Another Pathway to Reduce Medical Professional Shortage: Tap the “Unmatched” MDs

There is a pool of well-trained medical professionals who can provide care.

Several months ago, my former colleague Justin Leventhal made several interesting proposals in this blog to remedy the shortage of medical professionals, particularly physicians, whose numbers are artificially constrained by the federal Centers for Medicare & Medicaid Services (CMS), the primary funder of the hospital residency program — a key step in obtaining a license to practice medicine in most states. The proposals are: 1) raise the cap, 2) require hospitals to pay more for resident’s cost, and 3) let doctors contribute toward the cost of their residency training, given their lifetime earning potential. The last two options obviate the budgetary need for the cap. Today’s post adds a fourth option: The example set by Missouri, Arkansas, Kansas, Utah, Arizona, Louisiana and Idaho to allow medical school graduates who do not match to a residency program to “intern” with a licensed physician in the state. Such professionals carry titles during their post-med school training such as “assistant” physician or physician (not to be confused with physician assistant, a mid-level role comparable to nurse practitioners). The features vary by law in each state, but to a large degree, they all expand the supply of highly trained medical providers for patients, especially in designated high professional shortage areas (HPSA). A similar bill in Texas is making its way through the legislative process with widespread support from the medical professional community, including licensed physicians.

For the uninitiated: To practice medicine in any state in the US, physicians need to be licensed, and all states include at least a year of hospital residency (which may lead to being licensed in a specialty) as a licensing requirement. This is in addition to graduating with a medical degree (Doctor of Medicine [MD] or Doctor of Osteopathy [DO]) from an accredited medical school, passing the various exams (USMLE steps 1, 2/3 or COMLEX steps 1,2,3 for DOs). Since 1952, medical students have been algorithmically assigned residency programs through a process that is predicated on matching the preferences of both students and hospitals. In 1997, the AMA successfully lobbied Congress to limit the number of available residency slots. The cap is hardly ever raised (until recently), leading to severe shortage in medical doctors. Because there are fewer residency places available than candidates, some applicants are not matched to any program. Each year many MD/OD seniors (residency applicants) are unmatched. For example, in 2022, 6.8% (1,111) of MD and 8.2% of OD (439) seniors were unmatched. For unmatched students, there are very few options other than to try again the following year. Statistics show that many re-applicants find a match with the second try, but they would have “wasted” a year.

Instead of waiting for a year or more or trying other options (such as writing USMLE Step 3), we should put their rigorous clinical education to effective use. As the CDC documents, several areas in the country face significant shortages in medical professionals, including doctors. In 2014, Missouri pioneered a program where unmatched graduates would gain practice experience by working as “assistant physicians” in primary care under the supervision of a licensed physician. An analysis by the Cato Institute shows that because of this policy, the number of licensed primary care providers increased by 3% in 2023. Missouri restricted their practice to HPSAs and other rural areas. This restriction is unnecessary if we believe they are just as qualified. The relationship between APs and licensed physicians is like that between advanced nurse practitioners, who interestingly are increasingly able to practice independently in about twenty-two states. Other regulations exist to restrict what APs can do. For example, the bill in Texas limits APs (termed graduate physicians) to only primary care and is considered a general practitioner (residents who do not complete their program can practice as GPs in many states).

This policy raises obvious questions: are the unmatched significantly different from the matched? In other words, would they provide inferior medical care? In general, the analysis from the National Resident Matching Program (NRMP), the non-profit that runs the matching program, shows that there are some differences (see the reproduced table). For example, in the 2022 matching, the mean USMLE Step 1 (Step 2) score for the matched candidates was 236 (248) compared to 231 (242) for the unmatched. Thirty percent of the matched graduated from one of 40 medical schools with the highest NIH funding (a proxy measure for quality), compared to 22.2 % for the unmatched. However, the most key point is that the mean USMLE scores far exceed the minimum passing score (196). Therefore, I do not think these differences should significantly determine the quality of a physician. (I am open to evidence to the contrary).

The most interesting difference between matched and unmatched is the number of specialties applied to. Matched applicants apply to fewer specialties compared to their unmatched counterparts. This point requires further analyses, but there are several other factors that determine the likelihood of matching including personal attributes, geographical preferences, and the specialty applied that in no way affect one’s ability to practice as a physician. Another observation is that the unmatched are more likely to be minorities and other under-represented groups. Perhaps it’s important to ensure they don’t fall through the cracks.

Interestingly, many physicians are enthusiastic about the opportunity to mentor new physicians and welcome efforts in such states (see, for example, comments on the Texas bill). Are you a physician? Please share your thoughts. Will this work? What are some other pitfalls that I am missing? What could go wrong? I look forward to hearing your insights.