Despite canceled rotations and Zoom interviews, Sam felt confident about matching into a surgical subspecialty in March 2021. They had great grades and test scores, as well as plenty of research on their resume. They applied to over 60 programs and interviewed at more than a dozen. Their advisors told them they were sure to get a spot. They didn't.
"I was very surprised to get the email that I hadn't matched," they told Medscape Medical News. (Sam, not their real name, requested anonymity and the use of gender-neutral pronouns.) "I had put trust in advisors and put trust in the educational system, because I had done really well." Ultimately, Sam decided not to scramble for a spot and deferred graduation to try again for the specialty of their choice next year.
Although many have begun to call out the stigma associated with going unmatched, it remains one of the biggest fears among med students. There is also a huge financial consideration, inasmuch as most have taken on massive educational debt. Although a delay in acquiring a regular salary is certainly a problem, that concern is amplified for those who find themselves chronically unmatched.
Those US citizens who are educated overseas face comparatively low match rates along with their student debt. Compounding all of this is the fact that the Association of American Medical Colleges (AAMC) warns of a physician shortage in the next decade, making the idea of doctors being unable to practice counterintuitive.
"I think it's a real problem, and I think it deserves more attention," says Bryan Carmody, MD, associate professor at Eastern Virginia Medical School and a pediatric nephrologist at Children's Hospital of The King's Daughters, in Norfolk, Virginia. "It's a horrendous waste of human capital."
The roots and scope of the problem are complex. Even defining the "crisis" is difficult. If the question is whether fewer US MD seniors are matching every year, the short answer is no. With roughly the same numbers of doctors matching each residency application cycle, it's the dynamics that are shifting.
The issue of who isn't matching and why has been chronically understudied and underexplained. And experts say that simply increasing the number of residency positions likely can't solve the problem.
The Math of the Match
In 2021, slightly more than 38,000 positions were offered in the National Residency Matching Program (NRMP) ― the most in the program's history. A little over 35,000 were for first-year residents. About 42,500 registered applicants submitted rank lists. This number includes fourth-year medical students at US MD and DO medical schools, US citizens who attended medical school abroad (international medical graduates [US IMGs]), and non-US citizens who attended medical school outside the United States (non-US IMGs).
As has always been the case, US MD seniors and US DO seniors fared best. Of the more than 19,800 US MD seniors who submitted match lists, about 18,400 matched. Of the nearly 7100 US DO seniors who submitted rank lists, around 6300 matched. All told, this means around 2000 US MDs and DOs went unmatched this year. That number doesn't include the hundreds who withdrew their applications or did not submit rank lists.
In terms of other candidates, slightly fewer than 5300 US IMGs applied. About 3150 matched into first-year residency spots. Nearly 8000 non-US IMGs submitted rank lists. Only about 4300 of them matched into PGY-1 positions. That means nearly 6000 IMG applicants went unmatched, again not including the several thousand who didn't submit rank lists or withdrew.
Among those who had graduated from medical school prior to 2021 (ie, those who had been eligible for a previous Match cycle), more than 1600 applied. Only about half of those candidates matched. Results were similar for DO graduates from years prior to 2021: Around 600 applied, and only 270 matched.
The NRMP is primarily concerned with applicants who do match, not how many are ultimately unsuccessful and move on to other careers or default on loans, says Carmody. "There is no census for the unmatched," no database keeping track of who doesn't match year over year and why, says Carmody, who has written about this topic extensively on his medical education blog.
It would be really helpful, for example, to know the demographic breakdown of just who is going unmatched, says Helen Kang Morgan, MD, clinical associate professor of obstetrics and gynecology at the University of Michigan, in Ann Arbor. Morgan researches medical student transitions and resident well-being and has written about the match process. She says program directors and researchers don't have access to that information from the NRMP or the Electronic Residency Application Service (ERAS).
An important missing piece is seeing who applies through ERAS for a specialty but then doesn't register for the match through NRMP. Without that kind of granular data, experts say, it's nearly impossible to know the scope of the problem in the first place.
Application Tidal Wave to Blame?
Why do some US MDs go unmatched? Although there aren't enough data to draw sweeping conclusions, dynamics of the match process and pressure to pursue the most competitive specialties likely play the biggest roles.
