The Mess That Is Matching in Psychiatry

Dinah Miller, MD


December 21, 2021

The day I interviewed at Johns Hopkins, like every other day of residency interviews, was a very long and draining day.

I started by meeting alone with Dr Philip Slavney, the residency director, who spoke with me about the program and gave me a schedule to follow. I was to meet with residents and psychiatrists, some of whom had graduated from my medical school, and was sent to the Bayview campus a few miles away to have lunch and attend a few meetings. By the time I boarded an Amtrak train at Baltimore Penn Station, I was tired but I liked what I had seen. By the end of the interview season, I had crossed four programs off my list and had decided to rank only three.

In 1987, there were 987 residency positions in psychiatry in the United States, and 83.6% of those positions filled with a combination of US and international medical graduates. Still, this was a risky move; the programs that I decided to rank would fill, but I was matching separately for an internship year in internal medicine in New York City and decided that I would rather reapply in a year than risk matching at a program I didn't want to go to.

I wasn't quite sure where I wanted to rank Hopkins on my list, so I called Dr Slavney and said I wanted to come back and meet more members of the department. He did not hide his surprise and was quick to tell me that no one had ever requested a second set of interviews. I mentioned specific people I wanted to meet with, and he was kind enough to accommodate my request and set up a second day of interviews for me.

Needless to say, the residency match felt very personal — at least to me — and although I felt vulnerable, I also felt empowered. Because of the low pay, patients with stigmatized illnesses, and the rampant belief that psychiatry was not "real" medicine and the patients never got better, psychiatry was not a desired specialty.

The residency application process in psychiatry (and every other specialty) has become a much different process. In 2006, the Association of American Medical Colleges (AAMC) called on medical schools to increase their enrollments to address the national shortage of physicians. Soon, there were more medical schools, bigger classes, and more doctors being minted, but the Balanced Budget Act of 1997 prevented a proportional increase in residency positions.

Len Marquez, senior director of government relations at the AAMC notes, "The Resident Physician Shortage Reduction Act of 2021 (S. 834), sponsored by Sen Robert Menedez (D-NJ), Sen John Boozman (R-AR), and Majority Leader Sen Charles Schumer (D-NY), would support 2000 additional Medicare-supported residency positions each year for 7 years, but Congress has not yet acted on the legislation. We were very pleased that last year, Congress passed the first increase in Medicare-supported graduate medical education in 25 years by including 1000 new slots as part of the Consolidated Appropriations Act, 2021.

In addition, the Build Back Better Act, which is currently being debated in Congress, would provide 4000 more graduate medical education slots, including a specific requirement that 15% of them go to "psychiatry-related residencies."

Over 90% of graduates from US medical schools currently match into a residency position. That statistic for international medical graduates is notably lower, with perhaps as few as 50% of all applicants matching.

Since 2014, the number of applicants to psychiatry residencies has nearly doubled. For the 2021 match, there were 2486 applicants applying for 1858 positions in psychiatry — so 1.34 applicants for each slot. Of the 1117 senior medical students at US schools who applied to psychiatry residencies, 129 did not match. Overall, 99.8% of residency positions in psychiatry filled. 

"It used to be less competitive," said Kaz J. Nelson, MD, the vice chair for education at the University of Minnesota's School of Medicine's Department of Psychiatry and Behavioral Sciences, adding that interest in psychiatry has increased over the years. 

"Interest has skyrocketed as the word has gotten out about how great a field it is. It helps that reimbursements are better, that there is less bias and discrimination against patients with psychiatric issues, and that psychiatric care is seen as a legitimate part of medicine. It has been exciting to watch!" Dr Nelson said.

The numbers are only one part of the story, however. 

Application submission now involves a centralized, electronic process, and it has become easier for applicants to apply to a lot of programs indiscriminately. It's not unusual for applicants to apply to 70 or more programs. The factors that have limited applications include the cost: Electronic Residency Application Services (ERAS) charges for each application package they send to a program, and applicants traditionally pay to travel to the programs where they interview. This all changed with the 2021 cycle when in-person interviews were halted for the pandemic and interviews became virtual. While I recall applying to seven residency programs, this year the average number of applications was 54.7 per applicant.

"It used to be that the cap on interviewing was financial," Dr Nelson said. "It was discriminatory and favored those who had more money to travel to interviews. There are still the ERAS fees, but COVID has been an equalizer and we are getting more applicants, and interviewing more who are not from Minnesota or the Midwest. We have been working to make our program attractive in terms of diversity, equity, inclusion, and justice. Our hospital is located a mile from where George Floyd was murdered, and it's our responsibility to lead the effort to ensure the psychiatry workforce is diverse, and inclusive, as possible." 

