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.  

Advice for the International EM Applicant

This post is by Max Hockstein, a US citizen who went to medical school in the caribbean and who successfully matched into a U.S. Emergency Medicine residency in 2015.  He is now starting his internship and wanted to share some advice on navigating the EM match as an international applicant...

Before you choose EM

Over the past few years, emergency medicine has become increasingly competitive.  As you get started as an International Medical Graduate (IMG) applicant you need to know what you are getting into.  According to the Results and Data from the 2015 Main Residency Match there were 1821 emergency medicine PGY-1 positions with 2352 total applicants.  Of those, 739 were “independent applicants” (31.4%), which includes those who went to med school internationally.  EM had a 99.6% fill rate with almost 80% of those spots going to US allopathic seniors and 11% filled by osteopaths. This adds up to some sobering news for the international applicant.  Just 4% of spots were filled by IMG’s who were US citizens and just 2% by non-US citizen IMG’s. And that left 30% of independent applicants unmatched among those who listed EM as their only specialty (did not hedge with also applying to another specialty).  

Why is this?  

IMG’s are still considered (by some) to be second-rate applicants.  In addition, residency program directors (PD's) get many, many applications, and they need a way to screen them.  When the NRMP conducted a program director survey in 2014 83% of PD’s ranked being a graduate of an American medical school at a high level of importance. And less than half (47%) of PD’s will interview and rank IMG’s.  

About rotations

One of the most difficult things about IMG’s matching into emergency medicine is their ability to get their foot in the door because clerkships are hard to schedule.  The holy-grail clerkship is one where you can get a departmental Standardized Letter of Evaluation (SLOE) from an emergency medicine residency.   Because international schools are not affiliated with academic EM programs, we have to find places that not only allow rotators, but foreign rotators.  There’s no registry of places that allow IMG rotators because hospitals change their policies so quickly.  Your first step should be to ask your school where students that have successfully matched into EM have rotated.  The second place you can look is your schools’ (and other foreign schools) match list – see where IMG’s have matched and call those departments to see if you can schedule a rotation there.  The last, and unfortunately the most common way, is to call the departments where you’re interested in rotating (and potentially applying to) to see if they’ll let you rotate.  This takes time: you are busy and the clerkship coordinators are definitely busy – it can be a tough job.    

An added wrinkle...

Certain states have requirements to be eligible for licensure which have to do with the rotations (clerkships) that you did during third/fourth years.  There are two terms you’ll being hearing a lot on this topic: Green-book and Blue-book.  Green-book rotations mean that the rotation has an associated residency while Blue-book rotations means there is no associated residency with an established rotation.  States that are stricter about licensure requirements (for example, Texas) require that all of your rotations be Green-book to be granted licensure after doing residency in that state.  This does not mean that you can’t do residency in one of the more selective states – it just means that you can’t get licensed after residency until you pass your boards if you did Blue-book rotations when you were a student.  

Your application

ERAS opens September 15th – your application needs to be complete (with the exception of possibly one SLOE) by then.  This means you need to have your last SLOE in ERAS by October 1st at the latest.  This means the optimal time to do your rotations is before September.  When you’re setting up your core rotations (third year), do them all back-to-back because (most, if not all) EM rotations require that your core rotations be complete prior to the rotation.  

One of the reasons that program directors want to see SLOE’s from ED’s with residency programs is because one of the questions on the SLOE is how that program plans to rank that applicant – it gives the SLOE more context.  Because of the demand to do clerkships at Emergency Departments with affiliated residencies, some non-academic departments offer rotations.  The bottom line is: do a rotation at a non-academic department if you have to in order to get at least two SLOE’s, but know that having a residency affiliated SLOE is preferred to any other letter you could receive.

There’s no statistically favored number of programs that guarantee you a certain number of interviews.  Apply to programs that you know have matched IMG’s over the past few years (do this by looking at the match lists published by the schools) as well as applying to programs you’re generally interested in.  If you haven’t heard from programs that you’re interested in, or are lacking in interviews, don’t be bashful.  Call coordinators, email program directors – be enthusiastic but not overbearing or demanding.  And be ready at a moment’s notice later in the interview season – spots open up during interview days – and you need to jump on them, they’re not easy to come by.  Though they are scheduled in a rush, these interviews carry just as much weight as any other and programs will appreciate your flexibility.  All that said, hedge your bets.  EM is difficult to interview for and match into.  Apply broadly for emergency medicine but also apply for other specialties you see yourself succeeding in.  If you don’t match into EM – do not rely on SOAP.  Vanishingly few (if any) international applicants in recent history have SOAPed into EM.    

The interview

Once you get interviews, you have to knock them out of the park!  Beyond having impeccable interview skills, you need to be prepared to address the awkward flamingo in the room: the IMG thing.  You have to be able to explain why you took the IMG route – and turn it into something that makes you into the applicant that they must have.  For example, if you had problems with standardized testing, you need to be able to show that it was a struggle that you overcame, emerging stronger and better prepared for having persevered.  

And finally, the rank list

From the 2014 Match data, to have an over 90% chance of matching into EM as an IMG, an applicant had to rank over ten programs. And though no number of interviews guaranteed a 100% match rate, having ten programs to rank as your goal should leave you feeling pretty safe.  When it comes time to ranking – don’t try to outsmart the algorithm.  The match is applicant-weighted.  Go with the conventional wisdom: rank based on where you want to go – there’s no trick to ranking as an IMG.  Again, hedge your bets – rank all programs (EM or otherwise) you interviewed with.  Remember, you’d rather your rank list be too long, not too short.

EM Presentations 2.0

The not-so-secret "secret" of doing well on your Emergency Medicine (EM) rotations is to be able to give patient presentations the way that your supervisors want to hear them.

We have covered this in the past in a post on "The Secret to Honors", and that advice has not changed. The best way to make a good impression is with organized and focussed presentations that include a worst-first differential diagnosis and a plan appropriate to an acute care setting.  There is even a bit of literature to back-up this approach. The 3-Minute EM presentation article has been a staple of EM clerkships for years.

Some ingenious folks at the Emergency Medicine Residency Association (EMRA) and Clerkship Directors in Emergency Medicine (CDEM) have improved upon this resource with this video on Patient Presentations.  The 10 minutes invested will undoubtedly pay off on your EM rotation.

Enjoy!

Adam Kellogg is an Associate Residency Director. When he was a Clerkship Director he gave every student a copy of the 3 Minute EM Presentation.  Some of them even read it.