The 2018 Match
Amanda Chassuel-Mahon, MS, Shaunmonique Clark, MD, MHSA, Megan Narula,MD, Mohammad Faraz Naqvi, MD, Umer Farooq, MD, MBA, Sarah Diekman, MD, MS.
Introduction to the Match
The ultimate step to completing a medical education. The step that permits the final stage of training. The stress of this singular moment is palpable in dozens of YouTube videos from doctors who successfully matched. For many, match day is the light at the end of the tunnel. After deciding to pursue medicine, sacrificing to ace the pre-medicine curriculum in college, arduously mastering the Medical College Admission Test (MCAT) to get into a medical school, and persevering through the United States Medical Licensing Exams (USMLE), the final step is here: matching into a residency program in order to complete medical training. According to 2018 match results, roughly 56,093 fresh medical graduates applied for residency in September of 2017, eagerly hoping for good news in March. Unfortunately, only 29,040 matched into a residency program, leaving slightly less than half unmatched. For international medical graduates, this number was even lower, a mere 11,300 out of the 28,393 that applied. The road to residency is a long and arduous one and matching into a program is the sweet reward every student yearns for. After shedding a little blood, some sweat, and lots of tears, whether a student matches into residency program or not can make or break their medical career, putting their years and years of hard work at stake.
Becoming a Physician
The journey to becoming a physician in the United States begins with applying to medical schools in your junior or senior year or college. There are usually years of build up to that point which often even precedes college; students who dream about becoming physicians are already mindful about their academics in high school. Questions such as “Will my high school advanced placement courses be accepted by the medical school to which I apply?” “What pre-med college to attend?” “Will medical schools will accept prerequisites from a community college?” “What is the ideal GPA?” and “When should I take the MCAT?” are amongst those most frequently asked.
At a minimum these prerequisites required include:
● One year of English
● One year of biology
● One year of physics
● Two years of chemistry (up to and including organic chemistry)
Most medical schools are looking for well-rounded applicants and will demand various experiences, such as healthcare jobs and volunteer hours at clinics or hospitals which demonstrate more than just a passing interest in the field, as well as an extracurricular activity profile which adds to the school’s portfolio. Quite often the road students take to their first day in medical school has many detours on it; many of them acquire master’s degrees, take post-baccalaureate courses, and have doctoral degrees by the time they begin medical school. With every passing year the process of admissions becomes more competitive than the year before.
After passing all those hurdles there were 51,680 MD applicants to who applied to an average of 16 medical schools in 2017; out this total, only 21,338 students were enrolled. The average grade point average (GPA) of these accepted students was 3.71 with MCAT scores of 510.4. The MCAT is an exam all applicants must conquer before applying with scores reported over four different sections 1) Chemical and Physical Foundations of Biological Systems (CPBS), 2) Critical Analysis and Reasoning Skills (CARS), 3) Biological and Biochemical Foundations of Living Systems (BBLS), and 4) Psychological, Social, and Biological Foundations of Behavior (PSBB). The top score, according to the American Association of Medical Colleges (AAMC), is 528. After relinquishing thousands of dollars for MCAT prep courses, thousands of aspiring physicians are forced to change their career goals after achieving low scores on this exam. For those aspiring to become osteopathic physicians (DOs), the competition is just as difficult. The American Osteopathic Association (AOA) reports 20,836 applicants competing for 7,3171 AOA Commission on Osteopathic College Accreditation (COCA) approved seats in fall 2017. The undergraduate GPA mean for these applicants was 3.45, with the mean MCAT score of 501.1.
Currently there are two different routes to becoming a physician in the U.S., either a medical doctor (MD) degree or a doctor of osteopathic medicine (DO) degree. Both routes involve four years of undergraduate education with similar science prerequisites, GPA requirements, consist of four years of medical school, and four similar licensing examinations, either the USMLE for MDs or the Comprehensive Osteopathic Medical Licensing Examination (COMLEX) for DOs. Both will be competing for the same Accreditation Council for Graduate Medical Education (ACGME) residency positions beginning in 2020, a requirement for graduates of both MD and DO schools.
