To fix the doctor shortage, we must create new pathways for residency

The medical education system is in crisis. By 2034, the American Association of Medical Colleges (AAMC) predicts a shortage of between 37,800 and 124,000 physicians in both primary and specialty care. This shortage is especially pronounced in rural areas and communities serving marginalized populations. 

Faced with the stresses of both a growing population and an increase in the number of retiring physicians, action must be taken to ensure the future of American healthcare. We call on members of the U.S. House and Senate to pass the Increasing Competition for Medical Residency Act (H.R. 8131), which would repeal the antitrust exemption granted to the residency match process for medical school graduates and allow for alternative certification pathways. 

Current policy is akin to placing a band-aid on a hemorrhaging artery. All medical school graduates must secure a residency position to eventually practice medicine in their chosen specialty. However, there are not enough residency positions to keep up with the number of graduates. 

Congress has attempted to add resident physicians at roughly 2,000 positions per year from 2023-2029 through the Resident Physician Shortage Reduction Act; however, this increase is not nearly enough to remedy the dramatic doctor shortage. 

In 2022 alone, thousands of graduating U.S. medical students went unmatched via the National Resident Matching Program (NRMP) match system, effectively preventing them from practicing medicine unless they can find an unfilled position, switch to a different specialty, or reapply the following year. In addition to U.S. medical students, there are currently approximately 3,000 international medical graduates, who are not practicing due to their inability to secure residency through the match system. In both these cases, the match system stands out as a target for change, as it plays a large role in precluding qualified medical graduates from practicing medicine independently. In a world reeling from the aftermath of a pandemic, this cannot stand.

So, what stands in the way of changing policies surrounding the match system? Based on legislation from almost 20 years ago, the match system is immune to lawsuits on antitrust grounds. In 2002, Jung vs AAMC alleged that the AAMC, NRMP, and many major academic institutions violated statutes of antitrust law by “illegally restraining market competition for resident physician services,” removing the ability of residents to negotiate salary and forcing them into specific programs and locations. The lawsuit ended when Congress passed legislation in the unrelated Pension Funding Equity Act of 2004 that these organizations were exempt from antitrust law based on the unique nature of medical training.  

Antitrust law prevents market monopolies and the stifling of competition, which is precisely the control the match system wields over medical graduates. The introduction of H.R. 8131 aims not to abolish the match system, but instead repeal the AAMC and NRMP’s exemption to federal antitrust laws, compelling them to follow the same set of laws as other institutions of their ilk and potentially allowing for alternative certification pathways.  

There is little current legislation delineating specific practices that the NRMP and AAMC must follow. Rather, these organizations are responsible for passing their own pieces of legislation that apply to stakeholders taking advantage of their services. Examples of stakeholders in this group include medical students, residents, medical schools and residency programs. Additionally, the AAMC often supports and makes recommendations regarding pieces of relevant legislation, as seen with their endorsement of The Resident Physician Shortage Act and legislation to protect 340B hospitals.  

As it stands, alternatives to traditional certification are limited. However, they do exist. To combat the increasing physician shortage and its disproportionate impact on rural areas, Missouri implemented the assistant physician program in 2014 to provide unmatched medical graduates the opportunity to practice medicine as assistant physicians under the supervision of licensed physicians. After three years of supervised practice, assistant physicians become eligible to enter a traditional residency program. 

Although this initiative has been met with some controversy given its unconventional approach, it has also set the foundation for change. This program inspired the creation of Missouri House Bill 550, which would allow assistant physicians in Missouri to apply for full licensure after five years of supervised practice. Although the bill itself is promising, it died in committee discussions in 2021. Several provisions have been split into separate bills that are not currently listed for discussion on the House calendar, indicating their relative lack of priority despite the ever-growing need for a solution. 

Signing H.R. 8131 into law may be the missing piece needed to revitalize this legislation not only in Missouri but in other states as well. Upon removal of the match program’s special antitrust exemption, the exploration of alternative certification pathways moves from theory into practice. Stakeholders will realize the necessity of allowing all medical school graduates to practice medicine, opening the door to new possibilities for mitigating the physician shortage crisis. 

This parallel implementation pathway would not be without its challenges. After all, the match system is a process that has dictated the flow and evolution of medical students to residents for over 70 years. Namely, programs would need to be built from the ground up while simultaneously ensuring adequate training for residents. This could lead to alternative certification pathways being viewed as inferior or non-competitive, with the contrasting results of either failing to attract qualified applicants who do not want their training to be perceived as less than or diluting the quality of medical professionals by training those genuinely unfit to practice. 

However, it is important to realize that the challenges which may accompany eliminating the antitrust exemption are not sufficient to oppose its repeal. Given the lack of significant reforms to the AAMC/NRMP over the past several years, the system is ripe for an overhaul. We have numerous qualified medical professionals that are sitting on the sidelines and are being funneled through an overburdened, sclerotic system. The time for change is now. 

Aamir Hussain is a resident physician practicing in Washington, D.C. Umayr Shaikh, a medical student at Georgetown University, assisted in the creation of this story.