on your list 1234 or 123 program? Does anyone have any similar experiences? I am third year student trying to narrow down my choices on where to do elective rotations, my #1 choices, etc....looking at LA County, and some other CA programs, which a lot seem to be 234.

I don't understand your issue. You match into it the same as if you matched into any other program. If you match into a 2-3-4 you will, at the same time, match into a prelim IM/Surg or trans spot either there or whatever other prelim/trans programs you applied to. You do not match trans one year and then reapply for 2-3-4 the next.

Also, you cannot match farther down your list than programs have space for you. If you are ranked #56 at your #1 choice and they have space for you, you will match there even if your #2 has you ranked #1.

Most people I met on the interview trail didn't apply to 2-3-4 becasue they a) didn't want to do the extra year, and b) didn't also want to have to apply to a bunch of trans/prelim programs in addition to residencies.

Casey

 

[joaquin13]

Sorry, I guess I was confused. Do all of the EM 234 programs offer tracking internships? I am a third year student so I havent gone through all of the application process yet.

 

[Seaglass]

To you, what is a "tracking" internship. Are you asking if they have 1st year positions that automatically lead to being a PGY-2 in their program? If so then I think you still don't quite understand the system, which is very reasonable since it is a bit confusing.

I think you are equating these 2-3-4 programs to something like a surg residency. In any surg program there will be a certain number of prelim spots in the 1st year where people from neurosurg or optho or whatever will do their intern year, as well as a certain number of "categorical" spots which automatically lead to being a PGY-2 in that surgery residency. Prelims may or may not make it to PGY-2 in that residency. EM 2-3-4 programs are not like this.

Think of EM 2-3-4's as something like a radiology residency. As a fourth year you apply to these programs in a process that is exactly the same as applying to any 1-3 or 1-4 program. The difference is that, again similar to radiology or other residencies that start PGY-2, you ALSO need to apply to and interview at transitional programs or at medicine/surg programs for a PGY-1 spot (a prelim spot). YOU DO NOT REAPPLY AFTER YOUR PGY-1 YEAR, you already have matched at a spot as an MS-IV, and they will welcome you with open arms as a PGY-2 no matter where you did your PGY-1 year.

So, in summary, you only have to apply and match once, as a MS-IV, regardless of length of program (1-3, 1-4, 2-4) the DIFFERENCE being that if you do 2-4 you ALSO have to apply to a PGY-1 position, either at that hospital or elsewhere. Where you do your PGY-1 has no impact on whether you get to PGY-2 in that 2-4 program, they have already accepted you.

Hope this clarifies.

Casey

 

[Seaglass]

You did mention one other issue in your first post that I misuderstood though. You mentioned that, if you don't match at your #1 (2-3-4) choice that you may be matched at some other program that starts PGY 1 (1-3, 1-4) even though you prefer 2-3-4 programs. If you really don't want to do a 1-3 or 1-4 then don't rank them and only apply 2-3-4. If you did mix it up you would still match as I described above. When applying to a residency that starts PGY 2, there is a separate match list for the PGY 1 spots you have selected. The way it works is, if you match at that 2-3-4 then the computer tries to find you a PGY-1 spot from your list. If you don't match at the 2-3-4 then the computer moves down to your next choice, be it 2-3-4, 1-3, 1-4 or whatever.

 

[uclacrewdude]

Originally posted by cg1155
To you, what is a "tracking" internship. Are you asking if they have 1st year positions that automatically lead to being a PGY-2 in their program? If so then I think you still don't quite understand the system, which is very reasonable since it is a bit confusing.

I think you are equating these 2-3-4 programs to something like a surg residency. In any surg program there will be a certain number of prelim spots in the 1st year where people from neurosurg or optho or whatever will do their intern year, as well as a certain number of "categorical" spots which automatically lead to being a PGY-2 in that surgery residency. Prelims may or may not make it to PGY-2 in that residency. EM 2-3-4 programs are not like this.

Think of EM 2-3-4's as something like a radiology residency. As a fourth year you apply to these programs in a process that is exactly the same as applying to any 1-3 or 1-4 program. The difference is that, again similar to radiology or other residencies that start PGY-2, you ALSO need to apply to and interview at transitional programs or at medicine/surg programs for a PGY-1 spot (a prelim spot). YOU DO NOT REAPPLY AFTER YOUR PGY-1 YEAR, you already have matched at a spot as an MS-IV, and they will welcome you with open arms as a PGY-2 no matter where you did your PGY-1 year.

