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The 2017 Match and the Future US Workforce

      For 25 years from 1980 to 2005, the number of US MD medical schools and the number of MD students did not increase because of predictions of an oversupply of US physicians by the Council on Graduate Medical Education (COGME).
      • Dalen J.E.
      The moratorium on US Medical school enrollment from 1980 until 2005: what were we thinking?.
      Then, in 2005, the COGME reversed its opinion and predicted a shortage of physicians. The COGME recommended a 15% increase in enrollment of US MD and DO medical students.
      • Council on Graduate Medical Education
      Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 2000-2020.
      In 2006, the Association of American Medical Colleges recommended a 30% increase (over the 2002 enrollment) of US MD medical students by 2019.
      • Association of American Medical Colleges
      AAMC statement on the physician workforce.
      They recommended that the increase should be achieved by increased enrollment in Liaison Committee on Medical Education schools and an increase in the number of medical schools.
      • Association of American Medical Colleges
      AAMC statement on the physician workforce.
      In 2010, the COGME recommended an increase in the percentage of generalists from the then 32% to 40% of US practicing physicians.
      In response to these recommendations, there has been a brisk increase in the number of US MD and DO medical schools and in the number of enrolled medical students.
      • Gudbranson E.
      • Glickman S.A.
      • Emanuel E.J.
      Reassesing the data on whether a physician shortage exists.
      Will these increases solve the shortage of US physicians and will they increase the percent of generalist physicians? The results of the 2017 National Resident Matching Program (NRMP)
      • National Resident Matching Program
      2017 NRMP main residency match the largest match on record.
      together with the 2017 American Osteopathic Association (AOA) match
      • American Association of Colleges of Osteopathic Medicine
      provide some clues as to the future US medical workforce.
      The 4 main groups of physicians who compete for postgraduate first-year positions are US MD graduates, US osteopath graduates, US international medical graduates, and non-US international medical graduates.
      MD graduates of US and international medical schools compete for US resident postgraduate first-year positions through the NRMP.
      • National Resident Matching Program
      2017 NRMP main residency match the largest match on record.
      Graduates of US osteopathic schools may enter the NRMP match or the AOA match.
      • American Association of Colleges of Osteopathic Medicine
      An increasing number of DO graduates are entering the NRMP match rather than the AOA match.

      Applications for US Postgraduate First-Year Positions in 2002 and 2017 National Resident Matching Program
      • National Resident Matching Program
      2017 NRMP main residency match the largest match on record.
      • National Resident Matching Program
      Main residency match data and results.
      and American Osteopathic Association Matches
      • American Association of Colleges of Osteopathic Medicine
      • Obradovic J.L.
      • Winslow-Falbo P.
      Osteopathic graduate medical education.

      In 2017, applications for postgraduate first-year positions from US MD seniors increased by 29% and osteopath applicants increased by 128%. US MDs and DOs together increased by 45%. This increase in US MD and DO physicians meets the recommendations of the Association of American Colleges
      • Association of American Medical Colleges
      AAMC statement on the physician workforce.
      and exceeds the recommendations of the COGME
      • Council on Graduate Medical Education
      Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 2000-2020.
      In addition, there was a striking 150% increase in applications from US international medical graduates and a 60% increase in non-US international medical graduates.
      Despite the large increases in US and non-US international medical graduates, US MD and DOs accounted for two thirds of the applicants. The total increase in applicants to the 2017 NRMP and AOA match was 57% greater than the 2002 applicants (Table 1).
      • National Resident Matching Program
      2017 NRMP main residency match the largest match on record.
      • American Association of Colleges of Osteopathic Medicine
      • National Resident Matching Program
      Main residency match data and results.
      • Obradovic J.L.
      • Winslow-Falbo P.
      Osteopathic graduate medical education.
      Table 1Applicants to National Resident Matching Program and American Osteopathic Association Match 2002 Versus 2017
      • National Resident Matching Program
      2017 NRMP main residency match the largest match on record.
      • American Association of Colleges of Osteopathic Medicine
      • National Resident Matching Program
      Main residency match data and results.
      • Obradovic J.L.
      • Winslow-Falbo P.
      Osteopathic graduate medical education.
      20022017% Increase
      Total US MD14,33618,53929%
      DO NRMP/AOA26025937128%
      Total US MD/DO16,93824,47645%
      US IMG20295069150%
      Non-US IMG4556728460%
      Total applicants23,52336,82957%
      AOA = American Osteopathic Association; IMG = international medical graduate; NRMP = National Resident Matching Program.

      Which Applicants Matched to Which Postgraduate First-Year Positions?

