The Case Against a 4-Year Mandate

REQUIREMENT

COMMENTS

4.1
The educational program in emergency medicine must be 48 months in duration. (Core)

OPPOSE.
Recommend current language allowing 3- and 4-year formats. We can strengthen EM training without mandating 4 years.

Support EMRA's proposed structure:

• EM: 94 wks & at least 5,000 patient encounters
• Peds: 24 wks
  • Peds EM: 18 wks & 1,000 patient encounters
  • ICU: 4 wks (2+ wks in PICU)
• Critical Care: 16 wks (incl. 4 peds)
• OB: 2 wks
• Vacation: 12 wks
• Structured experiences, electives, etc: 12 wks
  • We suggest Admin/QA, Tox/Addiction Med, and EMS be structured experiences.

RC cited multiple factors as supporting a 4-yr mandate

1. Downtrending ABEM board pass rates
   • ACGME has offered no evidence to suggest 4-yr graduates are better prepared
   • 2023 ABEM study showed 3-yr graduates actually have higher board pass rates
   • Thus, citing the downtrend in board pass rates to lengthen training is incongruent with the available evidence

2. Decreasing work hours/patient encounters
   • RC suggested 124 wks of EM so that an average resident at an average program would have approximately 5,000 adult ED patient encounters
   • Time on a rotation only guarantees time on a rotation. Mandating time spent in ED will not guarantee the desired outcome.
   • Focusing on minimum # of patient encounters and time in ED will better guarantee the desired outcome while allowing programs more flexibility in curriculum development
   • Assuming a mean of 45 hrs/wk in ED, resident would need to average 1.2 patients/hr to meet EMRA's proposed minimum. If programs cannot meet these minimums—whether due to boarding, staffing by APPs, etc.—then they will need to decrease their complements or choose a 4-yr format.

4.11.d.1
Emergency Medicine: At least 124 weeks of each resident’s clinical experience must take place in the emergency department under the supervision of emergency medicine faculty members, including. (Core)

OPPOSE.
We suggest requiring a minimum of 94 weeks in ED AND 5000 patient encounters.

ACGME's proposal is contradictory to existing evidence. ACGME cited a decline in board pass rates and decreased patient volumes as the reason for this change. 

1. Downtrending ABEM board pass rates
   • ACGME has offered no evidence to suggest 4-yr graduates are better prepared
   • 2023 ABEM study showed 3-yr graduates actually have higher board pass rates
   • Another 2023 study did not find any significant differences between 3- and 4-year graduates when comparing metrics related to efficiency, safety and flow in the first year of attending practice
   • Thus, citing the downtrend in board pass rates to lengthen training is incongruent with the available evidence

2. Decreasing work hours/patient encounters
   • RC suggested 124 wks of EM so residents would, on average, have ~5,000 adult ED patient encounters. This end goal can be accomplished in EMRA's proposed 94 weeks.
   • Time on a rotation only guarantees time on a rotation. Mandating time spent in ED will not guarantee the desired outcome.
   • Focusing on minimum # of patient encounters and time in ED will better guarantee the desired outcome while allowing programs more flexibility in curriculum development
   • Assuming a mean of 45 hrs/wk in ED, residents would need to average 1.2 patients/hr to meet EMRA’s proposed minimum. If programs cannot meet these minimums—whether due to boarding, staffing by APPs, etc.—then they will need to decrease their complements or choose a 4-yr format.

4.11.d.3
Critical Care: At least 16 weeks of each resident’s clinical experience must be dedicated critical care rotations, of which at least 8 weeks must occur at the PGY-2 level or above (Core)

OPPOSE.
ED management of a critical patient is very different from ICU management of a critical patient, and that ICU experience is not a substitute for critical ED patients. We highlight our comments on 1.8.j where we recommend a required minimum number of critical care patient encounters (180). Adopting a required number of encounters would eliminate the need for this requirement.

4.11.d.4
At least 24 weeks, or the equivalent, must be dedicated to the care of neonates, infants, and children. The time is calculated by summing identified rotations and equivalent months. (Core)

SUPPORT, WITH AMENDMENT.
We support the overall requirement for 24 weeks, or the equivalent, to be dedicated to pediatrics. However, we recommend increasing the Pediatrics Emergency Department time to 18 weeks and requiring a minimum of 1,000 pediatric patient encounters throughout residency.

