Yesterday, on November 30, 2022, the results of this year’s fellowship match for internal medicine and pediatric subspecialties was released. This is for fellowship positions that will begin in July 2023. Every specialty has its own fellowship match and the dates of the match results vary from as early as May the year before the start of fellowship (vascular surgery, thoracic surgery, pediatric surgery) to January the year of the start of fellowship (sports medicine, psychiatry). The internal medicine and pediatric match results are released at the end of November.
The results of all of the fellowship match results are made available in a report published by the National Resident Matching Program in March every year. Last year’s match showed that more physicians are subspecializing, fewer foreign medical graduates applied, certain subspecialties were very competitive (surgical and OB/GYN subspecialties) and certain subspecialties were less popular (most internal medicine and pediatric subspecialties). Although we will not know the complete results of all subspecialty fellowship matches for several months, internal medicine and pediatrics represent the largest number of fellowship positions and so we can draw preliminary conclusions for yesterday’s match results in those subspecialties.
The terminology used in physician specialization can be confusing. As an example, internal medicine is a specialty and cardiology is a subspecialty within internal medicine. This means that a cardiologist must first complete an internal medicine residency and then do further training in a cardiology fellowship. This post will focus on the recent subspecialty fellowship match results for the specialties of internal medicine and pediatrics.
Overall, there were 2,042 different programs participating in this year’s internal medicine subspecialty fellowship match and these programs offered a total of 5,779 fellowship positions. 82.1% of programs filled all of their positions and 89.5% of all positions in the country filled. These results are similar to last year. Of the physicians who did match, 46.8% were U.S. MD graduates, 13.5% were U.S. DO graduates, 12.8% were U.S. citizens who attended foreign medical schools, and 26.7% were foreign medical graduates. This is a slight decrease in the percent filled by U.S. MD graduates and a slight increase in foreign medical graduates compared to last year.
As in the past, certain internal medicine specialties were more competitive than others. Competitive programs are those that had a higher percentage of their total positions filled. The most competitive subspecialties were cardiology and interventional pulmonary that both filled 100% of their positions, followed by gastroenterology (99.8%) and hematology/oncology (99.7%). Three subspecialties filled fewer than 65% of positions: adult congenital heart disease (63.6%), transplant cardiology & heart failure (55.9%), and geriatrics (45.4%).
Two other subspecialties had relatively low fill percentages: infectious disease (74.4%) and nephrology (72.8%). These two subspecialties are concerning because their total number of fellowship positions is considerably higher than other low-performing subspecialties. There were 441 infectious disease fellowships offered and 493 nephrology fellowship positions offered compared to adult congenital heart disease (22 fellowship positions offered) and transplant cardiology & heart failure (127 positions offered). The implication of these results is that our country will face a much larger shortfall in the number of internal medicine infectious disease specialists and nephrologists in the future compared to other subspecialties.
A second way of determining the competitiveness of a subspecialty is by the percentage of positions filled by U.S. medical school graduates (MD). In general, most subspecialty fellowships are affiliated with medical schools offering MD degrees (as opposed to DO, or osteopathic, degrees). Historically, U.S. MD graduates tend to have an advantage over U.S. DO graduates, U.S. citizens graduating from foreign medical schools, or foreign medical school graduates who are not U.S. citizens. Subspecialties with the highest percentage of U.S. MD graduates filling available fellowship positions were adult congenital heart disease, gastroenterology, hematology & oncology, and interventional pulmonary. Pulmonary medicine had a very low filling percentage by U.S. MD graduates but there were only 27 total positions offered in 2022 since most physicians instead choose to do a combined pulmonary & critical care medicine fellowship (748 positions offered).
Graduates of U.S. osteopathic (DO) schools were most likely to fill pulmonary medicine-only fellowships or critical care medicine-only fellowships. But again, these fellowships offer very few available positions since most available positions are in combined pulmonary & critical care medicine fellowships. Geriatrics, infectious disease, and nephrology all had high percentages of U.S. osteopathic graduates.
U.S. citizens attending foreign medical schools account for nearly as many filled subspecialty fellowship positions as U.S. osteopathic graduates and followed a similar trend with a high percentage in pulmonary-only and critical care medicine-only fellowships followed by nephrology, interventional pulmonary, geriatrics, and endocrinology.
The final group of physicians filling positions in the 2022 internal medicine subspecialty fellowship match was non-U.S. citizens who graduated from foreign medicine schools (foreign medical graduates). Subspecialties with the highest percentage of positions filled by foreign medical graduates were endocrinology, pulmonary-only, and nephrology.
Overall, there were 919 different pediatric subspecialty fellowship programs that together offered 1,814 fellowship positions in the 2022 match for fellowships to start in July 2023. 74.9% of the programs filled and 84.7% of all positions were filled. Pediatric subspecialty fellowship positions were most likely to be filled by U.S. MD graduates (61.6%) followed by foreign medical graduates (14.8%), U.S. DO graduates (14.7%), and U.S. citizen graduates of foreign medical schools (8.8%). These percentages were unchanged compared to the previous year’s match. Compared with internal medicine, more pediatric subspecialty fellowship positions fill with U.S. MD graduates.
The most competitive pediatric subspecialty fellowships were gastroenterology, emergency medicine, and cardiology which all filled more than 97% of available fellowship positions. Similar to internal medicine, the least competitive subspecialties were infectious disease (49%) and nephrology (54%), as well as endocrinology (61%).
The pediatric subspecialties most likely to fill with graduates of U.S. medical schools were adolescent medicine, hospital medicine, and infectious disease – all of which filled 73% of positions with U.S. MD graduates. The least likely were transplant hepatology and endocrinology, each of which filled 50% of available positions with U.S. MD graduates.
Subspecialties with the highest percentages of graduates of U.S. osteopathic schools were child abuse (31%), gastroenterology (19%), and hospital medicine (19%). Subspecialties with the lowest percentage of U.S. DO graduates were infectious disease (5%) and rheumatology (4%).
There were only 135 U.S. citizen graduates of foreign medical schools who matched into pediatric subspecialty fellowships with the highest percentages in developmental-behavioral medicine (16%) and endocrinology (14%).
Foreign medical graduates had the highest representation in rheumatology (30%) and transplant hepatology (33%). They had the lowest representation in hospital medicine (1%).
Implications of the match
The overall trends of the 2022 match (for fellowships to begin in July 2023) are similar to the 2021 match. For both internal medicine and pediatrics, two subspecialties continue to be unpopular and had a high percentage of unfilled positions: nephrology and infectious disease. In both pediatrics and in internal medicine, physicians in these two subspecialties have lower annual incomes than other subspecialties due to the current U.S. physician billing and reimbursement model. For internal medicine, these 2 subspecialties are also those with the highest percentages of foreign medical graduates filling fellowship positions.
The results of the match suggest that the United States will see an increasing shortage of both adult and pediatric nephrologists and infectious disease specialists. Pediatric endocrinology and adult geriatrics will also face physician shortages In order to attract these subspecialists, hospitals will need to subsidize their salaries as they are not able to generate competitive incomes by professional revenues alone. As these shortages become more severe, the clinical services provided by these subspecialists will need to increasingly be provided by primary care physicians and advance practice providers.
December 1, 2022