In 2010, an Association of American Medical Colleges (AAMC) study that was published in JAMA identified the top reasons for students going unmatched. These included the applicant's not being a strong candidate in his or her first-choice specialty, United States Medical Licensing Examination (USMLE) test score problems, or rank order list mismanagement. Geoffrey H. Young, PhD, senior director of student affairs and programs at AAMC, says that more applicants are now competing for each spot.
The increased competition, in part, is due to applicants applying to more places. For example, 10 years ago, each ob/gyn applicant applied to an average of 20 programs; in 2021, the average was 71, says Morgan. Although plenty of positions are available for US MDs, fewer are matching into their top-choice programs. In 2021, 43% matched into their first choice, the lowest rate on record; the highest segment ever (26%) matched into their fourth or lower choice.
The application tidal wave has made program directors more reliant on filters to sort through the applications, which could hurt otherwise competitive applicants who score below a certain USMLE threshold or who are sorted out on the basis of year of graduation, Morgan notes. There's a preference among programs for applicants who recently completed their undergraduate medical education, as well as an assumption that if someone didn't match the year of their graduation, there must be a reason, says Carmody.
These filters can also introduce biases based on race, gender, and other factors, says Morgan. A 2020 study published in Health Science Reports, for example, found that underrepresented minorities in medicine (URiM) applicants had lower average USMLE Step 1 scores than non-UriM applicants, raising the possibility that using Step scores as a filter for initial recruitment would target those applicants.
Nevertheless, there are more positions each year than there are graduating US MD seniors, says Tania Jenkins, PhD, a sociologist at the University of North Carolina at Chapel Hill and author of the book Doctors' Orders: The Making of Status Hierarchies in an Elite Profession. Match rates for this group have remained between 92% and 95% for decades, she notes. The match rate for this group in 2021 was 92.8%.
The narrative about insufficient residency spots for US MDs may persist because there are a limited number of very prestigious and very desirable positions available, and the pressure to snag one of those has increased, says Jenkins.
There's a lot of social pressure to pursue programs and specialties with the highest compensation, best lifestyle considerations, and other factors, says Jenkins. "There's this increasing drive among medical students to get as much out of that education as possible," Jenkins says. In her research of internal medicine, Jenkins also found that US MDs received explicit guidance from mentors to pursue more prestigious programs.
As Carmody wrote on Twitter, his theory is that as the number of applications per applicant skyrockets, the "residency selection marketplace" gets congested, making it harder for programs and applicants to figure out if the other party is really interested in them. The result is a more chaotic process for programs and applicants alike, he says.
The US Citizens Left Behind
After digging into the data, Carmody is particularly worried about US citizens who go to medical school overseas. The match rate for this group in 2021 was 59.5%, relatively consistent with the rate for the past 4 years (between 54.8% and 61%). Carmody says this percentage is overly optimistic because it doesn't include US IMG physicians who were not "active applicants" who had participated in at least one interview and who had submitted a rank order list. According to the 2021 NRMP data, more than 700 US IMGs in the 2021 match withdrew their applications, and around 1400 did not submit a rank list; therefore, they were not considered active.
US IMGs struggle to match for several reasons. Many students choose to go to medical school in the Caribbean ― a popular location for US IMGs, with dozens of medical schools ― because they fear they won't get into an MD or DO school in the United States or they failed to get in. Thus, many residency programs view them as if they're not as competitive, says Carmody. There can also be a belief that having too many graduates from Caribbean medical schools could diminish a program's prestige, he says, citing Jenkins' book.
Structural reasons also contribute. US IMGs tend to have lower USMLE test scores than US MDs. In 2020, the average Step 1 score for US IMGs who matched was 223; the average score for US MD seniors who matched was 234, according to two reports from the NRMP. It can also be harder for US IMGs to access research opportunities or to acquire letters of recommendation from well-known mentors, Carmody says. "Basically, any metric that is commonly used to discriminate among applicants systematically works against US IMGs," he said.
It's important to keep in mind that these factors are specific to US IMGs and do not necessarily apply to all IMGs. For example, in 2020, the Step 1 scores of non-US IMGs who matched to US residency programs were comparable to those of US medical students.
Many US IMGs attend for-profit medical schools in the Caribbean or elsewhere and have few options if they don't match in the United States, Carmody further explains. Many of those students are also taking on federal US loans that they likely have little hope of paying back if they don't match. In contrast, non-US IMGs may have training or practice opportunities in their home countries, he notes.
