To the Editor: Concerns About the Findings of the Emergency Medicine Program Requirements Working Group

We read with interest “Building the Future Curriculum for Emergency Medicine Residency Training” by Regan et al¹ and appreciate the efforts of the Program Requirements Working Group (PRWG), but we would like to highlight some concerns regarding this article.

Though it is admirable that the authors were able to survey 60% of emergency medicine (EM) program directors (PDs), key stakeholders were omitted, including current residents, recent graduates, practicing physicians, department chairs, designated institutional officials, and hospital administrators potentially affected by this training format revision.

Our greatest concern with the survey is that PDs’ ideal length of training was extrapolated from the granular survey questions about ideal rotation length. This led to significant variability in “ideal” program length from 41.6 months from 3-year PDs to 50.7 months from 4-year PDs (with a large SD of 10.4 and 9.5, respectively). The authors also describe removing 5 responses after being identified as “outliers.” As presented, the survey suggests that there is far from a consensus regarding optimal program length. We believe that the responses regarding program length would have been different if this question had been posed directly.

Furthermore, the proposed change in program length will force 3-year programs into a contraction of 25% of their spots in each class if they do not expand their complements, leading to significant understaffing. While programs may pursue expansion of their existing complement to address the resulting shortfall, this is unrealistic at a time when 40% of hospitals are facing financial deficits.² Moreover, the adjustment would result in a lack of graduates from all 3-year programs in 2030, leading to significant disruption to the EM workforce.

The PRWG cites a decline in the passing board examinations as an additional justification for the change in training length. However, the American Board of Emergency Medicine recently published data that demonstrate that the written board examination (“Qualifying Examination”) pass rates are actually higher for 3-year format programs.³ It is plausible that the 23% increase in approved programs (over 51 new programs) between 2014 and 2021 in our specialty⁴ could be a more likely culprit.

Finally, the PRWG references 5000 patient encounters before the conclusion of EM residency as a target for sufficient training, an arbitrary target not supported by empirical evidence or outcomes. Even if 5000 patient contacts was assumed to be a validated goal for patient encounters, there are no data to suggest that 3-year programs fail to meet this objective, or that it is routinely accomplished in 4-year programs.

While we applaud the PRWG for exploring ways to advance education in EM, there is a lack of supporting evidence to assert that changing to a 4-year format will address the concerns highlighted by the authors. The administered Accreditation Council for Graduate Medical Education survey has methodological shortcomings that undermine its support for the modification. Finally, the resulting contraction in residency class size will have significant downstream effects on hospital finances, various service lines outside of the emergency department, and, most importantly, the day-to-day care of our patients.