Emergency Medicine Program Director Perceptions of Declining Qualifying Examination Pass Rates: A National Survey of Program Structure and Board Preparation Practices

Objectives In 2024, the American Board of Emergency Medicine (ABEM) Qualifying Examination (QE) first‐time pass rate declined to 82%, the lowest in recent years. We sought to describe residency program‐level structures, preparation practices, and program director (PD) perceptions of factors potentially influencing QE performance across U.S. emergency medicine (EM) residencies. Methods We conducted a national, cross‐sectional survey of EM residency PDs. The survey included twelve items (10 multiple‐choice, two free‐text) and was piloted prior to distribution. Invitations were emailed to 280 programs with two reminders. Descriptive statistics were calculated for discrete responses, and free‐text responses underwent thematic analysis. Results We analyzed 128 complete responses (46% response rate). Most responding programs were 3‐year programs (77%). Primary training sites were academic (45%), community (41%), county (13%), and other (2%). Programs were geographically distributed across the Northeast (33%), South (30%), Midwest (23%), and West (14%). Since 2019, most programs reported three or fewer total QE failures, with 15% reporting none. PDs commonly believed failures occurred immediately after graduation (69%). Thirty‐two percent perceived a recent decline in in‐training examination (ITE) performance, while 53% reported no decline. Thematic analysis of free‐text responses identified three primary PD‐perceived factors associated with declining QE pass rates: decreased competitiveness of EM as a specialty, changes in resident study habits, and concerns regarding undergraduate medical education rigor. Conclusions Across EM residencies, structured board preparation is nearly universal, yet heterogeneity between programs' educational structures exists. Responding PDs expressed concerns regarding the changing landscape of EM competitiveness, resident study habits, and UME rigor. Future work can help triangulate PD perceptions with objective outcomes and link to recently published program‐specific QE data.