3 vs. 4 Year Residency - Which is better?

This is a draft of an article I am writing for the SAEM (Society for Academic Emergency Medicine) Newsletter. The goal is to provide some perspective on a question that students applying for EM often struggle with: "Should I apply to 3 year or 4 year residency programs?"

Many Emergency Physicians have strong opinions as to which length of training is better: 3 years vs. 4 years.  This often directly correlates with the duration of training they themselves completed. Though there is some crossover with graduates of three year programs who ultimately feel that four years is better, just as there are some four year graduates who wish they had been done in three.

These arguments are frequently built around the financial implications, the quality of the training, and the impact on career options.  There are advantages and disadvantages to both formats. However, which is overall “better” may be the wrong question to ask. What matters more is the best fit for the individual applicant.  

The “$200k” mistake

This is a common perception among those who trained at a three year program, or who regret doing a four year program.  The extra year cost them a significant amount of attending income.  The financial argument against four years of training is hard to dispel if your primary driver is monetary. If making as much money as you possibly can, as quickly as you can, is highly important to you, then you are probably not agonizing over this decision. Targeting an intense clinical education at a three year program is likely to leave you satisfied with your training experience.

Conversely, if you are considering an academic career you will be giving up far more of your total earning potential than will be lost in one extra year of training (academic emergency physicians are usually paid less than their peers in community practice).  There is a similar reduced financial impact of an extra year of training if you choose to work in a highly competitive market where emergency physicians are paid less.

More is always better

Four years can be considered better training simply by virtue of being longer. However, competency is achieved at variable times. Some residents are already competent after two years of training while others may need more than the four. In general, having a fourth year of directly supervised practice gives you a greater chance of achieving competency, or even proficiency, while supervised. Though you may not find yourself as a clinician, confident in your skills and practice patterns, until your fifth or sixth year in emergency medicine. By then you will be an attending on either pathway.

A different way to think about this would be to consider your confidence as a clinician, more than your actual competence.  Having more supervision during your first few formative years should appeal to those who have concerns about when they will achieve competence and proficiency.  

The pathway to academics

Historically, four years of training was considered an advantageous path to an academic job, particularly as a four year program is unlikely to hire the graduate of a three-year program to supervise their senior residents (who are the same post-graduate level). This advantage has diminished over time as post-residency fellowship training has become more common.

There certainly remains several advantages to an additional year of training when considering academics.  You have more time during your training to figure out what direction you want your career to take. I am the Associate Program Director at a three-year residency and I see my brand new third years having to make career altering decisions about the next stage of their career that would be easier to make a year later.  You also have more time during training to explore and develop areas of interest, to get involved in research, and to actually complete projects.  And you will often be better prepared as a teacher when your senior year of training includes supervising junior residents (which is much more common at four year programs).  This pre-attending supervisory experience can both develop your teaching skills and allow you to make a more informed decision on pursuing an academic career.  

Fellowship training is now commonly seen as the best path to an academic position. Many graduates of four year residencies are opting to complete a fellowship to gain the additional expertise and to cultivate a specific niche within emergency medicine. The shift towards fellowship training has made completion of a three year residency a much more viable path to an academic career. Particularly if as a student you already know your career destination and which fellowship will get you there.

The extra-time in training is only as valuable as what you actually accomplish. Doing more training, getting a certificate or additional certification, is not the same as being productive in that time. Avoid approaching the fellowship decision as though completing one, regardless of effort invested, will get you the job that you want. Similarly, it is entirely possible that in a three-year residency you can accomplish the things that will make you an impressive candidate for an academic position. Though you will need to be particularly driven and focussed to make that happen.  

The verdict

Ultimately this discussion is not about which option is better because that answer does not exist. What matters is which program is the right fit for what you need from your training. That fit may relate to the length of the training program, or the composition of the curriculum, or the mentorship that you will receive there. The best program for you is going to be the one that best fits your personality, your learning style, and your needs and future goals. Regardless of how many years that program lasts. If you choose for those reasons you will be satisfied with your training irrespective of how long it was.

Adam Kellogg is an Associate Residency Director and a former Clerkship Director. He is member of the SAEM Resident and Student Advisory Committee. He thinks he did a 3 year residency, but it was so long ago he is no longer sure.