The Most Competitive Medical Residencies: A Complete List (2024)
/A guide to the nation’s most highly selective residency specialties, including matching difficulty, and why these residencies are so competitive
What are the hardest medical specialties to match intO?
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Part 1: Introduction
Though residency matching takes place during your final year of medical school, the road towards matching actually begins much earlier, with the process of choosing a medical specialty. If you’re a current medical student, you’ve probably given some thought to which specialty you’d like to go into and why.
While you’ve likely considered factors such as salary, work-life balance, and, of course, your interests, the competition to enter certain specialties sometimes gets overlooked. Nevertheless, the competitiveness of different medical residencies is an element that you should weigh while making such an important decision.
Matching with any residency position is an accomplishment, but you may find yourself facing significantly different levels of competition depending on which specialty you choose. For instance, the primary care specialties combined offer tens of thousands of residency positions annually, while in certain other fields, positions number in the single digits.
So, what are the most competitive medical residencies? In this post, we’ll address that question and others, including: What are competitive residencies’ fill rates (i.e., those that fill the highest percentage of their positions with the most allopathic M4s)? And what are the average salaries and step scores associated with these competitive specialties?
How competitive is residency matching, in general?
The 2024 NRMP Main Residency Match boasted a high number of applicants and positions, with 44,853 certified applicants vying for 41,503 residency spots. This statistic represents applicants graduating from both MD and DO programs, along with graduates of international medical schools (IMGs) and graduates of medical schools who didn’t match in previous years. It also accounts for postgraduate year one (PGY-1) and postgraduate year two (PGY-2) residency positions.
Among seniors at U.S. medical schools, 93.5% of MD applicants and 92.3% of DO applicants matched with a PGY-1 position. Those are somewhat reassuring statistics, but they don’t tell the whole story. Slightly over a third of those positions filled by MD seniors, and just over half of ones filled by DO seniors, were in the primary care specialties: family medicine, internal medicine, and pediatrics, which had respective fill rates of 29.2%, 35%, and 47.6% among U.S. allopathic medical school seniors.
When we look at the numbers for specialties outside of primary care, the competition for residency positions grows even more stiff.
For a full list of medical specialties and subspecialties, see the Association of American Medical Colleges’ comprehensive website detailing specialties and specialty paths.
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Part 2: What are the most competitive residencies?
According to the American Medical Association, the NRMP considers the most competitive residency specialties to be, as we mentioned above, those with the highest fill rates—the ones that are filling their positions with the most allopathic M4s. Using this metric, along with data from the 2023 NRMP Main Residency Match on U.S. allopathic medical school seniors, we’ve compiled a list of the most competitive residency specialties among those that offered over 30 positions in 2023.
In this guide, we’ve ranked not the competitiveness of individual residency programs, but rather, the competitiveness of entire specialties. In highly competitive specialties, like the ones we’ve listed below, nearly all residency programs will be a challenge to match with.
In contrast, individual programs within less competitive specialties will have a wider range of selectivity. For instance, even though pediatrics is considered a less competitive specialty overall, some programs like Boston Children’s are still highly selective while a program like Rutgers New Jersey Medical School is considered more accessible.
Before we get into the list, here are a few points to keep in mind regarding the data you’ll encounter below:
We’ve chosen to primarily provide data on the residency matching trends of seniors at U.S. allopathic medical schools. This isn’t to elevate this group of applicants above others, such as osteopathic med school seniors or IMGs. Rather, because U.S. MD seniors make up the largest applicant pool in the NRMP Match (around 48% in 2024), this data simply provides the clearest insight into which specialties are most competitive.
Data on average salaries come from Doximity’s 2024 Physician Compensation Report.
