2012 Match Summary and Analysis

"Family physicians are committed to continuing, comprehensive, compassionate, and personal care for their patients. They are concerned with the care of people of all ages, and understand that health and disease involve the mind, body, and spirit and depend in part on the context of patients’ lives as members of their family and community.”
--The Future of Family Medicine Report, 2004

The information in this report is based on data from the National Resident Matching Program (NRMP) for 2012. The information provided includes the number of applicants to graduate medical programs for the 2012-13 academic year, specialty choice, and trends in specialty selection. This information will be useful to advocates of family medicine—including family medicine departments and residency programs—as well as legislators who are interested in trends predicting the primary care workforce of the future.

This report is prepared by the American Academy of Family Physicians Division of Medical Education.

Preliminary information available from the 2012 National Resident Matching Program (NRMP) indicates that for family medicine residency programs 2,611 positions filled out of 2,764 positions offered (94.5%). This represents an increase in the number of family medicine residency positions offered and filled through the NRMP over 2011. [Included in this category are family medicine-psychiatry, family medicine-emergency medicine, family medicine –preventive medicine and family medicine-internal medicine programs.] Thirty-four more family medicine positions (1.2%) were offered in 2012 compared with 2011. Thirty-five more positions (1.3%) were filled in 2012 compared with 2011 (2611/94.5% vs. 2,576/94.4%)

Eighteen more U.S. seniors (1,335 vs. 1,317) chose family medicine in 2012 compared with 2011. Fewer U.S. seniors participated in NRMP in 2012 compared with 2011 (16,527 vs. 16,559), but still with a resulting increase (8.5% vs. 8.4%) in the percentage of U.S. seniors who chose family medicine. This is the first time since 2002 that fewer U.S. seniors participated in the NRMP than the preceding year.

One hundred and fifty-six more positions (3.0%) were offered in 2012 compared with 2011 in internal medicine-categorical (5,277 vs. 5,121). Thirty-nine fewer positions (2.1%) were offered in internal medicine-preliminary (1,861 vs. 1,900). Twenty-five more positions (8.0%) were offered in 2012 in internal medicine-primary care (311 vs. 286) and three fewer positions (0.8%) were offered in internal medicine-pediatrics (362 vs. 365). One hundred and forty-one more positions (1.8%) were offered in internal medicine-all types (7,874 vs. 7,733). Seven fewer positions (0.3%) were offered in pediatrics-categorical (2,475 vs. 2,482), with a decrease of seventy-six positions (3.0%) offered in pediatrics-all types (2,509 vs. 2,582).

One hundred and fifty-six more positions (3.1%) were filled in internal medicine-categorical in 2012 compared with 2011 (5,226 vs. 5,065), with one more positions (0.03%) filled with U.S. seniors (2,941 vs. 2,940). Six more positions (0.3%) were filled in pediatrics-categorical in 2011 (2,443 vs. 2,437) and thirty-six fewer positions (2.1%) were filled with U.S. seniors (1,732 vs. 1,768).

Three pediatric and internal medicine match position types are considered primary care. One of the three filled with more U.S. seniors in 2012 when compared with 2011. Thirty-one more positions (10.3%) were filled in internal medicine-primary compared with 2011 (300 vs. 269), with twenty more positions (10.8%) being filled with a US senior (186 vs. 166). Two fewer positions were filled (3.1%) in pediatrics-primary in 2012 compared with 2011 (64 vs. 66), and one less (3.7%) U.S. seniors filled the available positions (27 vs. 28). Eighteen fewer positions (5.2%) were filled in internal medicine-pediatrics compared with 2011 (344 vs. 362), and thirty-three fewer (12.0%) U.S. seniors chose internal medicine-pediatrics compared with the preceding year (276 vs. 309). For these three primary care specialties, thirty-six more positions (1.3%) were filled in 2012 compared with 2011 (708 vs. 699), and fourteen fewer positions (2.9%) were filled with U.S. seniors (489 vs. 503).

In the 2012 NRMP, the primary care programs experienced some change in fill rate percentage compared with 2011. The fill rate for family medicine increased 0.1%, internal medicine-primary increased 2.4%, pediatrics-primary decreased by 4.0% and internal medicine-pediatrics decreased 4.2%.

