Three vs. Four and Everything in Between

Image Credit: Pexels

Author: MohammedMoiz Qureshi, MD
AAEM/RSA President
Originally published: Common Sense January/February 2019

As interview and rank season comes to an end and the ever-anticipated Match is just a few short months away, I thought it would be a good time to reach out to our medical students who have questions and concerns regarding the variations in residency training programs. Emergency medicine programs are abundant nationwide and vary in length between three and four years. Students are often confused whether the extra year makes a difference in overall training or ability to pass board certification and it remains one of the most commonly asked questions on the interview trail.

“The 300K Dollar Mistake”

Emergency medicine physicians are not known for withholding their opinions and most are vocal for or against the four-year programs. Many have deemed it the “300 thousand dollar mistake,” implying that fourth year residents give up a year of attending salary for no tangible benefit. Others however are adamant that a career in academics is hindered without that fourth year. From a logistical perspective, generally the average medical student has had anywhere from 8-10 years of education and in the grand scheme, a single year of attending salary will not make or break retirement plans. So from a monetary perspective, if the program faculty, location and curriculum are appealing, the loss of income is marginal for four years of contentment.

“More Conducive to Academics”
After anecdotal experience from working with and interacting with residents and attendings from both three and four year programs, the collective consensus remains that residents graduating from three year programs are just as capable as residents graduating from four year programs. In fact there has been no correlation of higher board passing rates between the two training lengths. Furthermore, most will agree that if three year graduates truly want a career in academics, pursuing a one year fellowship or accepting a junior faculty position at the desired institution for a year will suffice for a more senior/tenured position very shortly thereafter.

“Variety/Career Building”
Most of us went into emergency medicine because we knew what we were getting into. We wanted sporadic rushes of adrenaline, variety in our clinical practice, and wanted definitive start and end times. Often, however, there are those of us that desire a more specific niche. Exposure to fellowship opportunities, different ward experiences, and international electives, these are all opportunities that are more afforded to residents in four year programs; simply because of the increased time available. This is not to say three year graduates don’t get them, more so the frequency is less. The argument also remains that if a resident in a three year program is truly invested in these same opportunities, then building a custom fellowship after graduation will allow similar experiences.

In the end most people agree given all this variety that the ideal EM training
program would be three and a half years. And while this is obviously not possible, deciding ranking/applying between the two should not be the end all be all for students. The end of fourth year is a celebration of the culmination of four years of intense hard work and is an important transition for an even harder few years to come, so look to celebrate, plan an exciting trip if possible, and reflect on your remarkable journey.

“Words of Caution”
As some parting advice, while completing a three vs. four year residency program will only marginally alter your career path, considering lay entity run residencies is much more concerning. A lay entity means that a nonphysician owns and operates the emergency department and the subsequent emergency medicine residency. No one wants to go unmatched, and I would be remiss to advise not ranking all programs, but for the more competitive applicants it is imperative to ensure the programs you rank support the mission of the specialty. For an excellent history lesson I encourage every medical student and resident to read The Rape of Emergency Medicine:

In it readers are exposed to the ongoing threat of lay corporations fighting to take control of emergency departments nationwide. A growing number of emergency medicine residency programs and fellowships are operated by said incorporated lay entities. Some of these lay corporations have been found to encourage family medicine practitioners to complete one-year EM fellowships. This continues to prove to be dangerous, as research has shown that patient outcomes in the ED are optimal when there is a board certified emergency physician managing their care. Applicants and residents should be well aware of their future and current employers and the motives that drive the program.

Lay entities that manage emergency departments and residency programs can be found nationwide with at least 14 residency programs and significantly more projected to come.

Corporate-owned programs exist in Florida, Georgia, Pennsylvania, Ohio, Michigan, West Virginia, Illinois, Nevada, Texas, and Oklahoma.

For a list of questions to ask on the interview trail or follow up email communication to ensure please visit: