Shake-ups in Medical Residency Training

The changes will benefit medical students seeking unfilled and advanced residency positions.

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The upcoming academic year heralds quite a few changes in the residency application process and potential changes in program structures, at multiple levels, in the near future.

The National Residency and Match Program (NRMP), a nonprofit, recently announced changes in the matching process. Gone are the days of unmatched applicants making frantic phone calls to program directors in an effort to secure an unfilled spot (the "scramble"). Now program directors rank applicants who receive offers during this Supplemental Offer and Acceptance Program (SOAP) week.

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Starting this year, applicants will learn at noon eastern time on the Friday before the all-important Match Week whether they are eligible to participate in SOAP. Monday at noon eastern time will still be when applicants learn if they matched or partially matched into a residency program, although they won't learn about specific programs; however, applicants will now need to apply through the NRMP R3 system to access unfilled programs. According to the NRMP, applicants will now only be shown unfilled programs for which they are eligible, rather than the general list of unfilled programs as was made available in prior years.

As matching becomes more competitive, the number of residency training spots is expected to dwindle, and institutions either receive reduced funding or limit growth to brace for potential reductions, this change could have a substantial impact for medical students across specialties. This impact will manifest in three main ways:

1. Allocation of unfilled spots is more time sensitive: The NRMP states that starting on Wednesday at noon eastern time of Match Week, the first round of SOAP starts. Since program directors can rank their desired applicants, there is now an opportunity for applicants to receive multiple offers. However, each "round" of SOAP lasts two hours. If an applicant receives an offer but does not accept within two hours, the NRMP says the offer may not be re-extended. Offers are given Wednesday afternoon and three times per day until Friday at 5 p.m. eastern time, when the process concludes.

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2. More advanced residency positions are now included: Applicants seeking second year or more advanced training positions, or transferring between specialties, may now have to use the Electronic Residency Application Service (ERAS) and the NRMP to apply for these positions. Previously, many of these positions were offered outside of the NRMP match process.

3. The number of unfilled residency positions has decreased: A study by the NRMP, assessing the first year of the SOAP program and examining statistics from prior years, shows the number of unfilled PGY-1 (postgraduate year one, or intern) spots had decreased almost 50 percent over the past decade. The NRMP does say that while the system is matching applicants for unfilled positions with greater efficacy, it differs starkly between specialties. For example, orthopedic surgery had four open spots for 142 applicants who preferred that specialty, whereas family medicine had 153 unfilled spots for 29 applicants who preferred that field.

Changes in residency procedures aren't limited to the match; recently, the Accreditation Council for Graduate Medical Education announced a pilot program to lengthen the residency program in family medicine from three to four years in select programs starting in July 2013. With the steady decline in students choosing to specialize in primary care, and an Obama administration proposal to cut Graduate Medical Education (GME) payments to programs by 10 percent, there is a fear that these changes could accelerate an existing trend. Just 30 percent of U.S. physicians practice a primary care specialty today—down from 50 percent in the 1960s, when much of the residency and Medicare funding structure was put in place.

Shifts in clinical funding for training positions, lengthening residency training, or changes in the already stress-inducing residency application process could have a trickle-down effect on medical education. While the SOAP program appears more organized than the previous scramble, the requirement to reapply to programs, combined with the time-limited and program-controlled rounds of offers, could actually alter the playing field in an unintended way.

And with fewer physicians able to complete residencies, particularly in certain specialties, there could be major changes coming to medical education in the future.

Ibrahim Busnaina, M.D. is a graduate of the University of Pennsylvania School of Medicine and coauthor of "Examkrackers' How to Get Into Medical School." He has been consulting with prospective medical school applicants, with a special focus on minority and other nontraditional candidates, since 2006.