The recent proposal by the ACGME to extend all EM residency programs from three to four years represents one of the most significant structural shifts in graduate medical education in decades. While couched in language about safeguarding patient care and ensuring adequate clinical exposure, what the proposal actually does is mandate that physicians delay their transition to full attending practice with all of its attendant autonomy, income, and professional stability for another year, sans any high-quality evidence supporting such a drastic change.
The costs to the individual are profound. An EM resident can expect to earn an average of $60,000 annually. In contrast, the average EM attending salary often exceeds $385,000. By obligating a fourth year of residency, the proposal effectively strips each physician of roughly $325,000 in direct earnings, not to mention the lost investment potential, delayed debt repayment, and postponed retirement contributions that accompany such a deferment. When compounded over a career, this economic setback can reach well into seven figures.
Yet the ethics of this proposal become even more troubling when we consider who precisely populates this additional year. This is not an influx of novice interns still learning to manage basic presentations under tight supervision. It is, rather, an entire cadre of seasoned near-attendings; physicians who, under the existing system, would already be practicing independently. This proposal does not simply extend the training length for residents. It guarantees institutions an extra year of highly skilled, low cost labor. Hospitals benefit enormously from the presence of senior residents. These physicians run codes, oversee the care of multiple simultaneous critically ill patients, teach and supervise juniors, generate billable patient care, stabilize EDs, and uphold hospital throughput metrics. That they do all this for a fraction of the cost of hiring an attending physician is an economic windfall for health care systems and one that is rarely openly acknowledged but is deeply relevant to the ethical calculus of this policy change.
The broader consequences for the specialty also merit attention. Although the issue in recent years has improved, EM residencies recently faced significant challenges in recruiting sufficient applicants. Just two years ago, the specialty faced an unprecedented shortfall, with hundreds of unfilled positions in the national residency Match. For medical students contemplating their future, the prospect of an additional year of training may tip the scales toward alternative career paths. As a current fourth-year medical student, I have many close friends applying to EM this year. While this change would not affect their class, several have told me they would not have considered pursuing EM if a fourth year were mandated, as the three year structure remains one of the specialty’s main draws.
Moreover, there is a paradox embedded in this proposal. By elongating the path to independent practice, medical educators may inadvertently dissuade graduates from pursuing the very subspecialty training that enhances the depth and breadth of emergency care. Fellowships in areas like ultrasound, pediatric EM, toxicology, and critical care provide essential expertise that strengthens both EDs and the broader health care system. By stretching residency to four years before fellowship even begins, this proposal may discourage trainees from pursuing further subspecialization altogether. Ironically, then, a policy intended to bolster clinical training could produce a workforce with less advanced specialization and fewer academic leaders.
What is perhaps most striking about the ACGME proposal is how profoundly it departs from the principles of evidence-based practice that underpin modern medicine. In clinical care, physicians rightly demand rigorous data before adopting new therapies. We weigh benefits against harms, costs, and opportunity losses. Yet here, we contemplate imposing a sweeping alteration in the structure of EM training without compelling evidence that it would yield better physicians or safer patients. Recent investigations, including a national study published in 2025 evaluating patient volume thresholds, have suggested that the vast majority of EM programs (except for one singular program) already meet proposed exposure benchmarks within the existing three year framework. Prior analyses have also shown no consistent advantage in board certification outcomes or clinical preparedness among graduates of four year programs compared to their three year peers. To move forward with such a consequential change absent persuasive data contradicts the very ethos of our profession.
All of this returns us to a fundamental ethical question: Whose interests are being prioritized? The extension of EM residency threatens to subordinate the well-being and financial security of trainees to institutional imperatives, whether they be rooted in concerns regarding staffing models or economic efficiencies. It risks treating the years of residency not primarily as a period of educational growth, but as a convenient reservoir of inexpensive labor, even at the cost of individual physicians’ livelihoods and the specialty’s long-term viability.
What are your thoughts on the change? Share in the comments.
Forrest is a fourth-year medical student interested in rural medicine and how to best address the physician shortage in these areas, as well as being particularly interested in health policy and the way it is applied to different groups of people in the U.S. Forrest is a 2025-2026 Doximity Op-Med Fellow.
Illustration by Diana Connolly
