It is always a challenge to read the tea leaves on the implications of residency "Match Day" for graduating medical students. Although we can spot some trends — close to 400 more students opted for a residency in internal medicine this year than last but still almost 20% fewer than internal medicine trainees identified in 1985 — it is particularly difficult to prognosticate future internist labor supply from Match Day numbers for a few important reasons.
First, this year only a little over 60% of all residency applicants were matched by Match Day. This means a significant chunk of residency applicants (this includes medical school seniors as well as graduates of osteopathic and international medical schools) are now in the process of still seeking a match. Their matchmaking, however, is almost entirely demand driven. The unmatched, in short, must compete for the slots available even, necessarily, changing their area of medical specialization in order to achieve a match.
Who sets the specialization ratios (considering internal medicine as a specialty, for these purposes)? These are set, overwhelmingly, by our nation's acute care hospitals. Whatever you think of our nation's acute care hospitals, their staffing needs are at best a rough proxy for our country's escalating need for community based care providers and specialties. This need will only increase with the roll out of the Affordable Care Act.
Second, many of the students officially matched to internal medicine will ultimately choose subspecialities like cardiology, pulmonology, oncology, and gastroenterology that — though important — are at least a step removed from primary care. The best indicator of how many internists we may hope are in the pipeline is still to monitor those who emerge from training as primary care providers. As I have observed elsewhere, we see only a slight uptick in primary care physician production.
Third, forces that push graduating seniors to primary care may include the reality that for each of the past several years, residency matches — long considered a sure thing — have become harder to obtain. Some of this has to do with simple math. Multiple medical schools have opened while the number of residency slots has remained unchanged.
The story of residency funding — primarily through the Medicare program — may help explain why, in an era of budgetary constraint, no new Medicare funded residency slots are on the horizon. Although there has been discussion of corporate-funded residency slots, those proposals have fallen out of favor in an era of increased skepticism about the role of pharmaceutical companies and others in the world of continuing medical education, never mind medical residencies.
So, there we have it: a sobering need for more internists and primary care physicians of all types but a limited number of seats in which that training may take place. Maybe the medical residency bottleneck itself needs re-invention. Maybe Medicare needs to step up to the plate to increase the residency slots available. Maybe the public needs to demand good value for the Medicare residency dollars it spends (close to $80,000 per year per slot, by one estimate). This might mean designating Medicare residency funding toward favoring the physician specialties — including primary care specialties — most needed by those footing the bill.