Although the evidence is anecdotal, it appears that psychiatry is facing a relatively new phenomenon: U.S. medical school graduates who are unable to match to psychiatry. Psychiatry has seen U.S. and International Medical Graduate (IMG) physicians not matching to psychiatry in the past, but not in the numbers seen lately. As noted by Bailey et al. [1], the difficulty in matching has been increasing, and for the most part, it has not been widely publicized and addressed.

Psychiatry’s Success

Interestingly, the increased difficulty to match is happening while psychiatry is experiencing increases in the numbers of both available residency positions in psychiatry and U.S. allopathic and osteopathic seniors matching into psychiatry. In 2020, 1858 total psychiatric positions were offered in the Match (compared with 1740 offered in 2019 and 1384 offered in 2016) [2]. Of these, 1838 were filled: 1473 by U.S. senior medical students, 71 by physicians who graduated in earlier years, and 293 by U.S. and non-U.S. IMG physicians and one by “other” [2]. These numbers are certainly encouraging, especially for those of us who remember the 1990s, when match numbers were in the 400s for much of the decade [3, 4]. The percentage of allopathic seniors selecting psychiatry rose to 6.3% in 2020, from 5.9% in 2019 and 5.0% in 2016 [2].

Psychiatry is clearly attracting more medical students after years of lamenting that U.S. medical students are not interested in it. We do not have a full grasp of the reasons for the increased interest, but it appears probably multifactorial, and we can speculate that included factors may be competition for other specialty slots [3], increased advances in psychiatric research and new treatments (e.g., esketamine, transcranial magnetic stimulation, new psychotherapies), a very broad domain of topics of special interest and relevance (e.g., human trafficking and other forms of interpersonal violence and exploitation, ethics and philosophy in clinical psychiatric practice, looming mental health consequences of the COVID-19 pandemic, global mental health), availability of more time to spend with patients, new generations of physicians who are more focused on lifestyle, and medicine’s increased understanding of behavioral and mental issues and their ubiquitous presence in all of health care.

Unintended Consequences

Failure to match is potentially devastating to the graduating senior medical students, many of whom will have large loans to pay. Some of those who fail to match may not be able to remain in the profession in any capacity despite having already invested a considerable amount of effort and time to do so.

Success frequently brings growing pains and problems. In 2019, U.S. allopathic seniors applied on average to over 50 psychiatric programs [5]. This high number places a significant strain on both the applying medical students and Graduate Medical Education programs, and this strain will only worsen as the numbers of applicants continue to increase. The upcoming conversion of the United States Medical Licensing Exam (USMLE) Part 1 score to pass/fail will also strain the residency programs. Holistic reviews of inflated numbers of residency applications conducted with one filter removed (the Part 1 score) will require much more administrative time, in many cases hundreds of hours [6]. Medical schools will also likely be tasked with advising an increased number of unmatched students, and perhaps affiliated residency programs will be pressured to assist.

Available Remedies?

The issue of failing to match is not a new one, and the attempts to help unmatched students are also not new. Some psychiatrists and physicians in other specialties created programs for unmatched applicants to help them increase their chance to match in their future attempts to obtain residency (usually in any specialty). These informal programs, frequently revolving around one enthusiastic person, originally started as a help for IMG physicians attempting to match to psychiatry. Their existence and success have spread usually by word of mouth, the Internet, or social media.

An example of such an informal program is the work begun by Steven Lippmann, M.D., from the University of Louisville over 40 years ago (Steven Lippman, personal communication, June 22, 2020). Originally inspired by the fact that his father was a refugee, Dr. Lippman began his efforts with the desire to help refugee physicians from Iran, then Jewish physicians coming out of the Soviet Union, and later other refugees representing other waves of migration. There have been only a few U.S. medical graduates over the years in this program. Dr. Lippman allows participants in his program to round with him, arranges research opportunities if possible, and requires that they write articles with him and advises them to take the USMLE Part 3. He may have up to 12 persons a year in the program, and he claims that most people match after working with him (not just to psychiatry). He does not have any formal evaluation of the match success rate of his program “graduates.”

