Trends in international medical graduate representation in urology residency and fellowship matches

Abstract

Background

Diversity enhances quality, innovation, and cultural competence; however, international medical graduates (IMGs) may face disparities in matching into American residency and fellowship programs. This study aimed to examine the influence of medical education [US/Canada (US/CA) vs. IMGs] on match outcomes in urology over time.

Methods

We analyzed the American Urological Association residency and subspecialty fellowship match data (2014–2024), examining trends in total match slots and those filled by US/CA vs. IMG applicants across residency and fellowship programs. Secondary analyses assessed residency and fellowship trends separately, compared match rates, and evaluated unmatched applicants. Spearman’s correlation assessed trend monotonicity, and chi-squared tests compared match outcomes by applicant group.

Results

7,273 applicants [6,061 (83.3%) US/CA; 1,212 (16.7%) IMG] participated in urology matches from 2014–2024, with 4,995 (68.7%) applying to residency and 2,278 (31.3%) to fellowship programs. Total residency and fellowship slots significantly increased from 385 in 2014 to 586 in 2024 (ρ=1.00; P<0.001). Matched US/CA applicants rose significantly from 342 to 499 (ρ=0.99; P<0.001), while matched IMGs showed no significant change (ρ=0.51; P=0.10). US/CA applicants primarily drove the increase in filled slots. Secondary analyses showed US/CA applicants had significantly higher match rates overall [odds ratio (OR) =10.5, 95% confidence interval (CI): 9.1–12.1, P<0.001], in residency (OR =6.7, 95% CI: 5.3–8.5, P<0.001), and fellowship (OR =17.8, 95% CI: 14.4–22.5, P<0.001).

Conclusions

Over the past decade, urology residency and fellowship slots have increased, predominantly filled by more US/CA applicants. In contrast, IMG participation and match rates have remained stagnant, with significantly lower outcomes overall and within both matches.

Highlight box.

Key findings

• Over 2014–2024, American Urological Association residency + fellowship ‘slots’ rose 52% (385 → 586), yet the gain was filled almost entirely by US/Canadian graduates (US/CA), compared to international medical graduates (IMGs).

• IMGs filled only 6.9% of all positions (3.2% residency; 15.1% fellowship) and matched at one-third the rate of US/CA applicants (25.5% vs. 78.4%).

• Unmatched IMG numbers climbed steadily, driven by fellowship rejections, while unmatched US/CA numbers stayed flat.

What is known and what is new?

• IMGs supply a quarter of the overall US physician workforce but remain underrepresented in competitive surgical fields such as urology. The 2020 shift of the US Medical License Exams (USMLE) Step 1 to pass/fail removed a key objective metric for IMG differentiation.

• This decade-long, specialty-wide analysis quantifies the widening disparity: expanding training capacity benefits US/CA applicants almost exclusively, and certain fellowships (e.g., Pediatric Urology) match <7% IMGs, whereas reconstructive programs with international missions reach ≈35%.

What is the implication, and what should change now?

• Persistent IMG underrepresentation limits workforce diversity and exacerbates urologist shortages—especially in underserved regions that rely on IMGs.

• Stakeholders should invest efforts to: (I) establish IMG-inclusive funding lines or dedicated positions within residency and fellowship programs; (II) advocate for uniform state licensure pathways and visa processes that remove administrative barriers during training; (III) develop alternative, objective evaluation tools (e.g., standardized specialty assessments) that fairly compare IMG and US/CA applicants post-USMLE pass/fail; (IV) expand international accreditation partnerships to elevate global urology training and reciprocity.

Introduction

International medical graduates (IMGs) represent nearly 25% of the United States (US) physician workforce, with approximately 325,000 IMGs currently practicing in the country (1). This proportion is expected to grow given the projected shortage of 37,800 to 124,000 physicians by 2034, including substantial shortfalls in surgical specialty care (2). IMGs will likely continue to play a crucial role in addressing these ever-widening gaps, especially in underserved areas that are heavily reliant on them (3). Organizations, including the American Medical Association’s IMGs Section, advocate for supportive policies, such as streamlined visa requirements and simplified immigration processes (1), but even with these efforts significant barriers remain for IMGs and vary widely on a state-by-state basis.