Daniel E. Gih, MD, is the program director for a new psychiatry residency at the University of Nebraska. When the program started in 2019, there were spots for four residents and the program had 588 applications. In 2020, the program grew to five positions and this year there were 553 applicants. Dr Gih attributed the high number of applications to his program's strong social media presence.

"Going through the applications and meeting the students are some of the most enjoyable parts of my work," Dr Gih said. "I feel guilty though, that I'm likely going to miss a great applicant. Each application averages 35 pages and it's inevitable that programs have to take shortcuts. Applicants worry that they'll be ranked by board scores. While we certainly don't do that here, students might feel ruled out of a program if their numbers aren't high enough. Furthermore, wealthy students can apply to more programs. The pandemic has really highlighted the inequity issues."

Dr Gih noted that the Zoom interview process has not been disappointing: "Two of the people we matched had never been to Omaha, and many expressed concerns about what it is like here. Of course, on Zoom you don't catch subtle interpersonal issues, but we have been pleasantly surprised that the people we matched were consistent with what we expected. It is exciting to meet the people who will eventually replace us as psychiatrists, they will be here to deal with future challenges!" His enthusiasm was tangible. 

While the program directors remain optimistic, the system is not without its stresses, as many programs receive over 1000 applications.

"This is difficult," Dr Nelson said." It's wonderful for the programs, but for the medical students, not matching is experienced by them as being catastrophic, so they apply to a lot of programs. Getting this many applications is a challenge, yet I don't want to interview someone if they are going to rank our program number 80 on their list!" 

Residencies have dealt with the deluge of applicants in a number of ways. Some specialties started a "signal" protocol wherein candidates and programs receive a certain number of tokens to indicate that each would rank the other highly, but psychiatry has not done this. Early on in the Zoom process, multiple applicants would be offered interviews simultaneously, and the interview would be given to the candidate who responded first. Students vented their frustrations on Twitter when they lost interview spots at their coveted programs because they hadn't checked their email in time or had gone to take a shower.

"The American Association of Directors of Psychiatry Residency Training Programs issued guidelines saying that it is unacceptable to offer interview spots without allowing a reasonable time for the applicant to respond, and that it is not appropriate to offer multiple candidates one spot on a first-come, first-serve basis," Dr Nelson explained.

Her program has managed some of the application chaos by using a software program called Scutmonkey, co-developed by David Ross, MD, PhD, the associate program director of the Yale Adult Psychiatry Residency Program.

"It lets us screen applications for candidates who specifically are interested in being here, and for those who qualify as part of the mission we are trying to fulfill."

One fourth year student at a mid-Atlantic medical school who is applying in psychiatry — who I'll call Sacha to protect his anonymity — applied to 73 psychiatry programs and to date, has interviewed at six. He describes a stressful, roller coaster experience:

"I got those six interviews right away and that was an amazing start, but then I didn't get any more. The interviews I had went well, but it has been disappointing not to have more. Some were all-day interviews, while other programs had me meet with residents and attendings for 20 minutes each and it was all done after 2 hours."

He has mixed opinions about not seeing the schools in person. "There are very heavy pros and cons. I've saved thousands of dollars in travel expenses that would have limited my applications, so logistically it's a dream. On the other hand, I've interviewed in cities I have never been to, it's hard to get a sense of the intangibles of a program, and the shorter interviews feel very impersonal." 

Sacha expressed anxieties about the process. "With so many applicants, it's difficult for someone with a nontraditional story to get a spot and it's easier for the programs to toss applications. With all of my classmates, there is the palpable fear of not matching anywhere, it's common enough and everyone has seen someone who has gone through this. At times, we feel powerless; we have no real agency or control. We send stuff out and then we sit in the prayer position and wait."

I think back on my own application process with a sense of gratitude. I certainly didn't feel powerless, and in today's world, post-interview communications with program directors are regulated for both parties. Dr Slavney was kind enough to humor my request, but I don't believe this would be feasible in the current environment.

Even though it is wonderful that more doctors have figured out that careers in psychiatry are rewarding, the current situation is overwhelming for both the applicants and the programs. With over 100 applicants for every position — many of whom will have no interest in going to some of the programs they apply to — qualified candidates who go unmatched, and a roulette wheel which requires heavily indebted students to pay to apply, this is simply not sustainable in a country with a shortage of physicians — psychiatrists in particular. 

We hear that mid-level practitioners are the answer to our shortages, but perhaps we need to create a system with enough residency positions to accommodate highly trained and qualified physicians in a more inviting and targeted way.

Dinah Miller, MD, is co-author of Committed: The Battle Over Involuntary Psychiatric Care (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

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