The NRMP data show that a higher percentage of USMDs are filling positions in procedure-oriented/lifestyle-oriented specialties than in primary care. However, this does not consider the added outside-the-match offers we explored in our analysis. When the total number of available positions (obtained from the AAMC) is used as the denominator instead of the total number of NRMP-offered positions, USMDs appear to fill an even smaller percentage of primary care positions (5690 of 12
558, 45.3% versus 5690 of 10
091, 56.3%) than reported by the NRMP. Likewise, the disparity in USMD choice between primary care and procedural/lifestyle programs is underestimated if the NRMP data only are used as the total number of positions for a given specialty. Alternatively, the actual number (not a percentage of positions) of USMDs entering the primary care specialty is greater than that entering the procedural/lifestyle residencies (5690 versus 4036). The authors recommend that AAMC data should be formally coupled with the NRMP results when examining USMDs' residency choices. It is not clear if our findings are representative of the crisis in primary care in the United States, which may contribute to USMDs choosing procedure-oriented/lifestyle-oriented specialties over primary care.
About 1 in 5 positions in nonprocedural, primary care specialties are offered outside the match. Also, 54.7% of all primary care PGY-1 positions were offered to non-USMDs, of whom 35.9% took positions outside the match, whereas 3977 non-USMDs who registered for the match withdrew before the match. While around 1200 offers (Mona Signer, MPH, E-mail communication, December 15, 2009) were withdrawn for candidates' failure to meet Educational Commission for Foreign Medical Graduates testing requirements, the remaining candidates (2777) are presumed to have been offered and to have accepted outside-the-match offers, closely approximating the 2825 outside-the-match offers made in the specialties studied. This observation suggests that most (70%) of the withdrawals were to take offers outside and before the match, though proof of this is lacking. In procedure-oriented/lifestyle-oriented specialties, only 26.2% of all positions are filled by non-USMDs and only 6.5% of all such positions are estimated to be offered outside the match.
The possible effect of the current unregulated system of offering outside-the-match residency positions has been to create a recruitment method in graduate medical education (predominantly in primary care specialties) characterized by program directors “giving” positions primarily to non-USMDs who are eager to secure a position rather than take their chances in the match. This situation is similar to that which existed for USMDs before the match (before 1952) and needs to be addressed. Our estimates suggest that outside-the-match offers occur to an extent previously unrecognized, especially in 4 specialties (family medicine, internal medicine, Pre S, and transitional year). Furthermore, the amount of prematching in internal medicine may be linked to the lack of availability of fellowship positions.
It may be useful to consider why program directors choose to offer and candidates choose to accept positions outside the match. Program directors may do so to address 2 recruitment issues: (1) to prevent losing interested, non-USMD candidates to other programs offering outside-the-match contracts and (2) to avoid the “scramble.” Offering positions outside the match reduces a program's match quota, thereby limiting the number of unmatched positions. The “scramble” has been likened to college basketball's “March Madness,”8
and candidates taken in the postmatch period seem to perform less favorably when compared to those accepted in the match.9
The potential situation for candidates is similar. Non-USMDs, correctly perceiving their generally less competitive status relative to USMDs, may, if they wish to compete in the match, choose to apply to more programs and risk needing to “scramble” if they fail to match. Reginald Fitz, at Boston University, summarized a student's perspective in 1939: “… there are very few men who have the conceit to pass up a very good appointment in 1 locality offered early simply on the gamble of competing for a somewhat more desirable appointment made later in another locality.”10
Non-USMDs also may be disadvantaged in the “scramble,” as they may not receive the dean's office assistance with phone calls and paperwork; additionally, they may experience difficulty getting through to program directors who hope to fill their unfilled position(s) with USMDs. Also, the timeline for obtaining a visa is shorter the longer one waits for a position, making a prior-to-the-match offer additionally enticing for foreign citizens.
indicates perceived match violations, including promises to applicants before the match, thus putting in question the ethics and morals of program directors and candidates alike. The NRMP has considered proposals to limit outside-the-match offers15
and to conduct a second match for unmatched candidates.16
Neither has been adopted, in part because of concerns expressed by program directors “dependent” on international medical graduates, who might have difficulty getting visas in time for their July start dates. Our study represents a preliminary attempt to elucidate the amount of prematching occurring in the United States. Since prematching data are not officially reported anywhere, our calculations may be overestimating or even underestimating the extent of out-of-match offers. If, however, it is confirmed that primary care programs (particularly internal medicine and family medicine) need to consistently, year after year, recruit 1 of 5 applicants outside of the match, then this negative finding should be further examined. These proposals should be reconsidered in the context of our study findings. We advise the community against drawing strong conclusions from these initial results, which analyze only a fraction of 1 academic year's match. Further research, by independent groups and spanning multiple academic years, is needed to confirm or disprove our findings and to analyze prematching trends in all specialty areas.
One limitation of this study is that the AAMC Data Book5
provides only the programs' reporting of both the total number of residents working in each specialty (without a breakdown by year of training) and the number of positions offered in total and in the PGY-1 year. When the total number of positions offered (Table F7 of AAMC Data Book5
) is compared to the total number of residents reported (Table F8 of AAMC Data Book5
), there is a 3% difference in nonprocedural primary care specialties and a 1% difference in procedure-oriented specialties. This difference between positions offered and filled should have little effect on the study, as it probably is evenly distributed over all years of residency training. Since preliminary internal medicine positions and Pre S positions are a part of—but much different than (with regards to a career)—the overall internal medicine and surgery program of a given institution, respectively, we analyzed them separately from their categorical counterparts. In doing so, we had to assume that no prematching occurs in preliminary internal medicine or categorical surgery positions. The actual number is likely a small percentage, and the assumption does not significantly affect the results of this study. Also, we assumed that all available postmatch positions were given to non-USMDs. Since 9% of all graduating allopathic students are theoretically available in the postmatch period, it is reasonable to assume that some postmatch positions are being filled by USMDs. For a given specialty, this would probably represent a very small percentage of their positions; this assumption also does not alter the prematch findings of this study. Finally, the data in the AAMC Data Book5
are entered online by the training programs through GME Track Census and may overstate or understate the number of positions offered and/or filled. It is the official source of the data used by the AMA and the AAMC, and it is unlikely that programs would willingly provide inaccurate information.
Despite these limitations, our study is the first to estimate the potential extent of outside-the-match offers of graduate residency positions. About 1 in every 5 positions in nonprocedural primary care specialties appears to be filled outside of the match, effectively circumventing the intent of having a matching program. As a result, USMDs are more limited in the number of open positions in the match and non-USMDs are subjected to the pre-1952 recruitment conditions that the NRMP was designed to alleviate.