from what i have seen, ability to do a 2nd residency hinges much more on visa status than add'l PGY years per se.
trained at a large county hospital w/ FMG-heavy IM program and highly regarded EM program. program was 2-4 so we had some later comers but few doing a 2nd residency - iirc all were US citizens. not sure if any EM residents required H1b's, only 1 i could imagine out of 80+ w/ whom i trained at any point. a few IM residents voiced interest in and/or applied to EM, can only think of 1 who was successful.
if your IM institution has an EM program, that is likely your best option, depending again heavily on how competitive the EM program is.
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EM after finishing IM
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