The NRMP is evolving to relieve med students of their worst fear

By Alpana Mohta, MD, DNB, FEADV, FIADVL, IFAAD | Fact-checked by Barbara Bekiesz
Published April 29, 2024

Key Takeaways

  • The NRMP saw a historic high in 2024, with 50,413 applicants competing for 41,503 positions, marking a 2.8% increase from 2023 and a 93.8% fill rate.

  • From the Cooperative Plan in 1945 to the inception of NRMP in 1952, the matching algorithm has evolved over the years to better accommodate interns, advanced positions, and couples.

  • Despite recent legislative efforts to increase residency slots, 17.9% of applicants remained unmatched this year after the NRMP and SOAP.

Each year, 4th-year medical students place their hopes into a computer algorithm that will, hopefully, match them into their desired program via the National Resident Matching Program (NRMP). 

Matching isn't guaranteed, of course—this year saw more than 9,000 applicants out of a total of 50,413 (17.9%) remain unmatched after the NRMP and the Supplemental Offer and Acceptance Program (SOAP), according to the AMA.[] 

A bird’s eye view of Match 2024

In 2024, the NRMP offered 41,503 positions across 6,395 programs—marking a 2.8% increase over last year and the highest in its 72-year history. The fill rate was 93.8%, with 38,941 positions filled.[]

The primary care fields include family medicine, internal medicine, and pediatrics. Although these specialties formed 47% of all offered positions, their fill rate was 92.9%—a 1.4% decline from 2023. Pediatrics’ fill rate dropped the most, from 97.1% in 2023 to 92% this year. 

However, emergency medicine showed a notable rebound, filling 95.5% of its positions (a 13.9% jump from 2023). During the SOAP, 2,399 out of 2,575 positions were available, with a 93.3% filling rate. All in all, AMA figures show, the Match and SOAP filled 99% of the available positions.

The evolution of the algorithm

As stated in a commentary from the Journal of Graduate Medical Education, 80 years ago, US hospitals and medical students faced a tumultuous internship process due to the surplus of positions over graduates.[]

The Association of American Medical Colleges (AAMC) introduced the "Cooperative Plan" in 1945 to regulate this, delaying academic record releases until late in the student's final year. However, this led to intense, last-minute offer periods, forcing quick decisions from students.

Realizing the need for a better system, the University of Chicago's dean proposed a central preference-listing system for students and hospitals. This evolved into the National Intern Matching Program, inaugurated in 1952 to fairly match students with programs.This program, now known as NRMP, fills residency positions in almost all medical specialties in the US (except for ophthalmology, urology, and military hospital medicine, which use separate systems).

Since its inception, the NRMP's matching algorithm has been refined to handle both intern and advanced position matching and to accommodate couples. 

The fate of unmatched applicants

A stark contrast to the early years, recent times have seen a surplus of applicants over available positions. 

The cap on residency slots, originating from the 1997 Balanced Budget Act, has restricted growth to about 1% annually. Recent legislative efforts added 1,200 slots through the Consolidated Appropriations Acts of 2021 and 2023, but these increases are still considered inadequate.[]

Annually, under 10% of US medical graduates and over 30% of international medical graduates (IMGs) fail to match. The SOAP offers some a second chance, yet thousands remain unmatched.[]

While certain aspects of the Match have remained stable, like the high match rates for US MD graduates, new challenges have emerged. ERAS data indicates that the number of applications per applicant has surged, with the average US medical graduate applying to 78.4 programs in 2023.[]

"This overapplication increases costs for applicants and programs, leads to reliance on convenient screening metrics in applicant evaluation, and does not ultimately improve Match rates."

Authors, Journal of Graduate Medical Education

Unsuccessful matches are attributed to most students' desire to target top-tier specialties and prestigious institutions or their lack of necessary skills. A critical issue is the mismatch between graduates and available residency slots.

Future directions

Since 2023, the NRMP has introduced initiatives like preference indication, standardized interview methods, and geographic preference.

The authors of a 2023 letter to the editor of the Journal of Graduate Medical Education propose reforming the residency match process by moving away from relying solely on Match data.[] Instead, they write, all aspects of the residency application process, including participants (applicants, program directors, educators, accrediting bodies) and facilitators (ERAS, NRMP), should be analyzed to guide changes effectively.

Furthermore, in an attempt to increase the physician workforce—and indirectly free up residency slots for US graduates—the state of Tennessee is facilitating the integration of internationally trained doctors. Tennessee’s new law allows IMGs to bypass US-based residency if they've had similar training and practice elsewhere. The states of Idaho, Arizona, Nevada, and Missouri are planning similar bills.[]

For students who successfully matched into their desired specialty, it's important to keep striving and set an example for your peers and juniors. However, for those who didn’t match, there are still options.

While preparing for the next match season, you can consider a gap year for additional clinical exposure, attempt USMLE Step 3, or apply for post-graduate research and fellowship training. You can also explore preliminary-year programs or alternative pathways like military or service corps scholarships, international residency programs, and medical scribe roles. 

What this means for you

Originating from a tumultuous internship process, the National Resident Matching Program (NRMP) formed in 1952 to effectively and fairly match students with residency programs. Over time, the algorithm has been refined to handle a variety of matching scenarios (even accommodating couples). Despite recent legislative efforts to increase residency slots, challenges remain, leading to suggestions for reforming the matching process and exploring alternative pathways for unmatched applicants.

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