Current match data show significant disparities for IMGs across a wide range of residency (4), and fellowship (5-7) programs, despite evidence of IMGs being highly competitive applicants and valuable contributors to ongoing diversity initiatives in medicine (8). In urology, evidence is limited but suggests that these disparities are even more pronounced. While IMGs comprise about 23% of residents across all specialties (9), representation in urology was only 7.3% in 2017 and has sharply declined to just 3.3% in 2022 (10). At the attending level, IMGs represent just 10% of the workforce in urology, compared to nearly 25% overall in medicine, and this proportion in urology continues to decrease (11).

Recent changes in the application process have made it increasingly difficult for IMGs to secure a US residency match. The US Medical Licensing Examination (USMLE) Step 1 exam, previously a key metric for IMGs to showcase their qualifications to program directors unfamiliar with international curricula (12), recently adopted a pass-fail scoring model (13). With over 90% of examinees passing, its ability to differentiate candidates has diminished, disproportionately affecting IMGs who relied on high scores to offset unfamiliar foreign programs.

Fellowship matching poses different challenges. A recent study by Malshy et al. (2024) found that only 36% (68/189) of fellowship programs in the 2025 American Urological Association (AUA) match were potentially open to IMGs (14). Eligibility requirements, such as US/Canadian (US/CA) citizenship, American Board of Urology certification, or graduation from an Accreditation Council for Graduate Medical Education (ACGME)-accredited residency, often exclude international applicants, alongside other less-reported factors. In contrast, some subspecialty societies, such as the Endourological Society (EUS) and the Society of Genitourinary Reconstructive Surgeons (GURS), offer international fellowship positions that are not restricted based on medical school location, providing alternative training opportunities (14,15).

In this study, we hypothesized that there has been an increase in available urology residency and fellowship slots; however, we also hypothesized that these positions are primarily filled by applicants trained in the US/CA. To explore this, we analyzed trends in applicants to urology residency and fellowship programs participating in the AUA match, the primary pathway for urology training, which attracts interest from candidates worldwide. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-367/rc).

Methods

Data collection

Annual match data for urology residency and for five fellowship societies participating in the AUA Match were obtained from the American Urological Association Match statistics (2014–2024). These included the EUS, Society for Urologic Oncology (SUO), American Society of Andrology (ASA), GURS, and Society for Pediatric Urology (SPU) (16). Notably, in the AUA match system, graduates from Canadian medical schools are grouped with US graduates and not considered IMGs. Accordingly, we refer to this combined category as ‘US/CA’. Moreover, IMGs are classified based on the location of their medical school, regardless of citizenship status.

The dataset included year-by-year application and match figures for both residency and fellowship programs, stratified primarily by type of medical training background (US/CA vs. IMG) and gender. Detailed, individual-level data—such as applicant profiles or program-specific outcomes—were not available in the official statistics and were therefore not included in this analysis. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Study design and population

To address our research questions, we analyzed match data from all programs participating in the AUA match between 2014 and 2024. Each position offered annually by a residency or fellowship program was defined as a ’slot’. For the primary analysis, we aggregated both residency and fellowship data, referring to the combined set of positions as ‘total slots’. It is important to note that the American Society of Andrology (ASA) and SPU joined the AUA match in 2016 and 2015, respectively; therefore, data for these subspecialties are only available from those years onward. Among the participating fellowships, only SPU holds ACGME accreditation. Eligibility requirements for SPU include graduation from an accredited US or Canadian residency program, which may include IMGs who completed such training domestically.

