Doing Time | Sameer Desai, Chris Belcher, Blake Davidson

The ACGME is planning to add a year to Emergency Medicine residency training. 

Emergency medicine stands at a crossroads.  Should EM residency training be standardized at four years?

On the show today are three Emergency Medicine residency program directors.  Together, we discuss the history of 3- vs. 4-year EM programs, the evolving demands of emergency medicine, and what a fourth year could mean for future physicians, the healthcare system, and the patients we serve. From rural workforce implications to the shifting landscape of ultrasound, addiction medicine, and EMS, we discuss the nuances of a moment of transformation in medical training.

We close the episode with a reading of Roald Dahl’s powerful and heartbreaking essay on vaccine-preventable illness, and a sobering look at the 2025 resurgence of measles and pertussis.

Sameer Desai is the program director for the EM residency at UK and was previously the associate and an assistant EM residency program director.

Chris Belcher is the associate program director for UK EM.  After residency, he spent 4 years in active duty Air Force service in San Antonio working with Air Force and Army EM residents and flying ICU and ECMO patients around the world.

Blake Davidson is an assistant program director for UK EM.  After residency, he spent a year completing an EMS fellowship in Alabama. He also serves as the Medical Director of UK Transport.

***********

If you have any feedback, show/interview recommendations, or want to collaborate on the show, please reach out!

Email: Tama.TheMDM@gmail.com

Instagram: TheMDM.podcast

Twitter: theMDMpodcast

***********

Host: Tama Thé | Pediatric Emergency Medicine
Producer: Melissa Puffenbarger | Pediatric Emergency Medicine
Communications Director: Katrianna Urrea | MD Candidate

Music: Spencer Brown

Transcript

00;00;00;00 - 00;00;22;22
Hello and welcome to the MDM, a show about the ways medicine is adapting to the modern world. I'm Tama The. Emergency medicine residency training has always been a little unique. Depending on where you go, you may have a three year or four year curriculum. That just seems weird, right? Like, if I told you in some states high school was three years, you'd say, well, that doesn't sound right.

00;00;22;25 - 00;00;41;14
Unknown
There must be some difference between graduates from a three year program versus a four year program. If not, why would anyone even do a four year program? But if so, what are those differences? Do graduates from a four year program make better clinical decisions than those who graduated from three year programs? If not, what's the advantage? Why would you do it?

00;00;41;17 - 00;01;05;12
Unknown
It seems like someone should standardize this though, right? The Academy, the accrediting body for residency programs, recently proposed that we standardize this. This would mean a monumental shift in emergency medicine residency training, moving from the traditional three year model to a standardized four year program. And at first glance, an additional year of residency seems straightforward enough, right? More training means better prepared physicians.

00;01;05;14 - 00;01;32;25
Unknown
But as with most things, it's so much more complicated than that. The proposal highlights several reasons for this extension. Fewer patient encounters due to shorter shifts and tighter workout restrictions. A declining board exam pass rate in an increasingly complex curriculum. But each year of additional residency carries real and tangible costs for residents. It means another year of lower pay, accumulating interest on your medical school debt and postponing their career advancement and financial independence.

00;01;32;28 - 00;01;56;12
Unknown
And for residency programs, especially smaller ones, it could mean significant resource challenges. And for the health care system, it could potentially worsen physician shortages, especially in rural and underserved areas. So today, to unpack this complex issue, I'm joined by three of our emergency residency program directors here at the University of Kentucky. Samir Desai is the program director for emergency medicine residency here at UK.

00;01;56;18 - 00;02;18;25
Unknown
Before that, he was the associate program director and before that the assistant program director. So he has been in this position for long enough to see many changes in the way that we teach residents. Chris Belcher is our associate program director. After graduating in residency, he spent four years in active duty Air Force service in San Antonio, working with Air Force and Army residents, flying ICU and chemo patients around the world.

00;02;18;27 - 00;02;36;29
Unknown
And finally, Blake Davidson is one of our assistant program directors. He spent a year doing an EMS fellowship in Alabama and is also currently the medical director of UK transport. Each of them brings their unique perspectives in years of experience to help us navigate what might just be one of the most significant changes in emergency medicine training in decades.

00;02;37;01 - 00;02;47;00
Unknown
So welcome to season three, episode one of the MDM doing Time the Future of Emergency Medicine residency.

00;02;47;02 - 00;03;16;29
Unknown
Welcome, Samir Desai, Chris Belcher and Blake Davidson. I want to hear your opinions. When you have a student who's applying for your program and you have that conversation about what kind of program do you want to go to a 3 or 4 year program? How do you usually have that conversation with them before this projected change? The first thing I usually like to hear is what their goals for after residency are going to be, you know, whether they have a strong desire to be in academics, a certainty that they want to do community medicine, working, an underserved community, a rural area.

