As the profession of medicine has developed over the centuries, so too has its training. What began as an apprenticeship has evolved into the distinct field of medical education, leading students through medical school and residency before independent practice.
Throughout its history, medical education has experienced constant change and innovation to better serve patients. A proposed change by the Accreditation Council for Graduate Medical Education (ACGME) to Emergency Medicine training, however, flies in the face of everything we have learned thus far as a profession.
As medicine and society have progressed, the institutions that govern how we train our doctors have morphed to match science and technology changes and to meet the needs of learners. By the early 1900s, the precursors to our current institutions began to spring up, leading to the development of many fundamental components of our current medical education system. For example, the Medical College Admissions Test (MCAT) administered by the Association of American Medical Colleges (AAMC) was developed out of a fear of high drop-out rates of medical schools in the 1920s.1 The ACGME, and its precursor the Liaison Committee on Graduate Medical Education, was established to centralize and standardize the education of residents and fellows across this country.2
Competency at the Core
Standardization is a noble goal. However, for medical study and training, one size does not necessarily fit all. The AAMC, one of the original co-sponsors of the ACGME, and the ACGME itself recognize this and label it: "competency-based medical education." The label is not accidental and focuses on a trainee's competence, that is their ability to do a certain task or set of tasks rather than arbitrary restrictions on timelines or length of training. ACGME teaches a "competency-based medical education" course that highlights the value of competency rather than time-based learning.3
Emergency medicine is currently the only specialty that has different training times for different trainees, but perhaps ACGME and other specialties should learn from this instead of forcing emergency medicine to go pedagogically backward. This is not a theoretical task, as Canada has fully embraced competency-based medical training.4 It is widely accepted that there should be minimum requirements for graduation, but the programs in Canada structure themselves differently to allow trainees to experience different electives, pursue further degrees, or graduate when they are competent and not when an arbitrary length of training has been reached. Focusing on objective competency requirements in curriculum development would be a more worthwhile task first; then, utilizing evidence to evaluate timing to best accomplish this or a time-variable approach could be explored.
Misplaced Emphasis
Why has the ACGME assertively proposed that all emergency medicine programs need to become 4-year programs?5 There is no data suggesting that this change would make our emergency medicine physicians more competent.
Conversely, there is data from the American Board of Emergency Medicine demonstrating that graduates of 3-year programs actually have higher board pass rates than those of 4-year programs.6 With concerns for board pass rates, this proposed change is directly contradictory to the data available. Instead of focusing on an arbitrary length of time of training, it is important to recognize that spending this amount of time in training is not going to guarantee a specific number of patient encounters or further guarantee our graduating physicians' competence any more than the current training model.
The ACGME has proposed other changes in addition, including changes to required rotations and the addition of "structured experiences" into emergency medicine residency, a time when there’s already a myriad of components to pack. The idea that a certain training model or time length must be adhered to because of these new requirements is without substantiated evidence and goes against the good developments in medical training thus far.
Evidence and Evaluation
The ACGME needs to first look at their recommended changes and truly evaluate whether they are necessary for the development and training of a competent emergency medicine doctor. Development of residency training requirements should be evidence-based rather than aspirational. Adding requirements is reasonable when there is a need to be met, but the problems aiming to be solved with some of the additional changes are unclear. In the absence of data, this proposed change suggests the existence of other motivating factors leading up to this significant modification to our current model of training.
More importantly, the ACGME needs to recognize that an overarching time requirement does not make sense. One could simply add up all of the ACGME's proposed additional requirements, some of which are without obvious purpose, as above, but if a program can achieve it all in 3 years, would that not be adequate? If a trainee checks the boxes to prove their competence by the end of those 3 years, why does it matter if it was 3 or 4 years?
Strengthen Through Collaboration
Not all of the ACGME’s recommended changes are negative. Indeed, there are many good considerations that seek to ensure that we, as emergency physicians, are fully prepared for the honor of caring for our patients. Shoving a square peg into a round hole, however, isn't the answer. These changes will have a significant impact on trainees, programs, and patients for years to come, and they should be evaluated with a focus on the crucial nature of that.
As emergency medicine physicians, we all seek the same goal: outstanding, high-quality training that produces competent physicians. We simply ask for evidence-based considerations in the development of residency training requirements. Our specialty will be impacted for years to come by these changes, and now is the time to speak and take action.
EMRA members are clear in their desire to raise standards while still allowing for both 3- and 4-year program structures. Add your voice to EMRA's by submitting comments to the ACGME Public Comment Page.
Use EMRA's detailed comments to guide your response or copy and paste from our list.
References
- AAMC History. Association of American Medical Colleges. https://www.aamc.org/who-we-are/aamc-history.
- Accreditation Policies and Procedures. Accreditation Council for Graduate Medical Education (ACGME). Feb. 2, 2025. Available at https://www.acgme.org/globalassets/ab_acgmepoliciesprocedures.pdf.
- The Foundations of Competency-Based Medical Education. Learn at ACGME. https://dl.acgme.org/courses/competency-based-medical-education-cbme.
- Karpinski J, Stewart J, Oswald A, Dalseg TR, Atkinson A, Frank JR. Competency-based medical education at scale: a road map for transforming national systems of postgraduate medical education. Perspect Med Educ. 2024;13(1):24-32.
- ACGME Program Requirements for Graduate Medical Education in Emergency Medicine Summary and Impact of Major Requirement Revisions. ACGME. 2025. Available at https://www.acgme.org/globalassets/pfassets/reviewandcomment/2025/110_emergencymedicine_impact_02122025.pdf.
- Beeson MS, Barton MA, Reisdorff EJ, et al. Comparison of performance data between emergency medicine 1-3 and 1-4 program formats. J Am College Emerg Physicians Open. 2023;4(3):e12991.