In February 2025, the Accreditation Council for Graduate Medical Education (ACGME) announced significant updates to emergency medicine (EM) residency program requirements,1,2 including revisions to key procedures required for graduation.3
These changes, if approved, would take effect in 2027 for new cohorts of trainees, though ACGME representatives have noted this is not a strict date for full conformance to the proposed requirements.4
The proposed revisions reflect a broader shift in the vision of emergency medicine training, aiming to better prepare future EM physicians for the evolving demands of the field. These changes have been shaped by feedback from a variety of stakeholders, including focus groups including members of organizations such as the American College of Emergency Physicians (ACEP), the American Osteopathic Association (AOA), the Emergency Medicine Residents' Association (EMRA), and surveys from program directors.2,4
As the Education Committee of EMRA, we aim to provide a clear summary of these changes. We strongly encourage all residents, faculty, and stakeholders to read the full documents and share their feedback by submitting comments before the deadline of May 1, 2025.5
Proposed requirements are as follows:
1. Duration of all EM training programs increased to 48 months
After gathering feedback from program directors, stakeholders, and focus groups, the ACGME concluded the need for increased time spent in the emergency department, enhanced exposure to pediatrics, dedicated time for low-acuity care, and more.1,2 At the same time, ACGME acknowledged the reduction in overall training hours due to changes in duty hours and work-life balance safeguards. Without a set timeframe in mind, a curriculum was developed to address these goals. When this curriculum was completed, it could not be accommodated within the current 36-month training period. As a result, ACGME recommended extending the program length at all institutions to 48 months.1
It is important to note that this change does not directly mean "3-year programs will become 4-year programs" in the sense of the current 4-year model. Rather, all EM programs will need to revise their curricula, given the new requirements (detailed below). While the program length may remain the same for some, the curriculum will undergo significant changes. A clearer way to think about this is that "All EM programs will now evolve into a new type of program, requiring a new 4-year curriculum."
2. Resident Numbers and Program Size
Feedback from program directors and ACGME focus groups indicates that the number of patient encounters during residency often serves as a surrogate for preparedness as an attending physician.4 While extending the duration of residency training increases patient encounters, the writing group emphasized the importance of ensuring that these encounters are both unique and appropriately varied in acuity.1
The proposed requirement stipulates that each program must have at least 3,000 annual patient visits per resident. This includes encounters at other sites such as community hospitals, freestanding emergency rooms, satellite sites, etc.1,2
It is important to note that the number of residents is not simply calculated by the formula: ([Annual visits Site A + Annual visits Site B] / 3,000). For a detailed breakdown of how the number of residents is derived, please refer to page 8 of the proposed changes. This formula takes into account the actual number of weeks a resident spends in the ED.1,2
Regarding acuity, the same requirements apply to critically ill patients. A program must have at least 120 annual visits involving critical care patients per resident. If a program cannot meet this requirement, they will need to incorporate an additional month of critical care rotation into their curriculum.1
To adjust to these new requirements, some programs may need to reduce the number of residents, while others may need to adjust class sizes by adding an additional year (eg, transitioning from 8-8-8 to 6-6-6-6 per class). In some cases, programs with high-volume sites may be able to expand their resident numbers, such as increasing from a 12-12-12 model to 12-12-12-12, growing their total program size from 36 to 48 residents.1
This shift in requirements will require careful planning and adaptation, as programs balance patient encounter numbers, resident class sizes, and the acuity of care to meet the new standards.
3. Procedures to Graduate & Where to Log Them
In response to the evolving needs of EM, the proposed procedure requirements for residency have undergone significant revisions. These changes aim to ensure that EM physicians are prepared to handle a wide range of patient conditions across all age groups.4
- New Procedures Added
The following procedures are now required for graduation, each with associated counts:3
-
- Arthrocentesis: 10
- Arterial Lines: 10
- Paracentesis: 10
- Neonatal Resuscitation: 15
- Pediatric Vascular Access: 15
- Intraosseous Access: 10
- Neonatal Intubation: 3
- Regional Anesthesia: 10 (excluding digital block and single-tooth block)
- Increased Procedure Counts
The absolute number of historically required procedures has increased, including:
-
- Adult Intubations: 35 → 75
- Central Venous Catheter Access: 20 → 303
- Simulation and Procedure Counts
Simulation can still count toward total procedure requirements, but the amount of simulation-based completion may vary depending on the procedure. High acuity, low occurrence procedures that may be completed entirely through simulation include:3
-
- Cardiac Pacing
- Neonatal Intubation
- Pericardiocentesis
- Surgical Airway
- Procedural Sedation
- Resuscitation Leadership
Residents will be expected to lead resuscitations, rather than participate. The proposed changes do not specify a required absolute number of leading versus participating roles in resuscitations.3 - Point of Care Ultrasound (POCUS)
POCUS scans will no longer be counted toward the procedural log totals. However, POCUS remains an integral part of the curriculum.1,3 See below for further details. - Logging Procedures
All procedures must be logged using an ACGME-affiliated procedure tracker, ensuring standardized documentation.1
4. Utilization of One High-Resource ED and One Low-Resource ED, with One Board-Certified Emergency Physician as On-Shift Faculty
Feedback from focus groups indicated that residents often feel unprepared to work in lower-resource settings, as most training occurs in high-resource EDs with readily available specialists and minimal need for transfers.4 To address this, the updated guidelines introduce a requirement for exposure to low-resource EDs.1