In the October 2020 issue of Academic Psychiatry, Bailey and colleagues [1] describe a program developed at Meharry Medical College in 2009. They present the results of this program in the form of the match rate of its graduates over the last decade. Similar to the Louisville program, participants (“externs”) in this program are encouraged to publish articles in academic journals, present posters, write grant proposals, assist with paralegal work and forensic cases, and attend national conferences, where they network with psychiatrists. The authors contacted 22 previous participants of this program, and 15 responded. All responders ultimately matched to psychiatry after completing an average of 16 months of this program. Even with seven participants not responding to the survey, the success rate appears to be at least 68% or better, which is remarkable. Some of the limitations of this small study were lack of information about whether participants graduated from U.S. or foreign medical schools and lack of a comparison group.

Both of these programs focus on strengthening participants’ future residency applications by encouraging a wide array of activities such as additional clinical experience in psychiatry, publishing, and presenting at meetings. These programs are also likely to provide connections within the psychiatric community and to offer further invaluable advice.

Further Consequences

Unfortunately, no information is available on the number of U.S. medical graduates from U.S. and non-U.S. medical schools versus IMG physicians completing any program such as these two. We can hypothesize, on the basis of some anecdotal information and experience (such as Dr. Lippman’s), that these programs have been, so far, mostly attended by IMG physicians. Although IMG physicians have historically constituted a significant portion of the U.S. psychiatry work force (around 25%), the number of IMG physicians applying through the Electronic Residency Application Service (ERAS) has been declining (e.g., from 3267 in 2014 to 2088 in 2020) for various reasons. The percentage of psychiatry positions filled by IMG physicians through ERAS was 15.8% in 2020.

We know even less in terms of how many U.S. medical graduates of U.S. and non-U.S. (mainly Caribbean) medical schools do not match in psychiatry and need counseling and help after an unsuccessful match. We also know little about how we can specifically help them to obtain a residency position in the future. As Bumsted, Schneider, and Deiorio [7] note, the number of unmatched seniors is only expected to increase due to the opening of new medical schools and larger class sizes at existing medical schools, thus exceeding more and more the number of available positions in postgraduate year 1 (PGY-1). They further noted that 27,655 first-year students were attending MD- and DO-granting medical schools in the United States, which was 362 more students than the number of PGY-1 position available in the Match [7]. These numbers continue to grow. In 2020, there were 40,084 active applicants for 37,256 PGY-1 and PGY-2 positions [2]. Thus, the chance of U.S. medical students not matching in general will be increasing. Similarly, the chance of medical students not matching to psychiatry will likely increase too.

What Can Be Done and By Whom?

Interventions that address failure to match should probably start with preventive measures. Medical students need to be appropriately counseled before applying for residency, with an honest focus on their strengths and weaknesses. It is plausible that with the change of USMLE Part 1 scoring, program directors will be paying even more attention to issues such as disciplinary and other adverse actions taken by the medical school, leaves of absence, failed courses and rotations, failure to pass Part 1 or 2 of the USMLE, delayed graduation, and a history of mental illness or disability. It is well known that professional lapses in medical school predict problems in residency [8]. It is also known that “disclosing a mental illness during the residency application process decreases chances of obtaining interviews and lowers overall ranking for a residency position” [9]. This potential disadvantage in comparison with applicants who do not disclose mental illness is significant, though not insurmountable [9]. Thus, students with these issues and their counselors need to reflect on any difficulties during medical school or mental health issues, thoughtfully consider programs to apply or not apply to, and especially consider what to disclose. Whatever is disclosed should be adequately explained in a personal statement and during interviews.

The first step after a medical student receives notice of not matching should be participation in the Supplemental Offer and Acceptance Program (SOAP). Medical schools have a responsibility to support their graduates in the next steps of seeking a matched position. Students need to be properly counseled and guided through this process.

