They’re about to graduate from medical school with an MD to their names, but hundreds of students across the US learned this week that they haven’t advanced to the next step of training — and will not be allowed to practice medicine.

Most medical students found out Friday where they’re headed for their residency, where they’ll work alongside licensed doctors, gradually gaining more responsibility. But each year, a sizable group learns shortly before the official “Match Day” that they’ve been shut out of this training.

This year, for instance, more than 29,000 applicants got placed in a first-year residency through the main matching process. But 8,640 did not — a number that includes international applicants and aspiring physicians who graduated from medical schools in recent years, as well as current fourth-year students.

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That mismatch has prompted a policy debate: Should the rural and urban clinics that struggle to find doctors be allowed to scoop up unmatched graduates so their talents don’t go to waste? Or would it be dangerous to put them in front of patients without a traditional residency, which typically lasts at least three years?

Missouri, Kansas, and Arkansas have passed laws to allow unmatched graduates to work in medically underserved areas without doing a residency.

Otherwise, “a lot end up wasting all of their education, because there is no place for them in the health care delivery system without having a residency,” said Dr. Edmond Cabbabe, a plastic surgeon in St. Louis who conceived of the Missouri law.

Passed in 2014, but not yet implemented, the law will create an “assistant physician” license for these newly minted doctors, who will work with a collaborating physician. That physician will have to directly supervise the new doctors for at least a month before they can see patients on their own. One impetus for the law: Nearly all of Missouri’s 101 rural counties face a shortage of primary care providers.

Arkansas this year approved new rules allowing recent medical school graduates with ties to the state to work as a “graduate registered physician” before residency. Kansas, too, created a special license; it’s restricted to graduates of the University of Kansas School of Medicine who strike out in the match process, and it allows them to work, under supervision, for just two years. At that point, they’re expected to move on to a residency.

While supporters hail such laws as a groundbreaking solution, the medical establishment has frowned on them.

The Association of American Medical Colleges “is concerned by efforts that would bypass the experiences necessary for physicians to provide safe and effective patient care independently,” said Tannaz Rasouli, AAMC’s senior director of government relations.

The American Medical Association also came out against such programs. Instead, it has called on government, insurance payers, and foundations to pitch in money to create more residency spots.

So far, no one is practicing medicine under any of those new regulations.

But they could help MDs like Dr. Heidi Schmidt, a Juilliard-trained opera singer and entrepreneur who graduated from American University of the Caribbean School of Medicine on the island of St. Maarten. She received honors in clinical coursework, but struggled with standardized tests and had to make multiple attempts to pass two national board exams.

Residency programs often see multiple board exam attempts and degrees from foreign medical schools as red flags when evaluating candidates.

Schmidt, who also has master’s degrees in public health, music, and pharmaceutical science, has the title “doctor,” but her options are limited. Without at least one year of postgraduate residency, she can’t practice medicine in the United States. To work as a nurse or a physician assistant, she’d have to go back to school and get a different degree.

To stay in medicine, she volunteers in Indianapolis at Gennesaret Free Clinics for the homeless and working poor. She sees patients, but she said a licensed physician must sign off on all her work. Schmidt said she can’t get paid until she becomes a licensed physician. And she longs to treat patients on her own.

“My dream has always been to be a physician for the poor,” she said.

Heidi Schmidt Match Day
Dr. Heidi Schmidt at the St. Vincent de Paul food pantry in Indianapolis, Ind. After not being matched with a residency, Schmidt’s plans of becoming a licensed doctor are on hold, so she volunteers at a medical clinic there. Lucas Carter for STAT

Seniors in traditional (non-osteopathic) US medical schools have better odds than those from foreign schools: Their match rate has hovered around 94 percent. But that still means 1,130 didn’t get a residency in the main match this year.

That news can be a shock. As a senior at the University of Virginia medical school last year, Dr. Daniel Harris applied to 67 general surgery residencies and landed eight interviews at residency programs. On the Monday before Match Day, he got an email letting him know that none had accepted him.

Harris said he was in disbelief, but he didn’t have time to process that feeling. He had just two hours to decide which programs he would apply to through the Supplemental Offer and Acceptance Program, or SOAP, which helps unmatched applicants find open spots.

