I've been watching the Sheriff of Sodium break down medical education data on social media for years, so I'm thrilled to finally have Dr. Bryan Carmody on the show to help me understand what's actually happening to the system that turns medical students into doctors. We start with the basics What the Match is, why it was created in the 1950s to solve a headhunting problem that was stressing everyone out, and how the algorithm actually works. We quickly get into what's gone sideways since then: the residency selection arms race, where every year applicants have more publications, higher board scores, and more research experiences than the year before, and yet the match rate hasn't moved, meaning they've all just collectively agreed to suffer more for the same outcome. Bryan also breaks down what happened when Step 1 went pass/fail and the uncomfortable fact that about 25% of medical student publications have never been cited by anyone, ever.

We also go through the 2026 Match data, who's thriving, who's struggling, and what it actually means when programs can't fill their spots. Bryan puts the "physician shortage" debate in real context: it's not that we don't have enough doctors, it's that we've created terrible incentives for where doctors practice and what they do. We get into international medical graduates, the growth of new medical schools, and the signaling system, a newer mechanism that tries to fix the problem of people applying to 200 programs just to hedge their bets. I also reveal that stand-up comedy is what got me my residency interviews, which honestly tracks.

Takeaways:

The residency selection arms race is real but largely self-defeating, match rates for US medical students haven't meaningfully changed, meaning all the extra publications, research experiences, and board prep have just raised the floor without helping anyone actually get ahead.

The "physician shortage" is mostly a distribution and incentives problem, not a numbers problem, there are about 1.3 residency positions for every graduating US MD/DO, and the real issue is that doctors rationally choose to practice in places with better pay, better amenities, and better working conditions.

We probably don't need more medical schools, the constraint isn't classrooms, it's clinical training sites, and adding more schools without more high-quality hospital rotations just dilutes an already strained system.

Family medicine, pediatrics, and emergency medicine are the specialties with the most unfilled residency spots and it's a combination of too many new programs being created and not enough applicants choosing those fields, driven by the same incentive mismatches that cause geographic maldistribution.

Signaling is a genuine improvement to a broken application process, it gives programs a way to identify applicants who actually want to be there, rather than sifting through hundreds of applications from people who clicked every available program just to maximize their odds.

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Want more Dr. Bryan Carmody:

@jbcarmody on X/Instagram/Threads/Bluesky and Sheriff of Sodium on YouTube.

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