The field of emergency medicine (EM) is at a crossroads. Faced with rising burnout, a constantly changing health care landscape, and an evolving trend in unfilled residency positions, the specialty is now grappling with another proposed structural change: A proposed mandatory fourth year. While the idea has been periodically debated over the past two decades, it gained new momentum with proposed changes to the ACGME Program Requirements for Graduate Medical Education in Emergency Medicine (EM), including a mandatory 48-month curriculum. EM training should be held to a high standard, but a fourth year of training is unlikely to address the true challenges in our field and may ultimately cause more harm than good.
No evidence of superior outcomes with four-year programs
There is no evidence that graduates of four-year EM residency programs perform better clinically, have improved board pass rates, or achieve better long-term career satisfaction compared to their peers trained in three-year programs. On the contrary, a 2021 study in Western Journal of Emergency Medicine found no statistically significant differences in ABEM board pass rates between three- and four-year program graduates. Similarly, research has shown no consistent outcome advantages in patient care, patient outcomes, procedural competency, or job placement between the two tracks.
Emergency medicine’s broad scope and intensity may tempt stakeholders to “add time” as a catch-all solution to perceived deficiencies, but time alone is not a substitute for targeted curriculum reform. The ACGME has offered no evidence to suggest four-year graduates are better prepared than three-year graduates. In contrast, a 2023 study by the American Board of Emergency Medicine showed graduates of three-year programs actually have a slightly higher board pass rate than graduates of four-year programs. Citing an overall downtrend in board pass rates as a reason to lengthen training is incongruent with the available evidence and will not help identify or solve the real underlying reasons for this change.
Economic and workforce consequences
Expanding residency by an additional year imposes real financial costs — to trainees and the health care system alike. Graduating medical students in 2023 reported median debt loads of approximately $202,000 (AAMC). An extra year of residency translates into delayed earning potential, postponed retirement contributions, and another year of earning a resident’s salary — typically under $70,000. For many, this is an unsustainable proposition.
On a national scale, increasing training time could exacerbate workforce strain, particularly in rural and underserved regions. Though some projections forecast a surplus of emergency physicians by 2030, these models fail to account for persistent geographic maldistribution and the uneven closure of rural emergency departments. Delaying the pipeline of board-certified emergency physicians by a year will not solve these disparities — and may widen them.
A risk to recruitment in a match in recovery
Perhaps most concerning is the potential deterrent effect on future applicants. According to the 2025 National Residency Match, emergency medicine saw substantial improvement in filling EM programs across the country, with only 65 positions going unfilled, achieving a 97.9 percent fill rate (NRMP). This paints a stark contrast to the 2023 Match, where emergency medicine positions went unfilled at an unprecedented rate, with 555 unfilled slots in the initial match, demonstrating that EM’s performance this year is on track to return to the pre-COVID fill rate of 99 percent.
Though multifactorial, this is an optimistic trend reflecting that EM may once again attract a robust applicant pool.
Mandating a fourth year may further dissuade competitive medical students from applying. In an era where students weigh specialty choice alongside debt burden, length of training, and perceived future stability, an additional year may serve as a barrier rather than a benefit. Further, mandating a fourth year may drive some individuals with particularly high debt burdens or familial or health constraints away from applying into emergency medicine — further exacerbating the gap between EM physician need and supply and depriving our field of some outstanding potential candidates.
Focus on the right problems
Emergency medicine does not need a longer training pathway. It needs better post-residency practice conditions, more support for new graduates, and a renewed commitment to addressing burnout and moral injury at their root causes. The call for a mandatory four-year residency may be well-intentioned, but it diverts attention from the urgent reforms that could make a far greater impact. If the goal is to strengthen the specialty, let us focus on what we can improve within training — not artificially extending it.
Polly Wiltz and Anna Heffron are emergency medicine residents.
