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Residency mismatch: Canada’s crisis is America’s status quo

Lauren Vogel | CMAJ | May 15, 2018

More than a thousand American medical trainees didn’t match to residency positions last year, but unlike in Canada, it’s not causing much alarm.

Canadian medical schools and students are calling for urgent action to address the growing number of medical graduates locked out of residency. But south of the border, a decades-long residency mismatch hasn’t prompted the same crisis response.

About 6% of American medical school seniors don’t match to residency positions each year. That percentage has been stable since the 1990s but affects more students as medical school enrollees increase. Last year, 1059 American trainees (5.7%) went unmatched. This year’s match was the largest in American history, with more than 37 000 applicants from around the world vying for more than 33 000 positions. Among these, 94.3% of American medical students secured residency seats. For the remaining minority who didn’t match, the path ahead is uncertain.

Supports exist but are largely ad hoc and vary by school, says Dr. Janis Orlowski, chief health care officer for the Association of American Medical Colleges. “The majority of medical schools in the United States feel passionate about supporting their medical graduates, so they throw themselves into helping them, but it’s altruistic rather than a mandate or expectation.”

Most unmatched graduates take gap years, during which they may extend their studies, volunteer, seek out better references, or take additional licensing exams to improve their competitiveness. Usually, it’s left to the unmatched graduate to organize. There are signs of growing anxiety over the match among students, says Orlowski. For example, “the number of residency programs that they apply to has just gone up extraordinarily.”

In the past, a graduating medical student might have applied to 15 programs to ensure a match, Orlowski explains. “What we’re seeing now is applications to 50, 60 or 70. It’s just an incredible expense and very stressful.”

Unlike in Canada, this anxiety hasn’t translated into student advocacy for better supports for those who go unmatched. No one is asking for that help, says Perry Tsai, president of the American Medical Student Association. “In my experience, it’s not been a red flag.”

That doesn’t mean unmatched American graduates are any less distressed than their Canadian peers, notes Dr. Daniel Gouger, past education and advocacy fellow for the association. “It’s worth questioning whether or not trainees have the appropriate resources to be able to talk about it.”

Going unmatched is mostly framed as a personal problem rather than a system issue. A common refrain is that students need to be more realistic in their expectations. Authors of a recent letter to Academic Medicine argued that “residency placement fever” may have less to do with a shortage of positions than with graduates rejecting certain locations and specialties.

Orlowski shared the story of one student who was advised against pursuing a highly competitive specialty but ignored the advice and ended up unmatched. “We’re going to try to help them, but we try to help them act smarter.”

However, there are factors that complicate even a smart match strategy. American medical students face increasing competition for residency spots from international medical graduates and doctors of osteopathy. These additional applicants face worse odds, but had record match rates this year. Overall, “there are definitely more applicants than the number of positions available,” says Gouger.

Given that medical training is publicly subsidized, “this is a tremendous resource that you have to be careful not to waste,” says Orlowski. But it’s not yet deemed a “crisis” like in Canada. Partly this may be because unmatched medical graduates seem to have better career prospects in the US. Three years out from going unmatched, most will have found a residency position or switched to another advanced degree. “It looks like they had options,” says Orlowski. For example, “there’s the CEO of a dotcom, or they’re in a law firm, or they’re on Wall Street.”

Some states have passed laws to allow unmatched graduates to perform clinical work under supervision in underserved areas. “That we’re not supportive of at all, you know, because they’re not physicians,” Orlowski says.

The diverse mix of federal, state, community and private funders for residency positions also allows some flexibility in creating new positions. Since 2006, the ratio of seats to applicants has improved slightly, although it still remains below 1:1.

Medical schools are lobbying for the creation of more residency positions, although this is aimed at addressing physician shortages rather than fixing the residency mismatch. “We are very concerned about it and believe that there needs to be a modest increase in the number of positions that are supported,” says Orlowski.

For the foreseeable future, Canada has a better chance of ensuring its medical graduates match, she adds. “As far as Canada is different from the States, you actually are closer to being able to match them to the number of residency slots.”

Photo credit: asiseeit/iStock

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