Categories
Medical Education

The 2024 Residency Match

This month, the results of the main residency match for 2024 were released by the National Residency Match Program (NRMP). The results of the match give important insight into how medical students see prospects for different specialties in the future and also give hospitals insight into the future supply of various specialists. A record-high 50,413 applicants registered for the match this year and 44,853 applicants ultimately submitted a residency rank list. Overall, 80.2% of applicants submitting a rank list for a PGY-1 residency position successfully matched.

A little background on the match

In about September every year, senior medical students decide what specialty they would like to practice and send applications out to residency programs that they are interested in. The residency programs then select which students to interview for those positions and those interviews are carried out in the fall and winter. In February, after all of the interviews have been completed, the medical students create a ranked list of all of the residency programs that they would consider. Residency programs also create a ranked list of all of the medical students they would consider. In March, the NRMP computers “match” the medical students’ ranked lists with the residency programs’ ranked lists. On March 15th (“Match Day”), the NRMP releases the results of this match and the medical students find out where they will be spending the next 3 – 7 years of residency training.

The applicant pool is divided into six groups: (1) senior students at MD schools, (2) previous graduates of MD schools, (3) senior students at DO schools, (4) previous graduates of DO schools, (5) U.S. citizens who attend foreign medical schools, and (6) non-U.S. citizens who attend foreign medical schools. Students from U.S. medical (MD) and osteopathic (DO) schools tend to be more competitive than students from foreign medical schools.

U.S. citizens who attend foreign medical schools are categorized as U.S. international medical graduates (U.S. IMGs) and often attend medical schools in the Caribbean. Non-U.S. citizens who attend foreign medical schools (also known as non-U.S. IMGs) typically come to the United States on a training visa because high-quality specialty training is not available in their own country. Non-U.S. IMGs tend to be less competitive for residency positions than U.S. citizens. Although many non-U.S. IMGs return to their home country after completing residency, some elect to stay in the U.S. and pursue citizenship.

The largest number of applicants were U.S. MD senior students (19,755), followed by non-U.S. citizen IMGs (10,021), U.S. DO senior students (8,033), U.S. citizen IMGs (4,751), previous graduates of U.S. MD schools (1,662), and previous graduates of U.S. DO schools (616).

How many residency programs do students list?

This year, the average applicant who got into a residency ranked 12.14 residency programs and the average applicant who did not get into a residency ranked 4.13 residency programs. The implication is that the more residency programs a student interviews at and ranks, the more likely they are to obtain a residency position. However, these results can be a bit misleading because applicants to highly competitive residencies (such as vascular surgery) may need to rank more residency programs in order to ensure they get a residency position whereas applicants to less competitive specialties (such as family medicine) may only need to rank a small number of residency programs in order to insure that they match. The average number of residency programs that students ranked varied by the type of student:

There is also variation by specialty. For example, although the average U.S. MD senior student ranked 11.3 residency programs, the range was from a high of 21.9 programs per vascular surgery residency applicant to a low of 4.0 programs per internal medicine primary care track residency applicant. An important factor that influences the number of programs any given applicant ranks is how many programs that applicant interviews at. This in turn is influenced by how selective residency programs are in offering applicants interviews and whether those interviews are in-person or virtual. It is easier and less costly for applicants to interview at a large number of residency programs if those interviews are conducted virtually, thus obviating the time and expense of travel to those residency locations.

Residency programs that filled in the match ranked an average of 81.47 applicants (12.76 ranks per available position). Residency programs that did not fill in the match ranked an average of 63.05 applicants (8.73 ranks per available position). Because residency programs vary in size, the average number of ranked applicants is not terribly informative. However, the number of ranks per available residency position is informative and indicates that the more applicants any given residency program ranked, the more likely that program was to fill all of its available positions.

Results by specialty

As in previous years, categorical internal medicine had the largest number of filled positions (9,767). This is the traditional internal medicine track and a large percentage of these residents go on to do subspecialty fellowships after completing their internal medicine residency. The second most positions were in family medicine (4,577).

