Are There Sufficient ACGME-Accredited GME Positions Leading to Eligibility for Initial Board Certification to Absorb UME Growth in the United States? Open Access

Undergraduate medical education (UME) in the United States has undergone dramatic expansion over the past 22 years. In the spring of 2001, MD-granting schools graduated 15 793 physicians,¹  and DO-granting schools graduated 2510 physicians,²  for a total of 18 303 domestic graduates. In the spring of 2023, MD-granting schools graduated 20 920, and DO-granting schools graduated 7895 physicians, for a total of 28 779 domestic graduates, an increase of 10 476 domestic graduates (57.2%) (see Figure 1).

Concern has been raised that there are inadequate numbers of entry-level positions in Accreditation Council for Graduate Medical Education (ACGME)-accredited graduate medical education (GME) positions relative to the increasing number of domestic graduates of allopathic and osteopathic medical education in the United States. While increasing the output of UME was necessary, it was not sufficient to increase the output of the medical education pipeline. GME expansion would also be required to bring more graduates to eligibility for licensure and initial certification. Great concern was raised that, in the absence of expansion of Medicare-funded GME positions (capped at 1998 levels by the Balanced Budget Act), GME would be unable to expand sufficiently to absorb the flow of domestic graduates.³ 

The result is escalating numbers of applications by graduating medical students who are fearful of not “matching,” preoccupation with licensing examination score performance impacting the curriculum and test preparation, as well as a fundamental shift in security of the availability of GME positions upon successful completion of the UME curriculum.

During the summer of 2001, 24 129 physicians⁴  entered the first year of ACGME-accredited training in a discipline leading to initial certification in a primary specialty by either an American Board of Medical Specialties (ABMS) or an American Osteopathic Association (AOA) certifying board. During the summer of 2022, 36 628 physicians entered the first year of training in specialties leading to initial certification by either ABMS or AOA member boards, an increase of 12 499 occupied positions (51.8%). These numbers are confounded in that previously AOA-approved residency positions in 2001-2002 are not counted in the ACGME positions leading to initial certification, while all osteopathic graduates are counted in the graduation numbers. Similarly, a subset of positions accredited prior to 2015 by the AOA are present in the 2023 ACGME count due to the creation of the single accreditation pathway for GME in 2015 but are not counted in the 2009 numbers. It is estimated that the net increase in ACGME-accredited GME initial year positions leading to initial certification occupied from 2001 to 2023 is approximately 11 000, an increase of 45% (see Figure 1).

One way to examine the impact of expansion of these 2 phases of the continuum of medical education on graduating medical students is to calculate the number of positions available (using the actual number of positions filled in the subsequent academic year as a measure of GME capacity) versus the total number of graduates in a given year. Figure 2 demonstrates this calculation for the past 22 academic years (2001-2023) and shows how each year there is a significant excess of occupied positions over the total number of domestic MD and DO graduates. This occupied excess capacity is filled by international medical graduates. If one then examines the difference between domestic graduates and the total number of filled positions, one observes that the difference over time has not been constant (see Figure 2). As can be seen in this graphic, the difference between total filled pipeline positions and total domestic graduates reached a nadir in 2013-2014, with a surplus of positions of only 4043, a distinct drop from the previous surplus of 5000 to 6000 positions. One then sees a jump of approximately 1500 positions in 2016-2017, representing the accreditation of previously AOA-approved residency programs and positions. Interestingly, the difference continues to widen, despite continued growth of the UME graduate pool, implying a greater rate of growth of pipeline positions than domestic MD and DO graduates during the past 7 years, reaching its highest number of excess positions over the past 24 years at 7875 occupied positions. This growth in positions has been accomplished through both expansion of existing program positions, as well as development of new programs (data not shown).

In order to examine more specifically the nature of position growth, the growth of specialty positions was examined. Table 1 demonstrates the growth of each specialty leading to initial certification (pipeline specialties) over the past 15 years, from 2009 to 2023, and shows that overall growth in positions was significant, increasing from 25 506 positions filled to 36 628 positions filled (11 122, 43.6%). All specialties but 2 (medical genetics and genomics [−5, −12.8%] and nuclear medicine [-20, -35.1%]) increased their resident complement. Emergency medicine increased by 1536 positions, or 104.2%, and plastic surgery also more than doubled the number of occupied entry level positions. The largest numeric growth in specialty programs occurred in internal medicine (3429, 50.2%) and family medicine (1913, 59.6%). Psychiatry grew significantly over this period (825, 62.5%). In contrast, pediatrics increased positions only by 483 (17.7%). All of the surgical disciplines demonstrated growth in positions, with neurological surgery (80, 49.4%), obstetrics and gynecology (340, 28.3%), otolaryngology (90, 31%), orthopedic surgery (216, 31.7%), plastic surgery (202, 326%), surgery (230, 15.9%), and urology (121, 45.8%) all demonstrating significant growth. The net result of this heterogeneous growth was a reshuffling of the makeup of the GME distribution of positions filled by specialty. The distribution of pipeline specialty entry-level complement can be seen in Table 2.

The net impact of these changes would indicate that the surplus of GME positions in programs leading to initial certification in relation to the number of domestic graduates is being restored. Figure 3 demonstrates that despite the ongoing growth of domestic UME graduates, the relative excess of positions available and occupied has regained, and remains greater than 25%, similar to the relative excess prior to the expansion of UME over the past 20 years. All specialties leading to initial board certification other than medical genetics and genomics and nuclear medicine have expanded, with overall expansion of 44%. With the exceptions of neurological surgery, plastic surgery, and urology, the surgical discipline expansion has been slightly below the overall rate, and the medical disciplines (with the exception of pediatrics) have grown slightly above the overall rate, likely resulting in a heterogeneous impact on medical students, depending on their specialty of interest.