tmcn2697l.jpgThe latest Main Residency Match (registered Trade Mark) results are in. Officially it is an impartial venue for matching applicants’ preferences for residency positions with program directors’ preferences for applicants. Unofficially it reflects a lot more, as I have discussed before (found here). For those of you living in towns with medical schools, it is the day that the hometown paperbloggythingy is filled with pictures of medical students crying because they are so happy to be leaving their current God-forsaken burg for one of better value (in Mobile, typically one several states away). To make a long story short, without successfully working in a residency position for several years, a young physician will never be allowed to practice medicine in the United States (how much time in residency is required varies by state).

There has been discussion on e-mail by my colleagues about the Early Results (term not trademarked, results found here). The good news for family medicine is that of the 3037 positions offered, 2914 were filled (about 95%). That bodes well for primary care, say some, and thus the glass is half full. The bad news for Family Medicine is that out of the 17, 487 graduates of traditional US (allopathic) medical schools, only 1356 chose Family Medicine, filling only 44% of our positions and comprising only 7% of the graduates of these schools. 1097 graduates of these schools did not match into any program and though there were Family Medicine positions available, did not apparently want these either. They have chosen, I presume, to sit out a year and try for the specialty of their choice again rather than seek three years of training to make a nice living (over $200,000 a year after completion) as a family physician. Looking at it that way, the glass is half empty.

Our society needs physicians practicing primary care, and graduates of family medicine residencies are the most likely to practice this kind of medicine. Graduates of traditional medical schools tend to seek the “ROAD to success” (Radiology, Ophthalmology, Anesthesia, Dermatology) specialties, so named because the average work week is less than 40 hours and the mean pay is over $400,000. So, where do we look?

One place is Osteopathic schools. The students who attend these schools tend to have a lower MCAT (24, average for most allopathic schools 30-31) and lower GPA but more life experience. (MCAT and GPA beyond a threshold value have been found to only predict success on the first of three standardized tests and have no bearing on clinical ability.) The students are typically committed to a distributed education model and often chosen for interest in primary care practice. Previously, osteopathic schools were seen by some as the domain of those not “smart enough” to be admitted into allopathic medical school. For those interviewing with us this year, it was decidedly not the case. In our experience, osteopathic candidates for our residency resemble allopathic students in their knowledge base. Their clinical skill set is a little different than the allopathic students’ but different can be better. In our experience they are bright and committed to going back to their community to practice (often an underserved community). There were 2677 total applicants in the Main Residency Match and 2019 got a position. How many went into family medicine is unknown.

Another place is the Caribbean. Medical schools there have exploded in the past 10 years. This seems to be at the expense of the old 5th pathway program (US citizens going to Mexican medical schools a la Bad Medicine) and non-US citizens looking to come to America (the  J-1 programs, as seen here). It used to be that applicants with a marginal application (relatively low grade, MCAT, or both) would have a application with the following pattern: apply to allopathic school with a marginal MCAT/grades, get wait-listed, “make your application look better” by retaking the MCAT and bumping it up two points, work as a hospital orderly, reapply, repeat until accepted or life passes you by. This is dead. Many students give US schools one shot then apply to a Caribbean school.

Coincidentally, many of these students with marginal applications also have a strong interest in primary care. Many of them have parents who are in primary care and who did not go to US schools. Their children are not looking for prestigious medical school but for training that allows them to qualify to take the ECFMG test. Passing this test allows them to give residency training a shot, often in family medicine. In 2009 there were 3390 applicants from these schools and only 1600 matched. This year there were 5095 and 3601 matched. That is 15% of the matched pool. For these schools the standardization of testing for graduates of non-US schools (ECFMG, NBME, and clinical skills evaluation) has been the great levelers. These graduates are a large part of our current workforce and have filled our training programs for the past 10 years.

Can we look to traditional medical schools to supply a larger percentage of the primary care workforce? Allopathic schools expanded their classes by 10% several years back to fill a “need.” That 10% was supposed to be selected to correspond to the needs of the “community.” The additional allopathic students, unfortunately, tend to look like the other 90%, overwhelmingly white, overwhelmingly privileged, overwhelmingly looking for a ride on the “ROAD.” Telling to me were the results for the 1487 allopathic graduates who did not get a position last year. I am assuming they have not been working as a physician for the past year (because they can’t). They applied for positions in this year’s match. 758 of them were unmatched for a second time. This means that rather than “settle” for a primary care residency that will net them $200,000 a year at the end of 3 years, they are going to sit out another year, presumably looking to get on the ROAD.

So, in our class we have 2 osteopathic physicians, 2 physicians who are from a Caribbean school, one traditional resident, and one resident who did not match last year and elected to apply in family this year. We are excited about training them and, since 60% of residency graduates tend to stay within 100 miles of where they are trained, I’m happy to welcome them to the community.

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