Harris picked 20 programs and hit “submit.”

“I maybe started crying at that point,” he said. “There was nothing more I could do.”

Harris got lucky: He was one of 599 US medical school seniors who scooped up unfilled spots through SOAP last year. Other types of applicants — for instance, those from foreign schools — grabbed another 400-plus spots.

That still left hundreds of seniors at US medical schools, and thousands from international schools, halted in their quest to practice medicine in the United States.

Were they weeded out for good reason? That’s open for debate. Surely, some were ill-prepared. Others may have been unlucky or just played their cards wrong when picking which residencies to apply for.

The most common reason for not matching is poor scores on national board exams, according to a 2005 survey by the AAMC. Other reasons include: applying to a specialty that’s too competitive for the applicant’s academic standing; poor interviewing or interpersonal skills; and having to take a board exam multiple times to pass.

Some people in this situation, like Dr. Nick Milligan, decide not to pursue a medical license. Milligan graduated from St. George’s University School of Medicine, on the Caribbean island of Grenada, in 2014. He said he was disappointed not to match with a residency, but he ended up happily employed at Coachella Valley Volunteers in Medicine in California, where he has used his medical training to build a diabetes education program.

Medical school grads face a staggering $183,000 in debt, on median, but they can seek relief, as Milligan does, from federal programs that limit monthly loan payments to 10 percent of income.

Most graduates of US medical schools don’t give up on becoming a licensed doctor if they don’t match, said Geoffrey Young, AAMC’s senior director for student affairs and programs. They often spend a year doing research, or complete a fifth year of medical school, then apply to the match the following year.

More than 99 percent of US medical school graduates do end up practicing medicine within six years of graduation, Young and coauthors found in a study published in JAMA.

The new state laws might offer some of the unmatched students another route to a medical career.

Missouri is expected to open enrollment for its assistant physician license this fall. Because it has the least restrictive rules, it may face a flood of applicants from around the country.

Schmidt could be one of them.

If Missouri opens the door for her to treat patients, she said, “I’d pack up and move in a second.”

Update: The story has been updated to include statistics about the matching program for this year.

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  • The truth is that every March during the past five years, more than TWO THOUSAND of US physicians and lawful permanent residents that attended medical school abroad (US-IMG’s) are displaced from the medical training required to obtain license to practice medicine in the US by foreign national doctors- also educated abroad- (IMG’s) that have never paid US taxes.
    The majority of these training positions in teaching hospitals are funded by the US Government through MEDICARE, like you illustrated in your article. So, while the foreigners are getting trained and paid with US taxpayers contributions, the displaced and also taxpayers -US citizens- physicians, are forced to take unstable jobs in the medical field as lab techs or medical assistants were they are easily exploited and mistreated, like myself (The father of two girls recent grads from UC Irvine and a boy, a US Marine, currently deployed).

    Just last year’s (2015 MATCH, data obtained from ECFMG website) a total of 5,014 US-IMG’s applied for residency and only 2,660 positions were granted for them, meaning that 2,354 US Citizens were left UNDER-EMPLOYED.
    However, a total of 3,641 positions were given to NON-US nationals out of 7,366 that applied.
    If those positions, given to foreigners would have been given to US-IMG’s, all US nationals would have had secured a job and future in a residency program. Moreover, if we make the math correctly, after satisfying the demand of US physicians, about 1,200 spots were still unfilled, available to give to those NON-US nationals for their medical training.

    I am not saying that we need to close the doors to non-nationals in their attempt to obtain medical training in the US, I just simply saying that after giving priority to the local guys, we can still help the visitors. But not the other way around.

    Countries like Spain also offers medical residency training positions to foreigners as well, but only the 4 percent of total spots (about 240 positions). Spaniards give priority to their nationals or members of the European Community over foreigners. Mexico also offers training in medical residencies to a great number of Latin American graduated physicians but again, preference for positions are always given to their nationals over foreigners. Why can’t we be like Spain? Or Mexico ?
    This is another tragic -preventable- American story, that needs to be fixed.