00;03;17;00 - 00;03;38;28
Unknown
There's so many variations of emergency medicine, and if they are very sure of what they want to do, then that can kind of help guide the conversation. Also, if they have specific interests, such as certain subspecialties within emergency medicine, that can really make a big difference in kind of how I would advise that student. What has been the general consensus about the length of training?

00;03;39;01 - 00;03;55;24
Unknown
Is there that tension amongst program directors or in general, is it the program directors at three years are comfortable with the three years in. Those who are at four years are comfortable with the four. I think to preface that we should all say that we trained at three year programs, all of us. And so I think as this debate has come up.

00;03;55;25 - 00;04;16;24
Unknown
You've had some very strong feelings, like when we went to the council residency directors, there were three year program directors who came up and were very emotional, very passionate about the three year programs, and that they can crank out emergency medicine physicians that are super competent after three years. And there were four year programs who were very happy with this.

00;04;16;26 - 00;04;44;29
Unknown
And so I think you're getting impassioned discussion and debate from both sides. And coming from three year programs, we feel that we can make a competent emergency physician in three years, but we can also do better, I think, which is the argument that this again, many task group is, is making, and that 20 years from now, what is going to be expected from an emergency medicine physician, because things have changed even in the last ten years since I've been in residency.

00;04;45;02 - 00;05;08;09
Unknown
And what do we need to do to prepare our emergency medicine residents to practice in the future? I think is the whole crux of this. It's less about like three years versus four years. It's like, what do we need to make these successful emergency medicine physicians who are going to have long, fruitful careers? What does 20 years from now look like compared to now?

00;05;08;11 - 00;05;29;11
Unknown
Even since I've come out of residency, I think we all have noticed that we are doing more in the emergency department. We're doing more of the inpatient workups that that used to happen. It's getting harder to admit patients to the hospital. We have more boarding issues. It's getting harder to transfer patients. And so I think we need to know more, unfortunately.

00;05;29;11 - 00;05;50;18
Unknown
And that's that's just the way that emergency medicine is heading. The boarding issue seems kind of like a big deal for ended the show. Chris Nash had thought that one of the reasons that we're not seeing as many patients is because, you know, on a typical shift, if you if half of your patients are boarders, then you don't get those differentials in the workups and you have more people, you know, patients waiting for inpatient admission.

00;05;50;21 - 00;06;12;03
Unknown
What's your opinion on seeing fewer patients? Is that borne out in the data? Do you are you able to track that? Objectively, I've been tracking our residents volumes over the last 3 or 4 years, and there has been a slight downward trend in the total volume. And I think the way I want to first clarify that is it's not that I think our residents are working less hard.

00;06;12;08 - 00;06;34;00
Unknown
I think they're being asked to see less patients but do more for those patients. So the boarding is sort of indirect. It's not that, you know, if we didn't have boarders, the residents would see more patients that have more touches, which is I do think the residents need in general, more touches. But it's not that they're not doing enough as it is, it's that they're being asked to do so much for the ones that they see.

00;06;34;00 - 00;06;56;11
Unknown
And so what used to be a quick decision of, okay, I've just intubated someone, I'm calling the ICU. They're gone. Is now, you know, I'm intubating someone, I'm putting in a line, I'm getting MRI's, I'm calling three different consultants. I'm doing a lot of the first 24 hours of that patient's care while they're still in the E.D.. And so our residents are just doing so much more on those patients.

00;06;56;11 - 00;07;21;15
Unknown
And so that's helpful and valuable in the end of it. The total volume of patients that they've seen, the total conversations they've had with different patients is actually less. If you're looking for a number specifically, you know, I looked at this last graduating class and I would say our residents averaged about 4500 patients. I would say 10 or 15 years ago, that number was probably at least a thousand patients more.

00;07;21;17 - 00;07;41;12
Unknown
It would be interesting, you know, thinking about that data about how the residents are now taking care of patients longer will be interesting to me is and I don't know if you could do this, is to see how many patient hours they're accruing. You know, like if if a patient used to be down there for two hours and now they're down there for 24, their patient hours may have gone up while your actual patients have gone down.

00;07;41;14 - 00;08;00;16
Unknown
But I imagine that study is going to be really difficult. What do you think is the fundamental argument? Why has pushed come to shove now? Why are we needed to standardize it now? Let's review every like ten years or so about where are we at as a specialty? Where are we at? Do we need to change what we're doing as as a specialty in our requirements?

00;08;00;16 - 00;08;19;08
Unknown
And so I think that that's kind of what brought all of this up and looking for like, how do we want to grow our specialty. And I think that that's the biggest opportunity for me. And all of this is for me as someone that does a lot of event medicine or out of hospital medicine, how can we grow that into part of our field and make this is like emergency.

00;08;19;08 - 00;08;41;14
Unknown
Physicians are very versatile. If we get four years, how can we expand our residents exposure to these subspecialties and make us more valuable as physicians overall? Have you thought about if we do go to four years, how you all would do that? We've had some talks, and I think that a little bit of it goes into exploring those fields of addiction medicine and more focus on EMS or disaster medicine.