So, in summary, you only have to apply and match once, as a MS-IV, regardless of length of program (1-3, 1-4, 2-4) the DIFFERENCE being that if you do 2-4 you ALSO have to apply to a PGY-1 position, either at that hospital or elsewhere. Where you do your PGY-1 has no impact on whether you get to PGY-2 in that 2-4 program, they have already accepted you.

Hope this clarifies.

Casey

thanks casey, you rock hardcore!

 

[Seaglass]

np😉

 

[margaritaboy]

ucladude,

No worries. I've just finished interviewing in EM programs and I still did not know how the match mechanics worked for PGY 2,3,4 programs until I read the above.

Another thing I might add, is that some PGY-2,3,4 programs will automatically put you in a transitional program of their choosing, should you match with them. Others however, require that you interview seprately on your own.

I applied to one 2,3,4 program, and it was a hassle to try to squeeze in interviews for the EM program, and the transitional program which they would require you to attend. Each interview was a full day, and were offered 2 days apart (ie, Monday & Wednesday) at best.

 

[roja]

I applied to several 2-4's. Interviewed at one and realized that I did *not* want a 2-4 experience. And I didn't want to apply to transitionals.

I don't know of many that encorporate but I know that Denver does (and its as a surgical intern!)

 

[jazz]

certain 2-3-4 programs will allow you to interview with their medicine department during the same day, if you're interested in matching there.

denver is, as far as i know, the only one that requires you to do the pgy-1 year with them.

i know that bu, gw, and cook county, offer the opportunity to do the pgy-1 with them. i know that both bu and cook county have a reputation of having a hard pgy-1 year. a lot of people i know who take the 2-3-4 path decide on an easier pgy-1 year (ie transitional or cusher prelim medicine programs) because the pgy-2/em-1 year is being an intern all over again and as one resident at a 2-3-4 program told me -- "i didn't want to be burnt out before i started em"

 

[basementbeastie]

highland is also 1-4...but with a great schedule.

UCSD has a mandatory pgy-1 at mercy (a second day of interviewing that i decided to skip!)

 

[joaquin13]

thank you so much for the clarification of this issue, i obviously misunderstood the whole process! you have made things a lot easier for me. i am not in search of 234 programs in particular, it just seems like the two that i am really interested in (LA County, Kern County) are both that way....but thanks again casey!

 

[Seaglass]

Yeah, EM is more confusing than most since we have 3 different tracks, but I expect that in 20 years or so it will be a bit more homogenous.

Casey

 

[Seaglass]

Maybe we should have a sticky about the differences in the types of programs and the differences in applying to them. It seems like we go through this every month or so. (not that I mind, of course, as this discussion has put me over the 100 posts mark)

 

[goofballs]

Kind of off the topic of the original question, but I thought it'd be nice to get some perspective on the 3v4 argument from someone who is actively trying to match to a 4 year program. It seems that people who post on this website tend to be decidedly pro-3 year folks (almost anti-4 year). Judging from the interview trail there are way too many 4-year people for the number of spots (especially since the spots are so competitive) but I guess kind of a silent group as far as web forums go (maybe I can get to 100 some day).
When I'm looking at 4 year programs I ask myself what I'm going to get out of an individual curriculum and if the training I'll get really fits my training goals as I see them now. Whereas 3 year programs have very similar formats (out of necessity to fit all the RRC requirements in) 4 year training curriculums vary fairly widely. To a man, and I've asked 5 or 6, all of the PD's I've had this dicussion with feel that ideally EM residencies would all be 4 years (all, interestingly, have been from 3 year programs although I think all trained for 4 years). The feeling is that you can definitely fit all of the learning you need to train a highly competent EM physician into 3 years, the success of 3yr program grads have proven this, but a 4th year adds so much in terms of flexibility & administrative/academic/research/elective time.
As far as 2-4 programs go, a transitional year consisting of 5 ward medicine months, 3 radiology rotations, 2 anesthesias, and a couple PMNR rotations is pretty much wasted time. On the other hand, if you want to practice at a high acuity trauma center down the line, a surgery transitional would give you excellent preparation. Or a program like Denver General, mentioned above, gives excellent all-around training (the internship isn't a GS year at all with only 4 months of surgery and all seemingly super high-yield for an EM physician (ortho-trauma, peds surg, neurosurg-trauma, and trauma surgery) with a mix of critical care and EM rotations making up the balance).
I agree that this topic has been broached to death but it is a big decision as a whole year is a big chunk of time. Look at your goals and your situation. Good luck to everyone in the match as interviews wind down.

