Imagine spending most of your life preparing to be a doctor. You get straight As in high school and college. You are accepted to medical school and four years later you graduate with a Doctor of Medicine degree. Your training is not over, however. Medical school graduates must go through a residency training program, which is a requirement to practice medicine in all 50 states. Not all medical graduates will be accepted into residency. In other words, the National Resident Matching Program (Match) is a game of musical chairs, where the losers lose not only their seat but often their career.
Residency is advanced on-the-job training in a physician specialty that lasts from three to seven years depending on the area of practice. Here is the problem: there is a shortage of residencies in the United States. In many years up to 10,000 medical gradates get the bad news they failed to match to a residency. Some will try again next year, while many will never match and give up, embarking on a different career while saddled with student loans that rival a mortgage.
Today is Match Day for nearly 43,000 medical school graduates participating in the 2023 National Resident Matching Program. The Match, as it’s called, is a computer algorithm that matches medical school graduates with a residency program. The way this works is beginning in September applicants begin to explore residency programs at teaching hospitals across the United States. Medical graduates interview with program directors similar to job interviews. Applicants rank their preference of region they wish to continue their training and the specialty they hope will be their life’s work. For their part, program directors rank applicants in the order of who they prefer to hire (i.e. train). The computer algorithm processes the ranked preferences of applicants and program directors, finding the best match of applicants to programs. This would be great if only there were enough training slots for all applicants.
This year 42,952 applicants are competing for 40,375 slots. That means 2,577 students will be disappointed. Some who fail to match in 2023 will try again next year, while others will give up and never practice medicine. Many who give up have failed to match for several years. Over time that adds up to tens of thousands of medical school graduates who will never become physicians despite the growing physician shortage. It’s impossible to estimate how many medical school graduates over the past 25 years have been denied the opportunity to work as a physician in the U.S. but it’s well more than 100,000.
How did we get here? Most residency programs are funded by Medicare, while a few are funded by Medicaid and there are some state and local partnerships with teaching hospitals. Medicare froze the number of residencies it funds due to the Balance Budget Act of 1997, after the American Medical Association (AMA) convinced Congress there was going to be an oversupply of physicians. Congress, eager to cut costs, believed this ruse despite an aging population of 78 million Baby Boomers, the oldest of which were turned 50 the year residency funding was capped. This year Congress expanded residencies slightly, but is only adding 200 a year for five years.
Graduates from medical schools both domestic and abroad can participate in the match, although there is a definite bias for graduates trained in the United States. A handful of states allow medical school graduates who have not completed a residency to work temporarily under licensed physicians as assistant physicians or associate physicians. However, these are often limited to underserved areas or time limited to a handful of years before an associate physician is required to match to a residency or leave the profession.
What is needed: Due to the physician shortage Congress should consider expanding the number of residency slots it funds. Medicare could also work with states to create alternative residency arrangements, possibly with one year formal residency training and two or more years of on-the-job training in primary care or hospital settings. Medicare and states should also explore alternative ways to fund residencies. These include partnerships with the federal government, states, hospitals and even students sharing the costs for those students who are willing. States should also work to provide meaningful career opportunities for those who ultimately fail to match to a residency. Career opportunities, such as associate physician and assistant physician, should not be limited to a handful of years. Nor should states discriminate against graduates from out of state or programs apply only to selected in-state medical colleges. Years of work as an assistant or associate physician should, over time, provide credits towards full licensure.