Thirty-nine fewer preliminary positions in internal medicine were offered in 2012 compared with 2011 (1,861 vs. 1,900), and thirty-three fewer were filled in 2012 compared with 2011 (1,738 vs. 1,771). Seventy-six fewer U.S. seniors (5.3%) matched into internal medicine-preliminary (1,427 vs. 1,503). These students have chosen an internal medicine-preliminary year specifically as preparation for further training in another specialty.

Anesthesiology experienced an increase in positions filled (8.6%) in 2012 with fifty-six more students choosing the specialty (897 vs. 820). Despite a small dip in 2004, the number of positions filled in anesthesiology has almost quadrupled since 1997. The number of positions offered increased 8.5% (919 vs. 841) and fifty-four more U.S. seniors (7.4%) matched in anesthesiology in 2011 (725 vs. 671).

The number of positions offered and filled in diagnostic radiology decreased with nine fewer positions (6.7%) offered (135 vs. 144) and twelve fewer positions (9.6%) filled in 2012 compared with 2011 (124 vs. 136). Twenty-five fewer U.S. seniors (27.8%) matched in diagnostic radiology compared with 2011 (90 vs. 115).

Emergency medicine offered sixty-one more positions in 2012 compared with 2010 (1,668 vs. 1,607), representing an increase of 3.7%. Sixty-six more positions (4.0%) were filled in emergency medicine compared with 2011 (1,668 vs. 1,602), with sixty-seven more U.S. seniors (5.0%) selecting emergency medicine (1,335 vs. 1,268).

Obstetrics-gynecology offered thirty-five more (2.8%) positions (1,240 vs. 1,205) and filled thirty-one more positions (2.5%) compared with 2011 (1,223 vs. 1,192). Twenty more U.S. seniors (2.2%) chose obstetrics-gynecology in 2012 (913 vs. 893).

Surgery-categorical offered thirty-eight more (3.3%) positions (1,146 vs. 1,108) and filled thirty-seven more positions (3.2%) compared with 2011 (1,143 vs. 1,106). Seventeen more U.S. seniors (1.9%) chose surgery-categorical in 2012 (914 vs. 897).

The AAFP continues to track and report on the annual NRMP results as these have significant implications for physician workforce, health care reform, health care access, and health care policy. Health care outcomes are strongly linked to the availability of primary care physicians, and the shortage of primary care physicians has become critical in the United States. Increasingly, the public is aware of the need for a strong primary care physician infrastructure, and the important role that family physicians fill in providing health care to adults and children in communities all across the nation. Despite the increased attention for primary care, the percentage of primary care positions filled in 2012 (14.5% for all applicants/11.6% percent for U.S. seniors) continues to fall short of the peak interest that occurred in 1998 (21.3% for all applicants/22.0% for U.S. seniors).

Although the Match results are encouraging, student interest, however, is still not at the level it needs to be. Although the match rate in family medicine among US medical school graduates has increased, the majority of positions offered and filled in the NRMP, especially among US graduates, continue to be in non-primary care sub-specialties. In its 20th Annual Report “Advancing Primary Care”, the Council on Graduate Medical Education (COGME) affirms that the US physician workforce needs to be made up of "at least 40% primary care physicians" to ensure the nation's health, health care access, health care expenditures and health outcomes for the future.¹ COGME projects that to reach this 40%, 63,000 additional primary care physicians are needed. If health reform succeeds in increasing the number of insured individuals, more than 100,000 additional primary care physicians will be needed.¹ The number of students entering family medicine is most reflective of the future physicians who will provide primary care for adults in the future. The vast majority of internal medicine residents sub-specialize; only 2% of students entering an internal medicine residency choose to do general primary care after residency graduation in one study^.2

In 2009, the AAFP adopted a new workforce policy statement to identify the policy recommendations that should be implemented to support a strong family medicine workforce.³ The 20th COGME report identifies the complex interaction of a number of factors that influence medical students to choose sub-specialty careers over primary care, including compensation inequities, medical school admission policies which may disadvantage students more likely to enter primary care, career choice influences during medical school, and Graduate Medical Education (GME) funding issues. COGME recommends payment reform to substantially increase reimbursement for primary care services, strategies to improve the premedical and medical school environment, changing GME payment and accreditation policies to increase primary care production from residency training, and addressing the geographic and socioeconomic mal-distribution of physicians.¹

