All-In or All-Out? Residency Pre-Matches a Thing of the Past: New Changes Coming to the NRMP Residency Match in 2013

shutterstock_20651749 row of stick figures for all in or all outUnder the All-in Model, independent applicants, Canadian, Caribbean, and international medical student applicants will no longer be able to secure residency positions in the U.S. prior to the formal residency match that takes place in March. Independent applicants, such as osteopathic students and graduate applicants and  past allopathic medical graduate applicants, will not be privy to pre-match practices after the 2012 match year.

The NRMP (National Residency Matching Program) has announced that starting in 2013, participating residency institutions will not be able to offer a portion of their positions to students prior to the match. The NRMP Board of Directors decided unanimously in favor of the All-in Policy which states that U.S. residency programs must place all positions in the NRMP match or none. This greatly changes the landscape for both international medical graduates and U.S. medical graduates competing for very valuable residency positions. (Read NRMP announcement here: )

Under the current NRMP model, independent applicants can pre-match into residency positions and do not have wait until the formal computerized logarithmic results are announced in March. In an effort to create a more equitable system in times of mounting numbers of U.S. medical student graduates and increased competition for residency positions, the NRMP Board of Directors carefully researched past concerns expressed for the need for pre-match positions. The Board concluded that equity was best served with an All-in change in policy.

Some of the important factors reviewed and considered by the NRMP before making this decision were:

  • Would International applicants receive their visas by July 1st and be able to begin residency on time without the pre-match?
  • Through Board monitoring, it was discovered that over the past several years, IMGs requiring J-1 visas were successfully received in adequate time for residency.  ECFMG data show that in 2007, 86 percent reported receiving visas on time, rising to 92 percent in 2009.

The second issue, which concerns residency programs having fewer choices among applicants, is more difficult to assess. As Health Reform moves forward in the U.S., the need for primary care physicians is likely to become increasingly highlighted and the demand greater and greater. The number of residency positions stays stable as the years continue, largely due to governmental caps to Medicare, while the number of graduates increases. However, the number of positions in primary care continues to have plenty of room for U.S. students to match if they chose to do so, as discussed by Kevin Pho on his blog after the last match. Will our primary care residency programs suffer from missed opportunities afforded through the pre-match and signing on Osteopathic, Canadian, Caribbean, and IMG students looking to Family Medicine or Internal Medicine as their first choice career? Or will these positions be filled by U.S. students who take advantage of these primary care positions during the SOAP process substituting for the retired Scramble practice in this year’s residency match? It may be too early to tell.

Other considerations in the NRMP decision to move forward with the All-in policy include:

  • Approximately 1/3 of residency programs in NRMP-participating specialties accepted at least one resident outside the Match.
  • 1 out of every 7 residents found their positions outside the Match (a total of 3,935 residents), but only 94 were U.S. allopathic senior students.
  • Among NRMP-participating specialties, only 72 programs did not participate in the Match.
  • The states with the largest percentages of programs that took applicants outside the Match were Alaska, Wyoming, Kansas, Rhode Island, New York, New Jersey, Puerto Rico, and Pennsylvania.
  • Only 7 (1.9%) of Internal Medicine programs and 3 (0.7%) of Family Medicine programs did not participate in the Match.

An important note here is that this change is applicable at an institutional level rather than a program level. Therefore, an institution must decide whether all of its residency programs will be participating in the NRMP residency match or not and therefore be All-in. Hence, one residency program at an institution cannot choose to opt out once an institution has decided to participate.



NRMP Article


Medical Schools Can't Keep Up: As Ranks of Insured Expand, Nation Faces Shortage of 150,000 Doctors in 15 Years. US News and World Report


Kevin Pho

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