Mitigating the Problem of the Unmatched and How Their Medical Experience can be Utilized


 Author: Treven W. Cade


By now, it is common knowledge to cite the 2020 AAMC Report that projected a shortage of physicians between 54,100 and 139,000 by 2033. This range comprises a shortage of primary care physicians (between 21,400 and 55,200) and non-primary care specialty physicians (between 33,700 and 86,700). This is also not to mention the COVID-19 pandemic and its effect on the healthcare system. Although there are thousands of medical school graduates, doctors in name only, who are unable to match into residency programs, and, therefore, cannot practice as a physician. Medical graduates are not even permitted to work with patients under supervision, which is less than what they could have done while in medical school (Dewan). The disparity between positions to be filled and the number of applicants for the NRMP Match could be caused by many factors, such as the Balanced Budget Act of 1997, which froze the number of funded residency positions, but a more prominent and undiscussed question is how these medical graduates could assist in providing care even if they remain unmatched.

Below are the statistics of the unmatched, from a wide array of graduation and civilian statuses, gathered from the NRMP Archives. As one can see, unmatched PGY-1 applicants have consistently been between 7,000-9,000 every year since 2007. While some could be reapplicants, there are thousands of medical graduates that cannot further their training. More so, while these graduates have years of experience, “many of [them] are often relegated to working entirely outside the medical field” (Dayaranta), which is painful to consider in light of the physician shortage. This supply of medical graduates could no doubt alleviate the physician shortage, but they remain an unutilized resource.

Year Unmatched Senior/Graduate PGY-1  Applicants of MD Medical School Unmatched Senior/Graduate PGY-1 Applicants of DO Medical School Unmatched US Citizen Graduates of International Medical
School PGY-1 Applicants
Unmatched Non-US Citizen Graduates of International Medical
School PGY-1 Applicants
All Unmatched PGY-1 Applicants Percent of
Unmatched PGY-1
Active
Applicants

1993

1,234 / 542

286

275

1,796

4,180

20

20,916

1994

998 / 547

260

351

2,736

4,947

22.1

22,352

1995

1,072 / 559

276

369

2,757

5,078

22.1

22,936

1996

1,144 / 565

247

493

4,221

6,711

27.2

24,718

1997

1,060 / 658

281

829

5,298

8,160

31

26,323

1998

954 / 505

276

926

5,462

8,163

31

26,360

1999

900 / 446

313

957

5,410

8,064

30.5

26,462

2000

873 / 493

327

1,055

3,669

6,665

26.6

25,056

2001

913 / 517

365

951

2,822

5,627

23.5

23,981

2002

847 / 555

383

937

2,221

5,012

21.4

23,459

2003

988 / 585

413

902

2,230

5,159

21.5

23,955

2004

1,037 / 693

461

898

2,701

5,855

23.2

25,246

2005

921 / 712

479

948

2,467

5,588

22

25,348

2006

949 / 658

485

1,204

3,291

6,643

24.9

26,715

2007

1,005 / 691

516

1,347

3,812

7,430

26.6

27,944

2008

883 / 663

531

1,428

4,227

7,797

27.1

28,737

2009

1,072 / 677

605

1,771

4,372

8,548

28.6

29,888

2010

1,078 / 747

601

1,946

4,365

8,794

28.8

30,543

2011

971 / 764

617

1,885

3,938

8,203

26.8

30,589

2012

815 / 760

596

2,179

4,058

8,431

26.9

31,355

2013

1,097 / 880

675

2,404

4,012

9,091

26.5

34,355

2014

975 / 864

611

2,411

3,701

8,583

25

34,270

2015

1,093 / 858

610

2,354

3,725

8,653

24.8

34,905

2016

1,130 / 770

586

2,454

3,691

8,640

24.4

35,476

2017

1,059 / 795

500 / 157

2,292

3,470

8,281

23

35,969

2018

1,078 / 849

645 / 201

2,175

3,105

8,063

21.7

37,103

2019

1,162 / 811

653 / 273

2,083

2,841

7,826

20.4

38,376

2020

1,218 / 826

613 / 326

2,103

2,685

7,685

19.2

40,084

2021

1,431 / 866

774 / 339

2,143

3,587

9,155

21.5

42,508

*To view the full chart, please visit this blog on your desktop/laptop

Sources: Report Archives - The Match, National Resident Matching Program (nrmp.org) (Data can be found in “Results and Data: Main Residency Match” in the following yearly documents: 1999, 2006, 2011, 2016) and SAP Crystal Reports - (kinstacdn.com) for 2021

