Unmatched, But Not Forgotten

I recently read an anonymous post by a medical student who was applying to the residency match…for the second time. He was a bit melancholy and disheartened with the entire match process. He had good grades, performed decently on the MCAT, had great letters of recommendation and received many interviews. Yet he did not match. It broke my heart–I’ve been in his position.

Over 25 years ago, I applied for a slot in an emergency medicine residency. I had attended a great medical school, one of the top 25% in the nation. I performed well and graduated on time. I successfully completed an acting internship in EM at a major trauma center and received a magnificent LOR from the assistant residency director. When applying for the match, I selected my schools carefully and realistically. And I did not match. I was devastated. I entered the scramble(now known as SOAP). The APD of the program at which I had completed my AI knew the PD of a new program in New York and recommended me. I was interviewed by telephone and the PD offered me a position on the spot. He asked me how he could guarantee I would accept (as there were other new residency programs). I told him to send me a contract. He faxed it, I signed it and the rest is history. I segued from feeling like a total failure to a total success. In one week.

My entire residency class(except for one) consisted of people who did not match. We were all great candidates with all the right stuff. No clear understanding of why we did not match and others did. There is a presumption that most medical students who don’t match were simply not good candidates. After my experience, I questioned that presumption. Nevertheless, I was given a second chance and now, nearly 25 years later, I have had a successful career in emergency medicine. Back then, if one didn’t match the first time, they almost always matched during the scramble or if they re-applied a second time. The numbers of those who remained unmatched were relatively small. Nothing like the numbers we see today.

Currently, there are many more medical students than there are residency slots. As a result, we have had an unprecedented number of graduated medical students not matching and having to re-apply as many as five times before they give up or are successful at being accepted into a residency. This residency bottleneck is a result of a decision made over 20 years ago: the 1997 Balanced Budget Act that placed a cap on the number of residencies that Medicare would fund. Prior to that, the AMA, AAMC and other organizations predicted a physician glut that never occurred. Ironically, the number of medical schools has increased. What good does it serve to increase the number of medical schools when there is a residency bottleneck? It serves no purpose other than to make money for the school and create an astronomical debt for a student who may not have the ability to pay off that debt.

There is a physician shortage, but it is not due to a lack of candidates, it is from an insufficient number of residencies. Unfortunately, this false “shortage” is a goldmine for opportunists who believe they can step in and fill this “gap”. Logic dictates that if there is a physician shortage, one must consider filling that shortage with a physician. The question is where do we get those physicians? Well, there is a huge pool of unmatched, highly qualified doctors just clamoring for a slot. There are also foreign medical graduates(FMGs) and international medical graduates(IMGs) who are perfectly viable candidates to address this “gap”. There is a tremendous amount of bias against FMGs/IMGs for unfathomable reasons. Medical education is structured. The hoops that these graduates have to jump through to practice as physicians in the United States is significant. Because they have to follow the same standard as U.S. graduates. For example, there are 60 Caribbean medical schools in the world. Five have been approved by the U.S. Department of Education as having medical school curriculums EQUIVALENT to that of U.S. medical schools. Those graduates can complete their clinical rotations and residencies in the U.S. Students who attend schools that are not approved by the DOE must begin again…pre-med>>MCAT>>medical school>>residency. It takes years for foreign medical schools to be granted that stamp of approval by the Department of Education. No easy feat. The false narrative of FMGs/IMGs being unqualified is just that–false.

In February 2019, a bipartisan bill, the Resident Physician Reduction Shortage Act was introduced by Senators Menendez(D-NJ), Boozman(R-AR) and Schumer(D-NY). The bill would increase funding from Medicare for 15,000 residency slots over 5 years. In my opinion, every physician, every program director, every dean of every medical school and the public should be pushing their legislators to support this bill. The cap has persisted for too long. It makes no sense to discuss filling the physician gap with non-physicians when this option is on the table. It is not fair to the medical students who worked so hard to fulfill their dream to serve and it is most certainly not fair to the public.

