March 18 was a big day for graduating medical students: it was the day they found out where they are going to pursue training in the various specialties of medicine.
Medical students typically attend medical school for four years, then undertake a specialty residency (this is called post graduate training in the medical lexicon), This entails a minimum of three years of clinical training, but many disciplines require more, and further subspecialty training tacks on even more years. Nowadays, doing residency training is necessary to practice medicine–the one year of a general internship followed by practice no longer exists.
The National Residency Matching Program (NRMP.org) provides the mechanism by which newly minted doctors-to-be and training programs are matched. Candidates rank their preferences for residencies and residencies do the same for candidates. A computerized mathematical algorithm determines who will train where.
A detailed look at the match results from this spring is a bit abstruse, so details for those curious readers are in the footnote.*
What is important to know is that the percentage of positions that disciplines fill in the match reveal their relative popularity among medical students. Specialties that filled all available positions offered were, with a few exceptions, among the most lucrative in medicine.
A telling way to break down the results of the match is to look at the percentage of grads who are going into the primary care specialties. These are mainly Internal Medicine, Family Medicine, and Pediatrics. Primary care doctors are the first contact for patients and provide care over an extended period of time–not just episodic interventions. Their work is mainly cognitive, i.e., they perform few procedures.
The rubric of gauging the popularity of disciplines by the percentage of American grads (both MDs and DOs) who obtain positions in the match, highlights the relative lack of popularity of primary care among medical school graduates. For instance, Dermatology filled 91 percent of positions offered with MD and DO American grads. Orthopedics: 95%; Anesthesiology: 87% The fill rates for the primary care specialties ranged from 42 percent (Internal Medicine) to 63.5 percent for Pediatrics.
The results of the match are very important—they portend the composition of the physician workforce for years to come. In a document entitled The Complexities of Physician Supply and Demand: Projections from 2018 to 2033, published in July of 2020, the Association of American Medical Colleges has produced an authoritative breakdown of things to come in the physician workforce (aamc.org).
Notable is the projection of a physician shortage by 2033, estimates for which range from 54,000 to 139,000 (there are currently almost one million practicing physicians in the United States). The estimated shortfall for primary care physicians is more stark than for subspecialties, especially procedure oriented ones.
If these projections are accurate, health care policy should clearly aim to increase the number of practicing physicians in the coming years. And there should be a particular emphasis on increasing the number of primary care doctors. The need for more primary care practitioners has been the subject of discussion, and no little amount of hand-wringing, for years, with leaders in medicine wondering how to plug the gap. They have, however, largely avoided policies that address the elephant in the room, to wit, the net incomes of primary care doctors average about 69 percent that of subspecialists, who perform highly remunerated procedures.
In subsequent posts, I will expand on this disparity.
*Residency programs, which are located in both university and community hospitals, offered a total of 36,277 first year post graduate positions (i.e., PGY-1 positions offered for training in programs of at least three years duration), of which 51% were filled by graduating seniors from American medical school and 18.4% by graduating doctors of osteopathy (DOs receive training very similar to what MDs get, with more emphasis on musculo-sketetal disorders. I have known many DOs who are outstanding doctors, and a few who are terrible; the same goes for MDs ). The balance of the positions were filled by International Medical Graduates (IMGs), formerly known as Foreign Medical Graduates, the greatest percentage of whom are from India. Many IMGs go unmatched, as residency training programs prioritize the recruitment of American grads.
Almost half of the graduating seniors matched to programs in primary care, but this number is misleading. The number includes grads who are doing a year in Internal Medicine prior to going into a subspecialty such as, for instance, Dermatology. Of those who are going into a 3 year residency in Internal Medicine, the great majority plan on further training in the subspecialties of Internal Medicine, such as Cardiology, Gastroenterology, etc. These disciplines are procedure oriented and are not primary care. A significant number are intending to become hospitalists. These are hospital based physicians who care exclusively for inpatients–they are not primary care physicians either.
One variable in the solution, perhaps the most important, is more $ for primary. What changes are needed for that to happen? Maybe the next MB will have some suggestions! What other variables?