Every year, some specialties are more competitive than others. Competitive specialties have most or all of their residency positions fill in the match whereas less competitive specialties have a lower percentage of available positions that fill. Four specialties were highly competitive and filled all available residency positions: internal medicine/pediatrics, neurosurgery, plastic surgery, and thoracic surgery. Twelve specialties filled between 99% and 100% of available positions: anesthesiology, orthopedic surgery, otolaryngology, general surgery, radiology, neurology, OB/GYN, psychiatry, physical medicine, dermatology, internal medicine primary care, and vascular surgery. The specialties with the lowest percentage of filled positions were PGY-1 (first year after graduating from medical school) transitional and surgery preliminary; however, these are 1-year slots that are meant for applicants who are going on to do another specialty that does not begin until the PGY-2 year after medical school (such as some physical medicine and neurology residencies). The graph below includes residency positions that begin in both the PGY-1 and PGY-2 years.

Another way to determine which specialties are most competitive is to look at the percentage of available positions that were filled by U.S. MD graduates. Four specialties filled ≥ 90% of positions with U.S. MD graduates: thoracic surgery (98%), plastic surgery (94%), otolaryngology (91%), and neurosurgery (90%). These are considered to be extremely competitive specialties. At the other extreme, five specialties filled < 50% of their filled positions with U.S. MD graduates: family medicine (30%), categorical internal medicine (36%), emergency medicine (45%), pathology (46%), and pediatrics (49%). These are less competitive specialities. The graph below includes residency positions that begin in both the PGY-1 and PGY-2 years.

Specialties taking non-U.S. IMGs

The number of non-U.S. international medical graduate applicants increased significantly this year. In 2023, there were 8,469 of these applicants and that number rose to 10,021 in 2024, an increase of 1,552. This represents an 18% increase in non-U.S. IMG applicants in 2024. This has been a trend for the past decade as American residency programs become increasingly desirable to foreign medical students. The number of non-U.S. IMG applicants who matched to a residency position also increased from 5,032 in 2023 to 5,864 in 2024.

Non-U.S. international medical graduates tend to get into residencies that are not filled by U.S. MD and U.S. DO senior students. Four specialties had > 20% of available positions filled by non-U.S. IMGs: categorical internal medicine (30.3%), pathology (27.2%), neurology (22.6%), and internal medicine primary care (21.9%). On the other hand, five specialties had fewer than 2% of available positions filled by non-U.S. IMGs: thoracic surgery (0%), orthopedic surgery (0.2%), otolaryngology (1.3%), physical medicine (1.7%), and dermatology (1.9%).

Other notable observations

There were 1,218 couples who entered the couples match in 2024. This number has been relatively stable for the past 5 years. The match rate for couples match applicants was 93.6%, which has been relatively stable for the past 45 years.

Emergency medicine applicants have rebounded after a 3-year decline. Last year, only 81.6% of emergency medicine residency positions were filled but this year, that percentage rose to 95.5%. This increase was largely due to an increase in U.S. DO applicants applying to and accepted into emergency medicine residencies. In 2023, U.S. DO applicants comprised 24.3% of filled positions and in 2024, that number increased to 34.6% (an increase of 317 accepted applicants). The number of U.S. MD applicants applying to and accepted into emergency medicine was unchanged. Overall, this is good news for hospitals. Had the decline in filled positions that occurred during the COVID pandemic continued, hospitals could face staffing shortages in emergency departments. The increase in filled emergency medicine residency positions ensures that there will be an adequate future supply of emergency physicians.

OB-GYN remains competitive, but with a caveat. Historically, OB-GYN residency programs have had a low number of unfilled positions in the match. Similarly, there have been relatively few international medical graduates matching to OB-GYN because the vast majority of positions are filled by U.S. MD and U.S. DO senior students. Between 2018 – 2022, less than 1.5% of OB-GYN matched applicants were international medical graduates (including both U.S. citizen IMGs and non-U.S. IMGs). In 2023, the percentage of OB-GYN matches filled by international medical graduates rose to 5.8%, leading some observers to postulate that the overturning of Roe v. Wade was making OB-GYN a less desirable specialty to U.S. medical and osteopathic students. In 2024, 6.2% of OB-GYN residency matches were filled by international medical graduates. The majority of these were U.S. citizen IMGs (53 vs. 43 non-U.S. citizen IMGs). Overall, 99.6% of OB-GYN positions filled in the 2024 match, indicating that it remains competitive. However, the increase in international medical graduates matching to OB-GYN positions relative to historical numbers indicates that OB-GYN may have lost a bit of allure to U.S. MD and U.S. DO students since the overturn of Roe v. Wade.