      As shown in Table 2, the number of available postgraduate first-year positions increased from 23,075 in 2002 to 31,412 in 2017, an increase of 36%. The number of US MDs matching to a postgraduate first-year position increased by 30% from 2002, and the number of US osteopaths increased by 37%. US MDs and DOs filled 71% of the postgraduate first-year positions. US international medical graduates and non-US international medical graduates had significant increases in the matched positions. The number of physicians beginning resident training in 2017 was 8483 (41%) more than in 2002.
      • National Resident Matching Program
      2017 NRMP main residency match the largest match on record.
      • American Association of Colleges of Osteopathic Medicine
      • National Resident Matching Program
      Main residency match data and results.
      • Obradovic J.L.
      • Winslow-Falbo P.
      Osteopathic graduate medical education.
      Table 2Matches to Postgraduate First-Year Positions in National Resident Matching Program and American Osteopathic Association Match
      • National Resident Matching Program
      2017 NRMP main residency match the largest match on record.
      • American Association of Colleges of Osteopathic Medicine
      • National Resident Matching Program
      Main residency match data and results.
      • Obradovic J.L.
      • Winslow-Falbo P.
      Osteopathic graduate medical education.
      20022017% Increase
      PG1 positions23,07531,41236%
      US MDs matched13,48917,48030%
      DO matched NRMP/AOA3580490537%
      US MDs and DOs matched17,06922,38531%
      US IMG matched10922778154%
      Non-US IMG2335381663%
      Total PG1 matched20,49628,97941%
      AOA = American Osteopathic Association; IMG = international medical graduate; NRMP = National Resident Matching Program; PG1 = postgraduate first year.

      Impact of 2017 Match on Primary Care

      One of the reasons for the recommendation for an increase in the number of US medical students and medical schools was the shortage of generalist (primary care) physicians in the United States.
      • Dalen J.E.
      • Ryan K.J.
      • Alpert J.S.
      Where have the generalists gone? They became specialists, then subspecialists.
      The percent of generalist physicians in practice in 2002 was 32%.
      • Association of American Medical Colleges
      2016 Physician Specialty Data Book, November 2014.
      The goal of the COGME was to increase the percent of primary care physicians to 40%.
      • Council on Graduate Medical Education
      Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 2000-2020.
      Will the huge (41%) increase in physicians entering residency programs in 2017 compared with 2002 increase the percent of generalists when they complete their residencies?
      The US primary care workforce, the generalists, consists of general internists, general pediatricians, medical-pediatricians, and family practitioners. As shown in Table 3, the percent of 2017 applicants who entered these potential primary care residency programs increased by 43% from 2002 to 2017. How many of the physicians who entered these residency programs in 2017 will emerge as primary care physicians? Unfortunately, a minority of these physicians entering these residencies will enter practice as generalists.
      • Dalen J.E.
      • Ryan K.J.
      United States medical school expansion: impact on primary care.
      Table 3Number of Residents Entering Primary Care Residencies 2002 and 2017 (National Resident Matching Program and American Osteopathic Association (Match)
      20022017% Change
      Internal Medicine4664762864%
      Medical-Pediatrics3403565%
      Pediatrics2058273333%
      Family Medicine3114382523%
      Totals10,17614,54243%
      Most residents who complete a 3-year internal medicine residency take further training and enter practice as subspecialists.
      • Dalen J.E.
      • Ryan K.J.
      United States medical school expansion: impact on primary care.
      The percent entering medical subspecialties increased from 30% in 2002 to 88% in 2015.
      • American Board of Internal Medicine
      Number of candidates certified.
      There was a 52% increase in the number of internal medicine postgraduate first-year positions offered in 2017 (7944) than in 2002 (5237). Some 96% of the positions were filled. Because 88% or more of these internal medicine residents will become specialists or subspecialists, the percentage of internal medicine residents entering the US physician workforce as general internists will decrease. The same trend has decreased (to a lesser extent) the number of general pediatricians.
      • American Board of Pediatrics
      American Board of Pediatrics 2015-2016 Workforce Data.
      Nearly all who complete a medical-pediatrics residency will practice as generalists. Almost all residents who complete a 3-year residency in family medicine enter practice as family practitioners.
      In Table 4, we predict how many of these residents will enter practice as generalists. We predict that less than half (~6527) of the 14,542 physicians who were matched to a primary care residency in 2017 will emerge as generalists. The majority will enter practice as specialists or subspecialists. If this prediction is accurate, 23% of physicians who begin residency in 2017 will become generalists and 77% will be specialists. There will be no progress toward the COGME goal of a workforce of 40% generalists.
      • Council on Graduate Medical Education
      Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 2000-2020.
      Table 4Potential Primary Care Physicians in 2017 Postgraduate First-Year National Resident Matching Program
      • National Resident Matching Program
      2017 NRMP main residency match the largest match on record.
      and American Osteopathic Association Match
      • American Association of Colleges of Osteopathic Medicine
      No. Match% PrimaryNo. Primary
      Internal Medicine762812%915
      Pediatrics273360%1640
      Medical-Pediatrics35695%338
      Family Medicine382595%3634
      14,5426527