An analysis of the relationship between physician salaries and specialty choice found that US seniors are predominantly choosing the more highly compensated specialties.⁴ Though this information is not surprising, what has become more of an issue is the dramatic increase in the income gap between primary care and other specialties.⁵ Until this issue is appropriately addressed, the AAFP believes that many excellent physicians will be deterred from a rewarding career in family medicine where patients and communities receive effective, equitable, and efficient patient-centered care. COGME recommends that the average of primary care physicians’ salaries should be at least 70% of median incomes of all other physicians.¹ The AAFP believes that to further increase the number of medical students choosing family medicine, health care reform efforts absolutely must achieve payment reform to increase reimbursement for family physicians. Providing compensation for other important aspects of primary care, such as care coordination and comprehensive longitudinally personalized care, as in a patient-centered medical home (PCMH), will be crucial to resolve the income disparity between family practice and sub-specialty medical care.

The average debt load, as well as the proportion of students with debt, has steadily grown over the past thirty years. According to the AAMC, data indicates that the tuition and fees for medical school has increased dramatically. For the graduating class of 2010, the average debt of a medical school graduate was $157,944.⁶ The ability to be able to offer programs that address debt, in light of the income disparity between primary care and sub-specialty care, should be prioritized. These include funding both national programs, like the National Health Service Corp, and state based primary care scholarship and loan repayment programs. Participation in the NHSC scholarship program is associated with a quadrupling of the odds of choosing primary care.⁷

In this year’s NRMP Match, 2,611 individuals chose to become family physicians. These are individuals who have chosen to provide care to children and adults, women and men, throughout the continuum of the life cycle. They will provide care in rural and urban settings. These future family physicians will provide a personal medical home for their patients, reflecting one-quarter of the office visits to all physicians in the U.S.⁸

The general public as well as, business leaders, and decision-makers are becoming increasingly aware of the concept of the Patient Centered Medical Home (PCMH). In February 2007, the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), the American Osteopathic Association (AOA) and the American College of Physicians (ACP) developed a set of joint principles that describe a new level of primary care called the Patient-Centered Medical Home^.9 A patient-centered medical home is an approach to providing comprehensive primary care for people of all ages and medical conditions. The Patient-Centered Primary Care collaborative succinctly outlines those joint principles: a personal physician, physician-directed medical practice, whole-person orientation, coordinated and/or integrated care across the health care system, quality and safety focus, enhanced access, and payment for PCMH added value.¹⁰ In the past 5 years, Ontario, Canada established Family Health Team (FHT) models incorporating the joint principles of the PCMH which have demonstrated higher satisfaction among patients, higher income and more gratification for family physicians and more medical students selecting to enter family medicine.¹¹

Increasing student interest in family medicine is the “pipeline” to creating and sustaining the family physician workforce of the future. In September 2008, the AAFP Board of Directors reviewed a comprehensive student interest initiative plan and approved an enhanced student interest project. The Board approved and funded four regional Stakeholder Collaboration Workshops which were conducted in 2010-2011. The Workshops brought together all of the stakeholders in family medicine workforce development: students, residents, residency directors, medical school faculty, state chapters, Area Health Education Centers (AHECs), Family Medicine department chairs, practicing physicians, premedical advisors and Family Medicine Interest Group (FMIG) faculty advisors. The goals were to improve communication among the different stakeholders, and to develop infrastructure that will facilitate continued local collaboration around student interest.

The Society of Teachers of Family Medicine (STFM), the Association of Departments of Family Medicine (ADFM), the Association of Family Medicine Residency Directors (AFMRD), the North American Primary Care Group (NAPCRG), and the AAFP Foundation join the AAFP in continuing efforts to communicate the message of family medicine to medical students. The family medicine organizations also continue student interest efforts in four defined evidence-based areas of focus: 1) identification and preparation of inspiring and competent family physician mentors and role models, 2) focus on medical school admission characteristics of students likely to choose family medicine, which includes identifying and inspiring the pipeline for future medical students, 3) effective communication about the image of family medicine to medical students and to the broader community, and 4) effective education of medical students about the family medicine model of care.

A strong family medicine workforce is dependent on at least three factors: recruitment of students to the specialty, comprehensive training of family medicine residents to provide patient-centered care within the framework of a medical home, and support for practicing family doctors who provide the kind of care that the nation says it wants and needs. The challenge for the future is to clearly communicate with policymakers, educators, medical students, and the public that a well-trained, adequately equipped, and equitably distributed family physician workforce is the key to health care in the United States.