GME stands for Graduate Medical Education, the training doctors complete after medical school to specialize in a particular field. It includes residency programs, where new physicians learn to practice independently in a specialty like surgery or pediatrics, and fellowship programs, where experienced residents pursue even narrower subspecialties. In the United States, the Accreditation Council for Graduate Medical Education (ACGME) oversees the accreditation of these programs, and the system currently trains over 120,000 residents at any given time.
How GME Fits Into a Doctor’s Training
Medical school gives students the foundational knowledge and clinical exposure they need to earn their degree, but it doesn’t make them ready to practice on their own. GME is where that transition happens. A new medical school graduate enters a residency program in their chosen specialty and spends several years treating patients under supervision, gradually taking on more responsibility until they can work independently.
Residency length varies by specialty. Family medicine and internal medicine residencies typically last three years, while surgical specialties can run five to seven years. During this time, residents are licensed physicians who care for real patients in hospitals and clinics, but they do so within a structured educational program that includes regular evaluations and mentorship from attending physicians.
Fellowship is the optional next step. After completing residency, some doctors pursue one to three additional years of training in a subspecialty. A cardiologist who wants to perform catheter-based heart procedures, for example, would complete an interventional cardiology fellowship. Without that fellowship, they wouldn’t be allowed to perform those procedures. In short, residency trains a specialist, and fellowship creates an expert within that specialty.
How Residents Are Placed Into Programs
Most U.S. residency positions are filled through the National Resident Matching Program, commonly called “the Match.” Medical students rank their preferred programs, programs rank their preferred applicants, and a computer algorithm pairs them. In 2025, the Match offered a record 43,237 certified positions. After the initial match and a supplemental process for unfilled spots, 99.4% of all available positions were filled.
Competition for certain specialties is intense. Dermatology, plastic surgery, and orthopedic surgery consistently have more applicants than spots, while primary care fields and rural programs sometimes struggle to fill every position.
Who Pays for GME
The federal government is the largest funder of GME in the United States, primarily through Medicare. The funding comes in two streams. Direct Graduate Medical Education (DGME) payments reimburse teaching hospitals for the direct costs of running residency programs: resident salaries, faculty teaching time, and administrative overhead. Indirect Medical Education (IME) payments compensate teaching hospitals for the higher patient care costs they incur compared to non-teaching hospitals, calculated using a formula based on the ratio of residents to hospital beds.
The Department of Veterans Affairs is the second-largest federal contributor, providing roughly $850 million annually to support about 11,000 full-time equivalent resident positions across more than 250 affiliated institutions. The VA also distributes an additional $1.6 billion to cover infrastructure, instructor salaries, and educational administration at its facilities. Altogether, VA funding accounts for about 11% of resident positions nationally. Nearly all of these residents train in programs sponsored by affiliated academic medical centers rather than by the VA itself.
State governments, private insurers, and hospitals themselves also contribute to GME funding, though Medicare and the VA remain the dominant sources.
The Funding Cap Problem
In 1997, the Balanced Budget Act froze Medicare-funded residency positions at their December 1996 levels. That cap has remained largely in place ever since, meaning the number of federally supported training slots has barely grown in nearly three decades, even as the U.S. population has increased by tens of millions.
Small exceptions have been carved out over the years. The original legislation allowed primary care programs to add up to three positions and permitted rural hospitals to increase their caps by up to 30%. More recent legislation has authorized limited additional slots. But on the whole, approved full-time equivalent resident positions changed very little after the cap was introduced, with only modest growth in primary care.
This cap is one reason the country faces a projected physician shortage. The Association of American Medical Colleges estimates the U.S. will be short between 13,500 and 86,000 physicians by 2036. The greatest shortfalls are expected in primary care (20,200 to 40,400 physicians) and surgical specialties (10,100 to 19,900 physicians). Medical schools have expanded enrollment significantly, but if there aren’t enough residency positions for graduates to train in, the bottleneck persists.
The Role of International Medical Graduates
International medical graduates, or IMGs, fill roughly 25% of all GME training positions and make up about 24% of the active physician workforce in the United States. These doctors, both U.S.-born citizens who attended medical school abroad and foreign-born physicians, are especially important in specialties and regions that struggle to attract domestically trained graduates.
IMGs are more likely to enter primary care specialties and to practice in lower-income rural and urban communities that are underserved by U.S. medical graduates. They also contribute meaningfully to medical research, academic conferences, and the diversity of the physician workforce. At least 15 states have recently introduced legislation to create new pathways for IMGs to enter practice, in some cases allowing them to bypass traditional GME requirements in an effort to address local physician shortages more quickly.
Why GME Matters to Patients
The GME system shapes the healthcare you receive in tangible ways. The number and location of residency programs influence which specialties have enough doctors and which communities have access to care. A hospital with a large residency program typically offers more complex services and round-the-clock physician coverage. Rural areas with fewer training programs often have fewer practicing physicians, since doctors tend to stay near where they trained.
The ongoing tension between a frozen funding structure and a growing, aging population means GME policy decisions made in Washington directly affect how long you wait for an appointment, whether your community has a surgeon or cardiologist nearby, and how stretched your doctor’s schedule is on any given day.