Associate Physician, also known as Assistant Physician(AP), programs (not to be confused with physician assistant), which exist in Missouri, Kansas, Arkansas, and Utah with pending legislation in Georgia and New Hampshire (https://assistantphysicianassociation.com/), provide yet another option to fill the “gap”. The AP program began in Missouri as a bill proposed by an orthopedic surgeon who wanted to address the healthcare needs in underserved and rural areas of his state. The sponsor saw the value in utilizing these unmatched medical doctors who were being ignored by the medical establishment. The bill was opposed by nurse practitioners, physician assistants and members of the Missouri Academy of Family Physicians. It was supported by the Missouri State Medical Association. Working as APs allowed these doctors to maintain their knowledge and clinical skills while being supervised until they could again apply for a residency the following year. In Missouri, APs now have a license to practice provided they have a collaborating physician. And true to their word, they are working in these underserved areas. What they are not doing is opening medspas, hormone, dermatology and ketamine clinics under the guise of serving the underserved.

“Residencies” and “fellowships” for nurse practitioners and physician assistants are being developed and supported by some of my colleagues who choose to believe they have no other options to relieve the “shortage” but to use non-physician practitioners(NPPs). There are bills being introduced in various states which permit some limited primary care practice by naturopaths, chiropractors, and pharmacists. I’m baffled because of the various opportunities that exist to increase the physician pool and yet we choose other options. Many of my colleagues could be supporting the senate bill mentioned above but don’t either because they don’t know about it or don’t care. Some demonstrate no support for the unmatched students and have no compassion for their situation. These are unusual times that call for unusual measures. The “rule” that once an unmatched student has not matched in three years the likelihood of them not being accepted to a residency should be adjusted to account for the residency bottleneck that prolongs their time. Take that into consideration. Give them a chance. Make exceptions. Don’t leave that talent sitting on a shelf collecting dust. It’s not right. We should not turn our backs on them. Not when they need us the most. We should provide the same support for them that are given to NPPs.

To the unmatched doctors, our future physicians, I say this. Do not lose hope. You are not forgotten and you are not invisible. We see you.

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Natalie Newman MD

Dr. Natalie Newman is a residency trained, board­certified emergency physician who has been practicing for nearly 24 years. In 1991, she graduated from California State University in Sacramento, California with a degree in Biological Sciences. She then attended medical school at Case Western Reserve University in Cleveland, Ohio on an Army scholarship. As a graduating senior, Dr. Newman was presented with the Marjorie M. and Henry F. Saunders award for her compassionate care of patients within the family structure. After her graduation in 1995, she was accepted into the Emergency Medicine Residency at North Shore University Hospital in Manhasset, New York. Upon her graduation in 1999, Dr. Newman entered active duty service with the U.S. Army. Her first assignment was at Womack Army Medical Center in Fort Bragg, North Carolina. During her stint in the Army, Dr. Newman was deployed to Bosnia­Herzegovina(formerly Yugoslavia) where she was Chief of the Emergency Department at Eagle Base in Tuzla, Bosnia. She had the honor of serving under the command of Colonel Rhonda Cornum(now a retired brigadier general), a urologist, pilot and former prisoner­of­war during the Persian Gulf War. While in Bosnia, and as the only American female physician in the Balkans at that time, Dr. Newman was assigned as the personal physician for Queen Noor of Jordan during a humanitarian visit to a local hospital in Bosnia. After her return home to the U.S., she was promoted to Major and completed the rest of her Army service at Fort Bragg. Dr. Newman subsequently returned home to California where she continues to practice as a traveling physician and participates in multiple speaking engagements about the values of education, of which she is passionate. She is also a member of Physicians for Patient Protection, a patient and physician advocacy organization. 

  6 comments for “Unmatched, But Not Forgotten

  1. Estelle Farrell, DO
    March 15, 2020 at 11:33 am

    I agree wholeheartedly with Dr, Newman. My history was similar to hers. I was blessed to be fortunate in my career and the scramble. The odds for any student coming out of residency are poor now with this bottlenecking. There is significant push back federally on creating more residency spots and the competition for one when a hospital closes is outrageous!

  2. Aaron M. Levine
    March 12, 2020 at 11:33 am

    The world changed. I matched in 1971. I know there were some unmatched but they usually found an internship without too much effort as many were open. I remember JAMA had a classified ad section for interns and residents. We got unsolicited letters from nonacademic hospitals for positions. One set of my classmates reportedly took a summer vacation largely financed by traveling from hospital to hospital and getting meals and a room. I never confirmed this rumor. The movie House Calls (late 1970s) had a hospital staff meeting saying that no doctor applied or accepted their internship spot, although an acupuncturist did.