 

[iwakuni_doc]

In many ways, I agree with goofball - in fact if I was coming directly out of med school now, I would probably be looking at a 4yr program or a 2-4 like Denver with a surgery internship, but as it is I'm looking to get in & get out in the minimum 3yrs now.

I think that Denver's plan for the intern year is the way to go - it's very similar to the internship I did & while I'm probably biased, I thought it was excellent preparation.

One program that does deserve special mention in this discussion is Beth Israel Deaconess - I like what they've done in terms of their optional 4th year...adds a lot of the benefits of the 4yr programs, but financially is a lot more appealing - approx 100k for that year versus 40k.

 

[roja]

Originally posted by goofballs
Kind of off the topic of the original question, but I thought it'd be nice to get some perspective on the 3v4 argument from someone who is actively trying to match to a 4 year program. It seems that people who post on this website tend to be decidedly pro-3 year folks (almost anti-4 year). Judging from the interview trail there are way too many 4-year people for the number of spots (especially since the spots are so competitive) but I guess kind of a silent group as far as web forums go (maybe I can get to 100 some day).
When I'm looking at 4 year programs I ask myself what I'm going to get out of an individual curriculum and if the training I'll get really fits my training goals as I see them now. Whereas 3 year programs have very similar formats (out of necessity to fit all the RRC requirements in) 4 year training curriculums vary fairly widely. To a man, and I've asked 5 or 6, all of the PD's I've had this dicussion with feel that ideally EM residencies would all be 4 years (all, interestingly, have been from 3 year programs although I think all trained for 4 years). The feeling is that you can definitely fit all of the learning you need to train a highly competent EM physician into 3 years, the success of 3yr program grads have proven this, but a 4th year adds so much in terms of flexibility & administrative/academic/research/elective time.
As far as 2-4 programs go, a transitional year consisting of 5 ward medicine months, 3 radiology rotations, 2 anesthesias, and a couple PMNR rotations is pretty much wasted time. On the other hand, if you want to practice at a high acuity trauma center down the line, a surgery transitional would give you excellent preparation. Or a program like Denver General, mentioned above, gives excellent all-around training (the internship isn't a GS year at all with only 4 months of surgery and all seemingly super high-yield for an EM physician (ortho-trauma, peds surg, neurosurg-trauma, and trauma surgery) with a mix of critical care and EM rotations making up the balance).
I agree that this topic has been broached to death but it is a big decision as a whole year is a big chunk of time. Look at your goals and your situation. Good luck to everyone in the match as interviews wind down.

I don't agree that all of us in 3 years are anti-4. I interviewed at all 3 types of programs. And while I ended up cancelling all my remainding 2-4 program interviews after interviewing at one (and realizing doing a transitional was something I didn't feel was vital), I still interviewed and ranked several 4 year programs. Granted, I ranked them a little lower, especiallly since they were four year.

I think the key point in *all* programs is to find one that matches what you want in a residency and is a good personality fit. In EM, I would say that with the right attitude, all medical experiences have some value. However, its a 'cost-benifit' for me. I didn't feel like the extra time that was given in a year added as much to my career for the price of an additional year of residency. Plus, if you decide to do a fellowship (particularly if its peds or tox) this makes your residency training very long.

And there is actually a wide variety of things offered in 3 year programs. If you look around, you will see that. Some have medicine floor months, some have psych, some have burn rotations, some have trauma surgery. There is a lot of variety because the certification policy only mandates a few things.

In my 3 year program, we do as much ED time as 4 year programs. We have a 2 week U/S rotation, and a month of elective both in second and third years. We also have dedicated research time. We do tox, ortho, ob, EMS. We also do the equiv. of 3 mos of pediatric er over the 3 years.

Each type of program has something to offer. You just have to figure out which program is right for each person.

