Medical Examiner


The system for placing medical school graduates in residency programs is inefficient and ugly.

Fourth-year medical students from Tufts University School of Medicine gather on Match Day to receive their envelopes telling them where they will do their residency training
Medical students from Tufts University School of Medicine gather on Match Day, March 20, 2015, to receive envelopes telling them where they will do their residency training.

Photo by Jonathan Wiggs/The Boston Globe via Getty Images

What’s the most dramatic day of medical school? It’s not the first day of anatomy lab, when students cut into cadavers, or the beginning of rotations, when they meet patients for the first time. It’s match day—the day when soon-to-be doctors find out where they will complete their residencies.

Match Day is the culmination of a grueling process. After two years of basic science training and more than a year of clinical rotations, fourth-year medical students spend months interviewing with residency programs, sometimes dozens of them, at hospitals across the country. The ritual resembles a cross between job hunting and speed dating. Students aren’t just trying to impress residency program directors, they’re also trying to gauge whether the attraction is mutual. When all the interviewing is done, students rank their top hospitals, and hospitals rank their favorite students. You don’t want to waste your energy on a program that just isn’t that into you. After both sides have submitted their preferences, everyone waits for months while a somewhat opaque algorithm spits out the results.

The stakes are inevitably high, but medical schools ramp up the tension of the big reveal on Match Day, which took place March 20 this year. Some force their students to walk across a stage and announce their result, sharing their big moment with the assembled student body (either with a fist pump or barely disguised tears). Other schools hand out envelopes and ask students to open them simultaneously. It’s a contrived and uncomfortable situation—and that’s if you’re lucky.

The even darker side of the match process happens a few days earlier, on a day known as Black Monday. Students who haven’t matched with a hospital get a phone call from their medical school breaking the news. Medical students spend that day hoping the phone doesn’t ring, like worried military spouses.

Those who get the call have a chance to find a residency spot through the “scramble”—a frantic few days before the official match results are announced, during which unmatched students try to pair themselves up with hospitals that have unfilled slots.

Most students at U.S. medical schools don’t have much to worry about. Historically, about 94 percent of U.S. medical graduates match successfully on the first try. An additional 3 percent find a residency during the scramble. A few more students stumble into positions between Match Day and graduation.

By the time they get their diplomas, about 3 percent of U.S. medical graduates are still looking for a residency position. “Some of them had challenges during medical school with basic science or their clinical years,” says Geoffrey Young, senior director of student affairs and programs at the Association of American Medical Colleges. “But others applied to specialties—orthopedics, neurosurgery, etc.—they were not competitive for against advice they were given. These are students who have always been successful, and they think it can’t happen to them.”

Although failure to match is chastening, U.S. graduates have an excellent chance at finding a program the next year. In the meantime, many of them get a master’s degree, or they teach or work in a laboratory to strengthen their applications. If they decide not to pursue a residency, it’s almost always by choice. Despite the pressure of Match Day, life is pretty forgiving to U.S. medical school graduates.

For graduates of foreign medical schools, the world is a harsher place. This year, 12,380 doctors attempted to match from medical schools outside the United States. Only 6,301 matched, for a success rate of approximately 50 percent.* That figure, although very low compared with U.S. medical school graduates, probably flatters the international students. People who graduate from medical schools in the Caribbean or Eastern Europe often apply for programs such as family medicine that generally have a harder time filling their positions. This self-selection inflates the international students’ match numbers.

Why do they fare so poorly? I spoke with a couple of people who administer residency programs, on condition of anonymity because this is a sensitive subject that raises legal issues. They explained that there are two different categories of international applicants. “Foreign medical graduates,” or FMGs, grew up and attended medical school abroad. “International medical graduates,” or IMGs, are Americans who left the United States to go to medical school. (The terminology is strange, I know.)

The directors of residency programs aren’t at all enthusiastic about IMGs. American students who study medicine abroad, with rare exceptions, couldn’t get into U.S. medical schools. Some of them also failed to earn admission to colleges of osteopathic medicine, a parallel U.S. medical education that’s similar to traditional medical school but generally less competitive. (Osteopathic doctors have D.O. rather than M.D. after their names.) Their education abroad may have been fine, but residency selectors highly value the sorting function that U.S. medical school admissions offices perform, whether or not you consider it fair.

FMGs face an entirely different challenge. Many residency directors hold foreign medical graduates in high regard for their technical expertise and basic science knowledge. Medical schools in some countries, particularly in Asia, are hard to get into and even harder to graduate from. Since U.S. residency training is valuable all over the world, residency directors can basically skim off the top layer of foreign doctors. That’s especially valuable for less prestigious residency programs because they don’t get their pick of the U.S. medical graduate litter.

There is, however, a widespread perception that foreign medical graduates don’t communicate well with U.S. patients. I live very near a massive academic hospital, and I often hear patients saying on the sidewalk that their doctor “barely spoke English.” It’s a cringe-inducing complaint because you can’t become a doctor in the United States without speaking fluent English, but many patients equate sounding foreign with not speaking English. Yuck, I hate having to write that.

There’s a more legitimate side to the discomfort. Doctors in many foreign countries—even Western countries—are accustomed to making major decisions with little input from patients. That can be jarring to patients familiar with the American model, in which shared decision-making is valued.

These complaints have been heard, and most physicians are now acutely aware that their patients simply don’t like foreign doctors. For that reason, residency directors often shy away from foreign medical graduates, even if they are otherwise excellent candidates.

What happens to international doctors who don’t match in U.S. residency programs? No one seems to know. I sent three emails to the Educational Commission for Foreign Medical Graduates but never heard back. Apparently, they don’t like to talk about the low match rate for their clients.

A large proportion of the Match Day losers clearly give up, or the match rates would drop lower and lower under the weight of repeated failures. Foreign medical graduates may choose to practice medicine in their home countries or elsewhere outside of the United States. Many of the American candidates probably also practice medicine abroad, or go to work for pharmaceutical companies. (Don’t reserve too much pity for those people—big pharma pays pretty big bucks.)

The other big Match Day losers are American patients. Over the next decade, we will need to import tens of thousands of doctors. It would be smart to open up more residency slots now and bring in the brightest graduates of medical schools from around the world. The problem is Congress. The federal government pays for residency slots through Medicare, and Congress more or less froze the number of positions it’s willing to fund (and the amount residents are paid) several years ago. Without more money, few hospitals are willing to expand their training programs. The system, in short, is suffering from Congress-itis: an increasingly common ailment caused by the atrophying of the deliberative body.

*Correction, April 3, 2015: This article originally misstated that 52,860 doctors entered the match from medical schools outside the United States and only 26,252 matched. In fact, 12,380 applied and 6,301 matched. (Return.)