Why Some Specialties are More Competitive

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Ask any aspiring doctor and they will agree that some specialties are more competitive to get into than others. Ask them why, and you will get a variety of answers. What are the underlying factors that actually make a specialty competitive?

 

Defining What Makes a Specialty Competitive

Let’s start by defining what makes a specialty competitive.

The first thing that typically comes to mind is its match rate. Every couple of years, the National Residency Matching Program, or NRMP, posts data on the most recent residency application cycle.

They record a variety of different statistics, including the number of medical students that match into each specialty versus the total number of applicants to that specialty. This is referred to as that specialty’s match rate.

For most people, this is the holy grail of determining how competitive a specialty is. But it’s not all it’s chalked up to be.

Match rate alone is a very poor metric in determining a specialty’s competitiveness.

Is it helpful? Yes. Should we pay attention to it? Of course. But does it tell the full story? Absolutely not, and here’s why.

First, specialties are self-selecting, meaning that they attract a certain type of applicant.

If you’re not a competitive applicant, you’re not going to apply to something like dermatology or plastic surgery because you won’t get in. Plain and simple. So it’s in your best interest to only apply to specialties that you have a realistic chance at getting into.

Why does this matter when talking about match rates? Match rates don’t account for the fact that applicants are pre-screened before even applying.

For example, general surgery has a match rate of around 84%. In 2018, this was lower than plastic surgery’s 85%. But when you look at the average Step scores and other factors, in addition to the fact that many plastic surgery applicants use general surgery as a backup in case they can’t get into plastics, it becomes clear match rate alone isn’t a reliable indicator.

Another shortcoming of match rate that is often overlooked involves international medical graduates (IMGs).

Graduating medical students come from all over the world to finish their medical training in the U.S., and there are certain specialties that attract more IMGs than others. This is important because IMGs match into U.S. residencies at a far lower rate than U.S. graduates.

So, if a specialty attracts a large number of IMG applicants, it can make it difficult to compare to a specialty that doesn’t.

To overcome these shortcomings, I gathered data from the NRMP and organized it into a spreadsheet. I examined six categories of data: average match rate, Step 1 score, Step 2 CK score, number of publications, percentage of matriculants that were AOA, and percentage of applicants from a top 40 NIH-funded school.

 

What Factors Affect Supply?

Now that we’ve looked at the competitiveness of a specialty as it relates to applicant metrics, let’s look at it from a more macroeconomic perspective and explore the concepts of supply and demand.

Supply when referring to a specialty’s competitiveness refers to the number of open residency positions available. Specialties with few residency positions are generally more competitive than specialties with more residency positions. In essence, more residency positions equal more chances to get in.

The supply of residency positions for a given specialty is largely dictated by the societal demand for that specialty. Specialties like internal medicine have high societal demand.

Internal medicine physicians are the backbone of our hospital systems. They are often referred to as the quarterbacks of inpatient care. They manage the patient’s overall plan of care while in the hospital and often serve as the bridge between the patient and other consulting specialties.

Internal medicine is also a gateway into multiple fellowships including cardiology, gastroenterology, pulmonology, infectious diseases, hematology, oncology, nephrology, and more. Any physician wishing to pursue these specialties will have to go through internal medicine residency first.

For these reasons, our society needs a lot of physicians to go into internal medicine so the societal demand for internal medicine is high. According to the AAMC, there is approximately one internal medicine physician for every 2,800 people.

If we contrast this with something like plastic surgery that has less societal demand, there is approximately one plastic surgeon for every 45,000 people. I’m not saying plastic surgeons are not important, it’s just that objectively, there are fewer people that require the services of a plastic surgeon compared to an internist.

This is one of the contributing factors to plastic surgery being more competitive than internal medicine.

Additionally, the majority of funding for residency programs comes from the federal government through Medicare and Medicaid. Graduate medical education payments are made to teaching hospitals and health systems which then have control over how those funds are allocated.

The financial impact of residency training programs on these teaching hospitals and health systems is complex and not well understood; however, research has suggested that there are substantial differences in the financial impact of different specialties.

This means that hospitals may have incentives to fund residency positions for specialties that generate their facilities more revenue.

Internal medicine and its related services drive a large portion of a hospital’s revenue. For this reason, there is a financial incentive on the part of the hospital to fund IM residency positions. This may be another contributing factor to why IM has the largest number of residency positions by far.

This works in the reverse direction as well in that if a particular specialty does not generate the facility a lot of revenue, then there is a disincentive to adding residency positions for that specialty.

 

What Factors Affect Demand?

In addition to societal demand, demand can also refer to the number of medical students that want to go into a particular specialty. How desirable is that specialty to a medical student?

The primary factors that influence the desirability of a specialty are compensation and lifestyle. How much money do you make and how hard do you work to make it?

Many people will tell you that that money shouldn’t be a factor when becoming a doctor. Although this is true for most students when they enter medical school, by the time that they graduate, they often place a greater emphasis on the importance of lifestyle. For this reason, specialties that have a good lifestyle and high compensation like dermatology are typically seen as more desirable.

If we refer back to our competitiveness index, this may explain why dermatology is ranked as the #1 most competitive specialty. Additionally, plastic surgery, neurosurgery, and orthopedic surgery also ranked in the top 4 and just so happen to be the three highest compensated specialties.

Prestige is another factor that influences the desirability of a specialty – albeit to a lesser degree than compensation and lifestyle.

Some students are attracted to a particular specialty because of the respect and admiration they believe they will receive from others if they go into it. Surgical specialties in particular are often seen as more prestigious and coincidentally tend to be more competitive compared to non-surgical specialties.

Although this is an important factor for some, I would strongly recommend against letting it dictate your choice of specialty. Prestige is very externally focused. It takes the emphasis away from what you want and what you enjoy and places it on what other people think.

At the end of the day, going into a specialty that you actually enjoy will be far more important in your long-term happiness than the mental exercise of thinking which specialty has the best lifestyle, best compensation, or most prestige.

If you’re stuck deciding between specialties, be sure to check out our So You Want To Be playlist which contains comprehensive overviews of each specialty. Also check out my second channel, Kevin Jubbal, M.D. where we have day-in-the-life episodes for several medical specialties with more being added regularly.

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