Graduate Medical Education Positions And Physician Supply Continue To Increase: Implications Of The 2021 Residency Match

The National Resident Matching Program (NRMP) Main Residency Match occurs in mid-March each year. At that point, tens of thousands of students nearing completion of medical school and other physicians are matched with tens of thousands of graduate medical education (GME) training positions in nearly 6,000 training programs. With the merger of the Accreditation Commission for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA) accreditation system between 2015 and 2020, the “NRMP Main Match” now covers an estimated 96 percent of the physicians entering GME in the US. This post looks at some of the major takeaways from the 2021 NRMP Match including the implications for the physician workforce.

Serious concerns have been expressed that there are too few residency training positions in the US and that this is contributing to a gap between the number of medical school graduates and the number of training slots, often referred to as the “GME squeeze,” and that this shortage of residency positions is also contributing to a potential future physician shortage. In 2020, the Association of American Medical Colleges (AAMC) released their annual report projecting primary and non-primary care physician shortages between 55,100 and 141,900 physicians over the next decade.

GME—the residency and fellowship training where physicians differentiate into specialties—is a critical determinant of the physician workforce. GME is required for every physician seeking to become licensed to practice medicine. As such, GME determines the overall supply and specialty distribution of the future physician workforce (and to a certain extent, the geographical distribution and practice in rural and underserved settings).

The 2021 NRMP Main Match included all first-year positions in those specialties participating in the Match as well as some second-year positions that physicians can enter after a preliminary year of training. In this piece, we focus on the 35,194 first-year positions offered in the 2021 Match, and the 26,967 US MD and DO seniors actively participating in the Match for a first-year position.  

One advantage of analyzing NRMP data is that it provides an early indicator of workforce trends as the data are public even before physicians enter their graduate training. Those matched in the 2021 NRMP will not complete their training until at least 2024 and most will go on for several additional years of fellowship training. While the data provide a good indicator of the future physician workforce and their educational backgrounds, they provide only a partial picture of specialty choice due to future subspecialization rates. For example, more than half of internal medicine residents have gone on to subspecialize in the past.

Data Sources

The primary data sources for this analysis are the annual NRMP Advanced Data Tables published in March of each year and the Main Match Data and Results Reports published each May. Both sets of reports include data on type of medical education: allopathic (MD), osteopathic (DO), US citizen foreign medical school graduate; and non-US citizen foreign medical school graduate. The NRMP data also separately report MD and DO seniors and other MDs and DOs who completed medical school training in prior years. Some of the data for DOs in this post has been supplemented with data from the Association of American Colleges of Osteopathic Medicine.

Key Takeaways

The Number Of Entry GME Positions Continues To Grow 

There were 35,194 first-year positions offered in the 2021 Main Residency Match representing an increase of 2.7 percent from 2020. Comparing the combined number of ACGME- and AOA-accredited first-year positions in 2013 with the 2021 data indicates a 24.5 percent increase in positions over the eight years for an annual increase of 2.8 percent (exhibit 1). The net increase of 6,930 first-year positions over such a short period will be surprising to many given the absence of a major new federal funding initiative or change in GME policy. Some of these new positions may have received federal funding if at new teaching hospitals; others may have been self-funded by individual hospitals; and others may have received state support. For some specialties, hospitals may feel a training program will bring in additional revenue.

Exhibit 1: National Resident Matching Program applicants and first-year positions, 2013–21

Sources: National Resident Matching Program (NRMP) and Association of American Colleges of Osteopathic Medicine. Notes: DO applicant and total positions offered include first-year positions matched through the American Osteopathic Association from 2013 through 2019 as well as DOs entering Accreditation Commission for Graduate Medical Education positions. After 2019, all positions were offered through the NRMP.

There Are No Signs Of A Major GME Squeeze For US MD And DO Seniors

The number of new first-year GME positions is growing more rapidly than the annual number of graduating US medical school seniors. As noted above, the number of first-year positions grew by 6,930 positions at a 2.8 percent annual rate between 2013 and 2021. While 2021 graduation numbers are not available yet, during the period from 2013 to 2020, the number of MD and DO graduates combined grew from 22,961 to 27,273, an increase of 4,312 (18.8 percent); for an annual rate of 2.5 percent. In addition to the 35,194 positions offered in the NRMP Main Match in 2021, there were an estimated 1,500 other first-year positions offered in other Matches (the Matches for the military services, the San Francisco Match for Ophthalmology, and the Urology Match). Thus, in reality, there were an estimated 36,394 first-year positions available in 2021 compared to the 27,273 US graduating seniors in 2020.

Every year, there are some graduating MD and DO seniors who do not match at all. This is a serious problem especially for the individuals who have invested at least four years of their lives and usually a large sum of money to go to medical school. But the number of unmatched US seniors is relatively small and does not appear to be growing. In 2021, 2,205 MD and DO seniors did not match to first-year positions in the Main Match. However, there were 1,892 positions offered in the Supplemental Offer and Acceptance Program (SOAP) where US seniors generally do well. Analysis of unmatched MD graduates from 2005 to 2015 found that the percentage of unmatched seniors was between 2.6 percent and 3.5 percent each year, and after several years post-graduation, the percentage unmatched dropped to between 0.6 percent and 0.8 percent. The data from the 2021 NRMP Match appear consistent with these historical trends—if all SOAP positions were filled with US seniors, the unmatched rate for US MD and DO seniors combined would be 2.4 percent.

It is a different picture for graduates of schools outside of the US. For these graduates, the match rate is far lower. In the Main Match in 2021, only 56.7 percent of international medical graduates (IMGs) were matched. This is discussed further below.