Step score statistics come from the NRMP’s 2022 Charting Outcomes in the Match report (currently the most recent available) on U.S. MD seniors and give us a picture of which specialties require the highest academic performances. However, as of January 2022, Step 1 is scored on a pass/fail basis. Step 1 scores are listed below since they are published in the Charting Outcomes report. NRMP states that the majority of applicants whose data is reflected in the report took Step 1 earlier than the January 2022 change to pass/fail. This report is released every other year and as of this writing, has not yet been released in 2024. We will update the score information when it becomes available.
List of the most competitive residency specialties
(Note: To give a better general sense of the most difficult residencies, this data is focused on main residencies rather than sub-specialty residencies with fewer than 30 positions available. Medicine-Pediatrics is listed here for its high fill rate among U.S. MD seniors and high number of positions offered.)
Plastic surgery (integrated)
Fill rate (U.S. MD seniors): 88.3%
Number of positions offered: 213
Number of positions available per applicant (U.S. MD seniors): 0.8
Matched applicants’ mean USMLE Step 1 score: 251
Matched applicants’ mean USMLE Step 2 score: 257
Unmatched applicants’ mean USMLE Step 1 score: 240
Unmatched applicants’ mean USMLE Step 2 score: 247
Average annual salary: $619,812
Years of specialty training required prior to certification: 6
Otolaryngology
Fill rate (U.S. MD seniors): 88.7%
Number of positions offered: 382
Number of positions available per applicant (U.S. MD seniors): 0.98
Matched applicants’ mean USMLE Step 1 score: 250
Matched applicants’ mean USMLE Step 2 score: 257
Unmatched applicants’ mean USMLE Step 1 score: 243
Unmatched applicants’ mean USMLE Step 2 score: 250
Average annual salary: $502,543
Years of specialty training required prior to certification: 5
Thoracic surgery
Fill rate (U.S. MD seniors): 93.8%
Number of positions offered: 48
Number of positions available per applicant (U.S. MD seniors): 0.6
Matched applicants’ mean USMLE Step 1 and Step 2 scores: While the NRMP hasn’t published this information, anecdotal evidence suggests that thoracic surgery mean step scores for successful applicants are similar to other integrated surgical residencies—approximately 240–250 for Step 1 and 250–255 for Step 2.
Average annual salary: $720,634
Years of specialty training required prior to certification: 6–8
Vascular surgery
Fill rate (U.S. MD seniors): 77.0%
Number of positions offered: 100
Number of positions available per applicant (U.S. MD seniors): 1.07
Matched applicants’ mean USMLE Step 1 score: 241
Matched applicants’ mean USMLE Step 2 score: 250
Unmatched applicants’ mean USMLE Step 1 score: 238
Unmatched applicants’ mean USMLE Step 2 score: 245
Average annual salary: $556,070
Years of specialty training required prior to certification: 5–7
Neurological surgery
Fill rate (U.S. MD seniors): 84.6%
Number of positions offered: 241
Number of positions available per applicant (U.S. MD seniors): 0.9
Matched applicants’ mean USMLE Step 1 score: 241
Matched applicants’ mean USMLE Step 2 score: 252
Unmatched applicants’ mean USMLE Step 1 score: 238
Unmatched applicants’ mean USMLE Step 2 score: 246
Average annual salary: $763,908
Years of specialty training required prior to certification: 7
Interventional radiology (integrated)
Fill rate (U.S. MD seniors): 78.4%
Number of positions offered: 51
Number of positions available per applicant (U.S. MD seniors): 0.27
Matched applicants’ mean USMLE Step 1 score: 245
Matched applicants’ mean USMLE Step 2 score: 253
Unmatched applicants’ mean USMLE Step 1 score: 238
Unmatched applicants’ mean USMLE Step 2 score: 251
Average annual salary: $531,983 (Note: The salary listed is for Radiology. Interventional radiology as a specific specialty is not listed in the report.)
