NRMP Match – “All In”

July 3, 2012
The Residency Program Director 1

The National Resident Matching Program had for years allowed residencies to use the “match” to fill some of their PGY 1 resident positions while also using pre-match contracts for eligible applicants. Many hospitals had successfully filled first year classes with a mix of pre-match and match residents. US MD students from LCME schools are required to use the match in their graduation year, so specialties are popular among US grads.  Residencies at med schools were already using “All In” due to the NRMP obligation of their students graduating.  Family Medicine and Internal Medicine residencies at community hospitals were the main beneficiaries of the pre-match contract.  It was a strategy that seemed to allow them to bring in a higher caliber of applicant from the pool of IMG and DO students.

FM and IM residencies were increasingly considering this way of filling because their fill rates using  NRMP from 2000 – 2010 had a steady decline.

The reason NRMP allowed the pre-match contract process was to let IMGs with difficult immigration paperwork get their papers finished on time.  Many, many IMGs are US citizens so this has not been a big issue of late for starting residency on time.

The pre-match and match processes seemed to complement each other and residencies that could not fill using the Match were reporting signing good students who really wanted to be in the specialty.

Well, all that will end in 2013.  NRMP will switch to the “All In” format.   The only way to use NRMP as a residency is to list all of your spots in the NRMP.

Whether they believe they can successfully fill with all LCME US grads, few residencies can say that they do not want any LCME US grads.  So I believe almost all residencies will use the match for all PGY-1 hiring next year.

What are the implications of “All In” for applicants?  For MD US grads, it may improve their match statistics.  For the last 3 years there were 800-900 USGs who were unmatched.    This meant that there were more than 5% of US grads with no job on match day.   Even worse, there were very few unfilled programs on scramble day.  By the end of scramble week as many as 500 US grads had no job in medicine.   The number of unmatched programs was so few in part because of the pre-match signing trend.   So one group who may be happy about “All in” are US grads who get forced into scramble.

For IMGs with very good applications, loss of pre-match offers means an increase in uncertainty.  Even if there is a residency in your home town that likes you there will be no more guarantees in the form of a contract.  However, these candidates will still likely get jobs through the match.

For IMGs with average applications the “All In” era will not be trouble at first.  After all, there are in excess of 6000 more PGY-1 spots now than there are DO and MD US grads.   America still expects nearly a quarter of its physician workforce to be trained overseas.

Trouble is coming later.  Medicare funding is not going to increase.  The number of PGY-1 positions will hold fast at current levels or decline (now around 25,000).   The number of US medical school grads is increasing.  After a twenty year period with no new schools opening there has been a flurry of new school activity.  As many as 3000 more US grads per year are expected by 2013 (as compared to 2007).  Each new US grad will displace an IMG.   So the statistical chances of matching as an IMG will decline each year.   Will the new US med school slots go to US students who were considering training overseas?

In addition to “All In” for 2013, the scramble process was redesigned in 2012 to remove chaos and yet reviews from some programs that scrambled this year were mixed.

So for IMGs and USGs big changes are coming in recruitment, match and scramble, and at the same time chances of getting into a US medical school residency will drop.

Each year hundreds of US grads and thousands of IMG grads who have hopes to become a US residency trained doctor do not get a training spot.  From this point on this number of unemployed med school grads may grow every year.  Many have huge educational loans and no way to pay them back.  We do not need another debt bubble to pop.

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The Residency Program Director 1

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