 

[drpcb]

Since I did a family practice internship then went to work as a GP for 3 years, I have a unique perspective. I chose a 2-4 program (L.A. County), since I had to do 3 years in EM anyway to get boarded, and I didn't want to repeat my internship year (at a 1-3 program.) My FP internship counted for my 2-4 program. Had I gone into EM right out of medical school, I almost certainly would have opted for a 1-3 program, as I would have thought an extra year is a waste of time and money. After being in family practice on my own for 3 years, I have a much different perspective on the stresses associated with being in practice post training. My first year out on my own in FP was stressful in ways I hadn't imagined, mostly wondering which of my diagnoses would turn out to be missed, and when might I get sued, things I never thought about during training.

For me, finishing a 2-4 program will definitely give me a confidence in EM that will make my stress load much lower when I go out and practice after training, especially since I am at one of the busier programs in the nation.

I think that 1-3 program graduates are DEFINITELY qualified to practice EM. They are most CERTAINLY equally bright, sharp and competent. At least in my case, the difference with the extra year, is the level of confidence (or lack of stress) I will face early in my EM career.

To me, an extra year is a loss of $$$ but a gain of experience in a supervised setting, that will make it that much easier when it is my license alone on the line with the critical patients, some of whom will invariably die. In these cases, a high level of confidence that I met the standard of care will make the difference between going home to stress out or relax and recharge.

 

[Sessamoid]

I thought I'd pitch in my thoughts on the topic as a (relatively) recent residency graduate of a 3 year program. The current program director of my program is in favor of moving to all four-year programs, for the obvious reason that you can fit more learning into four years than three.

You can get much of the same benefit from a 4 year program if you choose your first job out of residency carefully, as I did. You can choose to find an academic spot, which obviously keeps you in the learning settting. There's nothing to get you to learn a topic like having to teach it.

The other option is to choose a job where you're at least double-covered most of the time, so that you always have a more experienced colleague to bounce cases off of. That's the situation where I first worked out of residency, and I picked up a lot of new information and ideas during my first year out of residency. It also helped that the hospital was a regional trauma center, so that even at night when we were single covered, there was almost always an experienced trauma surgeon around to help me through the vagaries of private practice and managing consultants. Their job is in many ways similar to ours, and having an experienced hand who also knows all the personalities of the other physicians in the hospital was invaluable at times.

I'd be pretty unsettled going straight into a single coverage situation out of residency, but plenty have done it, nonetheless. I do think they're missing out on education they could be getting.

 

[positiveaob]

I go to a 2-3-4 program. As far as applying to prelim programs, my advice is to only apply to 2 or 3. You may not need it anyway, and there are plenty of good ones that arent that selective. Unless things have changed in the past few years, you can probably scramble into a good one if need be. And the programs your applying to wont care what internships your looking at.

 

[JackBauERfan]

I go to a 2-3-4 program. As far as applying to prelim programs, my advice is to only apply to 2 or 3. You may not need it anyway, and there are plenty of good ones that arent that selective. Unless things have changed in the past few years, you can probably scramble into a good one if need be. And the programs your applying to wont care what internships your looking at.

wow pulling up an old thread huh haha.

 

[colforbinMD]

I agree with positiveaob, I had two 2,3,4 programs on my list and only interviewed at one prelim year as both programs offered spots in their prelim IM year if you matched with them, all you had to do was rank them. I "interviewed" (met with PD as a group for half an hour) at both these prelim programs on the day of my EM interview (built into daily schedule, here is our prelim year if you want it) I also interviewed at one other community hospital EM program because I rotated with them as a student and new what a diamond in the rough it was. That was it. One extra day of interviews was all it took for me to have two more programs on my ROL and in the end I matched at a 2-4 and am at my diamond in the rough now. As for the extra year of training and cost-benefit ratio. I did rank a few 1,2,3 programs higher but I am thrilled with the additional training I know I will have when my time as an attending arrives. Especially now that I have started my intern year and I am realizing how much I don't know. (ALOT! 😱 )
It really is in my opinion an issue of personal fit. How much do you perceive that additional year as a hassle? Does that program click with you as far as personalities, training strengths, location? etc.

 

[trkd]

I am still a bit in the dark about whether 4 year programs make you as marketable as 3 years and a fellowship. If so, it seems like the latter would be more advantageous because you can cater your 4th year to what you like. Anyone care to comment on that?

Cheers.