Years of specialty training required prior to certification: 6
Orthopedic surgery
Fill rate (U.S. MD seniors): 79.3%
Number of positions offered: 916
Number of positions available per applicant (U.S. MD seniors): 0.90
Matched applicants’ mean USMLE Step 1 score: 248
Matched applicants’ mean USMLE Step 2 score: 256
Unmatched applicants’ mean USMLE Step 1 score: 241
Unmatched applicants’ mean USMLE Step 2 score: 249
Average annual salary: $654,815
Years of specialty training required prior to certification: 5 years minimum, plus 2 years in clinical practice
Medicine - Pediatrics
Fill rate (U.S. MD seniors): 86.9%
Number of positions offered: 390
Number of positions available per applicant (U.S. MD seniors): 0.89
Matched applicants’ mean USMLE Step 1 score: 236
Matched applicants’ mean USMLE Step 2 score: 250
Unmatched applicants’ mean USMLE Step 1 score: 217
Unmatched applicants’ mean USMLE Step 2 score: 234
Average annual salary: $273,472
Years of specialty training required prior to certification: 4
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Part 3: Takeaways regarding the most competitive residencies
High fill rates mean high competition
To get a sense of how challenging it can be to match with residencies in the specialties we just mentioned, let’s take a closer look at fill rates.
The most selective specialties generally fill 80% or more of their resident positions with U.S. allopathic medical school seniors (and the higher the fill rate, the more competitive the specialty). As a comparison, across PGY-1 positions in all specialties, just 48% of positions were filled by U.S. MD seniors in 2024. And, as we noted earlier, fill rates among primary care specialties were similar or lower: 47.6% for pediatrics; 35% for internal medicine; and 29.2% for family medicine.
In contrasting these numbers, we can see that matching with residency positions in the eight specialties above is significantly more competitive than average.
Why are some medical specialties so competitive?
At least three things can go into making a residency specialty especially competitive: future pay, work-life balance, and the number of residency positions available.
It probably goes without saying that doctors are well paid, no matter what. The average physician’s salary in 2024 is $277,000 for primary care providers and $394,000 for specialists, yet some specialties pay far more than that. It’s clear that the most challenging residency specialties to match into correspond with some of the best-paid specialties in medicine. Surgical specialties, especially neurological and thoracic surgeries, command the highest pay grades.
On the other hand, while a specialty such as dermatology tends to pay less than the surgical specialties (though still well above average), it’s still highly competitive to enter due to its enviable work-life balance. The possibility of a flexible schedule, reasonable workload, relatively short residency length, and attractive compensation are among the reasons why many medical students are eager to become dermatologists.
The sheer number of resident positions available in a specialty also plays a role in how competitive it is to match into. For instance, though just 187 U.S. MD seniors applied to interventional radiology residencies in 2023, they were vying for only 51 available spots, which works out to 0.27 positions available for every applicant. On the other hand, while internal medicine attracted more than 4,000 allopathic M4 applicants, it also offered over 10,000 positions, meaning that there were more than two positions available for every U.S. MD senior who applied.
In general, the most competitive residency specialties offer one or fewer positions per allopathic M4 applicant to that specialty.
Competitive residencies require high USMLE Step scores
Regardless of why you’re drawn to a competitive specialty, you’ll need exceptional test scores to be in the running for the most competitive residencies. The mean USMLE Step 1 and Step 2 scores among matched U.S. medical school seniors were 231.3 and 242.2, respectively, in 2022. In comparison, with the exception of vascular surgery, the competitive specialties listed above attracted applicants with test scores that were well above these averages—typically around 244 for Step 1 and 253 for Step 2.
In fact, the average Step scores of applicants who were unsuccessful in matching into the most competitive specialties were often higher than the average scores of matched applicants across all specialties.
Final thoughts
While matching is an achievement regardless of specialty, applicants to some residencies will face significantly higher competition than applicants to others.
To decide which residency specialties you should apply to, weigh your priorities in terms of factors such as compensation, work-life balance, and residency length—in addition to what suits your interests. Then, compare your USMLE Step scores to different specialties’ averages so you can make a well-informed decision that will give you the highest chances of matching straight out of medical school.
