Proposed Changes to Emergency Medicine Residency: Potential Challenges for Consideration

The Accreditation Council for Graduate Medical Education (ACGME) has proposed significant revisions to Emergency Medicine (EM) program requirements, most notably, a return to a four-year training model. While the intent to enhance educational consistency and strengthen clinical training is clear, these proposed changes prompt important questions around feasibility, equity, and broader implications particularly for programs serving rural or resource-limited communities.

A Shift Back to Four Years: What’s the Impact?

Currently, most EM residency programs in the U.S. operate under a three-year model. A transition to four years would affect nearly 80% of existing programs, requiring careful adjustments to complement sizes, staffing structures, and operational planning. Many programs would face tough decisions whether to increase resident numbers, restructure class sizes, or reevaluate clinical coverage models. These changes would also necessitate recalibration of carefully designed team-based learning environments and faculty-to-resident ratios.

Moreover, this change introduces implications regarding financial sustainability. While it is very likely that new Emergency Medicine programs would be given an adjusted four year Initial Residency Period (IRP), which would mean eligibility for four years of funding per resident, it is unclear how CMS will address hospitals with longstanding Emergency Medicine programs that are already at or above their CMS Cap—as a Cap increase would be needed to account for the additional year if current class sizes were maintained.

Increased Patient Volume Requirements

Another major proposed change is the increase in required annual Emergency Department (ED) volume—from 30,000 visits required annually to 3,000 annual visits per approved resident position. For a proposed updated minimum size of 16 residents in the program, this would equate to at least 48,000 visits per year. While this may be easily achievable for large urban hospitals, it will likely present steep hurdles for smaller or rural programs operating near current minimums. These programs often serve communities with limited healthcare access but high need for trained EM physicians and a unique and high-quality clinical training experience.

To meet new thresholds, programs may need to rely on more distant sites, introducing out-rotation housing costs, or in some cases, reconsider their ability to sustain the program altogether—especially in rural areas.

Stricter Supervision Rules

The proposed revisions also limit who can supervise core EM training specifically requiring that supervision be provided by EM board-certified physicians. While this standard aligns with specialty-specific training goals, it creates challenges for programs where EM-trained faculty are in short supply. In many rural hospitals, programs rely on other board-certified specialists, such as Family Medicine physicians, who provide safe and effective clinical oversight.

Under the new guidelines, this form of supervision may no longer count toward the 124 required weeks of core training. That could create logistical difficulties for programs that have successfully integrated care in rural or low-resource settings utilizing physicians with other board certifications but significant EM practice experience. While the revisions underscore the importance of rural and community-based experience, they may also limit how such experience is recognized.

Subspecialty and Infrastructure Changes

New requirements in areas like NICU, PICU, ophthalmology, and telemedicine are intended to provide residents with a well-rounded skillset. However, not all institutions have access to these subspecialty services in-house. Many will need to arrange out-of-network rotations, with associated costs for housing, travel, and administrative coordination. Without additional funding or support mechanisms, these changes may be difficult to implement equitably.

Additionally, the requirement that workspace and support staff be "readily available" across multiple clinical sites adds another layer of complexity for programs already stretched thin. As programs expand their training networks to meet clinical diversity requirements, consistent access and staffing across locations will be a growing concern.

Looking Ahead

As the ACGME collects feedback on these proposed changes, it's crucial to weigh the potential benefits of a more standardized and comprehensive training model against the real-world challenges each program faces. Standardization and excellence in training are important goals, and they must be balanced with the operational realities faced by programs of all sizes and settings.

Emergency Medicine is, by nature, a specialty rooted in responsiveness and adaptability. GME standards should reflect those same principles. We look forward to seeing how ACGME engages directly with stakeholders from program directors to community hospitals in the coming months to ensure that any final revisions promote excellence in training without compromising access, equity, or sustainability.

Partnering Through Change

At Germane Solutions, we understand the complexity and nuance involved in GME reform. From shifts in program length to evolving clinical rotation requirements, the proposed changes to Emergency Medicine residency will require careful planning and expert navigation. Whether you’re assessing feasibility, redesigning your curriculum, or addressing supervision challenges, our team is here to support you.

We specialize in helping programs build sustainable, compliant, and innovative solutions tailored to the needs of their communities. As the EM landscape continues to evolve, we’re proud to partner with institutions to ensure continued excellence in graduate medical education.