The road more traveled: why U.S. graduates choose
orthopedics, dermatology, and radiology over primary care

Two matches in one

The National Resident Matching Program runs a single algorithm each March, but it resolves into two very different competitions. In one, applicants far outnumber positions and nearly every seat goes to a U.S. medical-school graduate. In the other, positions outnumber the U.S. graduates who want them, seats go unfilled, and international graduates fill much of what remains. The dividing line is not aptitude — it is which specialties U.S. graduates choose. The 2026 numbers make the split unmistakable¹².

Read the last two columns together. In orthopedic surgery and dermatology, U.S. MD seniors take three-quarters or more of the seats and international graduates take almost none — one to two percent. In family medicine and internal medicine, the proportions nearly invert: U.S. MD seniors fill a third, and international graduates fill as many seats as they do, or more. Diagnostic radiology sits between, with U.S. seniors filling roughly two-thirds. Family medicine did not even fill: 899 of its positions went empty in 2026, and its fill rate has been sliding¹. This is not a story of international graduates crowding Americans out of anything — the competitive fields are the ones Americans win almost entirely. It is a story of U.S. graduates concentrating themselves into a subset of specialties and leaving the rest, and the question worth answering is what they are concentrating toward. Several forces do most of the work, and each is measurable.

The pay gap that does most of the work

The largest force is the plainest. The specialties U.S. graduates flock to pay roughly twice what the ones they leave do, and the gap is not subtle³.

An orthopedic surgeon earns, on average, more than two and a half times what a general pediatrician does, and better than double what a family physician or general internist does. The gap compounds over a career into millions of dollars, and it maps almost perfectly onto the fill table: the fields at the top of the pay column are the fields U.S. graduates fill to the last seat, and the fields at the bottom are the ones left under-filled. The mechanism beneath the gap is the fee-for-service payment system, which rewards procedures and technical volume far more than the cognitive, longitudinal work of primary care — the surgeon’s operation and the dermatologist’s biopsy are reimbursed richly, the internist’s hour of managing a complex patient is not. A student choosing a specialty is choosing a lifetime income, and the market has priced these choices with a clarity no advising dean can match.

Lifestyle, prestige, and the hours that don’t come back

Money is not the whole of it, and the second force may be gaining on the first. The specialties U.S. graduates most prefer increasingly share a trait researchers named two decades ago: a controllable lifestyle — predictable hours, limited or no overnight call, a clean boundary between work and life. In the foundational study, controllable lifestyle “explained 55% of the variability in specialty preference” among U.S. students, and — the crucial part — it did so even after controlling for income, work hours, and length of training⁴. Lifestyle was not a proxy for pay; it was an independent driver, and a powerful one. The years since have only sharpened the pattern, as a generation of trainees weighs burnout and work–life balance more heavily than the one before it.

Dermatology and, in many practice models, radiology offer versions of that control that primary care structurally cannot — the dermatologist’s clinic closes, and much outpatient radiology is shift-bounded. But the lifestyle story is not uniform across these fields: radiology also carries overnight coverage, a worklist that refills, turnaround-time pressure, and real volume-driven burnout, and orthopedic surgery is not a controllable-lifestyle field at all — long operative days, trauma call, and a heavy early-career load. Orthopedics belongs in this essay for its pay and prestige, not its hours; the thread common to the fields U.S. graduates concentrate in is not a gentle schedule but some mix of money, control, or standing that primary care cannot match. What primary care structurally cannot offer is the boundary. The primary-care physician’s panel does not close — the messages, results, refills, and prior authorizations follow the day home, and the work of knowing a patient over years is, by design, never finished. Prestige tracks the same line and reinforces it: within the informal hierarchy of a medical school, the competitive specialties are the ones described as the hard ones to match into, and a student forms an identity partly by reaching for what the environment treats as the prize. Pay, controllable hours, and prestige are not three separate pulls so much as three faces of one gradient — and it runs uphill away from primary care.

The application arms race

A third force is competitiveness itself, and it works as a loop that feeds on its own output. The specialties U.S. graduates most prize are the ones that select on the strongest applications — and by selecting on them, they tell each incoming class exactly what to build. Matched U.S. MD seniors in dermatology and orthopedic surgery in 2024 carried mean USMLE Step 2 scores of 257 and reported, respectively, 27.7 and 23.8 abstracts, presentations, and publications — against 8.7 for internal medicine and 6.4 for pediatrics, and about 10.2 across all specialties⁵. And the same corner of the map holds the other fields U.S. graduates fill almost to the seat: matched otolaryngology, plastic surgery, and neurological surgery seniors reported 20.0, 34.7, and 37.4 such items — neurosurgery’s the highest research bar of any specialty. This is a tier, not three fields. The test-score gap is modest; the research gap is enormous, roughly three times the output. A student who hopes to match dermatology learns this early and begins accumulating publications in the first or second year — and that accumulation is the point: it both signals fitness for the field and raises the bar for the class behind them.

Two honest qualifications keep this from being a simple story. First, the research counts are self-reported and, in the NRMP’s own words, “not verified” and of a quality that “may vary greatly” — a stack of unrefereed abstracts is not a body of science, and the arms race rewards volume as much as substance. Second, competitiveness is partly manufactured: a specialty is “competitive” because able students pursue it, and able students pursue it because it is competitive, so the prestige and the credentials chase each other in a circle. But the circle turns, and its direction is the point — it pulls the most heavily-credentialed graduates toward the fields that already have their pick and away from the fields that cannot fill. It is prestige, not merit, doing much of the sorting.

The debt that tilts the scale

These pulls act on a graduate who is rarely choosing from a position of financial neutrality. 71% of the medical-school class of 2024 finished with education debt, a median of $205,000 among those who borrowed⁶. A debt of that size does not merely make the high-paying specialties attractive; it makes them feel, to many students, necessary. When the monthly loan payment is fixed and large, the difference between a $320,000 and a $650,000 income is not abstract — it is the difference between a decade of constrained repayment and a comfortable one, and it presses on the specialty decision at exactly the moment the decision is made. Debt does not create the pay gap, but it magnifies the gap’s pull, and it does so most on students from less-wealthy backgrounds, who carry the most debt and can least afford to ignore it. The result is a sorting mechanism that quietly disadvantages primary care twice over: once because it pays least, and again because the students most likely to be drawn to its mission are often the ones least able to accept its economics.

Pay, lifestyle, competitiveness, and debt are the forces this analysis can measure, but they do not act alone. They interact with softer ones it can only note in passing: the greater visibility of procedural role models in medical school, where students simply see more of the specialists and success stories in the high-earning fields; and field-specific differences in autonomy, scope-of-practice pressure, and malpractice climate. These are secondary to the economic and lifestyle incentives, and they do not all pull the same way — the liability that steers students away from some fields is heaviest in others, orthopedic surgery among them — but they are real, and a complete account would weigh them too.

The pediatrics puzzle

Pediatrics deserves its own paragraph, because it shows the sorting operating inside a field that was long considered safe. Pediatrics is not a low-status specialty and it is not an easy one; it draws committed U.S. graduates and still filled 48% of its seats with them in 2026. But it pays the least of the major fields — a general pediatrician averages $265,000, below family medicine and internal medicine despite identical training length and arguably higher stakes³ — and its fill rate has begun to slip, down to 94.4% in 2026¹. The paradox sharpens in the pediatric subspecialties, where more training buys a lower income than general pediatrics and several fellowships now fill below half their positions. Pediatrics is the clearest proof that the sorting is about the incentives and not about the medicine: a field can be intellectually rich, morally serious, and genuinely wanted, and still lose ground when it is paid the least — and it is increasingly, at its edges, another door international graduates are asked to help hold open.

Who fills what is left

Return to the fill table with the drivers in view, and the last piece follows. When U.S. graduates concentrate into the competitive specialties, the large primary-care fields are left offering more positions than U.S. seniors take — and those seats do not vanish. They are filled, disproportionately, by international medical graduates, who now make up 23% of the entire licensed U.S. physician workforce⁷ and 40% of its general internists⁸. In the 2026 Match, international graduates filled roughly 42% of categorical internal-medicine positions and a third of family medicine — the mirror image of their one-to-two-percent share of orthopedics and dermatology². The specialties U.S. graduates leave are the specialties international graduates enter, almost seat for seat.

This is the workforce fact beneath the whole essay, and it cuts against the reflex to frame the Match as a contest between American and foreign graduates. The primary-care and internal-medicine positions international graduates fill are not seats taken from U.S. graduates who wanted them; they are seats U.S. graduates, in the aggregate, chose not to take. Remove the international graduates and those positions do not convert into American primary-care physicians — they go empty, in a country the government projects to be short 187,130 physicians by 2037, with the shortfall heaviest in primary care and the places that have the least of it⁹. The sorting that sends U.S. graduates toward dermatology and radiology is the same sorting that makes the country’s primary-care workforce depend on the physicians who trained abroad. The open door and the road more traveled are two descriptions of one structure.

What this is not

Two guardrails. First, none of this is a criticism of the graduates who choose the competitive specialties, or of those fields. A student who chooses dermatology or orthopedic surgery for its pay, its hours, and its craft is responding rationally to the incentives medicine has set in front of them; the fields themselves are demanding and essential, and the surgeons and radiologists who fill them are not the reason primary care is short-staffed. The argument is with the incentive structure, not with the people navigating it — and the same holds in reverse for the U.S. and international graduates who do choose primary care, who are choosing harder, lower-paid, more needed work against the grade of every force described here.

Second, the sorting is not fixed. Every driver named above is a policy choice with a lever attached: the fee-for-service weightings that pay a procedure many times what an office visit earns, the debt a graduate carries into the decision, the loan-repayment and payment-reform proposals that could narrow the gap, the training culture that treats the competitive specialties as the prize. Countries that pay primary care closer to parity produce more of it; the United States does not, and its graduates sort accordingly. The fill table is not a measure of what American students are made of. It is a measure of what American medicine pays for — and it would change if the payment did. Where you stand on which lever to pull is a policy judgment; that the levers, and not the merit of the fields, are what the Match is measuring is what the data show. For an international graduate reading this, the practical takeaway is the hopeful one: the fields the country needs most, and can least fill, are the fields where the door is widest — and walking through it is not settling for what is left, but stepping into the work the system has left undone.

References

1. National Resident Matching Program. (2026). Results and data: 2026 Main Residency Match. https://www.nrmp.org/match-data/2026/05/results-and-data-2026-main-residency-match/ Of 44,344 positions offered, 41,482 (93.5%) filled. Orthopedic surgery, dermatology, plastic surgery (integrated), otolaryngology, and radiation oncology filled at or near 100%. Internal medicine (categorical) filled 95.2%, pediatrics 94.4%, and family medicine 83.6% (899 positions unfilled); primary care overall filled 92.1%. PGY-1 match rates: U.S. MD seniors 93.5%, U.S.-citizen IMGs 70.0%, non-U.S.-citizen IMGs 56.4%. ↩₁ ↩₂ ↩₃
2. National Resident Matching Program. (2026). Advance data tables: 2026 Main Residency Match (Table 2: matches by specialty and applicant type). https://www.nrmp.org/wp-content/uploads/2026/03/Advance-Data-Tables-2026_Public.pdf Of positions filled in 2026: U.S. MD seniors accounted for about 79% of orthopedic surgery (765 of 963) and roughly three-quarters of dermatology, but only about 38% of categorical internal medicine (4,001 of 10,657), 48% of pediatrics, and 33% of family medicine (1,492 of 4,592). International medical graduates filled roughly 42% of the categorical internal-medicine class (4,508 of 10,657), 34% of family medicine, and 30% of pediatrics — against about 1% of orthopedic surgery and 2% of dermatology. ↩₁ ↩₂
3. Doximity. (2025). Physician compensation report 2025 (2024 data). https://www.doximity.com/reports/physician-compensation-report/2025 Self-reported/modeled survey (over 37,000 responses, 2024 data). Average compensation: orthopedic surgery $679,517, plastic surgery $621,445, radiology $571,749, dermatology $508,401 — against internal medicine $326,116, family medicine $319,000, and general pediatrics $265,000. Three of the four most-recruited specialties in the report were internal medicine, family medicine, and pediatrics. ↩₁ ↩₂
4. Dorsey, E. R., Jarjoura, D., & Rutecki, G. W. (2003). Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA, 290(9), 1173–1178. https://pubmed.ncbi.nlm.nih.gov/12952999/ Controllable lifestyle “explained 55% of the variability in specialty preference from 1996 to 2002,” even after controlling for income, work hours, and years of graduate medical education required. The seminal quantification of the lifestyle driver; the pattern it identified has persisted and, by the fill data, sharpened. ↩
5. National Resident Matching Program. (2024). Charting outcomes in the Match: U.S. MD seniors, 2024. https://www.nrmp.org/match-data/2024/08/charting-outcomes-characteristics-of-u-s-md-seniors-who-matched-to-their-preferred-specialty-2024-main-residency-match/ Matched U.S. MD seniors reported a mean of 27.7 abstracts, presentations, and publications in dermatology and 23.8 in orthopedic surgery (mean Step 2 CK 257 in both), against 8.7 in internal medicine and 6.4 in pediatrics (Step 2 CK 251 and 247) — roughly three times the research output; the same tier includes 37.4 in neurological surgery, 34.7 in plastic surgery, and 20.0 in otolaryngology. The all-specialty mean was 10.2. NRMP notes that this applicant-reported research is not verified and “quality may vary greatly.” ↩
6. Association of American Medical Colleges. (2024). Debt, costs, and loan repayment fact card, class of 2024. https://students-residents.aamc.org/media/12846/download 71% of the class of 2024 graduated with education debt; among those with debt, the median was $205,000 and the mean $212,341. The 2024 first-post-MD-year (first-year resident) median stipend was $65,100. ↩
7. Federation of State Medical Boards. (2025). FSMB physician census identifies 1,082,187 licensed physicians in U.S. [News release; census data 2024]. https://www.fsmb.org/advocacy/news-releases/fsmb-physician-census-identifies-1082187-licensed-physicians-in-u.s/ Of 1,082,187 physicians licensed in the United States, 23% are international medical graduates. ↩
8. Association of American Medical Colleges. (2023). U.S. physician workforce data dashboard: Active physicians who are international medical graduates (IMGs) by specialty. https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-who-are-international-medical-graduates-imgs-specialty-2019 International graduates were about 25% of active U.S. physicians in 2023, but 40% of general internists — a concentration in exactly the primary-care fields U.S. graduates fill least. ↩
9. Health Resources and Services Administration, Bureau of Health Workforce. (2024). Physician workforce: Projections, 2023–2038. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/physicians-projections-factsheet.pdf HRSA projects a national shortage of 187,130 full-time-equivalent physicians by 2037, with the shortfall most severe in nonmetropolitan areas and in primary care disciplines. ↩

Match figures are for the 2026 Main Residency Match and change every year; compensation figures are survey- and model-based; the controllable-lifestyle study is foundational and dated, cited for the mechanism it established rather than a current magnitude. This analysis examines incentives and policy, not any individual, program, institution, or specialty; it is educational and is not career, financial, or policy advice.