The United States is facing a potential physician workforce shortage of an estimated 37 800 to 124 000 physicians by 2034, with major shortages in primary care as well as equity disparities across race, ethnicity, insurance, and geographic lines.1 Simultaneously, 2053 (1416 allopathic and 637 osteopathic) or 7.5% of US medical school seniors who entered the National Resident Matching Program (NRMP) in 2022 failed to initially match.2 This percentage has remained stable over many years: the number of graduates has increased but so has the number of first-year positions.3 Another 1172 prior graduates of allopathic and osteopathic schools went unmatched initially in 2022.2 At the same time, 2022 postgraduate year (PGY)-1 positions were unfilled after the initial 2022 Match; 68% of these unfilled positions were in critical specialties: preliminary year 1 surgery, internal medicine, and family medicine.3 Of PGY-1 positions, 4571 (12.6%) were filled with non-US citizen international medical graduates.3 With the subsequent, stressful, time-intensive Supplemental Offer and Acceptance Program (SOAP), 902 initially unmatched US medical seniors (39% eligible applicants) accepted 911 positions in 2022, and 43.2% of SOAP positions were filled, with only 151 positions in SOAP remaining unfilled.4
Historically, managing unmatched students has been viewed as an undergraduate medical education (UME) problem. Often the graduate medical education (GME) view is that UME leaders fail to counsel unqualified students toward appropriate careers, including careers outside of medicine. This attitude leads some GME educators to mistrust UME student competency assessments and to focus on more “objective” application elements, such as United States Medical Licensing Examination (USMLE) test scores, including using test numbers as hard filters for applicant consideration.
Who Are the Unmatched Students?
The unmatched student pool, both initial and following SOAP, is incompletely understood. In a 2010 study, medical school deans' perceptions of why their students had not matched, after SOAP, were that a small percentage (1.2%) were not qualified. Of those who were deemed qualified, the main reasons given were: not competitive for first choice specialty and USMLE score issues.5
A 2015 report from the American Medical Association Council on Medical Education, prepared in conjunction with the Association of American Medical Colleges and the NRMP, used Liaison Committee on Medical Education data to identify the causes for students going unmatched.5 In just over half, clinical grades and USMLE scores below the norm were cited as the reason. Other reasons were applications limited to one specialty (ie, no parallel plan) and limited number of applications. In almost 20% the reasons were considered unknown. Although medical school promotions committees expressed performance concerns at a higher rate for students who later did not match, this was not noted for all unmatched students.6
Some have suggested that admission to medical school is a key time for medical schools to act to increase students' match success.5 A holistic medical school application review, focused on demonstrated commitments to serve shortage specialties and needy communities, may be a first step toward increasing student match success. Similarly, residency program recruitment process changes, such as minimizing test scores as a hard filter, use of holistic application review, and situational judgement tests, which have been shown to increase diversity, may enhance match success.7 In addition, ongoing attention to mitigating faculty implicit biases, whether related to race, gender, sexual orientation, disability, age, medical school status, or other factors, may be beneficial.
Additional studies are needed to examine why qualified students fail to match; these should include the effects of a lack of transparency in UME competency assessments and residency program selection priorities, in the pursuit of improving trust between UME and GME.
The Way Forward: Local Solutions
In adopting competency-based medical education, we must accept that time to become competent is variable. Inevitably some students will need less time to develop competence and others will need more time. As a community, we lack systematic ways to address time-variable training within the competency-based education framework. Keeping qualified students in the medical education system represents one potential solution to the dual problems of unmatched students and physician workforce shortages. Yet, financial aid is not set up for time-variable training: many if not most students will have to graduate according to school policy, enter a new degree program, or find a job.8 These paths will prevent students from improving key clinical skills or adding experiences in a new target specialty.
A few states have passed laws allowing unmatched students to practice as assistant physicians or graduate registered physicians under another licensed physician's supervision.9 These initiatives provide additional clinical experiences and improved access to primary care for underserved communities. However, use of underqualified clinicians with light supervision risks patient safety as well as clinicians never acquiring key competencies.
Gathright et al describe an effective UME-GME partnership that creates a transitional year program for the school's unmatched students.10 This program adds PGY-1s to existing residency programs to support clinical care and provide educational experiences. The program can facilitate learner access to future categorical programs.10 Transitional year programs are an attractive option, as they must meet Accreditation Council for Graduate Medical Education (ACGME) standards. Transitional year programs should also promote a pluripotential learner for several career paths.
Funding for new transitional year positions might be achieved through medical school tuition funds or shared among medical schools, sponsoring GME institutions, and states, with the proviso that these residents enter specialties needed in the state and remain in the state for some time period. Another option, creating unmatched-only transitional year positions, which could be filled in a time-variable manner—June or off-cycle, in December—and which depend on the numbers of unmatched students, might require relief from the NRMP All In Policy.
Similar to transitional year opportunities for students from a program's own medical school, transitional year programs and specialties such as internal medicine, family medicine, and surgery could create openings for unmatched graduates from any school. Funding sources could include states as well as organizations and specialty associations concerned with physician shortages. Resources, particularly faculty able to frequently monitor trainee progress and provide feedback, would be needed in addition to resident salaries.
Another area for additional study is the growth of pre-residency “fellowships” in some specialties, such as orthopedic surgery and ophthalmology.11 While marketed as offering additional research experience and/or clinical exposure to augment a reapplication, these positions are currently unregulated, and the service-to-education ratio is unknown. National efforts could include monitoring and standardizing such experiences, similar to the initiative ACGME is pursuing with the Educational Commission for Foreign Medical Graduates for nonstandard training programs.12 Outcomes of pre-residency fellowships need to be rigorously studied to better understand their potential value for the physician workforce.
Recognizing the profound impact that being unmatched has on learners, another area needing additional study is how to assist unmatched students post-Match, beyond SOAP. For example, Canada uses a standardized approach, with mental health counseling, peer support, a toolkit from previous unmatched students, an additional structured year of medical school, 3 match rounds, and a longer time period between initial match results and the final match round.13-19 Canadian program outcomes, including career paths, physician supply, and costs, should be reviewed for relevance to the United States.
We believe unmatched US medical school graduates, allopathic and osteopathic, constitute a continuing problem that requires collaborative UME and GME responses. Assuming that all unmatched students are either unqualified or poorly advised in specialty and ranking choices seems an insufficient response to the problem. Given the country's workforce concerns and the need to ensure the public has an optimal return on investment, with public support of many medical schools, a more scholarly approach is needed. UME and GME stakeholders must work together to better understand, through focused study, why US senior medical students fail to match and where their subsequent career trajectories lead. We need to test creative solutions, for competent yet unmatched applicants, which could enhance the supply of qualified physicians, especially for critical disciplines. Reducing the number of unmatched students—which has remained remarkably stable—requires greater UME and GME collaboration across a more transparent continuum of medical education.