Students should also attempt to obtain feedback information from program directors of residencies where they applied and interviewed. They may ask whether there were any factors negatively influencing their ranking in a particular program, such as examination scores or delayed graduation. It is unclear, however, whether program directors have any obligation to provide this basically negative feedback, especially because its risks are unknown.

Bumsted, Schneider, and Deiorio [7] outlined pathways to securing a PGY-1 position following an unsuccessful SOAP, including the following:

  1. 1.

    Secure an open PGY-1 position immediately after the SOAP but before the start of the residency program. Opportunities could come through specialty-specific websites or listing services or the National Resident Matching Program (NRMP) posting of unfilled programs.

  2. 2.

    Secure an open PGY-1 position during the year following graduation through a residency vacancy.

  3. 3.

    Reenter the Match in the same or a different specialty in a subsequent year.

Part of the Match reapplication process should be to work on strengthening the application. Medical students can strengthen their application with or without the assistance of their medical school advisors or by participation in programs similar to the ones described at Meharry Medical College or University of Louisville. As Bumsted, Scheider, and Deiorio [7] recommend (p. 920), students should consider whether the activity allows them to obtain letters of recommendation in their chosen specialty, enhance their personal statement, demonstrate commitment to the specialty, gain personal knowledge of faculty, demonstrate leadership qualities, demonstrate interest in the program(s), gain volunteer experiences, demonstrate involvement in research, gain fluency in another language, and take step 3 of the USMLE (if allowed in that state, but it is possible to take in other states). We would add possibilities to publish.

Bumsted, Schneider, and Deiorio [7] also discussed in detail other options, such as paid employment; volunteer work; adding an additional degree (e.g., MPH, MBA, MHA, PhD, EdD, JD) or certification; or obtaining assistant physician jobs in underserved areas (a rather controversial option, raising concerns of the American Medical Association and the chief executive officer of the Accreditation Council for Graduate Medical Education [7].

Finally, some students may forgo pursuing a residency position and choose a nonclinical career, such as working in “public health, public policy and government, communications and journalism, infomatics, pharmaceutical research, and consulting” ([7], p. 920). Books or guides are available for medical school graduates who decide not to pursue clinical careers [10, 11].

There is clearly plenty to be decided and done once a medical student does not match. Students likely do not ponder these options while applying for residency. When they suddenly face the overwhelming and distressing reality of not matching, they are under considerable stress and lack information while they must decide what to do next. Students should be encouraged to use their school’s support services [7], which should include guidance of the various steps outlined in this editorial, but also seek help from debt management services and mental health services. Students should not feel that they are alone in this difficult situation. Medical schools should be the first line of help to unmatched students and need to be aware of options available, such as those suggested in this editorial.

Should there be also other lines of help via national medical education organizations or specialty-specific resources? For instance, should the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) and the Association of Directors of Psychiatric Residency Training (AADPRT) create a joint Task Force to address helping those medical students who are unable to match into psychiatry? Or should these organizations create a joint depository (website?) of information about vacancies and programs that provide help, such as those discussed here, research opportunities, observerships, and other important issues? Should there be a list of program directors willing to advise students who failed to match in psychiatry?

The measures discussed here apply mostly to U.S. medical school graduates. We should not forget, however, that large numbers of unmatched U.S. and non-U.S. IMG physicians need advice and help too. Who, in addition to programs such as Dr. Lippmann’s, should be helping and advising them? Are there any obligations, ethical or other, to help them, and if there are any, who should be addressing them?

Conclusion

The possibility of an increasing number of students who do not match to psychiatry raises various questions regarding assistance and guidance to these students (and other unmatched applicants, such as IMG physicians). The field of psychiatry, directors of medical student education, medical school counselors, and possibly program directors should educate themselves about various ways to help unmatched students, starting with proactive counseling throughout medical school to providing additional supports should students not match. It is a tragedy for the profession to lose those dedicated to a career in psychiatry, especially in this time of surging societal mental health needs related to the many pressures associated with the COVID-19 pandemic. Psychiatry needs to find more ways to help unmatched applicants, maybe starting more programs such as those of Dr. Bailey and Dr. Lippman.