00;08;41;16 - 00;09;01;06
Unknown
We're looking more into like low acuity patients, because I think that that's one of the other things about when you talk about patient volumes is that our numbers have gone down, but the complexity of the patients that we're seeing have gone up. And so, you know, a lot of these lower acuity patients that we're seeing are seen by the attending physicians and Pas, and not necessarily by the presidents all the time.

00;09;01;06 - 00;09;18;01
Unknown
And so how do we incorporate residents into seeing those low acuity patients that takes into becoming a good community physician? And so incorporating that a little bit more into the curriculum, along with like our toxicology rotations and things that we can kind of emphasize a little bit more time in and giving the residents more of a varied experience.

00;09;18;03 - 00;09;40;15
Unknown
Gotcha. Chris, earlier you mentioned that when you were at the program director conference that there were a lot of very passionate people on the three year side making arguments. What were some of those arguments? I think the argument, in particular that they brought up is there was a study a few years back that looked at board pass rates and things for three year versus four year programs, and there was no difference.

00;09;40;15 - 00;10;00;03
Unknown
And so they wanted data to back up these changes. And it's just not there because this task force has planned the emergency medicine of the future. So that was their argument. And right. It's also a financial argument, both from the resident perspective and from a GMI perspective, because it takes a lot of money to train a resident.

00;10;00;06 - 00;10;18;08
Unknown
And where are we going to get that money from, to have another year? And so there's a lot of people that are going to have to shrink their programs or in some cases, programs may go away because of these changes. And so that's a that's a real potential issue and an argument that, these three year proponents have have made.

00;10;18;13 - 00;10;43;09
Unknown
And I think it's a valid argument. Right? That is a year of a person's life where their loans are occurring, interests. They are not making money as an attending. They're just, you know, they're delaying their attending salary for another year. And, also from a GMI standpoint, we have a very limited amount of funds. And those funds may continue to shrink, unfortunately, with with a lot of changes that are coming.

00;10;43;11 - 00;11;01;12
Unknown
So we have to be very cognizant of the fact that this is going to be tough on both sides. And into that last point about funding from GMI. I used to know the subtleties of this, but isn't it like residencies get paid for for three years and then after that, if it's an additional year, then they only get covered like 50% and resent.

00;11;01;12 - 00;11;22;05
Unknown
Is that a thing? It's very complicated. Yeah. They they did a presentation on this, on the finances of it. And it was, it was a very heated argument. In short, with emergency medicine, it's even more complicated because there are three year programs in their four year programs. And so some of that fourth year is funded from a federal standpoint, and some of it isn't.

00;11;22;08 - 00;11;41;14
Unknown
If it was to become the standard, it would all be funded. Is is the way they phrased it. But, it is very complicated. Yeah. To your point about data, but that's a big one. No. Like if you show me that board scores are the same and there's no significant decrease in your clinical acumen, boy, that's a hard pill to swallow.

00;11;41;14 - 00;12;00;24
Unknown
To now say all of your residents are going to four years. Just thinking financially is looking at the numbers. You know, most residents have something like $200,000 worth of debt, you know, from undergrad, medical school. And then it starts to accumulate. The second that you graduate for medical school, there are some things around a pslf and some like loan repayment.

00;12;00;26 - 00;12;22;08
Unknown
But in general, the clock is ticking. And so you're talking about interest on $200,000 worth of loans, a resident salary, which is I've never heard of anyone greater than like $70,000. And so like, that's probably the upper limit. And then, you know, the difference between an attending salary and a resident salary at some places could be up to like $500,000.

00;12;22;13 - 00;12;41;12
Unknown
And so, you know, when you're talking about just like purely the numbers of years that you're going to work, unless you choose to continue to work an additional year, then you're you're essentially losing what's on the order of $500,000, plus whatever interest that you're running on. And then on top of that, it's the missed opportunity cost of all of that money that you could have had in the market.

00;12;41;12 - 00;13;10;03
Unknown
And so, I mean, to your point about the financial difference one year, I think people poop, poop. But $500,000 is yeah, it's a very reasonable argument. And I think that it's one that would be something that students are going to have to think about and consider now. But I also think that the medical students that are coming into the specialty know that I'm speaking to someone who did a fellowship, as someone who did a fellowship, everybody that you talk about that didn't do a fellowship is like, why would you waste that year of money and income?

00;13;10;03 - 00;13;28;28
Unknown
Right? And it was an intentional decision to not make an attending salary for a year, to do an extra year of training in order to be able to market myself in a different manner and get into a different field that I wanted to get into. Yeah, yeah. These are all proposed changes, right now, so that's always good to put out there to the medical students and the residents.