Privately owned, for-profit medical schools have become a growth industry in the past 20 years in the Caribbean and elsewhere, says William Pinsky, MD, FAAP, FACC, president and chief executive officer of the Educational Commission for Foreign Medical Graduates. "We are concerned about how many of these medical schools treat their students in terms of the cost, accepting them, and then the students are unable to successfully complete the school curriculum and pass the USMLE and yet have incurred a lot of debt for their tuition," says Pinsky.
The Search for Solutions
Organizations such as the AAMC continue to argue that increasing the number of federally funded residency positions could, in theory, address two problems at once: the projected physician shortage, and the number of physicians who go unmatched.
Medical schools have started to expand their classes to be able to fill the shortage, and residency positions need to expand as well to accommodate them, says Janis Orlowski, MD, chief healthcare officer at AAMC. "We want to make sure we have enough slots for those medical school graduates most qualified to become resident physicians to address our workforce needs," she says.
Several unmatched physician advocacy and awareness groups, such as Unmatched and Unemployed Doctors of America (UAUDOA) and Doctors Without Jobs (DWJ), have sprung up in recent years and have aggressively promoted the need for more residency positions. DWJ is a project of the organization Progressives for Immigration Reform (PFIR), which describes itself as "seeking to educate the public on the unintended consequences of mass migration."
Kevin Lynn, executive director of PFIR, says limiting the number of foreign-trained physicians coming into the United States could be a solution to the unmatched doctor crisis. The Southern Poverty Law Center has labeled PFIR an anti-immigration group that has ties to a network of anti-immigration organizations, as described in a recent Kaiser Health News investigation. UAUDOA says immigration reform is not part of their agenda and it is not a part of DWJ, although the two organizations have worked together in the past.
In opposition to DWJ's mission, data suggest IMGs are not shutting US citizens out of residency spots in meaningful numbers. For example, in the top five specialties where US MDs went unmatched most frequently in 2020 — neurosurgery, vascular surgery, otolaryngology, orthopedic surgery, and plastic surgery — more than 80% of those precious few spots were filled by US MDs, says Jenkins. These are also the only specialties where there are more US MD applicants than positions available, she says. In orthopedics and otolaryngology, for example, only 1.4% of the spots were filled by IMGs (both US and non-US citizens) in 2020, Jenkins notes.
IMGs, on the other hand, are more numerous in specialties such as family medicine, in which there's a great need, as well as less prestige and lower salaries, says Awad Ahmed, MD, radiation oncologist at MultiCare in Tacoma, Washington, and co-author of a 2018 study about IMGs in graduate medical education and the physician workforce. Jenkins has also found that although US MDs don't receive official priority in the match, they benefit from a preference for US-trained physicians. "All things being equal, a program will be typically more likely to choose an American-trained graduate compared to an IMG-trained graduate," says Ahmed.
At the end of the day, simply increasing residency slots "is not a long-term solution for solving the unmatched doctor problem," says Carmody. Medicine as a field has to balance the social contract it has with its trainees ― if you invest in a medical education, you'll be rewarded with a quality job ― with a broader social contract to provide society with the best possible medical care, says Jenkins. The number of residency positions needs to be based on public need for the physician workforce, says Carmody.
"Whatever solution we devise, it's going to be really important that we keep it learner centered and keep diversity, equity, and inclusion principles as the north star of what we're trying to fix," says Morgan. In her specialty, she says researching the demographics of who is going unmatched is a crucial first step in figuring out how to address the issue.
In the meantime, recent medical graduate Sam is preparing to apply again to their specialty of choice during the next application cycle. For them and others who are facing the problem of going unmatched this year, there are reasons to stay positive.
Margarita Loeza, MD, of the Venice Family Clinic, in Venice, California, has mentored an unmatched medical student or 2 for the past 8 years. Every one has gone on to match the next year, she says. There are other success stories. Sara Vidovic, MD, didn't match into urology her first time but waited, tried again, and matched to urology at Baylor Scott and White, in Temple, Texas, in spring 2021.
"The biggest thing is not to be too hard on themselves," says Vidovic. "The system is just very broken, and matching or not matching it is not a reflection on them and their worth."
Jillian Mock is a freelance science journalist based in New York City. She writes about healthcare, climate change, and the environment. Her work has appeared in many publications, including the New York Times, Audubon Magazine, and Scientific American.
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Cite this: Unmatched Doctors: How Big Is the Problem, and What Can Be Done? - Medscape - Jun 24, 2021.