Three vs. Four: Understanding EM Training Models (and How to Choose What Fits YOU)

Three vs. Four: Understanding EM Training Models (and How to Choose What Fits YOU)

Catherine Allen, MSIII
Marshall University School of Medicine
EMRA MSC Mid-Atlantic Representative

Anastasia Ipekci, OMSII
University of New England College of Osteopathic Medicine
EMRA MSC Northeast 2 Representative

Ivana Baldie
MSIV, SUNY Downstate College of Medicine
EMRA MSC Northeast Coordinator

 

The 3 vs. 4-year debate of emergency medicine training has come with significant contention when the ACGME released its proposed changes earlier this year, with the most widely debated being a 4 year-long mandate for all programs. As it currently stands, there are two parallel paths: a 3-year or 4-year EM residency. Out of 286 EM programs accredited by the ACGME, 232 (81%) are 3 years long, and 54 (19%) are 4 years long [1]. Today, students are left with the choice of pursuing either a 3-year or 4-year residency program, but it is important to note that neither pathway is objectively “better” than the other. In a study published in the American Journal of Emergency Medicine, there was no significant difference found between the clinical care delivered by new graduates from 3- and 4-year programs [2]. Each pathway comes to the same endpoint; competent, confident, EM physicians. The right fit for you depends on your learning style, career goals, and lifestyle circumstances.

 

What are the differences?

3-Year EM Programs:

  • These make up the majority of EM Residencies in the U.S. They’re structured around:
    • Fast-paced clinical exposure
    • Heavy ED time with less time off-service
    • Earlier clinical autonomy
    • Condensed, high volume clinical exposure; 3-year programs were noted to have a higher median program patient volume at 7616 compared to 4-year programs with a median program patient volume at 6520 [1].
  • Things to Consider
    • 1 less year of training means making an attending-level salary sooner.
    • Potentially less time to explore interests and complete research. However, if this is your passion, you can still fit it in.
    • Fellowship is still widely available if you have a niche or want the extra training.
    • Identical patient and procedure requirements, but less time to complete them leads to a compressed timeline (however, many residents note that they easily surpass the required minimum standards).
    • A shorter program has less time to cover core content compared to a 4-year program, leading to faster-paced teaching. This can either work with or against your personal learning style [3].

4-Year EM Programs:

  • A smaller number of programs use this model. They typically offer:
    • More elective and research time, which may lead to more published scholarly works [4].
    • More subspecialty and academic exposure. Time constraints in a 3-year program limit the ability to participate in experiences which may facilitate interest in fellowship training [3].
    • Senior year consisting of advanced responsibilities and “pre-attending” while still being supervised by an attending physician.
  • Things to Consider
    • An extra year of training meaning an extra year of resident salary.
    • An extra year of training does not replace fellowship
    • Higher likelihood of getting an academic job straight out of training, however this is still possible from a 3-year program [3][4]
    • At this time, an extra year isn’t a requirement for EM, so some trainees may not see the benefit in spending the time in training when they can still “meet credentialing requirements for taking the qualifying written board examination”[3].

 

How Should You Choose?

While the length of EM residency training program may seem like the most important consideration, there are many other factors that will inevitably guide your personal decision. A program’s mission, mentorship opportunities, patient population, location, and proximity to support systems may all be as significant as the length of a program. Even the seemingly marginal perks like parking, meals, and shift lengths are important, as they can impact your overall experience and quality of life. Ask yourself: can I see myself as a resident here? Will I be happy? If you mesh well with the faculty, residents, program mission, and overall “vibe” of the program, then that is the program for you. Regardless of the path you choose, this is guaranteed: you will be able to care for patients on what may be their worst day and be trained in a field that will continue to empower you to make impactful decisions on the lives of those you serve.

 

References

  1. Topping CE, Rothenberg C, Gettel CJ, et al. Patient volume requirements: Evaluation of the 2025 acgme proposal for emergency medicine residency programs. AEM Education and Training. 2025;9(3). doi:10.1002/aet2.70071
  2. Nikolla DA, Zocchi MS, Pines JM, et al. Four- and three-year emergency medicine residency graduates perform similarly in their first year of practice compared to experienced physicians. The American Journal of Emergency Medicine. 2023;69:100-107. doi:10.1016/j.ajem.2023.04.017
  3. Ross TM, Wolfe RE, Murano T, et al. Three- vs. four-year emergency medicine training programs. The Journal of Emergency Medicine. 2019;57(5). doi:10.1016/j.jemermed.2019.07.013
  4. Nikolla DA, Beeson MS, Pines JM. How Long Should an Emergency Medicine Residency Be? ACEP Now. November 16, 2023. https://www.acepnow.com/article/how-long-should-an-emergency-medicine-residency-be/. Accessed December 9, 2025.

 

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