00;13;29;04 - 00;13;46;29
Unknown
And it doesn't affect any of the current residents either, which is also that there's a lot of misinformation out there about that. And so the ones that this would affect would be currently, I think, in twos. And so they kind of know what they're getting into and they're a little undifferentiated for the most part. Like they haven't even started clinical years and things like that.

00;13;47;02 - 00;14;12;16
Unknown
So I think that's helpful, to make it an easier pill to swallow. But it you're right. It is a it is a lot of money, a year of your life. So our program has something on the order of, like 13 residents per year. And so over a three year program, that's 40 some odd residents. Do you expect that if we switch to a four year that we're we're going to add another cohort of 13, or how are you going to balance the number of residents we have?

00;14;12;19 - 00;14;31;04
Unknown
You know, the first thing is, the Academy has come out with the calculation that they require program directors to do to determine, you know, how much volume they have per resident and not just in the emergency department, but in the pediatric emergency department, the ICU patients. So I think the first step would be to actually do that calculation.

00;14;31;05 - 00;14;57;03
Unknown
See, what could we actually, justify and, you know, based on their calculations, my first gut feeling is that we would probably go down from 13 to a slightly smaller number, either 12 or 11 or something in that range. And so we'd slightly expand or perhaps even go down to ten and then basically be about the same number of residents, that we currently have just spread out over four years instead of three.

00;14;57;06 - 00;15;18;21
Unknown
Gotcha. So if that becomes a trend where residency programs around the country contract a little bit, to me that means that there's going to be fewer supply positions in emergency medicine, which can make it more difficult for for students. But at the same time, you can make the argument that you hear about people worrying that this is going to push students away from applying to emergency medicine.

00;15;18;23 - 00;15;40;16
Unknown
What's been really interesting is every time I bring this topic up around the residents, their knee jerk reaction is to talk about the finances of it in that they're going to lose a year of salary, what they think, what they don't think about. And this wasn't the intent of the task force. It's going to decrease the overall amount of emergency medicine trained attendings.

00;15;40;18 - 00;16;04;19
Unknown
And so in the long run, this could potentially increase their salary over time because there is less of them out there. And so I try to explain that to them. It doesn't always work, but their initial knee jerk reaction is always the finances. And then we bring it back around to the curriculum. And what other potential experiences they may have and what further training they could get.

00;16;04;19 - 00;16;27;08
Unknown
Because if you think about it, we did not do addiction medicine when I was a resident, and now we're prescribing Suboxone and even injectable long term medications for substance use disorder from the emergency department. That is not anything I had any training on as a resident, and now it's just standard of care. And so they're going to be prepared to do that.

00;16;27;15 - 00;16;44;29
Unknown
If we have a new curriculum that covers that. And I think that's really cool. And it's very forward thinking of the task force. That's really awesome. We are recording this on the day that you all just had a conversation with the residents. What was some of the other feedback that they gave you or other thoughts that they had?

00;16;45;01 - 00;17;06;21
Unknown
We talked about the number of emergency physicians out in the field, and then we talked about how more states are requiring imported physicians to staff emergency departments. 24 over seven, and how the reduction in physicians may impact the availability of emergency physicians in those communities and would of require them to shut down or not have providers to be able to take care of what they need.

00;17;06;28 - 00;17;32;21
Unknown
My come back to that is, I don't necessarily think that increasing physician numbers, or changing that would really increase physicians in rural areas. I use the analogy of like tort reform. There are a lot of states that have gone pretty heavily and and tort reform overall to try and attract physicians to their state. And they do attract physicians, but they attract them to areas that are desirable, like I use Texas and for example, like, no, they went through a large tort reform.

00;17;32;21 - 00;17;52;13
Unknown
They brought a bunch of physicians in, but they went to Austin, Houston and Dallas and not necessarily rural Texas, where they were hoping to bring physicians in. So I think that that argument, while I can see the logic, I just think we need to make rural jobs more tractable, which I think if we have less physicians overall, they would increase, be able to bring more people to those areas.

00;17;52;15 - 00;18;15;27
Unknown
And one of the proposed changes is to have a low resource experience in emergency medicine, which isn't standard. We we send our residents out to a more rural site, and not for a requirement standpoint, but we just think it's a good experience for them. We have a lot of residents going to community practice, but that's going to be the standard is to have some kind of a low resource experience, which I think is great.

00;18;15;27 - 00;18;33;03
Unknown
It'll expose a lot of residents to something that they may not have otherwise seen, which is really cool. Yeah. There was also a discussion about fellowships and whether this would drive, residents, away from doing fellowship. Yeah. Which is a valid concern. And, and I think it's honestly going to be hard to tell what's going to happen.

00;18;33;06 - 00;18;58;15
Unknown
I think the people who do fellowships typically are very interested and passionate about that subspecialty. And so hopefully this in itself would not drive them from doing that fellowship. I also notice just in general, all specialties surgery, orthopedics, even the neurosurgeons, people who have long residencies, all are doing fellowships after their residency. That seems to have become kind of the standard in a lot of these long residencies.