The Educational Commission for Foreign Medical Graduates (ECFMG) defines IMGs as physicians who received their medical education outside the US or Canada. This definition aligns with the AUA’s classification system, which categorizes applicants based on the country of their medical school, regardless of citizenship or visa status. Gender was recorded as either ‘male’ or ‘female’ in the available data; however, the reports do not indicate whether this information reflects gender identity, sex assigned at birth, or self-reported status. In this study, we use the term ‘gender’ consistent with the source data, recognizing potential interpretive limitations due to the lack of clarification.

The following calculations and definitions are used throughout this manuscript:

• ❖ Slot: an available residency or fellowship position offered by a program.

• ❖ Total applicants: sum of residency and fellowship applicants, referred to as total.

• ❖ Matched applicant: an applicant from a specific group (IMG or US/CA) who successfully matched into a residency or fellowship slot.

• ❖ Match rate: the percentage of applicants from a specific group or category (e.g., per year, total, residency, fellowship, IMGs, US/CA, etc.) who matched to a slot.

Statistical analysis

The primary analysis examined trends over time in the cohort of total (residency and fellowship) slots. Specifically, we plotted trends in the absolute total number of (I) slots listed by programs, (II) slots filled by US/CA applicants, and (III) slots filled by IMG applicants.

The secondary analyses utilized subgroups for residency and fellowship slots instead of considering them together. For each subgroup, we investigated the same three trends in absolute totals detailed as I–III for the primary analysis above. Additional secondary outcomes that we investigated included time trends in match rates for IMG and US/CA applicants, with separate analyses for total slots, residency slots, and fellowship slots. Finally, we reported trends for the absolute number of unmatched applicants by both slot and applicant type.

Spearman’s correlation coefficient (ρ) was used to assess the strength and direction of monotonic trends in the analysis. A chi-square test evaluated associations between medical school graduate type (US/CA or IMG) and matching. Odds ratios (ORs) for matching were calculated with 95% confidence interval (CI). Statistical analyses were conducted using Stata/MP (version 16.1) and DataTab (DATAtab Team, 2024) (17) with significance defined as P<0.05 in two-tailed tests.

Results

Applicant characteristics

A total of 7,273 applicants participated in the AUA matches during the study years, including 4,995 (68.7%) residency and 2,278 (31.3%) fellowship applicants (Table 1). Overall, 73.1% of all applicants were male. In the fellowship and residency applicant subgroups, 81.5% and 69.2% of applicants were male, respectively. The total number of slots listed throughout the study period was 5,423, with 3,712 (68.4%) of these for residency and 1,711 (31.6%) for fellowship positions. Of the total applicants, 6,061 (83.3%) were US/CA-trained while 1,212 (16.7%) were IMGs. In the fellowship and residency applicant subgroups, 37.3% and 7.3% of applicants were IMGs, respectively (Table 1).

Table 1. Summary of applicant demographics, match rates, and odds ratios by residency and fellowship programs.

Variable	Total	Residency	Fellowship
Total applicants, n (%)	7,273 (100.0)	4,995 (68.7)	2,278 (31.3)
Gender, n (%)
Females	1,845 (25.4)	1,457 (29.2)	388 (17.0)
Males	5,315 (73.1)	3,458 (69.2)	1,857 (81.5)
Undisclosed/others	112 (1.5)	80 (1.6)	32 (1.5)
Missing	1 (<0.01)	0 (0)	1 (<0.01)
Medical school, n (%)
US/CA	6,061 (83.3)	4,632 (92.7)	1,429 (62.7)
IMGs	1,212 (16.7)	363 (7.3)	849 (37.3)
Slots listed by programs, n (%)	5,423 (100.0)	3,712 (68.4)	1,711 (31.6)
Total matched, n (%)	5,069 (69.7)	3,678 (73.6)	1,391 (61.1)
US/CA	4,760 (65.5)	3,561 (71.4)	1,199 (52.6)
IMG	309 (4.3)	117 (2.3)	192 (8.4)
Total unmatched, n (%)	2,194 (30.2)	1,307 (26.2)	887 (38.9)
US/CA	1,301 (11.7)	1,071 (21.4)	230 (10.1)
IMG	893 (12.3)	236 (4.7)	657 (28.8)
Missing, n (%)	10 (0.1)	–	–
Match rate, %
All	69.7	73.6	61.1
US/CA	78.5	76.9	83.9
IMG	25.5	32.2	22.6

IMG, international medical graduate; US/CA, US and Canadian.

