Imagine spending eight years after high school studying for your dream career. After college you apply to every medical school you can think of. If you can’t get into a (cheaper) state school, you apply to more expensive private medical schools. Some people who cannot get into a U.S. medical school even apply to schools in other countries. Then imagine sinking hundreds of thousands into debt to pay for medical school, not to mention your time and effort.
When you finally graduate, you’re not free to practice medicine yet. You must apply for graduate medical education (GME) training programs that are required before you can get a license to practice medicine in all 50 states. Then you discover there are training slots for only 80% of those who apply. The remaining 20% may never be allowed to practice medicine. If this sounds impossible, it’s not. It happens every year in March.
This week the National Resident Matching Program (Match) will inform between 45,000 to 50,000 medical graduates whether they have a career in medicine or should try for Plan B. Some of those who failed to match will spend the rest of their lives trying to pay down $300,000 in medical school debt without an income capable of servicing that debt.
In the 2021 Match there were 48,700 medical school graduates competing for 35,194 first-year residency slots and just under 3,000 advanced residency slots. If you do the math, that leaves about 10,000 individuals who have graduated medical school without a way to obtain a license. Most U.S. medical school graduates ultimately match to a residency slot, but about 7% of MDs and 11% DOs do not. Those who fail to match the first round can try the supplemental offer and acceptance program (SOAP), which is similar to a second-round match to fill the few residency slots that remain unfilled. Last year there were only 1,773 unfilled slots in the SOAP match. The SOAP is sort of a Plan B. Applicants may have to switch fields or study far away from friends and family. Failing that, medical school graduates must wait another year and try to match again. The more years that go by without being matched to a residency program, the less likely it will ever occur.
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Some graduates don’t match because there were better candidates competing for a coveted specialty. Sometimes graduates' preferences were too narrow, say, they only wanted a dermatology residency in a popular, sunny location. Others fail to match because they chose a specialty with too few residency slots. Primarily, thousands of medical school graduates don’t match because there just aren’t enough residency slots to meet demand.
Fearing an overabundance of physicians and hoping to reduce costly subsidies for graduate medical education, Congress capped the number of GME residencies Medicare can fund back in 1997. Only recently has Congress authorized additional funding for 1,000 new slots. There are other sources of GME funding, but most are funded my Medicare. States use some of their Medicaid funds and some general funds to increase residencies. Some private payers also funds residencies. Teaching hospitals tend to have more residents than are funded through GME sources. However, this is not nearly enough. Medical school enrollment is 52% higher than it was in 2002 causing a shortage of residency slots required for MDs and Dos to complete their training.
A handful of states currently license mid-level providers called assistant physicians, when medical school graduates who have not matched to a residency are allowed practice under a licensed physician. States that have an assistant physician program are Missouri, Virginia, New Hampshire, Utah, and Arkansas. Similar legislation has been debated in Georgia, Kansas, Oklahoma, and Washington State. These programs are a good idea but more needs to be done. Furthermore, doctors tend to practice in the state where they were trained. If states wish to address the growing physician shortage, they will have to fund more residencies and create assistant physician programs.
Why should we care? The Association of American Medical Colleges estimates the United States has a shortage of nearly 20,000 physicians today. This shortage could possibly rise as high as 124,000 by the year 2034 as aging physicians retire. The U.S. has an aging population who will need care and many rural towns and urban areas are under-served by physicians. At the same time the U.S. has an excess of medical school graduates who would like to practice medicine but may never be allowed to.
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