  3. arf
    March 8, 2020 at 11:28 pm

    “How they perform on the USMLE, their LORs, U.S. clinical rotations, interviews and how they are ranked all determine who will be accepted to residency and who will not.”

    You didn’t mention the payoff. Where do you think the greased palms ranks among the interviews, LOR’s and all that?
    https://www.nytimes.com/2010/12/23/nyregion/23caribbean.html

    “St. George’s alone sends about 1,000 students, many through a 10-year, $100 million contract with the New York City Health and Hospitals Corporation, which runs public hospitals. (A high-ranking St. George’s official, who also sat on the board of the city hospitals corporation, was fined for a conflict of interest for his role in soliciting clinical training slots for the school.)”

    Again, all that being said, I agree. If medical schools put out more graduates, but the residency numbers remain the same, things will get ugly. It’s already happening, and will get worse.

  4. arf
    March 8, 2020 at 11:14 pm

    “And true to their word, they are working in these underserved areas. What they are not doing is opening medspas, hormone, dermatology and ketamine clinics under the guise of serving the underserved.”

    They are not “true to their word”, they are folowing the law. Missouri’s Assistant Physician law restricts the AP’s to primary care in shortage areas. They are not refraining from the medspas, derm, ketamine and all that, out of noble intent, they are simply not allowed to do that.

    https://www.msma.org/assistant-physician-law.html

    If you want doctors to practice in rural areas,
    1. – pay them
    2. – select as medical students, people who are from that rural area to begin with. Second best, train them in that rural area

    The J-1 waivers don’t work. The doctor will go there for J-1 service, and leave as soon as their obligation is over. And I don’t blame them. If the area is undesirable to a doctor from Cleveland, it will be equally undesirable to a doctor from India. What has been shown to work is training doctors who are from that area to begin with.

    Along those lines, I don’t expect the assistant physicians will stay rural, unless they can’t pass their exams or get a residency slot. The second they get their training slot, they will leave……well they will have to, for the training position. Will they come back at completion of their training? I wouldn’t bet on it.

    All that being said, I agree, the number of residency slots has to increase, or there will be hell to pay. It is absolutely irresponsible to open more medical schools, if there is nowhere to train the graduates.

  5. arf
    March 7, 2020 at 9:51 pm

    I don’t understand something. Long description of how shabbily the foreign medical graduates are treated in the USA.

    Stipulate that the foreign doctors are as good as any American graduate, for the sake of argument. What difference does that make, when perfectly good USA graduates cannot find residency positions? How would you feel if you had put yourself through medical school, did a decent job even if not top of the class, took on a six-figure debt, then ended up unmatched, and then found out that the programs that did not match you, DID match foreign nationals?

    I’m supposed to say how tough it was when I was training, and the new doctors have it easy. I can’t say that for medical training, we had it was easier than what I see graduates going through now.

    In my day (surely most readers here as well), an unmatched resident was either of poor quality, or set sights too high, trying for superstar competitive specialties and superstar competitive residencies. No longer; it’s getting to where perfectly good yeoman medical and osteopathic graduates in the USA, cannot find positions.

    And remember, our tax dollars pay for those residency slots. The foreign doctors are as good as Americans, also implies the reverse, that the Americans are as good as the foreign doctors. I will not apologize for wanting to take care of our own first.

    • Natalie Newman, MD
      March 8, 2020 at 3:40 pm

      That’s not my point. My article is that unmatched medical students, both foreign medical grads and international medical grads, need to be supported by increasing residency slots and AP programs. I do not believe the use of non-physician practitioners is warranted when there are unmatched medical school graduates waiting in the wings. If the U.S. Department of Education finds that certain foreign medical schools have an equivalent medical education to those in the U.S., then students are treated accordingly. How they perform on the USMLE, their LORs, U.S. clinical rotations, interviews and how they are ranked all determine who will be accepted to residency and who will not. An American who graduated from a foreign medical school approved by the Dept. of Education who has an exceptional application should not be dismissed simply because he/she attended a foreign school. Nor should a FMG who has completed all of the requirements as set by the U.S. Dept of Education. That is selective bias and I do not support any form of discrimination.

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