Absolute number of slots and matched applicants

The primary analysis revealed that the absolute number of total (residency and fellowship) slots increased significantly over the study period (Figure 1A), from 385 slots available in 2014 to 586 slots in 2024 (ρ=1.00, P<0.001). A similar and significant increase was also seen in the absolute number of matched US/CA applicants, from 342 to 499 over the same years (ρ=0.99, P<0.001). However, no significant differences were seen in the number of matched IMGs over these years (ρ=0.51, P=0.10). Ultimately, the proportion of slots filled by IMGs was 6.9% in total, 3.2% for residency slots, and 15.1% for fellowship slots. No significant trends were observed across these groups over the years (Figure S1, Table S1).

Figure 1.

Offered slots, matched US/CA graduates, and matched IMGs. (A-C) Positive trends in the number of offered slots by programs (green line) are shown alongside the absolute numbers of slots matched by US/CA applicants (blue bars) and IMGs (orange bars) for the total (residency + fellowship) (A), residency (B), and fellowship (C). Total slots and matched US/CA applicants showed significantly increasing trends over time, whereas no significant increase was observed among IMGs. IMG, international medical graduate; US/CA, US and Canadian.

In secondary analyses, these trends in matching were also reflected in the separate subgroup analyses of residency and fellowship slots (Figure 1B,1C). For residency slots, the absolute number of US/CA applicants matching increased significantly over time (ρ=0.99, P<0.001) while the absolute number of IMGs matching did not (ρ=0.22, P=0.51). The same was seen for fellowship slots, with US/CA matched applicants increasing significantly over time (ρ=0.91, P<0.001) while IMGs did not (ρ=0.43, P=0.18).

Match rate trends

Additional secondary analyses, which tabulated match rate percentages instead of the absolute number of applicants matched, found that US/CA applicants had significantly higher overall match rates than IMGs (Figure 2). Specifically, in the total (residency and fellowship) applicant cohort, the US/CA match rate was 78.5% compared to just 25.5% for IMGs (OR =10.5, 95% CI: 9.1–12.1, P<0.001). This trend remained significant in both the residency and fellowship program subgroup analyses. For residency applicants, the US/CA match rate was 76.9% vs. 32.2% for IMGs (OR =6.7, 95% CI: 5.3–8.5, P<0.001), and for fellowship applicants the US/CA match rate was 83.9% vs. 22.6% for IMGs (OR =17.8, 95% CI: 14.4–22.5, P<0.001) as shown in Table 1. Notably, no significant differences were observed in the trend analysis for match rate dynamics over the study period (Tables S1,S2).

Figure 2.

Match rates for US/CA vs. IMG applicants. (A-C) Significantly higher match rates (matched/applications) for US/CA applicants compared to IMGs across the total (residency + fellowship) (A), residency (B), and fellowship (C) throughout the match years. CI, confidence interval; IMG, international medical graduate; OR, odds ratios; US/CA, US and Canadian.

Among the five fellowship subspecialty matches, the SPU had the lowest match rate for IMGs, with only 6.7% IMG applicants matching. GURS, on the other hand, had the highest IMG match rate at 35.5%. The IMG fellowship match rates for the SUO, EUS, and ASA were 21.0%, 22.6%, and 15.8%, respectively (Table S3).

Unmatched applicants

An overall upward trend was observed in the absolute number of total (residency and fellowship) unmatched IMG applicants over the study period, including a minimum of 63 in 2017 and a maximum of 101 in 2022 (ρ=0.69, P=0.02). This trend was primarily driven by an increase in unmatched IMG fellowship applicants over time (ρ=0.69, P=0.02), while no significant trend was observed among IMG residency applicants (ρ=−0.36, P=0.28). No monotonic trend was found among their US/CA applicant counterparts, with the highest total number of unmatched US/CA applicants occurring in 2014 (n=162) and primarily consisting of residency applicants (Figure 3).

Figure 3.

Trends in unmatched applicants over the years. (A-C) Positive trends in the number of offered slots by programs (green line) are shown alongside the absolute numbers of unmatched US/CA applicants (blue line) and IMGs (orange line) for the total (residency + fellowship) (A), residency (B), and fellowship (C). Notably, there are significantly increasing trends in the number of unmatched IMG applicants, especially in fellowship programs. IMG, international medical graduate; US/CA, US and Canadian.

Discussion

In this comprehensive study, we analyzed over a decade of the most recent data from the AUA residency match and all five AUA fellowship match programs to explore disparities between IMG and US/CA applicant match outcomes. Over the study period, we observed a steady increase in the total number of residency and fellowship training program slots, which likely reflects the increasing demand for urologists in the US. A significant increase in the absolute number of US/CA applicants filling these slots was identified, but no increase was seen for their IMG counterparts. This finding was true across the total pool of applicants, as well as when residency and fellowship slots were considered separately. Taken together, we conclude that this increase over time in total residency and fellowship slots offered and filled was primarily driven by US/CA applicants, not IMGs, and represents a persistent disparity.

We also investigated the match rates of IMG and US/CA applicants over time, which accounted for the size of the applicant pool in a way that reporting absolute numbers matched does not. In all cases, across all groups and subgroups, IMGs had significantly lower match rates than US/CA applicants. Within the fellowship programs, heterogeneity in IMG match rates was seen. The SPU specialty was seemingly the ‘hardest’ for IMGs to match into, while GURS appeared to be the ‘easiest’, with the highest match rate, albeit still quite low at just 35.5%. This likely reflects unique features of the GURS specialty, such as the number of fellowships based outside the US and Canada. Additionally, GURS has a fellowship exclusively for IMGs, with international education as part of its mission (18). Notably, when examining the absolute number of unmatched applicants over time, we observed an increase in unmatched IMG applicants, particularly in the fellowship match, while the number of unmatched US/CA applicants remained relatively stable. This again supports the findings of the primary analysis, whereby US/CA applicants were primarily accounting for the overall increase in urology residency and fellowship slots filled over time.

In an ideal scenario, the process of matching to a residency or fellowship position would be free from biases related to gender/sex, ethnicity, nationality, or social status. It would instead consist of a holistic review emphasizing an applicant’s professional skills, their potential for growth within the field, and their ability to contribute meaningfully to their program, ultimately ensuring the best possible care for our patients by future clinicians. Despite the rigorous scrutiny applied to IMGs by the ECFMG and additional licensure requirements in their home countries to ensure clinical competency, as well as their essential contributions to the US healthcare workforce, disparities persist for IMGs in pursuing clinical training positions in the US. These barriers to entry may then result in further downstream harms, such as delaying or inhibiting academic careers.

While IMGs are more prevalent in specialties such as internal medicine or primary care, and in less desirable rural locations (1), their representation in more competitive fields like urology remains disproportionately low (4), for decades (19). In 2024, the match rate for IMGs was 61.2% over all specialties, but only 43% in urology. The highest percentage of first-year positions filled by IMGs was in the following specialties: Internal Medicine (43%), Pathology (37.4%), and Family Medicine (31.8%) (4). In contrast, in urology, our data shows a match rate as low as 19 IMGs out of 366 matched applicants (6.3%). Our data highlight that further efforts are needed to achieve more equitable match outcomes for IMGs, who face unique barriers, including state-specific policies that restrict their ability to practice in the US, even as supervised trainees (20,21). One approach to closing disparity gaps is by increasing the representation in both residency (22) and fellowship (23) training programs, alongside a rise in the total number of available training slots, which perhaps is contributing to the rise in women’s representation in urology (22-25).

Fellowship programs in leading US academic centers play an important role in global health, particularly for regions with limited access to specialized training. While many major universities recognize this importance in admissions to Schools of Public Health, they may neglect or deprioritize it in residency and fellowship admissions within Schools of Medicine. This creates a paradox where one part of the university seeks to reduce disparities, while another inadvertently widens them. A recent study by Baqain et al. (2024) highlights this paradox by revealing disparities among urology training programs in low- and middle-income countries (26). Challenges such as outdated curricula, limited faculty, and insufficient resources contribute to significant variability in training quality within these regions. While such limitations may hinder the competitiveness of IMG applicants, they also underscore the value of international exposure, which can play a critical role in enhancing training and advancing globalized patient care. In this context, international credentialing initiatives—such as ACGME-International (27)—represent a promising strategy to bridge training quality gaps and streamline the global licensing process, promoting more equitable access to high-quality postgraduate education.

Standardized tests such as USMLE Step 1 scores have historically enabled IMGs to distinguish themselves objectively in an exceptionally competitive applicant pool where more subjective factors, such as regional familiarity and in-person clinical rotations, are often emphasized by residency and fellowship program directors (12). Reports from the National Residency Matching Program (NRMP) indicate that 94% of program directors consider Step 1 important for interview selection, with 68% requiring a minimum score prior to the move to pass/fail reporting (28). As one of the key objective metrics for comparing IMG applicants with their US/CA-educated counterparts, recent policy shifts of reporting scores as pass/fail may disproportionately affect IMGs who have no other opportunity to offset unfamiliarity, or misunderstandings regarding the quality of their home institution (12).

Driven by low match rates and challenges in obtaining impactful recommendation letters, IMGs often engage in research and achieve high academic success (4,8). For example, one recent study analyzed the NRMP database from 2008 to 2022 for manuscript publication counts, comparing IMGs to US/CA residency applicants (29). Among those who successfully matched, IMGs had between three to five times more publications than US MD seniors. Geographic disparities were also found in this report, perhaps indicating state-level differences in law and policy, which make it more challenging for some programs to recruit IMGs than others. For example, Mississippi had the highest percentage of slots filled by IMGs and New York matched the highest absolute number of IMGs to training slots. Underrepresentation of IMGs was observed in all nine geographic divisions of the country, particularly in the West, South Central, and Pacific regions (29).

To our knowledge, this manuscript is the first to comprehensively analyze current trends in IMG representation in the American urology residency and fellowship matches. Our findings raise critical questions for further exploration: (I) What strategies can increase opportunities for competitive IMGs to succeed in the AUA residency and fellowship matches? (II) Should targeted efforts be made to create and fund spots specifically for IMGs? (III) Can academic societies exert influence on state-level health policies to support these initiatives?

Limitations

This study has several limitations that should be highlighted. The AUA’s residency and fellowship match reports lack detailed, de-identified applicant data, providing only broad categorizations by gender and US/CA vs. IMG status. This limits insights into training program priorities and excludes data on objective metrics like exam scores or research output, hindering competitiveness assessment and covariate adjustments. This limitation also hinders the ability to analyze the interaction among different groups experiencing potential disparities in the match, such as females or underrepresented minorities within the IMG pool, as well as the effect of matching rates in one group on another. Moreover, this prevents the ability to track repeat applicants across cycles; thus, some individuals may have applied multiple times, potentially inflating the total applicant counts.

Additionally, the analysis covers only formal AUA match outcomes, excluding slots filled during post-match ’scramble’ periods or outside normal timelines, which may affect IMGs’ odds and the generalizability of findings. Lastly, non-AUA-organized programs, including those by the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction and similar organizations, were not included.

Conclusions

Training slots offered by urology residency and fellowship programs have significantly increased over the past decade, benefiting US/CA applicants more than IMGs. However, match rates for IMGs remain significantly lower than those of their US/CA peers. This disparity highlights the need for both systemic and individual changes to foster a more equitable and inclusive field, ultimately increasing IMG representation in residency and fellowship programs participating in the match.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.