The Cost of Medical Education
Getting into medical school is one thing, affording it is another. The average cost of attending medical school has steadily gone up in the last few years, as has the average debt medical students incur, currently standing at $190,000 on average, according to the AAMC. This debt is not evenly distributed amongst medical students as the number of students who have graduated with medical school debt has decreased from 2010 and 2016, highlighting the fact that students from lower income families shoulder the burden of this disproportionately. Medical school debt then adds to the average student loan debt most medical students are already carrying with them from undergraduate universities, averaging approximately $28,400. The often-unspoken opportunity cost is the time a medical student attends medical school, generally four to five years, in which they could have been working and making an industry average $57,000 per year. By the time a resident starts their position where they will be paid around $55,000 for another three to seven years they have lost approximately $230,000 in lifetime earnings.
These numbers show that student pursuing medicine are not doing so for the sake of money. While these future physicians are well compensated upon graduating from residency, they will not be earning six figure salaries for at least three to seven years after graduating from medical school. In comparison, their peers who attend master’s level graduate programs, such as physician’s assistants, will be at full earning potential after two years of schooling.
Students choosing to attend offshore medical schools, primarily in the Caribbean, face an even higher financial burden. Generally, these students are qualified applicants who were either rejected from U.S. medical schools or were non-traditional and had gaps in their education. A handful of these schools are accredited in all 50 states and approved for graduate loans by the United States Department of Education, which means their tuitions are higher than most state medical universities in America. They are at a great disadvantage when it comes to applying for residency positions though. Medical students do in fact have remarkable graduation rates and 94.1% of them graduated in 5 years according to a study from 2005 to 2010.
The Cost of Applying to Residency
As part of the residency application and licensure process, students are required to take a series of USMLE and/or COMLEX examinations. The students themselves are required to shoulder the costs of multiple rounds of these exams, adding up to thousands of dollars before the student can be licensed. After completing two years of basic sciences during medical school, students begin to take their USMLE, which are standardized medical licensing exams required for clinical rotations and admission into residency. These exams are broken into 4 parts: Step 1, which must be successfully completed before clinical rotations, Step 2: Clinical Knowledge (CK) and Step 2: Clinical Skills (CS), which must be successfully completed before beginning residency, and Step 3, which must be successfully completed before finishing residency. Again, these exams are not free of cost, and students must cough up big bucks to even register for the exams. In 2018, the cost of Step 1 and Step 2 CK, which are computer based exams consisting of multiple choice questions, is $610 each for US graduates, and $910 for international medical graduates (IMGs). Since 2015, the fees for IMGs has steadily increased. While the fee was $850 in 2015, it increased to $865 in 2016, $890 in 2017, and is currently $910. U.S. graduates’ costs also see an upward trend in fees every year. Step 2 CS, which uses standardized patients to test medical students and graduates on their ability to gather information from patients, perform physical examinations, and communicate their findings to patients and colleagues, currently costs U.S. graduates $1285, and IMGs $1565. USMLE Step 3, which is a two-day, computer-based exam consisting of multiple choice questions as well as clinical case simulations, currently costs $850. Merely by registering for the required examinations, a U.S. graduate will have spent $3,335, while an IMG will have spent $4,235. This total doesn’t include the cost of the study materials, text books, review courses, and question banks that students use to prepare, adding further to their total expenditure and debt.