    • I know it would sound harsh, but I would want to see the most qualified and capable to become a physician in this country. You describe the current situation that you describe, where foreign-trained applicants get picked in the matching program while locals who are left in the cold. What I would like to know is, whether those foreign applicants are picked due to some affirmative-action-like program, or not. If not, and if those foreign applicants are picked based on merits, then I don’t see any problems in that.

      As the article has pointed out, foreign-trained applicants are often at a disadvantage when it comes to matching. Yet, you describe a situation where foreign applicants stand out over the local applicants. Does that tell us that the locals are simply less competitive or less capable or deficient in some areas (eg. grades? multiple tries to the exam?)? That, you do not elaborate. But if it’s indeed true that the locals are simply not as competitive or capable, then surely the foreigners deserve their place in the matching process.

      I guess you can write to Trump now to demand banning them to come into the country too.

    • Tiddle,
      ALL New docs: US GRADS, US IMG’s and Foreign IMG’s needs to pass the same examination boards in order to become eligible for post graduate medical training. The US GRADS got their Medical Diploma and both the US and foreign IMG’s an ECFMG ( Educational Commission for Foregin Medical Graduates) CERTIFICATION .
      Diplomas or ECFMG Certifications are needed as a MAIN requisite to enter a residency program. Program Directors are the ultimate filter to pick potential candidates. Some of them look for Scores Or # of Attempts or both at taking the test, but the truth is that It should not matter.
      Do you know/ have you asked your Doc(s) their score in licensing exams? or how many attempts to each exam they took when were medical student? And if they tell you that his/ her score were on the lower end , would you change Doctors?
      No study – until today- has been able to Predict A successful/ or not postgraduate Clinical practice as Doc treating patients. Studies have only proven that the most common causes of medical students to fail licensing test are: 1) poor reading skills and 2) poor test taking strategies. Not lack of knowledge. Another study ( of many) showed that: “USMLE STEP 1 performance is just one of many variables that may predict success during third year clerkship sand postgraduate training. However, whether it is predictive of PERFORMANCE IN THE LONG TERM PRACTICE OF MEDICINE IS NOT KNOW” (Study of Selected Outcomes of Medical Students Who Fail USMLE Step 1. By Biskoving DM et al. Med Educ Online 2006; 11:11) available at http://www.med-ed-online.org
      Lets don’t worry about future performance of these docs that failed to pass their licensing exams in the first attempt/ or obtained a lower score, WE SHOULD NOT JUDGE THEM “at priori”. Once they are licensed, any complaints / lawsuits for sub-standard care or faulty ethics, will be a bridge very far from now and will be the sole responsibility of State Medical Boards. The large majority of us look for a specialty in primary care , not in surgical specialties where most incidents of malpractice happens. I propose ONLY :
      1 )ECFMG CERTIFICATION,
      2) STEP 3
      3) Apply to PRIMARY CARE residency
      4) 2 year compromise to practice in underserved area after residency.
      There is a big pie of medical residencies in the US. After locals- that have paid taxes -have our share , we can share a slice with the rest of the world. And yes, I am writing a letter to President Trump, Dr Ben Carson, the four US Senators (R) who are physicians and to all Members of Congress that are MD’s as well. After all is Medicare ( tax payers) money the one that finances these positions.
      All the best

    • To answer your question, tiddle, those IMGs Aguero is complaining about are the absolute cream of the crop. The competition for them to land a residency is beyond intense. I’m a US-graduated MD who is currently a resident in one of the most competitive fields. I had some of the best grades, scores, evaluations, clinical and interpersonal skills, and research experience in my class. I don’t say that to brag, but to put it into perspective when I say that the IMGs who actually manage to squeeze into a residency — even a mediocre residency in a non-competitive field — usually blow me away on pretty much every level except English proficiency and bedside manner.

      As for unmatched US graduates, based on my own observations they tend to fall in two categories: 1) those who aimed a little too high (at programs and/or specialties too competitive for their portfolio) and fell just a little short, or 2) those who, unfortunately, were not up to snuff. The first category usually does well; they either buff up their portfolios and make it into their intended specialty the year after, or they “settle” for a somewhat less competitive specialty that nonetheless allows them to practice medicine. Usually less competitive specialties are happy to take “leftovers” from the extremely competitive ones. Either way, they do just fine and generally have successful, happy careers.

