It’s a problem that nearly every medical school in the country is facing – the growth of the number of residency slots has not kept pace with the increasing number of students graduating from the nation’s medical and osteopathic schools.
The number of U.S. graduates has grown approximately 30 percent through increases in the class sizes of existing schools, as well as the opening of new schools over the last decade.
There was excellent rationale for these increases in graduates given the projections of the need for more physicians as the U.S. population ages and more individuals have access to health care through health care reform.
Unfortunately, an increase in graduates without a corresponding increase in residency positions does not create a net increase in practicing physicians in the U.S.
Earlier this month, I attended the annual meeting of the Association of American Medical Colleges. The growing residency shortage was one of the recurring items of discussion.
So, what exactly does this mean for medical students?
For them to be able to practice medicine, they must complete residency training in a specialty. Depending on the field they enter, the residency training may last from three to seven years.
Fourth-year students are accepted into and matched to a specific residency program through a national computerized selection process, termed “the Match.”
This process ideally allows each student to be matched with the residency program that is highest on their preference list while factoring in the programs’ priority of applicants to their program.
This process is preceded by an approximately three-month long, on-site interview process for students at the programs to which they applied. This is followed by announcement of where the students matched in mid-March.
Students who do not match participate in a secondary process that hopefully matches them with positions that remain unfilled after the primary match.
With the lack of growth in residency slots, it is now becoming increasingly difficult for medical students to match in their chosen specialty.
Highly qualified students who would have matched in their preferred specialty area five years ago – before medical and osteopathic school class sizes expanded – are now holding their breath when Match Day rolls around.
A growing number of students at every medical school in the country are finding themselves unmatched and scrambling to gain access to a declining number of unfilled positions remaining after the match.
For many years, 95-96 percent of students matched in the primary match. That number dropped to about 93 percent in 2013.
The likelihood of not matching is particularly increasing in the more competitive specialty areas such as neurosurgery, orthopaedics, dermatology and ophthalmology. In many cases the open (unmatched) positions will not be in the specialty area to which the students had originally applied.
Historically positions in primary care specialties, particularly internal medicine and family medicine have been most likely to have open positions remaining, with many of those in internal medicine being preliminary one-year positions that are actually prerequisites for entry into other specialties.
Students who do not match are left with pursuing a career in a specialty area that may not be their first choice or taking a one-year clinical or research training position with the plan to reapply next year in their preferred specialty, recognizing that they may fare no better next year.
It’s unnerving to say the least. To increase the likelihood of matching, students are applying to and interviewing at a larger number of programs, usually at their own time and expenses for the most competitive specialty areas. This also puts a strain on the programs who must review a much larger number of applications each year.
Students seeking careers in the more competitive specialty areas increasingly have to develop a “plan B” – applying to and interviewing in a second, less competitive, specialty area.
There are no simple solutions. Boosting federal support for Graduate Medical Education (GME) through Medicare, which is the primary source of GME funding, is one of the obvious remedies. But, this is much easier said than done.
The number of residency positions funded by federal GME support has been frozen since 1997 as part of the Balanced Budget Act.
Although the number of residency positions has increased nationally since that time, this has largely been done at the expense of the hospitals and schools in which the programs are located using operating margin from the clinical programs. As hospital margins are declining nationally, they may be forced to eliminate some of their support for residency positions, further exacerbating the residency position shortage.
The same legislators who encouraged medical schools to increase their enrollment to meet the projected need for more physicians don’t seem to recognize that increased enrollment necessitates a corresponding rise in residency positions.
The AAMC has been leading the effort to encourage Congress to increase the number of residency programs supported with federal dollars, but thus far to no avail as these efforts have largely been trumped by the federal budget crisis.
Fortunately, it appears as though calls from some members of Congress to cut support for GME have at least been fought back through the efforts of the AAMC and others.
The solution most likely will come from a combination of funds – federal and state government as well as private health care organizations, perhaps targeted to specialty areas where there are projections of particular shortages of physician manpower, e.g. primary care.
Without such changes the projections from the AAMC are that the number of graduates from U.S. medical and osteopathic schools will soon exceed the number of U.S. residency positions in all specialties. This would be a disaster.
The issue is attracting more and more attention. The Metro Omaha Medical Society is planning a story for its next newsletter. The Omaha World-Herald also has a story in the works.
Publicity is good. We want the message to get out.
We need people to be aware of this unsettling dilemma for medical students and the threat that it poses for our ability to meet physician needs in Nebraska and nationally.
We need to encourage our legislators and members of the executive branch of state and federal governments to take action to address this critical issue.