History of EM: Three years or four?

Author: Louis Ling, MD (Professor of Emergency Medicine, University of Minnesota Medical School) // Reviewed by: Alex Koyfman, MD (@EMHighAK)

If you are a residency trained emergency physician, you know what that question means.  If you are anyone else, you are clueless.  But even if you asked and answered that question for yourself, you may still be clueless of how that dilemma even came to be.  How did we get 3 or 4 years of residency? What were they thinking? Was it on purpose or an accident?

There is actually an answer and it goes like this: once upon a time (which means a long, long time ago) in 1979, emergency medicine was approved as a specialty, with a two-year training requirement… after an internship.  If you think it is hard to believe that anyone could squeeze everything you need to know into two years, you are not alone.

In 1983, ACEP convened a Blue Ribbon Commission called the Length of Training Task Force, chaired by John Lumpkin to answer three questions: 1) What outcomes must be achieved in GME in emergency medicine? 2) What experiences must be provided to achieve those objectives and 3) What length of time is required to provide those experiences?  They analyzed 400 objectives from the Core Content, and using a modified Delphi method with 200 emergency physicians (a large percentage of a small number back then) concluded that 24 months was too short and that a minimum of 36 months in emergency medicine training, under the supervision of the emergency physician faculty was necessary.¹  (The members on the Length of Training Taskforce had just come out of the battle to become the newest specialty, so the concept of a unique body of knowledge was forefront on their minds.  Other specialties could teach specific skills but not the unique approach.  Thus, the requirement was that the training only counted if EM physicians could control the experience.)ABEM was initially a modified co-joint board, with more involvement from other specialties but despite some early confusion, agreed to require that 36 months of specific EM training was required to get board certified. (So far, it all makes sense).

In the US, the ACGME sets the length of time for residency training programs but they have to consider what the board requirements are since nobody would want to do two years of training and not be eligible for board certification. The last year of the old requirement in 1986-1987 said  “the minimum time of graduate training in emergency medicine is 24 months beyond the PG-1 year… this year may be part of a three year EM residency program”²  So you can see that even though everyone did three years of training, some did two years of EM training after an internship and some did all three years of training in the EM program.  It was not a stretch to change the length of training requirement for everyone to three years, but all in EM.

It gets more interesting when you decide how to add that third year.  Some were happy with their current PG1-3 program but some of the two-year PG2-PG3 programs decided they would like to add their third year on at the end as a PG4 year.  (Wouldn’t you rather share your shift with a PG4 instead of a PG1 resident?).  If you were “in the room where it happened” you would have heard: “a PG4 resident could stand toe to toe with a PG3 medicine resident who wants to block an admission… all of those physicians who are changing careers don’t want to repeat an internship… students won’t choose a four year program when they could do three… programs will change when they can’t get enough applicants… let programs choose what they want, the marketplace will decide.”  So, the Review Committee decided to be patient, confident that students would prefer three-year programs and that to attract them, the marketplace would eventually force all programs to settle on a PG1-3 format. The 1987-1988 Special requirements reflected that choice: “the minimum time of graduate training is 36 months in a curriculum designed and supervised by the emergency medicine program director… may be comprised either of the PG1-PG3 years or PG2-PG4 years.”³ Note the added language that the curriculum is under the emergency medicine program director. The battle to become a specialty was still fresh in the EM community. Much of the resistance was in academic medical centers where the traditional specialties did not want to give up control of the ED as a training site for their residents. Once EM was approved, those specialties wanted to maintain as much control as possible in a fight for control of PG1. It was not an accident that the primary fights were in academic medical centers, and at many, the only way to gain control over 3 years was to adopt a 4-year program.

Three years, two formats, but not everyone was happy. Every faculty member likes a “super PG4” senior resident but nobody likes to untrain the bad habits of a PG1 resident who trained somewhere else, especially if it was in a medicine or surgery preliminary year where they were pushed to think like internists or surgeons.  As you all know, emergency medicine is more than a sum of the knowledge, skills and attitudes of these other specialties.  The secret to successful emergency physicians is the “emergency medicine mindset”; a way of thinking that is different than the other specialties and unique to the challenges and issues of the emergency department.  This truism grew into a groundswell of support for incorporating the PG1 year into PG2-4 programs and by 1996-1997, the EM Program requirements clarified that the RRC recognized three educational formats PGY 1-3, PGY 2-4 and PGY 1-4 but asked that programs beyond 36 months present a rationale.  There was never a universally accepted agreement on the content for true 4 year programs. Some would have argued that you were essentially spreading a 3-year curriculum across 4 years. Other programs actually incorporated subspecialty-like experiences as the 4th year. Today the language in the current requirements has changed but the concept remains and explicitly state that programs “are configured in 36-month and 48-month formats…”⁴

So, market forces worked unexpectedly: as the number of programs grew, the number of applicants grew faster and there is still debate about three years or four.⁵

But enough about history; what of the future? What we have today evolved from a Task Force report from a generation ago. Think of the monumental changes in emergency care since then, the increased complexity of what we can do, how we do it and how we learn and teach it in our residency programs. And what about the dramatic increase of residents seeking subspecialty training, the birth of joint specialties that incorporated multiple primary specialties, and the resulting prolonged length of training for many?  Can we replace time-based with competency-based training?  Every generation or so, shouldn’t the specialty have another Residency Length Task Force?

References:

1. Gray, BK; Lumpkin, JR; Gallery, ME; Rorie CC. Length of residency training in emergency medicine: An outcome-oriented approach. Ann of Emerg Med 1986, Vol 15(4), p.493. abstract
2. https://www.acgme.org/Portals/0/PDFs/1986-87.pdf
3. https://www.acgme.org/Portals/0/PDFs/1987-88.pdf
4. https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/110_EmergencyMedicine_2020.pdf?ver=2020-06-26-125701-320
5. Hopson L, Regan L, Gisondi MA, Cranford JA, Branzetti J. Program director opinion on the ideal length of residency training in emergency medicine. Academic Emergency Medicine Vol 23(7); July 2016, pp 823-827

Special thanks to John Lumpkin, MD, MBA and Benson Munger, PhD. for sharing their insights.