00;18;58;17 - 00;19;18;13
Unknown
And so I think this change is not as drastic. You know, it may feel drastic within emergency medicine, but it's not drastic within medicine in itself to have a slightly longer training period. It's always been unusual to me that emergency medicine has two different tracks of two different lenses. I think you said it at the beginning. I don't think there's any other specialty that has that.

00;19;18;13 - 00;19;59;11
Unknown
You know, I think that was always kind of an unusual quirk about emergency medicine training is that their programs a different lens to begin with. Every other specialty in medicine is more than three years primary care specialties are the only ones that are three years. And so emergency medicine going to four years kind of makes sense that if you separate into the bucket of primary care versus specialties, and also perhaps being a four year residency will help justify the argument that we've always been making, that you should be a board certified emergency physician to work in the need, and that three year general physician in a from another specialty who works in an Ed, is

00;19;59;11 - 00;20;21;19
Unknown
now underqualified in many ways, now partly just from one year less of training than everyone else. Yeah, that's a great point. Another topic is, you know, there's a lot of discussion at our national meeting about the survey that was sent to program directors that didn't tell you what the survey purpose was. And as I filled out the survey asking how many weeks of talks do I think a residency is?

00;20;21;19 - 00;20;38;28
Unknown
How many weeks of ortho, how many weeks of stroke? I didn't know that they were adding it all up. Nobody did. I think the three of us sort of think that they did it the right way. But a lot of people at our national meeting felt very tricked and that they were lied to. You asked me a question, but I didn't know what your goal was.

00;20;39;00 - 00;20;58;06
Unknown
It was about like the biggest argument said. They were just very offended. They felt duped. I think it was. They use that survey data to basically justify the number that they came to for the number of months. And so they had their number that they came to. They had this number that the program directors independently came to, and then they put it together.

00;20;58;06 - 00;21;14;16
Unknown
But nobody knew that this was going to be used for that purpose. I mean, it is sneaky. It is variously it is, but I think that's the only way that you get an honest answer. You know, looking at it from a research perspective, that's what you want people to give their honest opinion. And realistically that came out to 42 months.

00;21;14;16 - 00;21;34;13
Unknown
To your point, if you're asking me how much time do you need to learn a specific subject? And then if you take that information and add it all together, it's a good argument. I do think that they got the most honest answer by asking it that way. It does seem weird that we're arbitrarily adding 12 months. If truly the consensus was 42 months.

00;21;34;13 - 00;21;56;28
Unknown
It does seem strange that just because of the typical way that we do academic year training, that we're artificially making it an additional six months, and there's probably some finances involved as well. You know, one thing that that was factored in is 36 month residency is really 33 months. Three months of vacation and a 48 month residency is really 44 months with four months of vacation.

00;21;57;01 - 00;22;12;29
Unknown
It's a great point, Chris. You said that there were probably some finances involved there. Yeah, it would be incredibly difficult to fund 3.5 years. That'd be really hard to justify on paper. You know, one of the things that I always think about a couple months ago, I talked to some of the residents at the University of Buffalo who went on strike.

00;22;13;05 - 00;22;33;17
Unknown
They felt like they were being exploited by this major health care system. You know, that the residents weren't actually employed by the university they were working for. They were employed by the health care system. And so the health care system had no incentive to make their lives any better. They had no incentive to give them more time off, because they knew that these guys were there for three years, and then they moved on.

00;22;33;22 - 00;22;54;08
Unknown
Right. And so they could milk every little bit of strength and humanity out of these residents. And so to your point about finances, it always does make me a little bit nervous about who is making these decisions. And there is a little bit of a conversation online, and I don't know how much to believe it, but there's a little bit of a conversation about now that they have residents for four years.

00;22;54;08 - 00;23;17;13
Unknown
And on top of that, the fourth year residents are very good. Then the health care systems are going to not need to pay as many attending physicians that they have essentially indentured servitude for a little bit longer. The counter side of that is the rural hospitals who are now going to need to find Em physicians who might be a little bit more expensive because they're going to be better trained.

00;23;17;15 - 00;23;40;27
Unknown
Those guys are going to be hurt. And so it seems like there's somewhat of an exacerbation of the underlying disparity between the very well-resourced places, like in this case, our university hospitals and those that are very not well resourced. Has there been any conversation about, like the health care finance side of this thing or the kind of the health care systems perspective?

00;23;40;29 - 00;24;05;18
Unknown
I love a good conspiracy to throw at least a no objective way or evidence two way can I tell that a bunch of big universities or administrators came together and influenced me to make this decision for some other, you know, secondary gain that they would have? What about the other side? Do you have more either thoughts or data about what the rural, the underserved situation is going to be like?

