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Results of the 2014 National Resident Matching Program®: Family Medicine

Stanley M. Kozakowski, MD; Philip W. Crosley, MBA; Ashley Bentley, MBA

Background and Objectives: The 2014 National Residency Matching Program® results reveal that the number of family medicine positions offered in the Match® by programs accredited by the Accreditation Council on Graduate Medical Education has increased compared to 2013 (3,132 versus 3,062), while the total of all other primary care specialties combined has remained unchanged (784). The number of US seniors matching into family medicine also increased in 2014 over the prior year (1,416 versus 1,374). The percentage of US seniors who matched into family medicine programs grew modestly in 2014 compared to 2013 (8.6% versus 8.4%). Approximately four out of five primary care positions offered in the Match are in family medicine residency programs (3,132 versus 784). Similarly, three out of four US seniors matching into a primary care specialty match into a family medicine program (1,416 versus 520). By way of comparison, nearly five times the number of US seniors matched into family medicine as compared to medicine-pediatrics, the next largest primary care specialty.

(Fam Med 2014;46(9):701-6.)

The Executive Summary of the Council on Graduate Medical Education (COGME) 20th report, “Advancing Primary Care,” begins with the statement, “There is compelling evidence that the health care outcomes and costs in the United States are strongly linked to the availability of primary care physicians.”1 The Institute of Medicine (IOM) defines primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”2 While many physicians provide limited primary care serv-
ices for a small sub-segment of their patients, only a few specialties meet the IOM definition of primary care and truly deliver primary care to the majority of their patients. It is for this reason that the authors have chosen to limit the definition of primary care specialties as family medicine, medicine-pediatrics, medicine-primary care, and pediatrics-primary care as listed in the National Resident Matching Program® (NRMP®) 2014 Main Residency Match publication. Family medicine residencies include family medicine categorical programs as well as combined programs with an Accreditation Council on Graduate Medical Education (ACGME) number for family medicine: family medicine-psychiatry, family medicine-emergency medicine, family medicine-preventive medicine, and family medicine-internal medicine programs.

One indicator of the future primary care availability is the number of medical school graduates participating in the NRMP and who match into the primary care specialties as defined above. The American Academy of Family Physicians (AAFP) Medical Education Division annually acquires data on all specialties from the NRMP. One author (PC) conducts an annual census of all family medicine residency programs accredited by the ACGME. The authors perform an analysis of the NRMP and census data from 2014 and previous years to identify short- and long-term trends in the number and percentages of US medical students and international graduates entering family medicine and other specialties. This information is used by those who develop programs, policies, and advocacy efforts to identify, recruit, and retain students and residents into primary care.

 

Methods

 
 

The authors used data from the NRMP Results and Data: 2014 Main Residency Match publically available online publication to obtain information about Match rates by specialty for 2014.3 The NRMP classifies a US senior as “A fourth-year medical student in a Liaison Committee on Medical Education (LCME)-accredited US school of medicine. A student with a graduation date after July 1 in the year before the Match is considered a US senior.” The other six NRMP applicant categories are previous graduates of US MD-granting medical schools; students/graduates of Canadian medical schools, DO-granting medical schools, fifth-pathway programs, US citizen international medical schools, and non-US citizens of international medical schools. Table 1 is derived from the NRMP Results and Data publication and utilizes the same definition of US seniors as noted above.

Table1

One of the authors (PC) conducts an annual online survey of allACGME-accredited family medicine programs. Nonrespondents were contacted by telephone and requested to complete the online survey. As in the past, a 100% response rate was achieved. Program data, including a list of all first-year residents, their medical school, and month and year of graduation, constitutes the annual census of family medicine residency programs. The same author verified those graduates of US LCME schools with a graduation date between July 1, 2013 to June 30, 2014 by contacting the medical school registrars or by the American Medical Association (AMA) Physician Masterfile. Residents reported in the Census who graduated outside July 1, 2013 to June 30, 2014 were not independently verified. The American Association of Colleges of Osteopathic Medicine provided the number of graduates from each DO-granting college of medicine. The authors limited primary care specialties as family medicine, medicine-pediatrics, medicine-primary care, and pediatrics-primary care as listed in the NRMP 2014 Main Residency Match publication. Family medicine residencies include family medicine categorical programs as well as combined programs with an ACGME number for family medicine: family medicine-psychiatry, family medicine-emergency medicine, family medicine-preventive medicine, and family medicine-internal medicine programs. The residency census was granted an exemption from the AAFP Institutional Review Board.

