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Academic Medicine Medical Education

Lessons From The 2022 Fellowship Match

This month, the National Resident Matching Program (NRMP) released the results of this year’s match for fellowships that will begin in July 2022. Match day for most subspecialty fellowships was in December 2021 although some subspecialties had their match day earlier in the year. The new report summarizes the results of these match days.

The process for physician training begins with medical school graduates entering a residency in a specific specialty such as internal medicine, pediatrics, obstetrics & gynecology, or surgery. After completing residency, physicians can do further subspecialty training in fellowships. For example, cardiology is a subspecialty of the specialty of internal medicine. Therefore, to become a cardiologist, a physician first completes an internal medicine residency and then completes a cardiology subspecialty fellowship. Some subspecialties have their own subspecialties. For example, a physician completing a cardiology subspecialty fellowship can go on to do an even more specialized subspecialty fellowship in cardiac electrophysiology.

In the match, physicians who are either in their final year of residency or have already completed residency apply to fellowship training programs. The physician applicants then rank the training programs in order of their preference and the fellowship training programs also rank the applicants in their order of preference. The NRMP computers then assign each applicant to a specific training program using an algorithm that matches the applicant’s preferences with the training programs’ preferences. Overall, the process works and ensures that the applicants get into their most preferred training program that will accept them.

Every spring, the NRMP releases an annual report of the data from the match and by examining the data, there is a wealth of conclusions about the current state of the various subspecialties.

More physicians are specializing

From 1995 to 2000, the number of fellowship positions as well as the number of physicians applying to fellowships fell. However, since 2000, there has been a steady increase in both the available fellowship positions as well as the number of applicants for those positions. This year, 13,586 physicians applied for 12,571 fellowship positions. The majority of applicants were U.S. MD degree graduates (7,141), followed by non-U.S. citizen graduates of international medical schools (2,619), U.S. DO degree graduates (1,991), and U.S. citizen graduates of international medical schools (1,791).

The number of fellowship positions has been increasing faster than the number of resident positions. Over the past 2 decades, resident positions have increased by 74% from approximately 20,200 in 2000 to 35,194 in 2021. During that same time period, fellowship positions have increased by 558%, from approximately 1,900 in 2000 to 12,571 in 2022. In other words, resident positions have not quite doubled in the past twenty years whereas fellowship positions have increased by 5.5-fold.

Internal medicine subspecialties account for the largest number of fellowship positions. 49% of the 12,571 fellowship positions were in internal medicine subspecialties, followed by pediatrics (14%), surgery (7%), and radiology (7%). The penetration of subspecialty fellowships varies between different specialties. For example, there were 1,137 resident positions offered in radiology in 2021 (the most recent year resident data is available) and 869 fellowship positions offered in radiology in 2022. Therefore, there were 0.76 radiology fellowship positions for every 1 radiology resident positions. If all resident and fellow positions were filled, then this would imply that 76% of radiology residents go on to do radiology subspecialty fellowships. Similarly, this analysis would estimate that 69% of internal medicine residents do fellowships whereas only 13% of physical medicine & rehabilitation residents do fellowships.

The number of foreign medical school graduate applicants fell

In recent years, the number of all types of applicants for subspecialty fellowships have been increasing. For the 2022 year, the number of non-U.S. citizens graduating from international medical schools (foreign medical graduates) decreased for the first time from 2,332 in 2021 to 2,280 in 2022. All other types of fellowship applicants increased in number in 2022. One of the main reasons for the decrease in foreign medical graduates was the COVID pandemic that resulted in immigration and travel restrictions that prevented many foreign applicants from coming to the U.S. for medical training.

Non-U.S. citizens who graduated from international medical schools make up a minority of physicians who match in most subspecialties. However, in subspecialties that are less popular with U.S. MD degree graduates, foreign medical graduates comprise the largest percentage of matched positions. Four subspecialties had more foreign medical graduates than U.S. MD degree graduates filling fellowship positions: adult endocrinology (40.4%), adult nephrology (35.8%), adult pulmonary (26.1%; note that there are relatively few positions available for adult pulmonary-alone fellowships and most positions are for combined pulmonary & critical care medicine), and medical genetics (52.2%).