      Impact of 2017 Draft on Family Medicine

      The majority of US generalists in the future will be family practitioners. The number of general internists and general pediatricians will continue to decrease.
      Will the continued increase in the number of US MD and DO medical students increase the number of future family practitioners? The number of postgraduate first-year positions in family medicine (NRMP)
      • National Resident Matching Program
      2017 NRMP main residency match the largest match on record.
      and AOA draft
      • American Association of Colleges of Osteopathic Medicine
      was slightly less in 2017 (4315) than in 2002 (4514). Some 98% of the family practice positions in 2017 were filled.
      • National Resident Matching Program
      2017 NRMP main residency match the largest match on record.
      • American Association of Colleges of Osteopathic Medicine
      As shown in Table 5, 180 more US MD and DO physicians matched to family medicine in 2117 than in 2002 (a 7% increase). In addition, the number of international medical graduates entering family medicine residencies increased by 399. The total increase in family practice postgraduate first year from 2002 to 2017 was 579, a 19% increase over 2002. Although the number of physicians who matched in 2017 increased by 8483, only 579 (7%) entered family medicine residencies. Table 6 demonstrates that family medicine was the first choice of only 9% of US MDs. Osteopaths and US international medical graduates were approximately 3 times as likely to choose family medicine than US MD graduates.
      Table 5Physicians Matched to Family Medicine
      • National Resident Matching Program
      2017 NRMP main residency match the largest match on record.
      • American Association of Colleges of Osteopathic Medicine
      • National Resident Matching Program
      Main residency match data and results.
      • Obradovic J.L.
      • Winslow-Falbo P.
      Osteopathic graduate medical education.
      20022017%
      US MDs139515138%
      DOs (NRMP and AOA)111811846%
      MD /DO251726977%
      IMGs (US + foreign)59699567%
      Total3113369219%
      % PG1 FP positions filled68%86%
      AOA = American Osteopathic Association; FP = family practice; IMG = international medical graduate; NRMP = National Resident Matching Program; PG1 = postgraduate first year.
      Table 6Percent of Applicants to National Resident Matching Program and American Osteopathic Association Match in 2017 Who Selected Family Medicine
      • National Resident Matching Program
      2017 NRMP main residency match the largest match on record.
      • American Association of Colleges of Osteopathic Medicine
      US MDs9%
      Osteopaths24%
      US IMG24%
      Foreign IMG9%
      Total11%
      IMG = international medical graduate.

      Conclusions

      The response to the 2005 COGME
      • Council on Graduate Medical Education
      Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 2000-2020.
      and the Association of American Colleges' 2006 recommendations
      • Association of American Medical Colleges
      AAMC statement on the physician workforce.
      for an increase in the enrollment of US Medical students has been dramatic. The 45% increase in US MD and DO physicians applying for postgraduate first-year positions in 2017 compared with 2002 indicates that the recommended increase in medical student enrollment was achieved by 2013 or earlier. In addition to the increase in US MD and DO graduates, there has been a significant increase in US and non-US international applicants. In 2017, 8638 more physicians entered US residency programs than in 2002: a 41% increase.
      • National Resident Matching Program
      2017 NRMP main residency match the largest match on record.
      • American Association of Colleges of Osteopathic Medicine
      We predict that less than 25% of the physicians who began their residency in 2017 will enter the workforce as generalists. The remaining 75% will become specialists and subspecialists. The increase in the percent of US generalist physicians recommended by the COGME
      • Council on Graduate Medical Education
      Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 2000-2020.
      will not occur. The percent of US physicians who are generalists will continue to decrease. If the number of US MD and DO medical schools continues to increase faster than the US population increases, a surplus of US specialists and subspecialists seems inevitable.

      References

        • Dalen J.E.
        The moratorium on US Medical school enrollment from 1980 until 2005: what were we thinking?.
        Am J Med. 2008; 121: e1-e2
        • Council on Graduate Medical Education
        Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 2000-2020.
        Department of Health and Human Services. Health Resources and Services Administration, Rockville, MD2005
        • Association of American Medical Colleges
        AAMC statement on the physician workforce.
        (June; Available at)
        www.aamc.org/download/55458/data/workforceposition.pdf/
        Date: 2006
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      1. Council on Graduate Medical Education, Twentieth Report: Advancing Primary Care. Department of Health and Human Services, Health Resources and Services Administration, Rockville, MD2010
        • Gudbranson E.
        • Glickman S.A.
        • Emanuel E.J.
        Reassesing the data on whether a physician shortage exists.
        JAMA. 2017; 317: 1945-1946
        • National Resident Matching Program
        2017 NRMP main residency match the largest match on record.
        (Available at)
        • American Association of Colleges of Osteopathic Medicine
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        • National Resident Matching Program
        Main residency match data and results.
        (Available at)
        http://www.nrmp.org/wp-content/uploads/2013-/08/results
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        • Obradovic J.L.
        • Winslow-Falbo P.
        Osteopathic graduate medical education.
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        • Ryan K.J.
        • Alpert J.S.
        Where have the generalists gone? They became specialists, then subspecialists.
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        • Association of American Medical Colleges
        2016 Physician Specialty Data Book, November 2014.
        (Available at)
        • Dalen J.E.
        • Ryan K.J.
        United States medical school expansion: impact on primary care.
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        • American Board of Internal Medicine
        Number of candidates certified.
        (Available at:)
        • American Board of Pediatrics
        American Board of Pediatrics 2015-2016 Workforce Data.
        (Available at)
        http://www.abp.org/content/workforce-data
        Date accessed: July 15, 2017