      The second category of unmatched US grads tends not to do well, goes unmatched repeatedly, and perhaps eventually ends up in a different profession altogether. As sad as that is, it’s probably for the best. We like to think everyone getting into medical school is fit to be a doctor, but that’s just not true. While medical school admissions committees really are pretty darn good at finding the right people (consider that the attrition rate + no-match rate in medical school, on average, is probably around 5-10%, which is leaps and bounds better than attrition + unemployed rates coming out of college or any other advanced degree), a few people who really just aren’t cut out to be doctors slip in. By and large, they’re the ones who end up in category 2 mentioned above.

      I realize I’m generalizing, and that there are some good people that just fall through the cracks, but there’s usually some good reason these folks don’t ever make it any farther down the path to becoming an attending physician: a lack of knowledge, judgment, clinical skills, and/or very basic people skills. And frankly, faced with that candidate pool, I’d rather have an extremely well qualified IMG practicing medicine any day.

    • Medicare stopped funding residencies in 1997. It’s a cap that has never been lifted for over 20 years, despite the increase in the number of medical schools. Now there is a bottleneck of students who cannot find residencies. 2017-approx 7000 graduated med students did not match. 2018- 8000 did not match. Now, in 2019, over 8000 did not match. All potential physicians working at Target or Starbucks while we talk about using mid-level providers “to fill the physician gap”. Ludicrous. Now there is a bipartisan bill to increase funding for residencies because it is time. The Resident Physician Reduction Shortage Act 2019. Every physician in this country should push their representatives to support this bill. This has nothing to do with foreign grads taking anyone’s slot. Tons of foreign grads who are American citizens. Each state(CA being the strictest) has a list of Caribbean schools they consider to have equivalent education and quality as those in America. The med school in Grenada has been around for decades. We need to stop with the bias and lay the blame where it belongs: on the Centers for Medicare and the AMA who enacted the cap in the first place. They created this shortage.

  • I am one of these people and just because it took me a few more times to pass does not mean that i will not make an excellent physician. I was a critical care nurse for years prior to going to medical school. I have passed all of my boards including step 3 which is supposed to be taken first year of residency( 1 attempt). I am working in research now and have applied for the past 4 years. It is disheartening and discouraging when i know i can and am a good a physician. there are many physicians that get residency spots that do not have the clinical judgement or critical thinking skills I have gained in my years of experience.
    I want nothing more than to treat patients and unfortunately because of SCORES I cannot follow my dream.
    I am considering starting a FNP program which may seem as a step backwards but on completion I will be able to treat and see patients.
    ~~~~~~Discouraged

  • It’s simple really. Lawyers just need to pass the bar exam to practice law. So doctors should just need to pass the boards. Residency is just an extension of med school with clinical practice.

  • While allowing those who don’t match to practice as a mid-level provider is a stop gap measure it is not a solution to the problem. There needs to be a simple bill passed that increases funding for residency.

    • There is. The Resident Physician Reduction Shortage Act 2019. Google it. Then push your legislator to vote for it.

  • THE MD IN QUESTION FAILED THE BOARDS MULTIPLE TIMES! She did not match because 1) she failed the boards multiple times, and 2) she went to a for-profit degree mill in the carribean.

    So disappointed in the author of this article for leaving out these glaring facts.