The Nation’s Overall Supply Of Physicians Will Continue To Grow Steadily In The Future 

The current inflow of new trainees is significantly higher than the cohorts of physicians who are likely to retire annually over the next decade. In 1980, there were 16,172 MD and DO graduates; in 1990 there were 16,927 graduates. In terms of the pipeline, these graduates were supplemented by 3,000 to 3,500 IMGs each year during this period. If physicians’ practice 30 to 40 years and retirement rates are relatively stable, the cohorts retiring would be about 20,000 physicians per year for the next decade.

As noted above, the number of physicians entering GME was above 36,000 in 2021. While some non-US IMGs may return to their country of origin, historically, the vast majority have stayed in the US. Thus, the pipeline of new physicians is far greater than the expected outflow of about 20,000. Over the next decade, we may see the overall physician supply grow by more than 150,000 physicians. In addition, the annual number of new nurse practitioner and physician assistant graduates now exceeds the number of new physicians completing medical school. Hence, the supply of physicians, NPs, and PAs are all growing rapidly.

International Medical Graduates Continue To Be A Major Source Of Residents And Physicians For America 

In 2021, there were 13,238 active IMG applicants in the NRMP Match of which 7,508 IMGs were matched to first-year positions (excluding SOAP). Overall, IMGs represented 22.5 percent of all applicants who matched to first-year positions. IMGs include two very different cohorts: US IMGs, US citizens who have gone to medical school outside of the US, mostly at for-profit schools in the Caribbean; and non-US citizens who attended medical school in a foreign country, usually their home country.

The numbers of both types of IMGs matched in the Main Match has been increasing slowly (exhibit 2), with 4,356 non-US IMGs and 3,152 US IMGs matching to first-year positions in 2021 (excluding SOAP). Interestingly, while the number matched went up 22.5 percent for non-US IMGs and 17.1 percent for US IMGs between 2013 and 2021, the number of active applicants was more consistent, rising only 5.0 percent and 3.9 percent over the same time period for each group. One notable exception was in 2020 and 2021 for non-US IMGs. Perhaps due to US policies designed to discourage immigration and the COVID-19 pandemic, the numbers of non-US IMG applicants dropped from 7,460 in 2016 to 6,869 and 6,907 in 2019 and 2020 respectively, only to rise by more than a 1,000 to 7,943 in 2021.

Exhibit 2: International medical graduates matched to first-year positions in the National Resident Matching Program, 2012–21

Source: National Resident Matching Program.

Both US and non-US IMGs who are unable to match have also been the focus of concern. These individuals have invested an enormous amount of time and effort into their medical education. In the case of US IMGs, many face hundreds of thousands of dollars of student debt. Since 2013, nearly 35,000 foreign-educated US citizens have entered GME training, mostly from for-profit Caribbean schools. The match rate for the graduates of these programs in 2021 was 59.5 percent for active participants, much lower than for graduating US medical school seniors. This match rate would be much lower, but many Caribbean students did not submit rank order lists or withdrew from the Match. Others may not have applied to the NRMP at all. Given the growth of US medical schools, the high cost of medical education, and the low match rate for US IMGs, it may be time for the US to reassess guaranteed student loans for these schools.

The high number of non-US IMGs may also be a problem for the rest of the world. Since 2013, more than 60,000 non-US IMGs have been accepted into GME. The vast majority stay in the US and most come from lower-income countries where their medical education was supported by public funds.

Steady Growth In GME Positions

The data clearly show that GME positions continue to grow. In 2015, Fitzhugh Mullan and colleagues published their analysis of GME trends in the New England Journal of Medicine and concluded that a GME squeeze was unlikely based on the data at that time on the growth of medical school graduates and residency positions. That conclusion was based on what was then a 1.7 percent annual growth in first-year positions and a 2.4 percent annual growth in graduating MD and DO seniors. Using more recent data, the current analysis finds that GME first-year positions are growing at about 2.8 percent per year compared to 2.5 percent growth of medical school graduates. The current analysis also found that the percentage of US graduates that are unmatched each year has been surprisingly consistent.

Concern for US MD and DO seniors who are not able to secure a residency position is appropriate. More needs to be done to assist them, including providing guidance in their selection of the positions they rank in the NRMP Main Residency Match. There are some specialties that are more competitive than others with more applicants than available positions in the specific specialty. In some cases, the number of US seniors selecting only one specialty exceeded the total number of positions available in that specialty. For example, in 2020, there were 921 MD and DO seniors who only ranked orthopedic surgery residency positions (and another 101 who listed the specialty first), but there were only 849 positions available. 

The fact that some US seniors don’t get matched in the Main Match is of concern. But this is not a function of too few residency positions, and the extent of the problem is not growing. Two key questions to consider for further research: Why are more than 7,000 IMGs matched each year over some US seniors? And what role does unrealistic match choices by US seniors play in this discrepancy?

The physician workforce will continue to grow over time as will the supply of NPs and PAs. On one hand, this is good news for rural and urban underserved areas as recruitment and retention should get easier. On the other hand, all three professions are likely to face increased competition for jobs, especially in desirable communities and near academic medical centers.

Finally, despite what has become an annual push by the AAMC and others for billions of dollars of new GME dollars to support more GME positions, the reality is that there has been steady growth in GME positions without any major new federal dollars and that GME growth has more than kept pace with increases in graduating MD and DO seniors. Furthermore, the current level of medical education and training appear sufficient to meet future needs when combined with the growth in NP and PA graduates.

Authors’ Note

Edward Salsberg is a member of the NRMP board but receives no compensation and this post relies only on publicly available data.