The question now becomes, how can this untapped resource of medically experienced individuals potentially be utilized if they are not matched. Most countries outside of America provide the necessary licensure to medical students upon their graduation, and it has been argued by Mantosh Dewan, MD and John Norcini, PHD, through the presentation of two models, that this process can be accomplished in America as well. These models include medical schools providing a one-year residency program for their unmatched graduates and the other being (albeit similar) to cut down the four-year medical school curriculum to three years plus an additional one-year residency. These models were contemplated off the fact that, in all but 15 states, one can obtain a physician license after one year of residency and that the fourth year of medical school has often been cited as inefficient (Dewan). The former model, which still fits within the current GME structure we have in America, has more or less been implemented by the University of Arkansas for Medical Science: the university implemented a transitional year program for their medical students who were unmatched. While the transitional year program only allowed for five resident positions, it was deemed as a success that “provided an institutionally valued solution to a concerning trend and was acceptable to learners for meeting their individual career direction needs and plans” (Gathright). These models may be concerning to some, as one year of residency is much different than the training provided by a full-length residency program; however, if medical schools have the ability to implement shorter residencies, such as the transitional year, they could provide an opportunistic avenue for their unmatched graduates to take.

Another model to utilize the skills of medical graduates who could not find their way within a residency program is a provisional license. This license could be given to medical school graduates to allow them to practice in the medical field under the supervision of a healthcare professional. Some states (Arkansas, Kansas, Missouri, and Utah) have implemented legislation that allows these graduates to pursue these licenses; although they usually come with a number of restrictions, such as one must have graduated medical school within a few years prior or must have graduated from a specific in-state medical school (Dayaranta). Missouri’s iteration of this legislation, the Missouri Assistant Physician Program, was implemented in 2014, and the state currently has 200 to 300 individuals acting as an assistant physician (Way), which is more or less the same amount of authority that was described for provisional licenses. Further legislation was discussed that would allow an assistant physician to apply for a full physician license after five years within the Missouri program—which would allow a physician to practice without the use of a residency program—, but it was opposed by the Missouri State Medical Association and not passed. Many medical organizations have shown opposition to the incorporation of a provisional license, such as the AMA, AAMC, ACGME, and ACCME (Way); however, it has been argued that “physician assistants and nurse practitioners do not receive substantially more training than medical students receive, yet they still treat patients throughout the country with a significant level of autonomy without having to undergo nearly [the same] extent of post-graduate training” (Dayaratna). Although their opposition to these measures is understandable: residency programs have been the sole pathway to become a physician since the 20th century. With this in mind, unmatched medical graduates still have the skills necessary to, at the very least, work with patients under the supervision of professional faculty from their medical school experience.

Models that fundamentally change the way in which healthcare education is brought about, such as changing the curriculum of medical schools or providing a pathway to become a physician without a residency program, will perhaps prove to be too optimistic to implement. Medical schools creating residency programs specifically for their unmatched graduates could alleviate the problem of unmatched residents and still fit within our current GME structure, but that will be dependent upon the initiative of multiple medical schools and the success they find. The implementation of the provisional license may prove to be the most impactful to alleviating not only the physician shortage but of the mass of medically experienced individuals that are not working within our health system as well. As stated before, having the provisional license provide a pathway to becoming a physician would fundamentally challenge the residency program and will most likely not be implemented in the near future; however, medical school graduates should at least not lose the ability to do what they have been doing throughout medical school—especially in times of the physician shortage.

 

Work Cited

Dayaranta, Kevin D. PhD and John O’Shea, MD. “Addressing the Physician Shortage by Taking Advantage of an Untapped Medical Resource.” The Heritage Foundation, no. 3221, May 30, 2017, BG3221_0.pdf (heritage.org).

Dewan, Mantosh J. MD and John J. Norcini, PhD. “We Must Graduate Physicians, Not Doctors.” Academic Medicine, vol. 95, issue 3, March 2020, pp. 336-339, We Must Graduate Physicians, Not Doctors : Academic Medicine (lww.com).

Gathright, Molly M. MD et al. “A Transitional Year Residency Program Provides Innovative Solutions for Unmatched Medical Students.” Journal of Graduate Medical Education, vol. 13, no. 4, 2021, pp. 561-568, A Transitional Year Residency Program Provides Innovative Solutions for Unmatched Medical Students | Journal of Graduate Medical Education (allenpress.com).

Way, Charles W. III, MD. “Are Assistant Physicians a Good Idea: Should We Create Jobs for Unmatched Physicians?” Missouri Medicine, vol. 118, no. 3, June 2021, pp. 179-181, Are Assistant Physicians a Good Idea? (nih.gov).

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