Exam Fee for US Graduates Fee for International Graduates
Step 1 $610 $910
Step 2 CK $610 $910
Step 2 CS $1,285 $1,565
Step 3 $850 $850
Total: $3,355 $4,235
Successful completion of these exams is a central requirement for obtaining residency. Other than Step 2 CS, which is a pass or fail exam, the remaining USMLEs have minimum passing scores set by the Nation Board of Medical Examiners (NBME) and Federation of State Medical Boards (FSMB). As of July 2018, the minimum passing score for Step 1 is 194, Step 2 is 209, and Step 3 is 196. Just like the fees associated with these exams, there has been a constant upward trend with scores as well, with the minimum passing score increasing every year. However, simply passing a USMLE exam is not good enough. Program directors often set their own minimum score requirements, depending on the specialty as well as the competitiveness of the program. This is where many students who have passed all of their exams struggle. They meet the minimum score requirements to pass the exam, however, their scores are average to below average, making it difficult for them to match. The unfortunate thing is that once an exam has been passed by meeting or exceeding the minimum score requirement it cannot be retaken again in order to improve the score.
The USMLE scores of students who matched to a residency program in 2018 were significantly higher than the minimum passing score. Those students who scored average to below average scores, but still passed the exam, were left unmatched. Based on information provided by the National Resident Match Program (NRMP) , applicants who matched in family medicine had an average Step 1 score of 219, with a range of 208 to 234. Those who applied to family medicine yet did not match had an average score of around 204, with scores ranging from 198 to 212. Data is similar for Step 2 results. Successful match applicants scored an average of 238, their scores ranging from 225 to 250, while those who did not match scored an average of 222, with a range of 215 to 230.
As mentioned above, the USMLE exams cannot be retaken once the minimum score has been met or exceeded. For a medical student applying for residency, the only thing worse than scoring low on an exam is failing it, even if just by one point, resulting in multiple attempts. Students can request for the exam score to be rechecked, but this review will cost the student an extra $80 per exam. Although some state licensing regulations allow up to six attempts on each USMLE exam, many programs will clearly state on their admissions criteria that they require or prefer first time passes for all exams. Some will allow multiple attempts, but they want to see significant improvement of the score on the next attempt, as well as on all subsequent USMLE exams. Each time an exam is retaken, the exam fees must be paid again, adding again to the total expenses.
After the USMLE exams required for residency are completed, medical students must apply for residency positions. Based on the results and data provided by the NRMP, a total of 56,093 students applied to residency this year, competing for just 30,232 positions offered. Of that, only 29,040 (96.1%) residency positions were actually filled, 17,740 (58.7%) of them by US graduates. The Educational Commission for Foreign Medical Graduates (ECFMG) reports that in 2018 IMGs showed a strong performance in the match, stating that 56.5% of all IMGs participating in the match obtained first year residency positions. The ratio of positions offered to applicants has been negatively skewed since the mid 1970’s, when the number of applicants begin to outnumber the number of residency positions available. Since then, this has been an upward trend as well, leaving thousands of qualified medical graduates without a match.
The number of programs a student will apply to depends on a number of factors, including their USMLE scores, GPA, letters of recommendation, which specialty they are applying to, as well as their budget for applications. The Electronic Residency Application Service (ERAS) reports that in 2018, the average number of programs US graduates applied to was 20.9, while the average number for IMGs was 19.4. These numbers vary significantly when specific specialties are taken into consideration. For example, the average number of family medicine programs U.S. graduates applied to was 30.8, while the number for IMGs was 64.1. For internal medicine, U.S. graduates applied to an average of 32.1 programs, while IMGs applied to an average of 82.7 programs. For more competitive specialties, US graduates are outnumbering IMGs. For example, U.S. graduates applied to an average of 59.3 dermatology programs, while IMGs applied to an average of only 19. ERAS also provided the number of programs students have applied to every year since 2013, and just like the USMLE passing scores, and the cost of USMLE exams, the numbers of programs students are applying to each year has been ticking upward. Matching into a residency is getting more and more competitive each year, so to increase their chances of matching, students are applying to various programs across multiple specialties.
Along with USMLE exams, residency applications are another big expense medical students must consider. The fees for applying depends on the specialty and number of programs per specialty to which a student applies. As the student applies to more specialties and programs, the application fees increase.
