By Jessica Freedman, MD
President of MedEdits
“I just hope to get a prematch offer so I don’t have to go through the main residency match.”
“What should I do? I got a prematch offer from a great program but it isn’t my number one choice and I think I would rather enter the main residency match. Should I take the prematch offer? Help!”
I hear these types of comments throughout the residency match process from United States and non-United States citizens who are considered “independent applicants.” Many independent applicants hope to receive prematch offers to guarantee they will earn a residency training position which can alleviate stress. For other independent applicants, however, prematch offers actually cause stress since giving up a guaranteed residency training position to enter the main residency match in hopes of matching at a “better” program presents a dilemma.
Under current National Residency Matching Program policy (NRMP), international medical students and graduates, osteopathic medical students and graduates, and past US allopathic medical school graduates, all of whom the NRMP considers “independent applicants,” can accept “prematch” offers from residency programs. What this means is that programs can offer residency positions to independent applicants before the main residency match, which takes place annually in March. However, the NRMP may modify this policy, which would completely change the landscape of the residency match and, based on the opinions of many individuals involved in the process, make it more equitable.
Before exploring the proposed change, let’s consider the history of current prematch policies and review some data regarding how many applicants may obtain prematch residency training positions.
In 2001, the NRMP proposed that “all sponsoring institutions participating in the Main Residency Match must register and attempt to fill all of their positions in the Match except those specialties or programs participating in other national matching programs.” Some specialties historically do not fill any positions outside the match, and they tend to be the more competitive specialties. Many other specialties and programs that traditionally accept independent applicants try to fill some spots outside the match and also fill spots through the main residency match. So, while some programs and specialties adopted this proposal in 2001, others did not.
The main concerns of programs that offer prematches is that non-US citizen international medical graduates (IMGs) might have difficulty obtaining visas by July 1st (which is required to start their training) if they have to wait until March to obtain a match. NRMP determined that 92% of IMGs requiring visas in 2009 received them by July 1st, but the impact that prematching early might have had on this statistic is unknown. Programs that offer prematches were also concerned about “losing” their most desirable independent applicants if those applicants entered the main residnecy match because, in theory, these independent applicants could be ranked highly by more desirable programs where they might ultimately match.
The NRMP reviewed data carefully to ascertain how many applicants actually obtained residency positions outside the match in 2008. Of 28,633 new residents who entered graduate medical education programs, 1,588 withdrew from the residency match. Of these, 791 individuals indicated they had obtained a “non-NRMP” position and 567 indicated they withdrew at “applicant’s request.” It is likely that both of these groups obtained prematch offers. Interestingly, 2,577 residents in NRMP specialties did not participate in the main residency match; it is likely that these individuals also obtained prematch offers. In total, 3,935 individuals probably accepted prematch offers, and only 94 of these individuals were US allopathic medical school graduates in 2008.
Under a newly proposed policy that will be distributed and discussed widely over the next year, the NRMP is proposing that all institutions participating in the main residency match be required to fill all of their residency training positions through the NRMP residency match or another national residency matching program. In other words, institutions (and not specific programs or specialties) would be held accountable and would not be allowed to offer prematch offers outside the match. This is why the NRMP is calling this an “All-In” policy; institutions would need to decide if they would enter all of the institution’s residency training positions in the match. To further evaluate the significance of implementing this change, the NRMP will be conducting a survey of all program directors in 2011.
In 2012, the NRMP is instituting the “managed scramble” and likely cognizant that too much change in one year can often lead to confusion so it is unlikely also to institute this “All-In” policy next year. Like the two applicants with divergent views quoted at the beginning of this article, many people will be in favor of instituting change while others will be ready to battle it.
Note: The data in this article is from the official document published by the NRMP: Proposed NRMP Policy Change: All Positions in the Match.
Dr. Jessica Freedman, a former emergency medicine associate residency director and medical school admissions member at the Mount Sinai School of Medicine, is president of MedEdits Medical Admissions. MedEdits offers advising and professional editing for applicants to medical school, residency, fellowship, and post baccalaureate and special master’s programs. Like MedEdits on Facebook.