U.S. DO degree graduates (osteopathic school graduates) have historically comprised the smallest number of subspecialty fellowship applicants but now exceed the number of applicants who are U.S. citizen graduates of foreign medical schools. Because of the traditional emphasis on musculoskeletal elements of disease and rehabilitation, osteopathic graduates tend to gravitate to certain subspecialties. Those with more than 20% of filled positions going to U.S. DO degree graduates include: pain medicine (21.5%), emergency medicine services (27.2%), global emergency medicine (22.7%), hospice & palliative medicine (20.7%), brain injury medicine (27.3%), spinal cord injury medicine (35.3%), and sports medicine (36.6%).

Highly competitive subspecialties

The more applicants (particularly U.S. MD degree graduates) there are per subspecialty fellowship position is a marker of how competitive that subspecialty is. Those subspecialties with more applicants than available fellowship positions are highly competitive whereas the subspecialties with more fellowship positions than applicants are less competitive. The 2022 NRMP fellowship match report reveals that some subspecialties are for more competitive than others. Overall, the average subspecialty fellowship filled with 51% U.S. MD degree graduates. The results listed below are the subspecialty fellowship positions that filled with more than 70% U.S. MD degree graduates:

  • Obstetrics & Gynecology. Overall, the subspecialties of OB-GYN are the most competitive of all major specialties: complex family planning (100%) filled all available positions with U.S. MD degree graduates followed by gynecologic oncology (94%), reproductive endocrinology (90%), maternal-fetal medicine (88%), pelvic & reconstructive surgery (79%), and minimally invasive gynecologic surgery (73%).
  • Surgery. Highly competitive subspecialties include: pediatric surgery (95%), hand surgery (85%), colon & rectal surgery (80%), and thoracic surgery (71%).
  • Pediatrics. Three of the 17 pediatric subspecialties were highly competitive: adolescent medicine (77%), child abuse (70%), and pediatric hospital medicine (70%).
  • Internal Medicine. Only hematology (85%) was highly competitive. However, relatively few physicians do a hematology-only fellowship (14 positions) and the vast majority do a combined hematology/oncology fellowship (663 positions).
  • Emergency Medicine. Medical toxicology (74%).

A second marker of competitiveness is the percentage of available fellowship positions in each subspecialty that fill with any applicant, including U.S. MD degree graduates, U.S. DO degree graduates, U.S. citizens graduating from international medical schools, and foreign medical graduates. Below are the subspecialties that filled more than 90% of their available fellowship positions:

Unpopular subspecialties

As in past years, some subspecialties are less popular. Those that filled with fewer than 40% U.S. MD degree graduates were mostly subspecialties of internal medicine and pediatrics:

  • Internal Medicine. The least competitive subspecialty was pulmonary disease (16%). However, relatively few physicians do a pulmonary-only fellowship (25 positions) and the vast majority do a combined pulmonary & critical care medicine fellowship (721 positions). Other unpopular subspecialties included nephrology (20%), geriatric medicine (20%), heart failure & heart transplant (27%), endocrinology (32%), infectious disease (38%), interventional pulmonary (38%), and oncology (38%). However, like hematology-only fellowships, there are relatively few positions in oncology-only fellowships (8) and most positions are in combined hematology & oncology (663) which was a considerably more popular subspecialty.
  • Pediatrics. The least popular pediatric subspecialty was infectious disease (20%) followed by developmental & behavioral pediatrics (29%), endocrinology (30%), and nephrology (32%).
  • Physical Medicine & Rehabilitation. Spinal cord injury medicine (32%).

