Every year, thousands of applicants in the United States register for the Electronic Residency Application Service (ERAS). Many graduate medical education (GME) programs receive thousands of applications that are reviewed by recruitment teams with fewer than ten faculty members. In recent years, there has been an increase in the number of applications for GME programs and an overwhelming number of interviews for ERAS applicants, even though only a few hundred applications may be selected for interviews. After the interviews, most or almost all interviewees are ranked in the National Resident Matching Program (NRMP).
Interestingly, more than 90 percent of U.S. MD/DOs are matched through NRMP into GME programs, and less than 10 percent of U.S. MD/DOs may be inadvertently deemed ineligible (unmatched through NRMP) during the annual recruitment season for GME programs. This suggests that the job performed by medical school recruitment teams, which find almost 60 percent of Medical College Admission Test (MCAT) applicants ineligible for admission to medical school, may be more important in shaping the future physician workforce in the U.S. Time and resource constraints may also play a role in the natural selection process, as only a few hundred thousand out of the millions of the U.S. population apply to take the MCAT.
Are student loan debts and society’s expectations for a return on investment in medical education unconsciously holding back less than 10 percent of U.S. MD/DOs from being matched through the NRMP into GME programs? It may be interesting to quantify how many of the more than 90 percent of U.S. MD/DOs who are matched fail to graduate from GME programs, as not all GME graduates become or remain board certified under the American Board of Medical Specialties (ABMS).
These questions raise the relevance of board certification. Unlike medical students, who are required to pass the United States Medical Licensing Examination (USMLE) before graduating from many medical schools in the U.S., almost all GME program matriculants can begin practicing their specialty as board-eligible specialists for up to seven years after graduating from GME programs, while still awaiting board certification from ABMS. They may even choose to continue practicing their specialty after the seven-year period of board eligibility has lapsed, as they may still be reimbursed at the same rates as board-certified specialists by third-party payers. This leads to a few more questions: Are we unconsciously worried about finding funds to extend the tenures of GME program matriculants on remediation and probation? Are there any unconscious concerns about defending against litigation by dismissed GME program matriculants?
Given that in-training exam (ITE) scores are strongly associated with subsequent success on the board certification exam, shouldn’t GME programs only be accountable for the ITE performance of their matriculants, rather than the board certification success of their graduates? GME program graduates may take a long time to get their time-limited board certification, or may choose not to become board certified at all by letting their board eligibility lapse, as they can independently practice their specialty in a time of never-ending specialist shortages in the U.S.
We believe that, just like the USMLE used by many medical schools, the in-training exam (ITE) should be used as a graduation tool by GME programs. This would allow GME programs to make objective, high-stakes decisions about delaying or voiding the graduation of their matriculants based on their performance on nationally standardized ITE and future nationally standardized in-training exams, such as the standardized oral exam (ITSOE) and the objective structured clinical exam (ITOSCE). As a result, GME programs would not have to err on the side of caution and graduate almost all of their matriculants to avoid litigation from anyone.
Alternatively, the U.S. system could be inspired by other countries where specialists must become board certified before they are eligible to graduate from GME programs and practice their specialty independently. This is especially relevant given that research has shown that board certification can reduce medical errors and deaths in the U.S. In the meantime, the “Swiss cheese model” may already be ensuring the success of the health care system for patients in the U.S., as compared to most other countries, because the health care team approach in the U.S. often makes board certification irrelevant for U.S. physicians who are naturally selected through imperfect processes to lead health care teams.