The wheels of bureaucracy grind slowly. At the very earliest, this may be implemented in 2015, if at all. There will be far too much resistance to easily pass this restriction on institutions.
ESPECIALLY after this year’s scramble clusterf%&@k
While I am in agreement with you that the wheels move slowly the fact of the matter is still that I chose to work my ass off and apply and got accepted to a us school and hopefully a decent residency. The individuals that decided or where guided not to apply in the us system are now going to compete with me in the residency arena. How can you possibly think that this is anyway fare? Its telling me that I should have partied harder studied less and just applied to a foreign school and I would have been afforded the same opportunities than a us grad, what a croc….Now it seems like some us medical programs are putting their name on the foreign program so this will add more credibility to the institution. This is all about money and profits…..Lets get out of the profit business and lets get back to medicine. PLEASE
Mr Jim,
Please pass a law that IMG’s should not apply for residency and then talk the crap that you are talking. IMG’s are applying to residency programs because they are allowed to do so.
Good. We need to push out the IMGs from the medical system, and keep the American grads, as those spots are paid for with our tax dollars.
This sounds very ignorant! I wonder how you made it to med school with type of attitude! Many of us “IMGs” are as American as you are and maybe more!
@GlennBeckRocks
Then make such laws. Tell the entire world that America no longer believes in diversity. Tell the world that America is no longer a land of opportunity. Tell the IMGS not to waste their money and time studying for USMLE’s since the AMG’s hate them.
Please GlennBeckRocks can you pass such a law so that the world knows that America is not a hypocrite.
GlennBeckRocks said:
“Good. We need to push out the IMGs from the medical system, and keep the American grads, as those spots are paid for with our tax dollars.”
I think I’d agree with what I think is your motivation behind such a statement: you’re looking to protect an American grad from potentially losing out a residency spot to an IMG. If this is more or less what you’re getting at, I think I’d agree with your sentiment.
At the same time, I don’t know if you’re including US-IMGs in this category. If you aren’t, then that’s fine. But if you are, then I think there’s a difficulty or two with saying what you’ve said:
1. What about American citizens temporarily studying in foreign medical schools and wishing to come back to the U.S.? I’m not solely referring to Caribbean medical schools, although I would include them. But I know of Americans in med schools which are arguably at least as good as the lowest ranked but accredited American medical school. I’m thinking about places like Cambridge University, King’s College London, Imperial College London, Oxford University, University College London, and many others. I’m also assuming these Americans have paid taxes in America because they have worked there in the past. Should they also be pushed out from our medical system?
2. Even if we agree US-IMGs are a minority among IMGs, nevertheless, the same argument I said directly above would still apply.
3. By the way, it’s possible there are American citizens from American med schools who have never paid state and federal taxes in their life. Maybe they never worked in high school, they went straight to college, and then straight to medical school. Now they’ve graduated from medical school. Technically, they haven’t paid for anything with their tax dollars. If you’re arguing we should exclude certain groups from our medical system on the basis of not having paid taxes, then would you exclude this group as well?
Again, I agree with what I think is your sentiment behind your statement. But I did see a couple of difficulties in making such a sweeping statement.
This will take a long time to be implemented, if ever. I think the NRMP needs to fix their own problems, before creating more.
“But I know of Americans in med schools which are arguably at least as good as the lowest ranked but accredited American medical school. I’m thinking about places like Cambridge University, King’s College London, Imperial College London, Oxford University, University College London, and many others.”
You mean, arguably at least as good as the highest ranked American medical schools. Peter, how dare you imply comparability of top UK medical colleges like Cambridge and Oxford with likes of Meharry, Howard and the Puerto Rican schools? What’s mind twisting here is that your post attempted to be the facilitator of reason, but made far less sense than the original post in question.
Meharry/Howard/Puerto Rico and other low-ranked USA schools are clearly nowhere as good as the UK schools listed above. If the top UK schools want to send grads to American GME, I say let them come.
