Graduate medical education (GME) is the period of clinical training that comes after medical school, where new physicians develop expertise in a specific specialty or subspecialty. It includes both residency programs (training in a broad specialty like surgery or pediatrics) and fellowship programs (advanced training in a narrower area like cardiology or sports medicine). In the United States, this training is overseen by the Accreditation Council for Graduate Medical Education, which sets standards for programs and monitors whether they meet them. Without completing GME, a medical school graduate cannot practice medicine independently.
How GME Differs From Medical School
Medical school teaches the foundational science and clinical skills every physician needs, regardless of specialty. GME is where that knowledge gets applied under increasing levels of responsibility. Residents treat real patients in hospitals and clinics, starting with close supervision and gradually earning more autonomy. The goal, as the ACGME frames it, is for trainees to progressively achieve the independence needed to deliver high-quality patient care without oversight.
This progression is structured around a competency-based framework. Rather than simply logging time, residents are evaluated on specific skills and knowledge areas called “Milestones.” A surgical resident might demonstrate competence in basic procedures early in training but take longer to master complex operations. Programs are expected to increase their direct observation of resident performance, assessing degrees of competence rather than just counting procedures completed.
Residency, Fellowship, and How Long They Take
Residency is the core of GME. Every physician completes one, and the length depends on the specialty. Internal medicine and pediatrics residencies run three years. General surgery takes five. Neurosurgery requires seven. During this time, residents rotate through different clinical settings, building breadth within their specialty while working under the supervision of attending physicians.
Fellowship comes after residency and is optional. It provides subspecialty training for physicians who want to narrow their focus. A doctor who completes an internal medicine residency might pursue a two- or three-year fellowship in gastroenterology or oncology. Not all physicians do fellowships, but many subspecialties require one for board certification.
The term “internship” historically referred to the first year of residency. It’s still commonly used in conversation, but it’s no longer a formally distinct phase. Your first year of residency is simply called PGY-1 (postgraduate year one).
Getting In: The Match Process
Most residency positions in the United States are filled through the National Resident Matching Program, commonly called “the Match.” Medical students apply to programs through a centralized electronic system, interview with programs they’re interested in, and then both sides submit ranked preference lists. An algorithm pairs applicants and programs based on mutual preferences.
In the 2025 Match cycle, 43,237 residency positions were offered. US allopathic (MD) medical school seniors filled about 48.5% of all positions, US osteopathic (DO) seniors filled 18.9%, and US international medical graduates filled 7.5%. The remaining positions went to non-US international graduates or went unfilled.
Applicants who don’t match on the initial round can participate in the Supplemental Offer and Acceptance Program (SOAP), which allows them to apply to programs that still have openings. During SOAP, unmatched applicants can apply to up to 45 unfilled programs over several days.
A Single Accreditation System
Until recently, the US had two separate accreditation systems for GME. MD graduates typically trained in programs accredited by the ACGME, while DO graduates often trained in programs accredited by the American Osteopathic Association. Between 2015 and 2020, these systems merged into a single accreditation framework under the ACGME.
The transition wasn’t seamless. Some osteopathic programs struggled to meet ACGME standards. Of 122 applications from formerly AOA-accredited family medicine programs, 89 received initial or continuing accreditation by mid-2020, while the rest had issues to resolve. Programs can now pursue “Osteopathic Recognition,” which preserves training in osteopathic principles within the ACGME framework. One notable trend from the merger: as more DO graduates enter the Match, they’re projected to eventually outnumber both MDs and international graduates in family medicine residencies.
Work Hour Limits for Residents
Resident work hours are capped at 80 hours per week, averaged over a four-week period. That includes all clinical duties, educational activities, and any moonlighting. Individual shifts cannot exceed 24 consecutive hours of scheduled clinical work, though residents can stay up to four additional hours for handoffs and education (but not new patient care responsibilities).
Residents must get at least one day off per week (averaged over four weeks) and at least 14 hours free after a 24-hour shift. The ACGME recommends eight hours off between all scheduled work periods. These rules exist because of well-documented links between sleep deprivation and medical errors, though many residents report that the 80-hour cap still feels grueling in practice.
How GME Is Funded
The federal government is the largest funder of graduate medical education, primarily through Medicare. Teaching hospitals receive two types of payments. Direct Graduate Medical Education (DGME) payments cover the actual costs of training, including resident salaries and benefits. These payments are calculated based on the number of residents a hospital trains and its share of Medicare patients. Indirect Medical Education (IME) payments compensate hospitals for the higher costs associated with being a teaching institution, since training programs tend to treat sicker patients and use more resources.
The number of Medicare-funded residency positions has been largely frozen since 1997, creating a bottleneck. The Consolidated Appropriations Act of 2021 authorized 1,000 new positions to be distributed over five years, prioritizing hospitals in areas with healthcare provider shortages. As of September 2025, 600 of those positions had been allocated. About half went to hospitals expanding primary care training. Nearly all recipient hospitals were in urban areas, which raised concerns that the distribution method may have disadvantaged rural hospitals.
The Physician Shortage Problem
GME capacity is directly tied to the nation’s physician supply. Training a physician takes over a decade from the start of medical school through residency, so decisions about GME funding today shape the workforce 10 to 15 years from now. The Health Resources and Services Administration projects an overall shortage of 141,160 physicians by 2038.
The 51 new medical schools that opened between 2010 and 2020 are producing more graduates, but those graduates still need residency positions to complete their training. Without expanding GME slots, more medical school graduates will be unable to train and enter practice. Federal programs like the Teaching Health Center Graduate Medical Education Program and the National Health Service Corps attempt to address shortages in underserved areas through loan repayment and direct funding, but the fundamental constraint remains the number of available training positions.
Requirements for International Medical Graduates
International medical graduates (IMGs) make up a significant portion of the US physician workforce, but entering GME requires additional steps. The ACGME requires all IMGs to be certified by the Educational Commission for Foreign Medical Graduates (ECFMG) before starting a residency or fellowship.
ECFMG certification involves several components. Applicants must have graduated from a medical school listed in the World Directory of Medical Schools with a specific ECFMG sponsor note confirming eligibility. They need to pass Step 1 and Step 2 Clinical Knowledge of the US Medical Licensing Examination. They must also satisfy clinical skills and communication requirements, typically through an ECFMG Pathway that includes passing the Occupational English Test for Medicine. An accepted, unexpired Pathway is required both for certification and for participating in the Match. ECFMG certification also serves as a prerequisite for taking Step 3 of the licensing exam.