 

[bartleby]

I've said it before and I'll say it again. If you're willing to devote four years to resident pay, you're going to make a far more appealing candidate to an academic job with a 1-3 residency and a one year fellowship than a 4th year fresh out of residency. What gets you a foothold in most academic jobs is a niche. What are you going to bring to the residency? Ultrasound? International EM? EMS? Tox? If you're crafty enough to pull this out of residency, good for you... it's not impossible (I did it). But a fellowship trained applicant is going to be more appealing.

If you're talking about private practice, the difference between 3 & 4 year residencies isn't on most ED directors' radar screens.

The feeling is that you can definitely fit all of the learning you need to train a highly competent EM physician into 3 years, the success of 3yr program grads have proven this, but a 4th year adds so much in terms of flexibility & administrative/academic/research/elective time.

 

[trkd]

I've said it before and I'll say it again. If you're willing to devote four years to resident pay, you're going to make a far more appealing candidate to an academic job with a 1-3 residency and a one year fellowship than a 4th year fresh out of residency. What gets you a foothold in most academic jobs is a niche. What are you going to bring to the residency? Ultrasound? International EM? EMS? Tox? If you're crafty enough to pull this out of residency, good for you... it's not impossible (I did it). But a fellowship trained applicant is going to be more appealing.

If you're talking about private practice, the difference between 3 & 4 year residencies isn't on most ED directors' radar screens.

Makes sense. This is the only thing keeping me from 4 year programs. There are a few I like but 4 years plus a fellowship to get a job is pushing it.

 

[GeneralVeers]

thank you so much for the clarification of this issue, i obviously misunderstood the whole process! you have made things a lot easier for me. i am not in search of 234 programs in particular, it just seems like the two that i am really interested in (LA County, Kern County) are both that way....but thanks again casey!

Two of the LA County programs are 1-3: Harbour-UCLA and King/Drew. If you are set on 1-3 training in L.A. these would be options. I'm not sure why USC has to be different and do 2-4.

 

[dlung]

Two of the LA County programs are 1-3: Harbour-UCLA and King/Drew. If you are set on 1-3 training in L.A. these would be options. I'm not sure why USC has to be different and do 2-4.

LA County used to be a 1-3... then sometime a couple decades ago, they decided that an extra year of training was useful to help their residents survive the madness.

 

[deleted52758]

i am a new starting em1 in a 2-4 program. i cant imagine trying to start in emergency medicine at a major county hospital coming right out of med school. that being said, i dont think the full year (internship) is necessary to transition. i think the ideal time would be about 6 months of general medicine/peds/ob/gyn. i think a program can ideally fit in about 3 1/2 years of training with the last 6 months of electives spread over the four years. that's just my 2 cents.

 

[GeneralVeers]

i am a new starting em1 in a 2-4 program. i cant imagine trying to start in emergency medicine at a major county hospital coming right out of med school. that being said, i dont think the full year (internship) is necessary to transition. i think the ideal time would be about 6 months of general medicine/peds/ob/gyn. i think a program can ideally fit in about 3 1/2 years of training with the last 6 months of electives spread over the four years. that's just my 2 cents.

Lots of people come out of med school and go right into a chaotic county hospital. It's overwhelming at first, but if you learn quickly, and work hard it quickly becomes tolerable. For me, I couldn't imagine having to waste my time in clinics, and medicine services in a transitional year.

 

[JackBauERfan]

Lots of people come out of med school and go right into a chaotic county hospital. It's overwhelming at first, but if you learn quickly, and work hard it quickly becomes tolerable. For me, I couldn't imagine having to waste my time in clinics, and medicine services in a transitional year.

funny everyone's saying they can't imagine this or that...I can pretty much imagine ANYTHING...most of the time its midgets on unicycles in a very green garden (can't remember which movie I saw that in haha).

 

[GeneralVeers]

funny everyone's saying they can't imagine this or that...I can pretty much imagine ANYTHING...most of the time its midgets on unicycles in a very green garden (can't remember which movie I saw that in haha).

Hmm......5 mg of Haldol IM should clear up those thoughts/visions for you.

 

[totalbodypain]

Hmm......5 mg of Haldol IM should clear up those thoughts/visions for you.

I don't know man. I am always a sucker for midgets and unicycles. It's only better if you can get some cows in there too....Funny stuff. I say hold the haldol.