We all know that is rarely the case: It’s the carib rejects, other international schools, and poor-english speaking immigrant docs who are trying to pour into our primary care residencies and beyond. Prematching at poor programs is generally the way they go.
Increase quality of GME by keeping it to Americans and Top International Grads.
GlennBeckRocks said: “Increase quality of GME by keeping it to Americans and Top International Grads”
I don’t get it! Do you want IMGs or not? and also, you pointed that residency spots are paid with tax payer dollars and should not be taken by IMGs who haven’t paind any taxes, but how can you make such generalization about IMGs?, so IMG=No-tax-payment?? That’s absolutely erroneous. IMGs come from different backgrounds, many have spent years in the US working in research (paying taxes), and others come after competing with everybody else and go through the Match (to start paying taxes upon working in the US), so it is unfair (and ingnorant!) to imply that IMGs take advantage of the system when in fact the investment in their medical education was spared to the American society becuase they were trained elsewhere… Good medicine is not only American medicine…
I completely agree on the issue of applicant quality, those who are top applicants are the ones improving healthcare in the communities in the US, the others (low quality) just profit!
Now, GlennBeckRocks said: “We all know that is rarely the case: It’s the carib rejects, other international schools, and poor-english speaking immigrant docs who are trying to pour into our primary care residencies and beyond”
Primary care?? what’s up with that?, American grads don’t want to do primary care, that does not leave enoough money!! With increasingly high educational debts the system has pushed many American grads towards the specialties (where the compensation is extremely dispair compared to primary care) because the need for self-preservation (that is wanting to pay what you owe, before collections) goes first in many cases over community retribution (and who can blame them?). So putting it that way (“trying to pour into our primary care residencies…”) just shows (once again) an ignorant xenophobic approach to the issue. I believe good quality IMGs are supporting good primary care practices in the US, and in fact in many places they are keeping primary care alive!!
Keep them coming!! Keep good IMGs coming, and fix the system so many more American grads fall in love with primary care and do it instead of being worried about paying their huge debts…
The Match should re-consider the “All-in” concept because many good quality IMGs and DOs find their residency spots this way to good rpograms who value their effort and qualifications. Waht should happen is that American allopathic grads should be allowed to go outside of the Match and get “pre-matches” as well…
Discrimination against international medical graduates in the United States residency program selection process
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2822781/
Study: Foreign-trained doctors as good as those trained in USA
http://www.usatoday.com/news/health/2010-08-08-doctors-foreign-training_N.htm
Incredibly sad that instead of focusing on the main theme here, this is yet again a bipartisan debate of AMGs vs IMGs. Apparently, the fear amongst AMGs is well-founded, not all of the reasons being based on principle but just maybe a lack of competency as well.
In any case, the quality of care is always the central theme and it is pathetic to watch AMG students sob and start spewing their vitriol as that kind of behavior is best reserved for grade school.
When I took an oath as a doctor it was to serve the patient’s best interest not my own.
I’m an IMG and I’m damn proud of it, also happen to have immigrated to the US a long time ago and am very happy to call America my country, although I naturalized in it.
Diversity is what makes us strong and anybody who is trying to break that concept is working against a truly American principle that has served us in all times good and bad.
The problem is that we are quickly arriving at a point in which the American medical education system will put out enough grads to fill every American residency slot. If this happens, then any American medical graduate (who is a citizen) should get priority for those slots. This isn’t xenophobia, it’s using tax dollars collected from the citizens of a country to benefit the citizens of that country (which is something that practically every other country does when it comes to medical education). As for the poster above who discussed how some American medical applicants had likely never worked a day in their lives – their parents very likely pay (and have paid) federal taxes on income that is being utilized to subsidize these residencies.
“Good. We need to push out the IMGs from the medical system, and keep the American grads, as those spots are paid for with our tax dollars.”