00;24;05;24 - 00;24;22;19
Unknown
Is this just an argument that people throw out there to try to to keep things at the status quo, or is there actually, you know, there's a trend right now where emergency departments are starting to close and not starting to close. This has been going on for for ten some years. And is this going to be fuel on that fire?

00;24;22;25 - 00;24;47;09
Unknown
Is it going to be harder for them to staff their ERS? Has there been an analysis of that? Not to my knowledge, and I'm aware of from a finance standpoint. But again from like finding physicians, like I said earlier, I don't necessarily think that the change in numbers, whether it be if we were to increase residences by like we I mean, what we've done in the past ten years as a specialty is increase the number of, residences nationwide.

00;24;47;12 - 00;25;12;23
Unknown
And we still have a rural health problem. Right. So I don't think that changing the number of physicians in the pool necessarily equates to more or less physicians in those fields. And it all comes down to my opinion that people have to have an interest to be able to want to go to work out there, and we have to make it more enticing for those physicians to be able to go out there and give them the resources available to be able to do their job appropriately.

00;25;12;25 - 00;25;37;19
Unknown
In the task force that was put together specifically, even mentioned this, that they are not equating supply and demand into this proposed curriculum change. They're just looking at what does it take to be a competent emergency medicine physician, and how do we get there? They're not even thinking about all of those other things. Yeah, yeah, yeah. That's well, I don't pack.

00;25;37;22 - 00;26;01;28
Unknown
Yeah. It's super awesome. What are the other arguments that you'll see online is that, that a four year residency will give residents longer time to do more sophisticated academic work, and that other people will push back and say, show me the data, and that there's not a lot of data that shows that an average fourth year resident has put out any more, like nature or Jama papers, than the average three year graduate.

00;26;02;00 - 00;26;19;14
Unknown
What's your opinion on that argument? Whether or not the importance of academic work is going to increase or not in should it increase or not? I don't think it's going to increase, to be honest. You know, I think there are certain residencies that are a little bit more geared towards research. And those residencies will continue to do so and hopefully, maybe even better research.

00;26;19;20 - 00;26;44;14
Unknown
And then the residencies that are not as research heavy will continue to not be research heavy. There was a requirement in the proposed changes to have an administration experience. And so I think you could bundle QE, I think, into that. And so I think residents could potentially get a more robust taste of administration and quality improvement through some of these changes and just having longer term projects, maybe.

00;26;44;16 - 00;27;05;11
Unknown
But people who are interested in research kind of self-select and get themselves involved in projects. And I'm not sure that having four years versus three years is going to change that all that much is so far, the things that you guys have brought up about additional elements of the curriculum. You've talked about addiction medicine, some kind of low resource medicine exposure.

00;27;05;14 - 00;27;37;18
Unknown
We talked about ultrasound. You talked about critical care. We talked about kind of borders. And now we're starting to bleed into inpatient medicine. What are some of the other reasons that people argue for expanding the curriculum? Yeah, I think observation medicine. The other one that comes to mind that as far as, you know, specifics. But I think the idea of giving residents more elective time, I think every institution has 1 or 2 things that they do that are very unique and might be the reason that students even come to that program, that they then don't get to experience that much because of limited time of residency.

00;27;37;20 - 00;28;07;24
Unknown
And in some earlier you were talking about fellowships, I did a year of ultrasound training, mostly because I did pediatrics, and we just didn't touch an ultrasound at all throughout my residency. But typically to people who do ultrasound fellowships are, in the past, people who were very enthusiastic about ultrasound and wanted to run an ultrasound program. And so kind of heavily weighted in the fellowship is the administrative side of things, almost more than the actual learning your ultrasound techniques in.

00;28;07;27 - 00;28;31;13
Unknown
That's only gotten, I think, more obviously different as time has gone on now that people are much more comfortable with ultrasound, to be honest, you could probably make the argument, and I'm not going to make it because I don't want angry emails. But some could make the argument that a typical residency training today regarding ultrasound technique is probably at least as good as as the ultrasound fellowship was ten years ago.

00;28;31;17 - 00;28;51;11
Unknown
So to your point about, are we going to see a decrease in the number of people doing fellowship? I think we had already seen a general trend in decreasing, at least in the ultrasound world. So I wonder if it's really even a bad thing, you know, so Su's thinking about ultrasound fellowship specifically with this recommendation to increase the length of training of emergency medicine.

00;28;51;11 - 00;29;11;10
Unknown
They also included some language that specifically affected the way that we perform and consider and document ultrasound in the emergency department. What are some opinions of that? Yeah. So our current situation is that we have a certain number of ultrasounds that we do during your residency years. You have to document them. You have to log them. We track that right.

00;29;11;12 - 00;29;37;27
Unknown
The new recommendations were that you don't necessarily have to do that because it's so ingrained into emergency medicine, ultrasound. That is just a part of the care that you provide at the bedside. It's so ingrained in how we take care of patients that we don't necessarily have to log that. We think that most emergency medicine residents are getting great training in ultrasound, because it's so ingrained into our culture now, that was interpreted as a myth, right?

