Abstract
Workforce projections predict a significant lack of primary care providers nationally. Increased family medicine residency programs and positions have been celebrated as the answer to these projections. Since 2012, the number of positions offered annually has increased almost 2-fold from 2,740 to 5,357. While this has the potential to help alleviate this disaster, very few are questioning the unintended consequences of additional family medicine positions. Over this same 14-year period, the number of programs failing to fill in the National Residency Match Program have increased 4.5-fold (64 to 288) with the number of unfilled slots increasing over 5.5-fold (142 to 805). Linear rates of change for unfilled residency programs per every 1,000 residency positions created have increased from 0.4 prior to 2018 to 69.3 between 2018 and 2021 to 271.5 after 2021. Unfilled programs experience multiple negative consequences including reputation damage and increase coverage responsibilities. Further addition of family medicine training position volume is therefore likely harmful to existing programs. Better solutions should be explored to creatively increase student interest in family medicine by emphasizing and leveraging the value of family medicine physicians and primary care.
Current national projections for the deficit in primary care providers are 57,559 to 87,150 in the next 15 years with nonmetropolitan areas impacted the most.1–3 Hoping to address this issue, residency programs have implemented the approach of more is better and leaders in Family Medicine have celebrated the expansion of positions in the National Residency Match Program (NRMP).4–5 Proponents of this strategy cite that the benefits of this approach have increased the total number of residents beginning their education in Family Medicine yearly by 95.5% (2,740 to 5,357) since 2012.6 This potential future workforce entering training as family physicians is hailed as the solution to this impending disaster for access to primary care.4–5 However, does unfettered expansion of 47 new training programs from the 2024 to 2025 NRMP seasons provide the answer to this monumental shortage of primary care providers? To poorly paraphrase the baseball movie Field of Dreams, “If you build it, will they really come?”
We have not fully ascertained the unintended consequences of the rapid escalation of Family Medicine residency positions on the existing Family Medicine residency programs, especially the most vulnerable ‘nonmetropolitan’ areas. Negative consequences to Family Medicine cannot be seen by looking at augmented workforce numbers alone. This nearly 2-fold increase in positions nationwide since 2012 has resulted in 4.5-fold increases in programs participating in the supplemental match and a 5.7-fold increase in open residency positions. When we plot the Family Medicine residencies left unfilled in the NRMP, an interesting pattern emerges, seen on Figure 1. A critical mass of nationwide residency positions were added around 2018, after which time the rate of unfilled programs in the NRMP accelerated from 0.4 to 69.3 programs/1,000 positions added. A second change in acceleration of unmatched programs to 271.5 occurred around 2021. In addition higher percentages of total programs remained unfilled after the NRMP of 14.6% before 2018 to 35.3% in 2025.6 Yet despite over a third of our programs failing to fill in the NRMP, residency spot after residency spot is created … as if the available number of positions is keeping students away from the specialty.
Comparison of residency positions offered and unfilled programs after the National Resident Match Program (NRMP).
Failing to fill for a residency program is not a benign occurrence as it causes a long list of consequences. Supplemental matching utilizes the resources of multiple faculty members, residents and administrators during ’Match Week’ interviews, leaving others to cover their normal responsibilities.7 The damage to the residency’s reputation is evident within the school, the specialty, and the upcoming students for years to come. If unfilled spots do find an owner in the supplemental match, it is likely with residents who did not want to be family physicians in the first place as evidenced in 2024 when only 32 (1.5%) MD or DO students who ranked Family Medicine did not match in the NRMP.8,9 If these programs remain unfilled, resident patient panels and rotational schedules will become distressed. This only adds to the provider burnout described throughout our specialty1 and is not the recipe to create the role models we hope to become for the impressionable students left at our schools.
Why is this occurring? The actual number of students attempting to match in Family Medicine decreased 16.6% (12,246 to 10,213 students) from 2019 to 2024.10 We are asking our students to enter a specialty that, while incredibly rewarding, has the fourth highest burnout rate and the lowest expected earning potential.11 With a patient population that is only growing older and getting sicker, cumbersome electronic health records, and required quality measures, the work we do is extremely difficult. Signaling and geographic preference changes were thought to better align students with programs, but the overall benefit is unclear.12 As the residency position supply exceeds the demand for students interested in Family Medicine, the benefit is less for the programs in the NRMP as match rates have decreases and unfilled programs have increased since signaling began.10 For the first time as clinician educators, our department is contemplating decreasing our residency positions to enhance our chances of filling.
We need to address the true reasons why students are not choosing our specialty. These celebrated increases in residency slots are not the answer. By better demonstrating our value to the students, the payers, and the entire health system, we can create a ‘field’ to which students want to come … and not feel forced to come. How can we reimagine Family Medicine in a way that attracts and expects the best and the brightest to our specialty. Ultimately, we need to build a better … not a bigger … ‘Field of Dreams’ of physicians who are excellent representatives of the specialty; those not too burned out to inspire the medical student of today toward the hardest job they will ever love. If it is built of overworked, undervalued, and burned-out physicians, no matter how many there are, soon there will not be any more students willing to come to our ‘Field of Dreams.’
Acknowledgments
The authors thank Kueitsung ‘Philips’ Shih, MPH, for the statistical analysis and Michelle Peters, MAT, for the formatting.
Notes
This article was externally peer reviewed.
Conflict of interest: None.
Funding: No funding was utilized for the work.
- Received for publication March 31, 2025.
- Revision received May 31, 2025.
- Accepted for publication June 16, 2025.
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