At Council of Emergency Medicine Residency Directors (CORD) Academic Assembly 2025, the Residency Review Committee (RRC) acknowledged the absence of a strict definition for "low-resource setting," allowing for program flexibility. Examples include freestanding EDs, critical access EDs in rural areas, and low-resource EDs in urban settings.4
Additionally, faculty at these sites must be board-certified emergency medicine physicians through the American Board of Emergency Medicine (ABEM) or the American Osteopathic Association (AOA). While some of these sites may have family medicine or other specialty-trained attendings, only shifts staffed by a board-certified emergency physician will count toward graduation requirements.1,2,4
5. Point of Care Ultrasound: Shift from Numeric Requirements to Competency-Based Training
Current graduation requirements mandate that each resident complete 150 POCUS scans, which must be reported to the ACGME.1,3 Under the proposed changes, this numeric requirement has been removed, and POCUS is no longer classified as a "procedure."1 Instead, it now falls under "Curriculum Organization and Resident Experiences," with an emphasis on residents demonstrating both the ability to perform and interpret POCUS.1,2 Programs will also be required to have designated POCUS faculty, though it remains unclear whether this must be a fellowship-trained faculty member or simply someone experienced in POCUS quality improvement.1,2
Given the recent ABEM exam changes, which now include POCUS completion and interpretation as part of the certification assessment,6 this shift may come as a surprise. While having a minimum scan requirement could serve as preparation for this exam component, the ubiquity of POCUS in emergency medicine training as well as the mention of the language "strengthening" the ultrasound requirements indicates a nod to POCUS as a standard of care in EM practice.1
6. Increase in the Amount of Pediatrics Exposure
Residents must now complete 24 weeks of pediatric exposure, with at least 12 weeks in the pediatric emergency department and 2 weeks in the Pediatric Intensive Care Unit (PICU).2 The remaining weeks are flexible and can include settings like the Neonatal Intensive Care Unit (NICU), among others.2 This change aims to address concerns about the need for further exposure to ensure competency in pediatric emergency medicine.1
7. "Low Acuity Medicine" and More
New requirements specify at least 8 weeks in low-acuity patient settings, such as urgent care, fast track, and equivalents with a focus on "performing common procedures encountered in lower-acuity settings." Additionally, residents will now be required to gain experience in telemedicine and observation medicine.2
8. Conference and Didactic Requirements
Programs are now required to plan 240 hours of synchronous content per year, which equals nearly 5 hours per week, excluding major holidays. Residents must accumulate 170 hours of didactics annually, accounting for 70% of the total hours.1,2
The new proposal also allows for a portion of these 170 hours to be individualized (asynchronous) instruction, though there is no clear cap on how much can be asynchronous. Historically, no more than 20% of the time could be asynchronous.1,2
9. Differentiating "Experiential Curriculum" vs. "Structured Experiences"
ACGME writers have clarified new program components. Experiential Curriculum refers to what we traditionally think of as rotations—typically in-person, hospital- or clinic-based, and focused on direct patient care. Structured Experiences, however, offer more flexibility, as they can include exposures without direct patient care, out-of-department electives, and individualized study elements. Examples include ophthalmological procedures, observation medicine, telemedicine, primary involvement on STEMI/Stroke teams, and practicing sensitive physical exams, among others.1,2
10. The Idea of a "Scholarly Project"
Previously, "Scholarly Projects" were categorized into specific buckets, though many of these allowed for variability and tailoring by both the program and the resident.1 Now, residents must disseminate a scholarly project, but this term has been left undefined, with writer acknowledging residents can participate in any type of scholarly project with "dissemination."1
Honorable Mentions
- Lowering the minimum number of residents required in a program, from 18 (6-6-6) to 16 (4-4-4-4) to better align with 4-year length.1,2,4
- Introduction of a mandatory rotation in Toxicology/Addiction Medicine2
- A requirement for 2 weeks in obstetrics, maintaining the 10 vaginal delivery minimum2
- Limitation on residents working no more than 6 consecutive days in the emergency department2 – change from minimum of 1 day (24-hour period) free per 7-day period
Reminder: YOUR VOICE MATTERS. The commenting period for these changes (including agreements, disagreements, feedback, and recommendations) ends on May 1.
Submit your thoughts and feedback HERE
for consideration before the final recommendations are made later this year.5
References
- ACGME Program Requirements for Graduate Medical Education in Emergency Medicine Summary and Impact of Major Requirement Revisions. Accreditation Council for Graduate Medical Education (ACGME). 2025. Available at: https://www.acgme.org/globalassets/pfassets/reviewandcomment/2025/110_emergencymedicine_impact_02122025.pdf.
- ACGME Program Requirements for Graduate Medical Education in Emergency Medicine. Accreditation Council for Graduate Medical Education (ACGME). 2025. Available at: https://www.acgme.org/globalassets/pfassets/reviewandcomment/2025/110_emergencymedicine_rc_02122025.pdf.
- PROPOSED REVISIONS Emergency Medicine Defined Key Index Procedure Minimums Review Committee for Emergency Medicine. Accreditation Council for Graduate Medical Education (ACGME). 2025. Available at: https://www.acgme.org/globalassets/pfassets/programresources/proposed-key-index-procedure-revisions-020625.pdf.
- ACGME Review Committee for Emergeny Medicine. RRC Update. Lecture presented at: CORD 2025 Academic Assembly; March 5, 2025.
- Comment Submission Form. Submit Comments for Emergency Medicine. Accreditation Council for Graduate Medical Education (ACGME). 2025. Accessed March 1, 2025. Available at: https://www.acgme.org/review-and-comment/110_emergencymedicine_rc/.
- Certifying Exam Content. ABEM Certifying Exam Content. December 5, 2024. American Board of Emergency Medicine. Accessed March 1, 2025. Available at: https://www.abem.org/get-certified/certifying-exam/certifying-exam-content/.