00;29;37;27 - 00;29;59;06
Unknown
That they didn't want people to get as robust of an ultrasound training. And I don't think that's what they meant at all. And it meant, as a sign of respect to the ultrasound world, that they've done such a good job of ingraining it into emergency medicine training. But the academy task force kind of apologize that it was, you know, assumed to to be taken as a myth.

00;29;59;09 - 00;30;28;15
Unknown
And I think their plan is to add those back in in some way to hopefully satisfy the outside community, but also quantify this number of exactly what should be expected. As a program director, I don't have any problem with them quantifying that. I think I know our program does an excellent job training ultrasound, and I think most programs do, but this is another test of programs to be able to prove that they are worthy, to be a program that they can teach the other necessary, ultrasound requirements.

00;30;28;17 - 00;30;55;25
Unknown
I know it's going to be years down the road before this decision is even brought into practice, but what would success look like to you, having transitioned after never having a four year program right now in emergency medicine, we are we are not very competitive. It's not a competitive specialty. Currently. If you look at our trends for unmatched spots, it went from 500 a couple of years ago to 150, 160 to 60 ish this year.

00;30;55;25 - 00;31;18;12
Unknown
So it's getting better, right? I think these changes are going to get people in emergency medicine who are actually interested, who want to do this. It's not just a backup specialty for anesthesia or something like that. It's not just an easy three years to get a paycheck. These are going to be people who are legitimately interested in the field, are legitimately interested in the subspecialties that it can offer.

00;31;18;19 - 00;31;36;06
Unknown
There will be more fellowship trained people in emergency medicine, I think 20 years from now, and there are going to be people who don't get burned out quite as easily because they are so invested that they were willing to do for years. Instead of doing three years. And so I think long term, this is great for the specialty.

00;31;36;06 - 00;31;55;04
Unknown
I think this may keep people around who would otherwise have had a very short career. That's what success looks like to me. It's people who want to be here, who want to advance the specialty and make it better. As opposed to just clocking and clocking out, getting a paycheck, if you don't mind, give me the argument. Let's say that I'm a medical student.

00;31;55;06 - 00;32;14;28
Unknown
Give me the argument for why this is a good thing. Let's say that I was on the fence between doing internal medicine or emergency medicine, or maybe doing surgery or emergency medicine, and now emergency medicine is going to increase the training, decrease the time before I get my salary, etc., etc.. What's the argument to the student to say that this is actually a good thing for you?

00;32;15;00 - 00;32;53;15
Unknown
For me, I think we really need to hone in to what we can do. More toxicology exposure or more disaster medicine exposure or EMS exposure, and really be able to hone in to we don't just work in the department, right. What encompasses the available city of emergency medicine physicians and what opportunities you may have as an emergency medicine physician after this type of training, and really to be able to to focus on the wide scope of practice that we are hoping to be able to encompass, but also trying to emphasize that this change is going to make you more marketable overall in whatever type of lifestyle that you want to make it.

00;32;53;18 - 00;33;17;03
Unknown
When I trained in emergency medicine and then, you know, random family or other people would say, well, what can you do now? Can you open an office? I honestly felt like there is nothing I can do but work in the Ed. I did see over the last ten years, people have been breaking out of the Ed who are m trained doing some of these other things, and I think part of these changes is to really embrace that and say, these things are now within our specialty.

00;33;17;03 - 00;33;41;24
Unknown
We want to train you in them so that when you go start a addiction clinic or you decide you want to do something, you know more with disaster medicine or global medicine or other, you know, things, we have trained you for that. And you're you're qualified for it. That's awesome. Yeah. I met with a medical student yesterday who's an M one who was just meeting with me to just talk about emergency medicine, and I didn't bring it up.

00;33;41;26 - 00;33;58;20
Unknown
And he said, have you heard about the new proposed changes? And I said, yeah, what do you what do you think about that? He's like, I'm for it. And I was I was floored. And he's like, you know, it just makes sense. You guys do so much and you see so much and there's all these different areas that you can get into, like three years.

00;33;58;20 - 00;34;17;24
Unknown
Seems like a really short time to be able to figure out that you want to do one of those things. He was like prior medic, and he thinks he wants to do EMS, but he's not sure. He's very interested in like critical care and like all these different things. And I think it just gives them, you know, a breath, you know, they can think a little harder about what they want to do with their life if there's four years to do it in.

00;34;17;26 - 00;34;34;21
Unknown
And, he was all for it, which was very shocking. And, also kind of refreshing to to hear an M1 talk like that. Sameer. Chris Blake, thank you so much for for coming into the studio and having this conversation. Hopefully maybe we can check back in maybe in a couple of years and see how things are going if the decisions finally been made.