Ignorant fool! Come to my neck of the woods, which is out in the boonies and you will not find a single AMG wanting to serve the area. The only ones that you can find for miles on end are IMG’s. Without those IMG’s, my rural community would not have a physician.
FYI, IMG’s do pay taxes too and invest a lot of money before they can get into residency. I would rather have an good IMG treat my mother than an AMG who scraped through med school, barely passed USMLE or failed them!!
No wonder Fox and Rupert Murdoch, who by the way is an Australian, is laughing all the way to the bank at the expense of ignorant American fools like @GlenBeckRocks!!!
@GlenBeckRocks: I’m a US born citizen and like many others, chose to go to a carib med school. Why? Because I didn’t want to waste time waiting another year or two for a ‘possibility’ at getting into a US school. There’s not enough US med school seats and still a huge shortage of docs. That’s always been a problem in the system. And yes I’m a US taxpayer and also a political conservative, for you Glen Beck lover.
In the end, we still take the same exact USMLE Step exams as US grads.. that is the equalizing ground, regardless where you studied. Many Carib grads have done well and surpassed many US grads on Step 1. We’re still US (or Canadian) citizens, but we studied basic sciences on an island, that’s all. (I can’t speak for those from other countries.)
Our education is not necessarily inferior. We study our asses off and learn the same stuff as US schools, use the same books, same integrated and problem-based style learning, etc. We do ALL our clinical rotations in the states right alongside US med school students and doctors.
So for anyone who looks down on docs just b/c we studied on a beautiful tropical island for a couple years, don’t hate because one day your life may be saved by one of us.
Well Said CaribDoc.
Not to be a jerk, but why are there so many indian americans in carib schools? I’m rotating with other med students from a carib schools and they are ALL indian. Is it a trend? Not bashing on them- some are pretty smart. I was wondering if maybe there was some tie to Grenada or Ross..
I am another proud IMG and I just got a residency position in the field I love. The AMG are in the right to fight. However you have to see what is going on around you, the rapid growth of none caucasian population will make this country of opportunities (freedom, work, research)more diverse, and people will demand or feel much better going to doctors with the same capacity but whom speak their same language and understand their culture. We could argue about all this social issues and the relationship between AMG residents and none English speakers, but there is one big fact, the Hispanic population is around 50 million people between legals and illegal immigrants, first and second generation, without adding the others minorities. I think, most of us pay our taxes every year, so in one way all these people have the right to have doctors from their own country to take care of their health and the IMG have a support (if we are talking about the tax payers) in the US.
That is indeed a good question – what about US citizen IMGs? I am one such person. I am doing my first 2 years of school in Australia, at a school that is considered a top medical school worldwide, and will do all my rotations at Ochsner in New Orleans, which is considered a top clinical school in the US. Yet, simply by fact that I have “IMG” attached to me, I am automatically considered an inferior applicant, even if I have excellent USMLE scores. And now there is a move to take away the slight advantage that I could potentially use – namely pre-matching? I mean, why tie the hands of the programs? Do you really think that they would be giving the spots to less qualified candidates so that the more qualified AMGs can’t get it? Please! They are filling a need in their program. For some IMGs, the advantage would be that they can opt into a less competitive residency in a less competitive locale, thus meeting needs in underserved areas. For some (like me, I hope) it will be to land the residency I want in the location I want by using some connections and selling myself effectively to the residency coordinator. That would take the stress off of me for the match, make me much happier, and give me more options – but you would be mad to think that the residency program would grant me a slot if I weren’t qualified for it!
Oh, and a side note – Glen Beck is a complete waste of carbon and oxygen. Few people deserve the title “human” less than him.
The person that said medical schools like those at Cambridge,Imperial and others are at least as good as the lowest ranked medical schools here is unbelievably stupid.Three of the schools you listed could be ranked in the class of the Harvard’s and others.There is nothing really special about US education except that you have to take out humongous debt loads and take tons of premed classes that have no relationship to what you will do as a physician.The “American system” thinking its the best is actually one of the worst,complicated,and useless in the world.