As we turn the calendar to 2030, it seems appropriate to reflect on the 2020s. Since the residency matching system began in 1952, no decade has seen such enormous and consequential change.1 Nine years ago, in 2021, after a year marked by a pandemic, the Federation of State Medical Boards and the National Board of Medical Examiners (NBME) stopped requiring the United States Medical Licensing Examination (USMLE) Step 2 CS. Then, on January 26, 2022 the NBME stopped releasing 3-digit scores for the USMLE Step 1. These 2 decisions began a decade of change that has revolutionized medical training. With a new decade upon us, what can we learn from the events of the one just finished?
The National Resident Matching Program proceeded in its usual fashion for the graduating classes of 2023 and 2024, but events were conspiring to make the process less workable. First, the newly formed National Medical Student Collective lobbied for the eradication of all clinical assessments during medical school. The Collective argued that clinical assessments were subjective, without proven predictive power, and biased.2 Medical school faculty, exhausted by how contentious grading had become, supported the Collective's call. The Association of American Medical Colleges acquiesced and mandated pass/fail grading systems across all 4 years.
In the absence of data to discriminate among applicants, residency program directors were left with little data to compare applicants. By 2024, application packets contained only a Medical Student Performance Evaluation that attested to the applicant's competency and 2 supportive letters of recommendation. An analysis of the language used in these letters demonstrated that the 3 most common descriptors used were outstanding, extraordinary, and stellar. Given the absence of assessments, all honorifics and student awards had also been abandoned. Student research productivity during medical school, once heralded as a reliable indicator of initiative, creativity, fortitude, and commitment, was also no longer considered an asset by residency selection committees. Data generated by career medical education investigators had demonstrated that publications and presentations did not predict future research activity, research quality, or residency performance.
Medical students, unable to reliably predict their competitiveness for specific residency programs (or even specific specialties), began applying to greater and greater numbers of programs, and concurrently to multiple specialties. While students in the late 2010s were applying to 30 to 70 programs in order to match, by 2025 the median number of programs to which students applied rose to 97, with 65% of students applying to more than 3 different specialties. Residency program directors, desperate to limit the number of applications, began requiring students to complete supplemental essays to gauge interest. This decision was quickly reversed, however, once selection committees realized these essays were predominantly being generated by artificial intelligence software freely shared by the Collective.
Assembling a reliably skilled residency class became so challenging that in 2026 the program directors took decisive action. Declaring that it was impossible to rank students solely on a score on the USMLE Step 2 CK and a brief virtual interview, the newly organized National Council of Program Directors agreed to only consider students from the 25 School Federation, a group of schools ranked highest by the robust, peer-reviewed metrics of US News & World Report. In distinguishing among the students from these institutions, residency selection committees looked to students' undergraduate college transcripts and Medical College Admissions Test scores for additional data points.
This is when the NRMP took its unprecedented step and replaced the 2027 Match with a lottery system. It bears remembering that many medical schools had already accepted the inevitability of randomness in the selection process for medical school entry.3,4 What occurred over the next 3 years was startling but, in retrospect, predictable.
After a brief peak in 2020, applications to medical schools fell precipitously, as the 2020 COVID-19 pandemic and the economic boom (what was already being referred to as the “Roaring 20s 2.0”) made a career in medicine less attractive. Schools that had been offering free tuition since the late 2010s could no longer do so as funds had to be diverted to repay pandemic-related debt or were earmarked for research into the microbiome. The institutions that made up the 25 School Federation (primarily expensive private medical schools) were unable to fill their classes as students refused to pay higher tuition without foreseeable benefit. These schools began to compete for a few students of enormous means, offering luxuries such as weekly craft classes and comfort animals. The cache of these schools fell as they garnered reputations as mere medical finishing schools.
Students who entered medical school encountered an educational environment in which all external incentives to excel had been removed. Medical schools remained dedicated to training the physicians of the future but had to adjust to 2 realities: dependence on tuition dollars for survival, and striking a balance between incentivizing mastery while not incurring the wrath of the Collective by demanding too much in the way of challenging coursework or full days of engaging in patient care. All schools increased class size to maximize tuition income.
Residency programs became the educational engine of medicine, but faced the conflicting aims of providing medical care while meeting the demands of the health care quality metrics set forth by the Universal Care Act of 2027 (commonly referred to as EMACA—the Even More Affordable Care Act). Residencies are now using the money allocated in EMACA to match twice the number of residents needed (at markedly reduced salaries). The first year of residency has become a rigorous, specialty-specific apprenticeship, with only 50% of interns promoted to the second year of training. The interns who are not promoted have either gone directly into practice or sought advanced training abroad. As recently as the 2010s, US medicine was an importer of talent, filling residency programs with foreign medical graduates who sacrificed mightily to come to the United States, worked tirelessly to meet US certification standards, and proudly trained in the world's most advanced health care system. Today, the United States is the largest exporter of medical trainees.
What lies ahead for the 2030s? Many see the potential for the next decade to look much like the early years of the last century. In the early 20th century, we saw interventions to improve medical education. There was the, now mostly forgotten, Flexner report, the creation of the NBME, the growth of the AAMC and the American Medical Association, and the beginning of Alpha Omega Alpha. This honor society originated as a student initiative to improve medical education. The current environment is clearly ripe for such a revolution.