What happens to applicants who do not match?

There were a total of 8,869 applicants to PGY-1 residency positions who were unmatched. Of those, 1,290 were U.S. MD senior students, 902 were previous graduates of U.S. MD schools, 621 were U.S. DO senior students, 323 were previous graduates of U.S. DO schools, 1,570 were U.S. citizen IMGs, and 4,157 were non-U.S. IMGs. There are a number of options for these unmatched applicants

After the results of the match are released, a program called the Supplemental Offer and Acceptance Program (SOAP) opens to allow applicants who did not match to a residency position to obtain a position in a residency program that did not fill in the match. This year, there were 2,562 residency positions in 787 residency programs that went unfilled. Historically, about 95% of unfilled positions ultimately get filled in the SOAP. The majority of these SOAP positions go to U.S. MD and U.S. DO senior students or graduates. For example, in 2022, there were 2,111 residency positions filled in the SOAP. These positions were filled by 911 U.S. MD senior students (43%), 125 U.S. MD graduates (6%), 511 U.S. DO senior students (24%), 91 U.S. DO graduates (4%), 305 U.S. citizen IMGs (14%), and 168 non-U.S. IMGs (8%). The data from the 2024 SOAP is not yet available but is likely to be similar to previous years.

Applicants who do not obtain a residency position in the SOAP can pursue a variety of career options. Some get non-physician jobs in a clinical setting, such as a scribe or an electronic medical record trainer. Some enroll in another graduate program, such as a PhD, MPH, or MBA. Some obtain jobs in research laboratories. Some obtain a job in an industry where an MD or DO degree is valued, such as insurance or pharmaceuticals. Some take a year to study and take the USMLE step III exam (usually taken by physicians during their first year of residency) – a favorable score on this exam can improve an applicant’s chances of matching to a residency program in the future. Others drop out of the workforce altogether; however, for the majority of U.S. applicants who have large education debts, this is not really an option.

Lessons for future residency applicants

After deciding on a specialty, medical and osteopathic students need to decide which residency programs to apply to. Once offers to interview are extended, they then have to decide how many programs to interview with. After all the interviews are completed, they then have to decide how many residency programs to rank and what order they will rank those programs. Each of these decisions is influenced by how competitive the specialty is and how competitive the applicant is.

A student who chooses a highly competitive specialty, such as vascular surgery, will need to apply to dozens of residency programs, interview at as many as possible, and rank at least 22 programs to ensure getting a PGY-1 position. On the other hand, students applying to a relatively non-competitive specialty, such as family medicine, may only need to apply to, interview at, and rank a handful of residency programs. Applicants to non-competitive specialties can afford to limit the geographic parts of the country that they are willing to consider for residency but those applying to highly competitive specialities must be less geographically selective. Applicants to the most competitive specialities, such as neurosurgery, plastic surgery, orthopedic surgery, and otolaryngology may need to have a back-up plan and apply to residencies in a second specialty in case they do not match to their primary choice.

An applicant can never make too long of a rank list but they can (and frequently do) make too short of a rank list. You never know what is going through the minds of residency program selection committee members and there is a great danger for applicants who overestimate their competitiveness. In general, applicants should rank all residency programs that they would even remotely consider. Even the lowest ranked program on an applicant’s rank list is usually preferable to whatever residency programs are left unfilled after the match in the SOAP.

Applicants must be realistic in their assessment of their own competitiveness, also. A student at a prestigious medical school who has excellent grades and USLME scores can afford to apply to, interview at, and rank a relatively small number of residency programs but students from lesser known medical schools and those with less than stellar academic performance must apply to, interview at, and rank a larger number of residency programs. This is particularly complicated for students entering the couples match – the student entering the more competitive specialty or with the lower grades may need to dictate the number of programs that both students in the couples match ultimately rank on their match lists.

An event like no other…

In the United States, match day is a day like no other. It is the one day out of the year that all senior medical students learn where they will do their residencies – what state, city, and hosptital they will be doing the most important part of their medical training in. It can be a day of great joy for students who land a residency that is high on their rank list and can be a day of despair for those who do not match to a residency program. The best way to fall into the former category rather than the latter is to have a high degree of self-awareness and be strategic in creation of the rank list submitted to the match.

March 28, 2024

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