 

Results

 
 

Family medicine programs offered more positions in the Match in 2014 compared to 2013 (3,132 versus 3,062). This is consistent with the trend of the last 5 years. The number of US seniors matching into family medicine also increased in 2014 compared to 2013 (1,416 versus 1,374). Of those US seniors who matched, there was only a modest difference in 2014 compared to 2013 (8.6% versus 8.4%).

Table 1 shows the number of positions offered and filled with US seniors in the Match for family medicine and the other primary care specialties. Approximately four out of five primary care positions offered in the Match were in family medicine residency programs. Similarly, three out of four US seniors matching into a primary care specialty matched into a family medicine program. Seventy additional primary care positions were offered in the 2014 Match when compared to 2013. However, only 20 more US seniors matched into primary care residencies in 2014. In contrast to family medicine, which had an increase in both the number of positions offered and the number filled with US seniors, the number of non-family medicine primary care positions offered remained unchanged from the prior year, and the number of US seniors matching into these positions declined by 22. Pediatrics-primary care residencies saw the largest decline with 28 fewer matching in 2014. By way of comparison, nearly five times the number of US seniors matched into family medicine as compared to medicine-pediatrics.

At the same time that the primary care specialties were experiencing only modest growth, categorical internal medicine and categorical pediatrics programs grew in the number of positions offered, filled, and filled with US seniors from 2010 to 2014. Internal medicine-categorical positions offered increased by 23.4% (from 4,999 in 2010 to 6,524 in 2014) while pediatrics-categorical increased by 9.5% (from 2,387 in 2010 to 2,640 in 2014). However, during the same years, the number of US seniors matching into those specialties declined (internal medicine-categorical 54.5% in 2010 to 48.5% in 2014 and pediatrics-categorical 70.3% in 2010 to 68.9% in 2014).

Figure 1 shows the percentages of US MD, DO students, and international medical graduates (IMGs) who entered family medicine residencies in 2014. As the proportion of US MD, DO, and US-citizen IMGs has increased, the percentage of non-US citizen IMGs continues to decrease. Figure 2 shows the total number of residents in family medicine programs and the number of accredited family medicine residencies by year since 1993.

Figure1

Figure2

The pool of primary care positions increased only modestly, with the number of family medicine positions increasing 1.8% since 2013, with the other non-family medicine primary care positions remaining unchanged. Family medicine positions comprised 80% of all primary care positions in the Match in 2014. Nearly three out of four US MD graduates matching into a primary care specialty chose family medicine. There was a significant decline in the number of US seniors matching into medicine-pediatrics programs (28).

 

Discussion

 
 

Population growth and aging, along with increased access to insurance through the Patient Protection and Affordable Care Act 2010 (PPACA) place additional demands on the health care system.4 To support efforts to ensure access to health care, and access to primary health care for all Americans, the primary care physician workforce needs to grow from 209,000 to approximately 261,000 by the year 2025.4 Since family physicians currently make up about 38% of the primary care workforce,5 a conservative estimate is that an additional 21,000 family physicians will be necessary.

Match results represent a snapshot of physician workforce pipeline and must be seen in the broader context of the health care needs of society. The United States needs a sufficient number of physicians practicing primary care to be the foundation of a health care system that meets the triple aim: improved patient care, improved quality, and lower costs.6 In 2010, the Council on Graduate Medical Education (COGME) issued its landmark 20th report, Advancing Primary Care, recommending that policies to support physicians providing primary care be implemented that raise the percentage of primary care physicians (general internists, general pediatricians, and family physicians) among all physicians to at least 40% from the current level of 32%, a percentage that was actively declining.1

The United States lacks a mechanism to align the educational pipeline with the nation’s workforce needs.7 The medical school portion of the pipeline has evolved considerably over the last 2 decades. In response to the 2005 COGME 16th Report, Physician Workforce Policy Guidelines for the United States, 2000–2020, predicting that demand for physicians would grow rapidly after 2015,8 the Association of American Medical Colleges (AAMC) responded in 2006 by recommending a 30% increase over 2002 enrollment in MD-granting medical schools by the year 2016 in areas of the country where the population has experienced rapid growth, and future growth is anticipated.9 There are wide variations in the concordance and discordance of medical school enrollment, population growth, and the supply of primary care physicians.10 The impact of the medical school expansion on the interest of matriculating medical students for a career in primary care has been variable depending on the public versus private support of the school as well as the degree of expansion.11 A number of schools have increased their enrollment through the development of regional medical campuses (RMCs) that have been promoted as a cost-effective way to increase enrollment. They may be defined as entities geographically separated from the parent medical school campus. Students graduating from RMCs match into family medicine at nearly twice the rate as those that graduate from the parent campus.12 Unfortunately, the net impact of the dramatic medical school expansion has resulted in only a modest increase in the number of students matching into primary care residencies over the same period of time.

