Advantages of a Four-year Residency.

Page 18 The California Journal of Emergency Medicine V:1,Jan-Mar 2004 A DVANTAGES OF A F OUR - YEAR R ESIDENCY Lori Weichenthal, MD, FACEP Assistant Clinical Professor UCSF-Fresno Department of Emergency Medicine Fresno, CA The debate over three-year versus four-year residency programs in emergency medicine (EM) has been raging for years. The American Board of Emergency Medicine decided that 36 months of training is all that is required to be eligible for board certification in EM. The curriculum has been set for EM residencies and core competencies have been established for residents during their training. So, if 36 months is all that is required, why spend 48 months? The answer is simple: time. Time to learn more in the controlled environment that a residency represents; time to explore particular areas of interest in EM that might be difficult to explore once residency is over; and time to gain the added maturity and confidence that is needed in the increasingly challenging world of emergency medicine. An added year of residency obviously provides more didactic teaching. Though the core curriculum can certainly be covered in three years, an extra year exposes residents to new ideas and innovations in the lecture and small group setting. This extra exposure not only gives residents the opportunity to learn more facts, but also allows them to develop better personal study skills which are so crucial when they leave residency. The added knowledge and learning skills that are gained during a four-year residency are of great importance as the fund of knowledge in the medical field continues to explode. A four-year residency also gives residents more opportunities to create and present lectures. This not only provides them the chance to see if they like this aspect of teaching, but also allows them to explore certain topics in depth. There is no better way to learn than to teach others. More important than the increased exposure to didactic instruction in the fourth year is the opportunity for more encounters with our best teachers—our patients. With each patient interaction, we learn of the varied disease presentations and how individuals respond to the same therapy differently. We learn that some patients present just as the textbooks describe but that most do not. These lessons continue outside of residency for the length of our careers. The advantage of the extra encounters during a four-year residency is that we are not alone. There is always an extra set of eyes, ears and hands—those of the attending—to assist in learning the most from each patient encounter. There is always someone to bounce ideas off of and to gain a second opinion. Once leaving residency, many of us will practice in a setting were we are the only EM physician around. We will continue to learn from our patients but the exchange of ideas with another EM physician that enriches the learning experience will be gone. With the new Residency Review Committee limits on work hours, the added exposure to patients provided by the fourth year may become even more important in the development of competent and confident EM physicians. The fourth year also allows more time to be exposed to and learn procedures. With the new requirements that residents perform a certain number of procedures prior to graduation, this added time is important. Common procedures such as central lines and chest tubes are not difficult to obtain in either three or four- year programs. More rare procedures, such as cricothyrotomies and emergency department (ED) thoracotomies, may be more difficult to experience. Some residencies use animal models or cadaver labs to provide their residents with experience in these procedures. Although such lab experiences are useful and fulfill the certification requirements, they are clearly not the same as performing the procedures on patients. Four years of residency provides added time to be supervised during these procedures in a true clinical environment.