This chart gives the breakdown of the fees ERAS charges for a certain number of programs that are being applied to. For example, if the average U.S. graduate applies to 30 family medicine programs and 32 internal medicine programs, their total payment for residency applications would be $1,130, $459 for family medicine, and $671 for internal medicine. Those with high scores and an exemplary application do not need to apply to as many programs. It is those student with low scores, exam failures or reattempts, and IMGs competing with U.S. graduates that apply to exponentially more programs to increase their odds of matching, spending multiple thousands of dollars on applications alone. This system works out and is worth every penny if the student matches into a program. However, if they do not match, the money is not refunded in any way. If they are lucky enough to get a decent paying job after graduation, which is hard enough to come by as an MD/DO with no license to practice, most applicants will spend majority of their savings during the next application cycle.
Many people falsely believe that all doctors are rich and live lavish lives, when the truth is far from it. The amount of money medical graduates put into their education can take years to make up for; the graduates that never match never even have the opportunity to make it that far. With medical school tuition already being so high, along with the expenses of the requires exams, study materials for those exams, and residency applications, living a rich and lavish life is the last thing on a medical graduates’ mind. If they are one of the lucky ones that do match into a residency program, they get to look forward to working excruciatingly long hours while being severely underpaid as a post graduate intern.
Residency and the Governing Bodies in Charge
The ACGME, ECFMG, and AOA are the key accredited governing bodies that affects one’s residency training.
The ACGME set standards for effective training programs and monitors compliance with those standards (the institutional and program requirements). There are specialty-specific committees of volunteer physicians, which include a resident/fellow representative, as well as a non-physician public member, that create a uniform set of high standards for each accredited specialty and subspecialty. These standards are applied across all accredited U.S. residency and fellowship programs educating and training physicians in those fields to ensure the highest quality physicians and patient care. Accredited residency and fellowship programs are continuously monitored for substantial compliance with the requirements set by the applicable review committee, including thorough data collection, evaluations, surveys, and site visits. The review committees regularly review the accreditation requirements to ensure they are based on current and best practices in the field.
The ACGME also sets standards designed to cultivate a team-based learning environment and culture in which residents and fellows serve as both learners and mentors in delivering high-quality patient-focused care. Residents and fellows provide regular feedback to the ACGME about their programs, offering an inside view which helps the organization to improve the overall quality of accredited programs. The ACGME requirements have historically included standards to address physician well-being, but in recent years the organization has increased its focus on this issue, recognizing it is crucial to the ability of physicians to deliver the safest, best possible care to patients.
The AOA is the representative member organization for the more than 129,000 DOs and osteopathic medical students in the United States. The organization promotes public health, encourages academic scientific research, serves as the primary certifying body for DOs overseeing 18 certifying boards, and is the accrediting agency for osteopathic medical schools through COCA. The AOA’s mission is to advance the philosophy and practice of osteopathic medicine by promoting excellence in education, research, and the delivery of quality, cost-effective healthcare.
In 2014, the ACGME, AOA, and American Association of Colleges of Osteopathic Medicine (AACOM) announced their agreement to a Memorandum of Understanding (MOU) outlining a single graduate medical education accreditation system in the United States. The single GME accreditation system allows graduates of allopathic and osteopathic medical schools to complete their residency and/or fellowship education in ACGME-accredited programs and demonstrate achievement of common milestones and competencies. The current model of accreditation has shifted emphasis from “time served” and compliance with minimum standards to competency-based assessment facilitated by monitoring and evaluating real-time data that tracks residents’ and fellows’ education and achievements.
From July 1, 2015, to June 30, 2020, AOA-accredited training programs will transition to ACGME recognition and accreditation. There will continue to be osteopathic-focused training programs under the ACGME accreditation system. Two osteopathic review committees will be developed to evaluate and set standards for the osteopathic aspects of training programs seeking osteopathic recognition. DOs and MDs would have access to all training programs. There will be prerequisite competencies and a recommended program of training for MD graduates who apply for entry into osteopathic-focused programs. AOA and AACOM will become ACGME member organizations, and each will have representation on ACGME board of directors.
