The NRMP's Perspective on Positions Offered Outside the Match: Commentary on: Outside-the-Match Residency Offers: The Possible Extent and Implications of “Prematching” in Postgraduate Medical Education Open Access

The issue of residency positions being offered outside the match is one of deep and long-standing interest to the National Resident Matching Program, which was founded decades ago to relieve the pressure and stress created by an unstructured process. We congratulate the authors of “Outside-the-Match Residency Offers: The Possible Extent and Implications of “Prematching” in Postgraduate Medical Education” for bringing additional attention to this important topic; however, we do not concur with some of their assumptions and conclusions.

We believe the authors' analysis may be flawed for several reasons. First, they contend that preliminary surgery positions make up all the outside-the-match surgery offers. This is a simplistic assumption. Preliminary surgery positions are complex in that many are offered as truly “preliminary” to a subsequent surgical subspecialty (generally urology) or anesthesiology position in the same institution, whereas others are labeled “nondesignated.” Categorical positions in surgery are more competitive and most are filled in the match, although the assertion that some are not offered outside the match is unsupported. This assumption also is inconsistent in the study design, as the authors contend that outside-the-match offers in surgery are solely preliminary positions but that preliminary medicine positions constitute none of the outside-the-match offers in internal medicine.

The authors presume that 2777 of the 3977 non-United States medical doctors (non-USMDs) who registered yet withdrew prior to the match were offered and accepted positions outside the match. Annually, approximately 1200 international medical graduates (IMGs) are withdrawn prior to running the matching algorithm if they have not fulfilled the testing requirements for certification by the Educational Commission for Foreign Medical Graduates. (Note that a similar process occurs for USMDs if their medical schools determine they are not eligible to enter graduate medical education on July 1.) The majority of the withdrawn IMGs, regardless of their reason for withdrawing, participate in the “scramble” for unfilled positions that occurs during match week. Therefore, a large percentage of those withdrawals are not for IMGs to take outside-the-match offers.

Many of the authors' conclusions are framed in the context of primary care training and comparisons to “procedural-oriented/lifestyle-oriented specialties.” The unusual grouping of several specialties in this analysis warrants comment. The authors do not include internal medicine-pediatrics and obstetrics-gynecology within primary care. Obstetrics-gynecology is grouped with the procedural-oriented/lifestyle-oriented specialties, which also include categorical surgery, preliminary internal medicine, and transitional year, an odd combination. Thus, any conclusions in this analysis that refer to match trends for primary care specialties should be interpreted in the context of the authors' unusual grouping of specialties.

The distribution of entering trainees among fourth-year senior students in US medical schools, international IMGs, and US-citizen IMGs is an issue of importance, and there are numerous confounding factors. One factor is the inability on entry to internal medicine and pediatrics to discern the eventual career paths of trainees. Some will become and remain full-time primary care specialists; others will subspecialize and spend only a portion of their time as primary care providers; still others may enter procedural specialties such as diagnostic radiology and anesthesiology. The analysis used by the authors to gauge interest in primary care may be misleading. Using their logic, the percentage of graduating USMDs entering primary care could rise each year, but if the number of primary care training positions increases at a greater rate, it is possible a smaller percentage of the positions would be filled by USMDs. Such a phenomenon could easily be envisioned with the anticipated expansion of primary care residency positions as well as the redistribution of unused residency slots mandated by health care reform legislation. In our view, USMDs' interest in primary care is best measured as a percentage of the graduating class electing to train in specialties that are traditionally designated as primary care.

How to encourage young physicians to enter primary care continues to be a subject of public policy debate, and it is generally conceded that the number of residents entering the field is not sufficient to meet our country's long-term manpower needs. As we began this commentary, the topic is important but greater clarity is necessary in the focus that should be brought on this issue.