Proposed Changes to Emergency Medicine Residency: Raising the Bar or Raising Barriers?

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 goal of advancing educational rigor and ensuring consistent training across institutions is commendable, these proposed changes raise critical questions about feasibility, equity, and unintended consequences—particularly for programs serving rural or resource-limited communities.

A Shift Back to Four Years: What’s at Stake?

Currently, the majority of EM residency programs in the U.S. operate under a three-year model. The proposed shift to a four-year format would disrupt nearly 80% of active programs. Beyond the logistical challenge of redistributing residents or seeking ACGME approval for complement increases, this change has broader implications for staffing models, faculty requirements, and clinical operations. For many programs, this will mean either increasing the number of residents or navigating year-to-year fluctuations in class size. In turn, faculty-to-resident ratios and team-based learning structures—carefully designed over years—would need to be recalibrated, potentially compromising the collaborative environments EM programs strive to maintain.

Moreover, this change introduces serious concerns about financial sustainability. Medicare reimbursement is tied to the minimum number of years required for board certification. Since the American Board of Emergency Medicine (ABEM) still recognizes three years as the standard, there is a possibility that fourth year would not be reimbursed through CMS, leaving institutions to fill a potentially large funding gap. In an environment where GME funding is already constrained, the lack of reimbursement could impact the quality and accessibility of emergency medicine training nationwide.

Increased Patient Volume Requirements: A Rural Roadblock

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. While this may be manageable for large urban hospitals, it poses an existential threat to smaller or rural programs, many of which are just meeting the current thresholds. These programs often serve communities with fewer resources but greater need for trained EM physicians. The new volume requirements could force such programs to send residents to distant sites, introduce expensive out-rotation housing costs, or in some cases, reconsider their ability to sustain the program altogether. The ripple effect? Reduced access to care in areas already facing healthcare workforce shortages.

Stricter Supervision Rules: A Narrow Definition That Limits Growth

In many rural EDs, EM-trained physicians are scarce. Programs often rely on other board-certified specialists—such as Family Medicine physicians—to provide competent supervision. Under the new proposal, only time spent under EM board-certified faculty would count toward the 124 required weeks of core EM training. This excludes valuable training that occurs in low-resource or rural settings, and could further disincentivize program expansion into underserved areas.

This change feels especially contradictory. On one hand, the proposed revisions emphasize the importance of low-resource ED exposure. On the other, they limit how that experience can be counted unless EM-certified physicians are available—an unrealistic expectation for many rural hospitals. Programs are left with few options: either stretch residents across longer distances to meet the supervision requirement, or risk ongoing citations that could threaten accreditation.

Subspecialty and Infrastructure Changes: Complicating Clinical Rotations

The proposed updates also introduce new requirements in subspecialty experiences—such as dedicated NICU, PICU, ophthalmology, and telemedicine training. While these are important domains, mandating structured rotations in settings not available at all institutions could cause logistical and financial strain. Many hospitals don’t have in-house pediatric intensive care or ophthalmology units, making these rotations possible only through out-of-network placements. Programs would then need to provide travel support and housing, without any guaranteed increase in financial support from CMS or other agencies.

Similarly, the expectation that support personnel and workspace must be "readily available" across multiple clinical sites is unclear. As programs expand to meet site diversity requirements, ensuring equitable staffing and access at each location becomes increasingly complex.

Looking Ahead

As the ACGME reviews 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 programs face. A one-size-fits-all approach risks undermining the flexibility and creativity that many EM programs have embraced—particularly those serving vulnerable populations.

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

Partnering Through Change

The proposed changes to Emergency Medicine residency requirements have created understandable concern for programs across the country. From shifts in program length to increased clinical volume requirements and stricter supervision standards, these updates pose significant operational, financial, and strategic challenges—especially for community and rural institutions. At Germane Solutions, we specialize in helping GME programs navigate complex transitions like these. Whether you're reassessing program feasibility, reworking block schedules, or planning for faculty recruitment and compliance, our team stands ready to provide expert guidance and hands-on support. As the Emergency Medicine landscape evolves, our team of experts is here to ensure your program remains sustainable, compliant, and well-positioned for long-term success.