Below are the subspecialties that filled fewer than 90% of there available positions with any applicant including U.S. MD degree graduates, U.S. DO degree graduates, U.S. citizens graduating from international medical schools, and foreign medical graduates:

Nephrology, endocrinology, and infectious disease remain unpopular

In both internal medicine and pediatrics, nephrology, endocrinology, and infectious disease are among the least popular subspecialties. One of the reasons that infectious disease and endocrinology remain unpopular is salary. According to the 2021 Medscape Physician Compensation Survey, the average general internal medicine physician had an income of $248,000 last year. However, despite requiring two additional years of subspecialty fellowship training after internal medicine residency, adult endocrinologists and infectious disease physicians made less than general internists at $245,000 for both subspecialties. It is difficult to justify investing two additional years into training in order to make less money than if you had gone straight into clinical practice after completing residency. A second physician salary survey is done by Doximity. Like the Medscape survey, Doximity also found that endocrinologists and infectious disease specialists have incomes less than general internists. In addition, the Doximity survey reports salaries for pediatric subspecialties and like their adult counterparts, pediatric endocrinologists and pediatric infectious disease specialists have a lower income than general pediatricians.

The Medscape survey also asks physicians if they feel they are adequately compensated – infectious disease physicians and endocrinologists are the least satisfied with their compensation at 44% and 50% of survey respondents satisfied respectively. The salary disparity has been particularly acute for infectious disease physicians who over the past two years of the COVID pandemic have been among the most over-worked physicians of any specialty. In other words, the message that internal medicine and pediatric residents hear is to go into infectious disease is to train longer, work harder, and get paid less.

The reasons for nephrology continuing to be unpopular are less clear. Nephrologists have a higher annual income than general internal medicine physicians with an average of $311,000 per year. However, this is less than other procedural internal medicine subspecialties such as pulmonary medicine, critical care medicine, cardiology, and gastroenterology. One of the primary clinical activities of nephrologists is overseeing dialysis. Most patients with end-stage renal disease receive hemodialysis three days per week, either Monday-Wednesday-Friday or Tuesday-Thursday- Saturday. Because of this schedule, nephrologists typically have a 6-day workweek to cover dialysis with a 1-day weekend (Sunday) whereas other subspecialties typically have a 5-day workweek with a 2-day weekend. It is possible that the longer workweek attendant to nephrology could be discouraging physicians from entering the subspecialty.

Geriatrics continues to be an unpopular subspecialty. Unlike many of the other fellowships, a physician can do either an internal medicine or a family medicine residency prior to a geriatric medicine fellowship. Salary is one of the barriers to applicants. Geriatric medicine requires a 1-year fellowship and most geriatricians practice primary care medicine for people over age 65. There is no additional compensation in terms of RVUs for caring for older patients and many of these patients have multiple concurrent medical problems as well as cognitive impairment. As a result, it can take a geriatrician longer for an outpatient visit while getting paid the same amount that a primary care internist or family physician would be paid for an office visit for a younger, less medically complex patient. Thus, the economics of geriatric medicine discourages family physicians and internists from entering the subspecialty.

So, what does all of this mean?

As fewer physicians go into specific subspecialties, there will likely be shortages of those subspecialists in the future. The pediatric subspecialties of endocrinology, infectious disease, and nephrology had a lowest percentage of available fellowship positions fill and will therefore face physician shortages in the near future. However, I believe that the most serious future shortage will be in adult nephrology. Pediatric subspecialists are relatively small in numbers and almost always located in large referral pediatric hospitals. On the other hand, adult nephrologists are needed in most community hospitals and any town large enough to have an outpatient dialysis center.

The number of unfilled subspecialty fellowship positions is even larger for geriatrics. However, general internal medicine physicians and family physicians can more easily fill in for shortages in geriatricians. Therefore, shortages of physicians trained in geriatrics will not be felt as severely by most communities.

For capitalism to work in medicine, supply and demand have to be unconstrained so that when the supply of a subspecialty falls, demand for that subspecialty can bring the supply back up through free market forces that increase the pay for those subspecialists. The U.S. system for paying physicians has led to an uncoupling of supply and demand. Unless health policy changes the way that subspecialists such as endocrinologists, infectious disease specialists, and nephrologists are compensated, we will be facing an increasing shortage of these physicians in the future. In the meantime, if your hospital has one of these subspecialists who is a high-performer, treat him or her well – they are becoming a very rare breed.

March 30, 2022

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital