Cost-of-Living and Emergency Medicine Resident Salaries: National Trends From 2021–2025

U.S. inflation approached 20% between 2021 and 2025, raising concern that residency stipends have not kept pace with rising living costs. This objective is to evaluate changes in Emergency Medicine (EM) PGY-1 salaries from 2021 to 2025 and the impact of cost-of-living (COL) on 2025 stipends across states, regions, and cities.

All ACGME-accredited EM programs were screened. Military programs and those without publicly available PGY-1 salary data were excluded. Salary information was available for 271 programs in 2025. Historical 2021 data were obtained from a prior study. Comparison of 2025 and 2021 PGY-1 salary data was possible for 197 programs due to program openings, closures, and data availability. COL indices were obtained from the Council for Community and Economic Research (C2ER) 2025 Q3 database, including 272 U.S. urban areas. Of 271 programs, 169 were in cities in the database; city-level COL values were applied. State-level COL values were applied to all programs. For the 2025-only analysis, published housing or COL stipends were added to base salary prior to COL adjustment. 2025 salaries were compared before and after COL adjustments.

Among paired programs (n=197), PGY-1 salaries increased a mean of 16.78% from 2021 to 2025 (SD 8.04; range −6.45% to 50.6%). For 2025–2026, the national mean salary was $69,095 (range $56,707–$101,200; SD $7,952). After city-level COL adjustment (n=169), the effective mean salary was $66,232 (range $33,841–$85,890; SD $8,156); 91/169 programs remained above the adjusted stipend while 78/169 fell below their original stipend. The difference ranged from −$57,673 to $25,827 (mean −$2,942, SD $12,932). State-level COL adjustment for all programs also showed reduced purchasing power and substantial regional variation.

PGY-1 EM salaries increased from 2021 to 2025 but did not keep pace with inflation. COL adjustments revealed reduced effective compensation for many residents, with almost half of city-based programs falling below their nominal stipend. These findings support integrating COL benchmarks into stipend determinations to promote financial sustainability for EM trainees.