    • Dear Educator,
      The CRUEL truth is that every year in March, more than TWO THOUSANDS of US physicians and lawful permanent residents that attended medical school abroad, are displaced from work opportunities and the medical training required to obtain license to practice medicine in the US by foreign national doctors- also educated abroad- that have never paid US taxes. The majority of these training positions are in teaching hospitals and are funded by MEDICARE, with US taxpayers money. So, while the foreigners are getting trained as specialist and paid with US taxpayers contributions, the displaced -US citizens- physicians are forced to take unstable jobs in the medical field as lab techs or medical assistants were they are easily exploited and mistreated.
      Just for last year’s (2015 MATCH, data obtained from ECFMG website) a total of 5,014 US-IMG’s applied for residency and only 2,660 were granted positions, meaning that 2,354 US Citizens were left underemployed. On the other hand a total of 3,641 position were given to NON-US nationals /IMG’s out of 7,366 that applied. If those positions would have been given to OUR NATIONALS , ALL of them -including Dr. Schmidt- would have had secure a position in a residency program. Moreover, after prioritizing US nationals , about 1,200 spots were still available to give to NON-US nationals for their training. The point here, we should give priority to US physicians and the left over positions for the rest of the world. Other countries like Spain also offers residency training positions to foreigners (4 percent of total spots), but give priority to nationals or members of the European Community.
      Even if someone had mediocre grades in med school and had several attempts and low scores in the USMLE’s exams, (but now you are ECFMG certified and passed Step 3 ) It is improper to label someone a “bad/mediocre doc” and prevent that person from obtaining a residency in Primary care, and give such opportunity to a foreign national. Let the medical boards of the state where you practice Medicine (they are the regulatory authorities) to determine if you are a bad Doctor. This will be after many complaints of the patients you treat. Not before you enter residency just because you had a bad or low score.
      This is another tragic -preventable- American story, that needs to be fixed.

  • And meanwhile Physician Assistants and Nurse Practitioners in Missouri prepare for widespread salary decreases and an increase in unemployment.

  • All medical students should become eligible to get license to practice medicine after passing required examinations.It should be the responsibility of medical schools to provide one year of general clinical training for all students who don’t match in speciality residencies.It is not right to abandon these students at the end of 4 years of medical school.This comment applies to US medical school.

    • Agreed. If they successfully completed the board work and passed their exams (even if it took more than one go) – then they should absolutely be considered credentialed enough to do at least a general medicine one-year residency. Otherwise, what was the point of 4 years of medical school and taking the boards anyway? What did it prove? It might be another situation for those coming from abroad where their medical school is credentialed differently – but this should at least apply to all American MD schools.

    • Absolutely Vijay, thank you. My niece spent 8 years pursuing her dream as a surgeon and she was informed today that she didn’t match to complete her training. Needless to say she is devastated. She passed all her boards with good scores and the surgeons at her med school loved to work with her. She can do the work, she has proved that. She knows the job and has the surgeon’s touch. This residency criteria is for the birds. Where do we get the funding for more residency slots?

  • why don’t they spend the money on increasing gme spots instead of opening so many more medical schools? I don’t get this logic but anyways.

    • True. And if the shortage is in primary care then the additional residency spaces should be created specifically for pediatricians, internists and family practice. Maybe general surgery – but not plastics, dermatology, etc.

  • This was place these graduatesites in a situation simular to PA’s. They actually would have more training than newly graduated PA’s who are seeking to practice without MD oversight. It appears like a food proposal – for them to continue working with MD oversight, similar to PAs

  • What? It seems mostly those mentioned are the graduates of foreign schools that American students apply to when they get rejected by schools in the US. I had the experience of matching into a program with two positions, in 1979 that took three residents! It seems to be nothing new to see people messed over by the system. After being dumped by that program, it followed me like the plague. I did finish the five year program at a different hospital, loaded with foreign nationals that were medical grads of foreign schools. I passed all of my license exams and boards. But, in the end, it did not prepare me for the nasty political scene in small rural hospitals. Having graduate school education made it much more difficult, as well. It was hard to fit in when your general knowledge level exceeded that of your “peers”. Extra knowledge in areas like endocrinology, reproductive endocrinology, neuroanatomy, and anatomy made other doctors complain “you act like you think you are smarter than us!” Glad I don’t swim with the sharks any more!

    • I do agree that board exam grades matter. Not that the one who scored higher has a better judgement. Let me throw a patient at you in the ER who got into motor vehicle accident and let me see what a 99% usmle scorer will do. Once you get an interview,it doesn’t matter what you got on board exams. Myself I have passed all the board exam and have a publication under my belt. I been struggling for 5 years to get a residency but this year I quit and enrolled myself into EMBA program. Hopefully this combination will bring any luck to me. Again there are too many candidates for residency and grades are just to filter them out.

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