Blog | Monday, April 1, 2013

What can the unmatched seniors tell us?

After the mayhem and jubilation of celebrating a successful Match on March 15 at the Pritzker School of Medicine with our students, I went onto Twitter to follow the #match2013 hashtag to understand what the reactions were. Most were positive, but one headline caught my attention, "In record-setting 'match day,' 1,100 medical students don't find residencies."

It is true this was the largest Match because it was "all-in," programs either were in the match for all their positions (including international medical graduates [IMGs]) or they were not. Obviously, many programs put more positions up for grabs in the Match. After I reposted this article to Twitter, there were many theories and questions about who these unmatched students were and why, some of which I have tried to answer to the best of my ability below. I welcome your input as well.

Are these IMGs? This number is U.S. senior medical students who have been admitted and graduated from U.S. medical schools but now have no place to go to practice medicine.

Does this include those that entered the "scramble" now called SOAP. Technically, those that entered SOAP and were successful would have been counted as "matched" on Friday. Last year, 815 U.S. seniors went unmatched after the SOAP.

Did they choose to go into competitive specialties? We have to wait for the 2013 NRMP statistics, which will likely address this. The 2012 data show that more unmatched seniors did choose to go into competitive fields. Last year, the percentage unmatched is much higher for students applying to radiation oncology, dermatology, and competitive surgical fields, for example.

Did they go unmatched to due to poor strategy or poor academic performance? While poor strategy such as "suicide" ranking only one program is related to the risk of going unmatched, the truth is getting into residency is competitive and there are some who will not match because of poor academic performance. Some even argue that medical schools have little incentive to fail students and a portion of these students should not be graduating to begin with.

If they had gone into primary care, would they would have matched? I hear this myth that program directors in primary care fields only take (IMGs) since not enough U.S. medical graduates apply. This is due to the largely untested assumption that any U.S. senior would be preferred to an IMG. However, I personally know program directors who would definitely take a seasoned and high performing IMG over a below-average U.S. student. The reason this is important is the rationale for not lifting the GME cap is that we have 50% of certain fields filled by IMGs and those spots would naturally be filled by U.S. grads. Interestingly, many of these spots happen to be primary care driven fields. Yet, it is still unclear if U.S. seniors will displace IMGs for spots in IMG oriented residencies. It is also unclear if they will be willing to apply to programs that typically cater to IMGs, since they are often not considered as prestigious or geographically desirable to U.S. students.

Is this related to the lack of GME spots? Certainly, it is true that more effective career advising may have resulted in applicants being more strategic about their rank list and not reaching for a competitive field. However, we cannot ignore the supply/demand side of this equation. At a time when there is a shortage of physicians and a call to increase the number of physicians, the U.S. medical school system by responded to this call. New medical schools have opened. Existing medical schools have increased their enrollments. So, there are now more U.S. seniors entering the match and there will be even more in the future as new medical schools mature their entering classes to graduating students over the next four years.

Given that the supply of matched candidates includes both foreign-born IMGs and U.S.-born IMGs, there are more candidates than spots. And while many believe IMGs will be the ones that get "squeezed out" in this shortage situation, again this is an untested assumption. It is also important to recognize that IMGs often play a significant role in ensuring primary care for rural populations and underserved communities, which are often not geographically desirable by US graduates.

We are left with a fundamental question: Do we owe it to our entering medical students who successfully graduate from medical school to have a residency spot? At a time when we have a shortage of physicians and a call for medical schools to increase in size, should we not expand our residencies? Unfortunately, GME funding is on the chopping block because of the belief that too much money is being wasted on residency training. Moreover, hospitals seem less enthusiastic about expanding residencies, as it is not as much of a bargain due to caps on hours residents work, and all the other new accreditation standards for residency training.

There is a potential solution. The "Training Tomorrow's Doctors Today Act" by Reps. Aaron Schock (R-Ill.) and Allyson Schwartz (D-Pa.), and the "Resident Physician Shortage Reduction Act of 2013" sponsored by Sens. Bill Nelson (D-Fla.), Charles Schumer (D-N.Y.), and Majority Leader Harry Reid (D-Nev.) would enable training 15,000 more physicians over 5 years. Moreover, spots would be distributed to programs and specialties in critical shortages, like primary care.

Given the time that it takes to train a physician, now is the time to act to ensure we have the doctors we need for the future.

Vineet Arora, MD, is a Fellow of the American College of Physicians. She is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, and directs the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.