Placement of US Medical School Graduates Into Graduate Medical Education, 2005 Through 2015

Medical school enrollment has increased in the United States during the past decade¹; however, growth in graduate medical education (GME) positions has been slower, raising concerns about whether graduates will be able to obtain the GME necessary to qualify to practice medicine.²

Particular concerns have been raised about graduates from minority groups traditionally underrepresented in medicine.³ We evaluated graduates of all US MD-granting medical schools from 2005 through 2015 to determine whether they entered GME training in the United States, with particular assessment of minority graduates.

We reviewed the Association of American Medical Colleges Student Record System⁴ to identify all graduates. At graduation (between July 1 and June 30 of an academic year), each medical school’s registrar populates this system with the initial GME program for each graduate. A graduate was considered unplaced if he or she was not designated as starting GME on July 1 after graduation by the registrar. The American Institute for Research granted a waiver of informed consent from study participants.

Race/ethnicity was self-reported by each student on his or her medical school application. Graduates who were foreign citizens or without US permanent resident status were grouped as non–US citizens.

To identify those unplaced in GME upon medical school graduation who ultimately entered GME, the GMETrack First Year On-Duty file was searched in September 2015 for the years 2004 through 2014. The GMETrack records trainees in all Accreditation Council for Graduate Medical Education accredited programs on December 31 of each year. Approximately 5% of residencies do not participate each year.⁵ Therefore, we also searched for initially unplaced graduates who did not appear in GMETrack in the American Medical Association Physician Masterfile as direct patient care physicians and in the Centers for Medicare & Medicaid Services National Provider Identifier database, assuming those identified must have received GME.

We determined the percentage of graduates unplaced in GME the academic year of their graduation and in 2015, overall and by race/ethnicity. We used a 2-sample t test to compare the proportion of minority vs white graduates unplaced in GME and used a paired t test to compare the proportion unplaced upon graduation vs unplaced as of 2015.

We used simple linear regressions to determine trend-line P values for the proportions unplaced in GME during the study years. We calculated the unadjusted and adjusted odds ratios for placement into GME upon medical school graduation using multilevel logistic regression in which medical school was entered as a random effect.

All P values were 2-sided; P < .05 was considered statistically significant. We used SAS version 9.3 (SAS Institute Inc) for all statistical analyses.

There were 186 937 graduates (48.2% female) during the study period, increasing from 15 762 in 2004-2005 to 18 705 in 2014-2015. The percentage of graduates unplaced in GME during the academic year of their graduation from medical school remained stable, ranging from 2.6% to 3.5% (P = .18 for trend) with a mean of 3.0% (Table 1).

Unplaced black, Hispanic, and non–US citizen graduates increased over time. Racial/ethnic minority graduates were consistently less likely to begin GME the year they graduated than whites (Table 2). However, within 6 years after graduation, more than 99% of all graduates entered GME or were found in practice in the United States. The racial/ethnic differences seen at graduation diminished with time but remained statistically significant (Table 1).

The percentage of US MD graduates entering GME the year of graduation has remained stable during the past decade despite an increase in the number of graduates. Within 6 years after graduation, almost all graduates entered GME, and the percentage of minority graduates ultimately entering GME approached that of their white colleagues.

Limitations include that we did not examine GME placement for other GME applicants, such as international medical school graduates and doctors of osteopathic medicine, and we reported only on placement into GME, not whether these graduates eventually completed GME and became practicing physicians.

As the number of US MD graduates continues to increase with the creation of new medical schools and the growth of existing schools, these trends should be closely monitored.

Corresponding Author: Henry M. Sondheimer, MD, Association of American Medical Colleges, 655 K St NW, Ste 100, Washington, DC 20001 (henry.sondheimer@gmail.com).

Author Contributions: Dr Nivet had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Sondheimer, Xierali.

Drafting of the manuscript: Sondheimer, Xierali.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Sondheimer, Xierali.

Administrative, technical, or material support: Sondheimer.

Study supervision: Nivet.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.