The graduate medical education system received nearly $15 billion in 2012 in pubic tax dollars, with more than 90% coming from Medicare and Medicaid programs.13 Despite evidence that the composition of the workforce impacts the access, quality, and cost of care, graduate medical education (GME) funding is provided without the accountability of specialty training expectations to address population needs.14 At the present time, primary care residency positions account for only 14.4% of all GME positions. This is inadequate to reach the goal of a national workforce of at least 40% primary care physicians. A number of people believe that medical schools should have a social mission “to care for the population as a whole, taking into account such issues as primary care, underserved areas, and workforce diversity.”15 This study has several limitations. The NRMP has evolved the Match policy over the last several years beginning with the implementation of the Supplemental Offer and Acceptance Program® (SOAP®) in 2012.16 SOAP provides a mechanism for unmatched applicants to try to obtain unfilled residency positions through successive matching cycles. It has likely changed the behavior of some applicants and residency programs with regard to participation in the traditional Match. The All-In Policy was in place for the second year in 2014.17 Prior to the All-In Policy, some residency programs withheld some of their positions from the Match in order to sign contracts with qualified osteopathic or international students outside of the Match process. The policy, which requires that residency programs place all of their offered positions in the Match, means that nearly all residency positions will be filled in the Match. These two changes in Match policy make it difficult to compare the data from the 2013 and 2014 Match with the years leading up to and including 2012. The All-In Policy has a limited number of exceptions that result in a small number of positions offered outside of the Match.17 The first year of the All-In Policy resulted in a 9% increase in the number of all specialty positions offered in the Match. By 2014, the number of positions offered rose by an additional 1.7%, still leaving a number of residency positions filled outside of the Match through the exceptions to the All-In Policy.

The NRMP Match and the census data provide a limited understanding of the total family medicine potential workforce since data is restricted to ACGME-accredited programs. The vast majority of graduates of DO-granting schools entering family medicine GME are trained in programs with ACGME accreditation. Those applicants entering residency programs only accredited by the AOA are not counted in this study. This will become moot over the next 6 years as the ACGME and AOA issue a Memorandum of Understanding in 2014 that would evolve all GME to a single accreditation system by 2020.18

The authors’ definition of primary care may raise objections on the part of some who would add other specialties into our list of primary care. First-contact, continuous, comprehensive, and coordinated care to populations undifferentiated by gender, disease, or organ system are the defining attributes of primary care.19 While some individual physicians within other specialties practices might meet this definition, the majority of physicians in those specialties do not.

Addressing the primary care physician shortage should be a national priority. Despite the demonstrated value of and need for primary care, when taken as a whole the US medical schools and the GME system continue to fail to produce an adequate primary care workforce as defined by the percentage of alumni actually practicing primary care 5 years after graduation. Growth in the number of GME positions should align taxpayer dollars with the training of primary care physicians. The AAFP urges the Centers for Medicare and Medicaid Services (CMS) to tie graduate medical education reimbursement to an expected minimum percentage of graduating senior medical students continuing to primary care GME training (defined as family medicine, medicine-pediatrics, medicine-primary care, and pediatrics-primary care residencies). While additional GME positions are needed, the 20th
COGME report noted that a free market system that allows across-the-board increases in GME specialty caps “would disproportionately increase the number of available non-primary care positions. The unintended result could be a net decline in filled primary care positions, especially in cases where applicants had a primary care specialty as their second or third choice.”1

With family medicine residency education constituting the majority of primary care training, recent positive trends in the number of family medicine positions offered and filled must be recognized as grossly insufficient when considered in light of the long-term trends of the last 2 decades. The number of family medicine residency programs, positions offered in the Match, filled, and filled with US seniors, has followed a sinusoidal pattern. (See “Total Positions Offered in Primary Care Specialties and Filled with US Medical School Seniors in the 2013 NRMP Match” at www.stfm.org/FamlyMedicine/Vol46Issue9/Kozakowski701.) The current levels of positions offered and filled with US seniors have not returned to the peaks levels of the late 1990s (3,293 positions offered in 1998 and 2,340 US seniors in 1997).

