To the Editor: In Response to “Building the Future Curriculum for Emergency Medicine Residency Training”
The recent article “Building the Future Curriculum for Emergency Medicine Residency Training” has sparked significant debate in the emergency medicine (EM) program director community.1 We represent 275 national leaders in EM education who cosigned a letter to the Accreditation Council for Graduate Medical Education (ACGME) formally opposing requirement 4.1 of the proposed changes to the ACGME Program Requirements for EM, as outlined by Regan et al, which describes the process used to develop the changes.1 While we support innovation to maintain high training standards in our specialty, the proposal to mandate 4-year training has 2 primary flaws.
1. Lack of Evidence
There is no convincing evidence that extending the program length would improve competency in EM. The ACGME writing group has suggested 5000 patient encounters as a target for competency, but many programs achieve these numbers with fewer weeks of training. The quality of a program should be measured by its efficacy, not its length. Additionally, the current guidelines allow for extending training for residents not meeting expected competencies. The writing group referenced subjective feedback from focus groups of employers without providing detailed support for their claims. More transparency and formal surveys are needed to understand the concerns. Existing literature shows similar performance between 3- and 4-year program graduates in early practice.2 The most recent data on first-time board passage rates of graduates trained during the COVID-19 pandemic3 has been cited as evidence for change, while the one published study comparing 3- and 4-year program qualifying examination pass rates shows a higher pass rate for 3-year graduates.4 A change of this magnitude must be grounded in data.
2. Undue Burden
The proposed change would require a major overhaul of the curriculum in most programs, which are already functioning at a high level. This change would require significant support from faculty, departments, and institutions without convincing evidence of need. The impact of additional training on residents, including higher burnout rates among EM postgraduate year 4 residents,5 effects on family planning, and financial repercussions, must be considered.6,7 Key stakeholders were left out of the development of this proposal. In the Regan et al study, program directors were surveyed about building an imagined program without constraints or limitations, and this survey was used as the basis for claiming consensus about the necessity for longer training.1 This consensus does not exist. In a recent unpublished survey conducted in April 2025 using the Council of Residency Directors in Emergency Medicine program director listserv, (response rate 63%, 181 of 289 EM programs,), just 32.6% of programs reported that they support the proposed change to 4-year training, while 62.9% support the current model (3- and 4-year formats).
The proposed 4-year mandate is serious, disruptive, and has unknown future impacts. Leaders in EM education believe that mandatory training extension to 4 years is inappropriate and ill-timed. We ask the ACGME and EM Review Committee to pause and seek robust data and systematic stakeholder input before moving ahead with the 4-year training mandate. The responsibility rests with the ACGME and EM Review Committee to ensure the change is undertaken with care, humility, evidence, and respect for residents and educators.
Author Notes