The ECFMG is an accredited governor body for international medical graduates. The program of certification assesses whether international medical graduates are ready to enter U.S. graduate medical education programs that are accredited by the Accreditation Council for Graduate Medical Education (ACGME). ACGME requires international medical graduates who enter ACGME-accredited programs to be certified by ECFMG.
ECFMG certification assures directors of accredited residency and fellowship programs, and the people of the United States, that international medical graduates have met minimum standards of eligibility. Only those who are qualified and truly committed to obtaining Graduate Medical Education (GME) training in the United States attain ECFMG certification. Even then, obtaining a GME position is not guaranteed. During the past 5 years, the ECFMG certified approximately 10,000 IMGs per year. In 2016, only 6638 (51.9%) of 12,790 IMGs participating in the National Resident Matching Program were placed in first-year positions. Without GME training (at least 3 years in most jurisdictions), an IMG is not eligible to obtain an unrestricted license to practice medicine in the United States. The ECFMG certification process, combined with the competitive nature of residency selection and strict state licensure rules, ensures that only high-quality; carefully screened IMGs enter the U.S. workforce.
Another governing body is the American Medical Association (AMA). Founded in 1847, it is the largest association of physicians (both MDs and DOs) and medical students in the United States. The AMA is historically the first organization to establish uniform standards for medical education, training, and practice. They are also responsible for the first national code for ethical medical practice.
Board Certification and Continuing Education
One may think that after gaining acceptance into a residency that their job is over. This is far from the truth. The process of completing residency itself is a long and arduous task that will test a young doctor’s tenacity. Just when you thought all of the hurdles were over, you are presented with an entirely new set of tasks.
Whatever residency specialty you choose, there are yearly in-training examinations mandated by the ACGME. While there may not be specific pass/fail scores like with the various USMLE exams, there are often required scores set by each individual program.
On top of this, many programs require residents to participate in quality improvement projects as well as research projects throughout their career. All of this culminates in a board examination at the end or after one has completed their training, in order to successfully become board certified and practice independently in their chosen specialty. This is the process by which a physician demonstrates their proficiency in a specialty by various written, oral and/or simulated exams.
There are 24 boards that can certify a physician in the U.S. Most hospitals demand that physicians be board certified to gain certain privileges, or even to be hired in the first place.
Physicians demonstrate this expertise in a specialty by earning board certification through one of the 24 American Board of Medical Specialties (ABMS) boards. Before physicians can become board-certified, however, they must first:
● Finish four years of premedical education in a college or university;
● Earn a medical degree (MD, DO or other credential approved by an ABMS member board) from a qualified medical school;
● Complete three to five years of full-time experience in a residency training program accredited by the ACGME;
● Provide letters of attestation from their program director and/or faculty;
● Obtain an unrestricted medical license to practice medicine in the United States or Canada; and
● Pass a written and, in some cases, an oral examination created and administered by an ABMS member board.
The ABMS encompasses 39 specialties and 86 subspecialties. Not only does one have to pass the initial board certification process, but they must continue to maintain this certification throughout the length of their careers. Each specialty has its own set of requirements to fulfill that involve retesting and continuing education at pre-set intervals.
Currently there are more than 880,000 board certified physicians in the United States, 59% in medical specialties, 27% surgical specialties, and 14% hospital specialties. California by far has the highest number of board certified physicians.
As one can assume, pass rates for board certification examinations vary greatly by specialty. Overall ABIM pass rates fell from 90% passing in 2009 to just 78% passing in 2013 for first-time test takers of the Maintenance of Certification (MOC) internal medicine board exam, according to statistics released annually by the American Board of Internal Medicine (ABIM).
There are many reasons why physicians might be seeing declining pass rates on board examinations. Some may include the increasing use of technology to look up diagnoses and pathologies; young doctors have become adept at finding information as needed, but no longer continuously study and learn medicine. Physicians also face a much higher demand to accomplish more administrative work in a smaller amount of time. Whatever the reason may be, the ultimate goal is always better outcomes for patients.
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