Total Positions Offered in Primary Care Specialities

Clearly more work is needed to change the trajectory of the primary care physician pipeline. The AAFP and the Council of Academic Family Medicine Organizations created a simple framework supported by four pillars to clearly communicate the factors and prioritize those activities that impact the primary care physician workforce.20 The pillars include efforts to increase the pipeline by identifying, recruiting, and retaining students and residents into primary care; ensure that the process of medical education trains physicians to practice evidence-based, compassionate, and comprehensive primary care; expose learners to transformed practices based on the patient-centered medical home model of care; and advocate for payment reform to address the need for appropriate reimbursement of primary care practice.

Corresponding Author: Address correspondence to Dr Kozakowski, American Academy of Family Physicians, Medical Education Division, 11400 Tomahawk Creek Parkway, Leawood, KS 66211. 800-274-2237, ext: 6700. Fax: 913-906-6289. skozakowski@aafp.org.

 

References

 
 
  1. Council on Graduate Medical Education. Twentieth report: advancing primary care. 2010. www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/twentiethreport.pdf. Accessed July 9, 2014.
  2. Institute of Medicine. Primary care: America’s health in a new era. Washington, DC: National Academy Press, 1996. 
  3. National Residency Matching Program Results and Data: 2014 Main Residency Match. http://www.nrmp.org/wp-content/uploads/2014/04/Main-Match-Results-and-Data-2014.pdf. Accessed July 12, 2014.
  4. Petterson SM, Liaw WR, Phillips RL Jr, Rabin DL, Meyers DS, Bazemore AW. Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med 2012;10(6):503-9.
  5. Agency for Healthcare Research and Quality. The number of practicing primary care physicians in the United States: primary care workforce facts and stats No. 1. October 2011. Rockville, MD: Agency for Healthcare Research and Quality. http://www.ahrq.gov/research/findings/factsheets/primary/pcwork1/index.html. Accessed July 12, 2014.
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  7. http://www.graham-center.org/online/etc/medialib/graham/documents/publications/monographs-books/2009/rgcmo-specialty-geographic.Par0001.File.tmp/Specialty-geography-compressed.pdf. Accessed August 5, 2014.
  8. Council on Graduate Medical Education. Physician workforce policy guidelines for the United States, 2000–2020. Council on Graduate Medical Education, Sixteenth Report. Rockville, MD: US Department of Health and Human Services, Health Resources and Services Administration, 2005. http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/sixteenthreport.pdf. Accessed July 12, 2014.
  9. Association of American Medical Colleges. AAMC statement on the physician workforce. Washington, DC: Association of American Medical Colleges, 2006. https://www.aamc.org/download/55458/data/workforceposition.pdf. Accessed July 12, 2014.
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  11. Shipman SA, Jones KC, Erikson CE, Sandberg SF. Exploring the workforce implications of a decade of medical school expansion: variations in medical school growth and changes in student characteristics and career plans. Acad Med 2013;88(12):1904-12.
  12. Liaw W, Cheifetz C, Luangkbot S, Sheridan M, Bazemore A, Phillips RL. Match rates into family medicine among regional medical campus graduates, 2007–2009. J Am Board Fam Med 2012;25(6):894-907.
  13. Institute of Medicine. Graduate medical education that meets the nation’s health needs. Washington, DC: National Academy Press, 2014. http://www.nap.edu/download.php?record_id=18754. Accessed August 5, 2014.
  14. Chen C, Petterson S, Phillips RL, Mullan F, Bazemore A, O’Donnell SD. Toward graduate medical education (GME) accountability: measuring the outcomes of GME institutions. Acad Med 2013;88(9):1267-80.
  15. Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M. The social mission of medical education: ranking the schools. Ann Intern Med 2010;152:804-11.
  16. http://ww.nrmp.org/residency/soap. Accessed July 12, 2014.
  17. http://www.nrmp.org/policies/all-in-policy/. Accessed July 12, 2014.
  18. http://www.acgme.org/acgmeweb/Portals/0/PDFs/NascaLetterACGME-AOA-AACOMAgreementMarch2014.pdf. Accessed July 12, 2014.
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  20. The four pillars for primary care physician workforce reform: a blueprint for future activity. Ann Fam Med 2014 Jan-Feb;12(1):83-7.

From the Medical Education Division, American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, KS.


Copyright 2017 by Society of Teachers of Family Medicine