00;34;34;23 - 00;34;50;02
Unknown
Absolutely. Yeah, that'd be great. We'll come back and talk about what actually happened and, how it's going. A debrief on it. Yeah, exactly. Thank you all so much. Thank you. Those.

00;34;50;05 - 00;35;20;01
Unknown
In 1988, Roald Dahl, the author of Charlie and the Chocolate Factory, Matilda The BFG, wrote, Olivia, my eldest daughter, caught measles when she was seven years old as the illness took its usual course. I can remember reading to her often in bed and not feeling particularly alarmed about it. Then one morning, when she was well on her road to recovery, I was sitting on her bed showing her how to fashioned little animals out of colored pipe cleaners, and when it came to her turn to make one herself, I noticed that her fingers in her mind were not working together and she couldn't do anything.

00;35;20;04 - 00;35;46;05
Unknown
Are you all right? I asked her. I feel all sleepy, she said. In an hour she was unconscious. In 12 hours she was dead. The measles had turned into a terrible thing called measles encephalitis, and there was nothing the doctors could do to save her. That was 24 years ago. In 1962. But even now, if a child with measles happened to develop the same deadly reaction that Olivia did, there would still be nothing the doctors could do to help her.

00;35;46;07 - 00;36;10;05
Unknown
On the other hand, there is today something that parents can do to make sure that this sort of tragedy does not happen to a child of theirs. They can insist that their child is immunized against measles. I was unable to do that for Olivia in 1962, because in those days of reliable measles vaccine had not been discovered. Today, a good and safe vaccine is available for every family and all you have to do is ask your doctor to administer it.

00;36;10;07 - 00;36;35;11
Unknown
It is not generally accepted that measles can be a dangerous illness. Believe me, in my opinion, parents who now refuse to have their children immunized are putting the lives of those children at risk. In America, where measles immunization is compulsory. Measles, like smallpox, has been virtually wiped out here in Britain because so many parents refuse, either out of obstinacy or ignorance or fear, to allow their children to be immunized.

00;36;35;13 - 00;36;54;11
Unknown
We still have 100,000 cases of measles every year. Out of those, more than 10,000 will suffer side effects of one kind or another, and about 20 will die. Let that sink in. Every year, around 20 children will die in Britain from measles. So what about the risks that your children will run from being immunized? They are almost non-existent.

00;36;54;14 - 00;37;13;21
Unknown
In a district of around 300,000 people. There will be only one child every 250 years who will develop serious side effects from the measles vaccination. That is about 1 million to 1. I should think there would be more chance of your child choking to death on a chocolate bar than from becoming seriously ill from a measles vaccination. So what on earth are you worrying about?

00;37;13;24 - 00;37;30;20
Unknown
It really is almost a crime to allow your child to go unimmunized. The ideal time to have it done is 13 months, but it is never too late. All schoolchildren who have not yet had the measles vaccine should beg their parents to arrange for them to have one as soon as possible. Incidentally, I dedicated two of my books to Olivia.

00;37;30;27 - 00;37;50;07
Unknown
The first was James and the Giant Peach. That was when she was still alive. The second was the BFG, dedicated to her memory after she died from measles. You will see her name at the beginning of each of these books, and I know how happy she would be if only she could know that her death had helped save a good deal of illness and death, among other children.

00;37;50;10 - 00;38;14;13
Unknown
And here we are 40 years later, in February 2025, a six year old girl named Kaylee Fair died of measles in Texas. In April 2025, Daisy Hildebrand also died from measles pulmonary failure. She was eight years old. Both of them were unvaccinated. Over 500 cases of measles has been associated with this outbreak, almost all of them occurring in unvaccinated children like Kaylee and Daisy.

00;38;14;15 - 00;38;40;18
Unknown
Meanwhile, on March 27th, 2025, another infant died of pertussis in Louisiana. This was the second in six months. Despite not having a single death due to pertussis since 2018, in 2024, there were 35,000 cases of pertussis reported to the CDC. That's up from 7000 in 20 3 in 2000. In 2021, this disinformation has consequences. These children could have been protected.

00;38;40;20 - 00;39;01;09
Unknown
It's up to us to decide when it's enough. Thanks for listening to this episode of the MDM, and thanks to everyone who gave feedback on the video episode about the AI powered Husky grater that we built. We took that post down while we work on it, but it should be back up soon. We've been on the road giving presentations and lectures and panels, and I'm hoping to be able to post some of that stuff here.

00;39;01;11 - 00;39;21;21
Unknown
In the meantime, I'm super excited for the next episode where we talked to Laura of Rubel. She's an E.R. doctor who just got back from a medical trip to Ukraine. Be sure to subscribe to the show so that you don't miss it, because I have no idea when that's going to come out, but hopefully soon. This episode was produced by Melissa Puff and blogger Catriona Oria is our Director of Communications, and the music is by Spencer Brown.

00;39;21;23 - 00;39;33;17
Unknown
See you next time.