Our suggested structure would be the following:

• At least 24 weeks, or the equivalent, must be dedicated to the care of neonates, infants, and children.
• At least 18 weeks, or the equivalent, must occur in an Emergency Department and total at least 1000 patient encounters.
• At least 4 weeks must occur in an ICU.
• At least 2 weeks must occur in the Pediatric ICU

For reference, averaging 45 hours/week for 18 weeks would give residents 810 hours in the Peds ED. To reach 1,000 patient encounters they would need to average 1.23 patients/hour.

4.11.d.5
Residents must have at least a 2-week experience in obstetrics. (Core)

SUPPORT.
We suggest requiring a minimum number of laceration repairs and I&Ds in the Key Index Procedures. There is agreement that some residents do not get enough experience in these settings and mandating a certain number of these low-acuity procedures is a great method for ensuring accountability to programs and residents.

4.11.d.6
Residents must have at least a 2-week experience in administration/quality assurance. (Core)

OPPOSE.
We recommend Admin/QA be a structured experience. We agree that Administration and QA are important topics for programs to cover in training but do not think they require a discrete time mandate. Many programs already accomplish this in a longitudinal co-curricular fashion and mandating a time component could hinder curriculum creativity and optimization, which is why we think it would be better as a structured experience. 

4.11.d.7
Residents must have at least a 2-week experience in toxicology, including experience in addiction medicine/substance use disorder. (Core)

OPPOSE.
We recommend Toxicology and Addiction Medicine be a structured experience. 

There is great variance in the number of Toxicology and Addiction Medicine cases among emergency departments. While some programs may benefit and/or need a rotation for these areas, many programs do not. Many emergency physicians encounter cases of addiction medicine/SUD on a daily basis, highlighting its nature as a core part of the practice of EM and the lack of need for a separate rotation. 

Toxicology, on the other hand, is not prevalent enough to ensure that every resident could have a meaningful clinical rotation, though we support a structured experience for this as well. Two weeks on a Toxicology rotation would not guarantee any breadth of clinical experience. 

4.11.d.8
Residents must have at least a 2-week experience in emergency medical services (EMS), including real-time medical control. (Core)

OPPOSE.
We recommend EMS be a structured experience. We support the continued requirement for experience in EMS in a longitudinal fashion during residency without adding a discrete time requirement. 

We also oppose the requirement for real-time medical control experience. Many programs will have opportunities for medical control experience while working an ED shift but do not think it should be required. 

1.8.h
The aggregate annual volume of patients in the emergency department at the primary and participating emergency department sites must total at least 3,000¹ patient visits per approved resident position in the program, determined via a calculation defined by the Review Committee. (Core)

OPPOSE.
While we believe this requirement moves toward residents seeing a certain volume of patients throughout the course of training, we think the intent is overshadowed by several flaws and/or poor assumptions in the proposed calculations. We should work to find a better alternative. 

We propose that residents be required to have a minimum of 5,000 patient encounters throughout their residency. 

This approach has multiple benefits. First, it guarantees a number of encounters, which would ensure correction of the trend ACGME has cited of decreased patient encounters. It would also negate any need for the complicated formulas currently proposed. While these formulas exist in hopes of ensuring an adequate number of patients are available to residents, they do not guarantee that residents are seeing those patients. The only way to ensure residents are getting enough patient encounters would be to mandate a minimum number of encounters. 

1.8.j
The aggregate annual volume of critical care patients at the primary and participating emergency department clinical sites must total at least 120 critical care patients per approved resident position in the program, determined via a calculation defined by the Review Committee. (Core)

OPPOSE.
We suggest residents be required to have a minimum of 180 critical care patient encounters in the ED throughout their training. These should be counted from those admitted to ICUs, step-down units, operative care, interventional or cardiac suites, or the morgue following treatment in the ED.

Similar to 1.8.h, the proposed calculation is complicated and does not adequately estimate the number of critical care patients a resident will manage. Rather than just ensuring availability, we need to ensure residents are seeing the available patients. Similar to our argument in 1.8.h, the only way to ensure residents get the desired number of patient encounters is to mandate a minimum and track it. 

180 represents 3% of the 6,000 patient encounters (5,000 adult + 1,000 pediatrics) as outlined in our other recommendations. Additionally, we oppose the carve out that allows for additional ICU rotations if ED critical care volumes are not met. ED management of a critical patient is very different from ICU management of a critical patient, and ICU experience is not a substitute for critical ED patients. We believe this approach better sets expectations for programs and will lead to a better educational experience for residents.