The Most Difficult Residency Specialties to Match Into & Why They’re So Competitive

This blog was originally published in 2023 by Dr. Alina Khil and updated for accuracy in February 2025 by Dr. Coco Stewart.

The Hardest Medical Specialties to Match Into

Choosing a medical specialty is a challenging task, especially when it comes to many of the more competitive specialties. Is it worth it? Am I competitive enough? Would I even like the specialty? More competitive specialties stand out not only for their intense competition, but also for the rigorous demands the residency often places on aspiring doctors. With a limited number of residency positions available, some specialties have garnered a reputation for being highly competitive. In this blog post, we will delve into the factors that make these specialties the most difficult to pursue, including the lifestyle sacrifices, the high level of compensation, and the unwavering passion required to succeed. Whether you’re contemplating your career path or simply curious about these challenging specialties, join us as we explore what makes them some of the most difficult residency specialties.

Don’t forget to check out some of our other residency resources, such as our residency application timeline.

What are some of the Hardest Residency Specialties to Match?

Before we jump into the more “competitive specialties” discussion, I must add a very important disclaimer: I firmly believe that all medical fields are highly respected and crucial parts of providing exceptional medical care to our community. And all residencies are difficult and strenuous in a variety of ways! Just because a residency doesn’t make this list, by no means devalues the work and contribution of that specialty. Many of the best, hardest working, and most patient-centered residents I know are not in a residency which will be discussed below.

That said, in the realm of the ever-mysterious “match”, certain fields stand out as the most challenging to secure a residency position. Although these certainly vary from year to year, many of these highly sought-after specialties include Cardio-thoracic Surgery, Vascular Surgery, Dermatology, General Surgery, Neurosurgery, Orthopedic Surgery, Ophthalmology, Otolaryngology, Plastic Surgery, Urology, Radiation Oncology, and Interventional Radiology. Year after year, it seems that these specialties consistently attract a significantly higher number of applicants than available slots. What drives the intense competition for these specialties? Let’s delve into the factors that make them so highly desired, unveiling the allure that sets them apart.

Why Do Match Rates Vary?

The match rates for a variety of specialties seem to vary from year to year. For example, Emergency Medicine was previously a much more competitive specialty, but the number of applicants has declined over the years. In 2023, the emergency medicine fill rate fell by 10.9 percentage points. Among Urology applicants in 2022, 556 applicants applied to 365 spots in Urology, but in 2024, only 500 applicants applied to 394 positions.

This ebb and flow of applications is often unexpected, but at times a decrease in the competitiveness of a field will drive more applicants to that field. Below you will find a table that reflects the changes of applicants to some of the most competitive specialties over the past 5 years.

Match Rate for US MD Seniors Who Matched Their Preferred Speciality Over the Past 5 years

Of note, we did not list match rates for US MD seniors who matched their preferred speciality for Cardiac and Thoracic surgery, Ophthalmology, and Urology, because the NRMP does not publish data for these specialties.

What Factors Contribute to the Competitiveness of the Most Difficult Residency Specialties?

When medical students choose their specialties, they carefully consider various aspects that define their career path. Among these, lifestyle, compensation, and procedural-based emerge as crucial elements that are sought after by aspiring residents.

Active Lifestyles and Work-Life Balance

Some of the specialties on the aforementioned list offer an active lifestyle, allowing residents to strike a healthy work-life balance. A desirable lifestyle, although subjective to each individual, often translates to fewer work hours, enabling more time for personal commitments, socializing with loved ones, and engaging in leisure activities. For applicants who value time outside of work, a specialty that offers ample personal time while still ensuring reasonable compensation becomes an attractive choice.

Despite the fact that some of these specialties may be perceived as specialties with a healthy “work-life balance,” I always remember a piece of advice that a physician gave me during medical school. As someone interested in urology, I spoke with a pediatric urologist and asked him about the “lifestyle.” He told me that he believes that much of our lifestyle in medicine will be painted by what we choose to do and what we choose to not do, regardless of the specialty.

Although our training may offer different hours (for example, surgery residency will likely be 80-hour work weeks and dermatology may be 40-50 hours per week), our careers will be shaped by the jobs we choose. For example, a radiologist, recognized as having a good lifestyle career, can choose to work 80-90 hours per week if they would like. On the other hand, a surgeon could choose to limit their workweek to 40-50 hours, or choose to take extra vacation weeks to spend more time with their family. Although our medical specialty certainly may orient us towards more or less work, once we finally become attendings, we have the opportunity to choose our lifestyle.

Lucrative Financial Compensation

Competitive specialties are also known for their high compensation rates. After investing significant time and financial resources into their medical education, students may seek specialties that provide appropriate financial rewards. Many aspiring doctors carry substantial loans, and a higher income from their chosen specialty eases the burden of repayment. Considering the sacrifices made to become a physician, it’s only natural to aspire for appropriate financial compensation.

While many of these residency specialties share desirable factors, each field possesses distinctive characteristics that attract a high number of applicants. By understanding the driving forces behind the competitiveness of these specialties, we gain valuable insights into the choices made by aspiring medical professionals. Let’s explore these specialties one by one.

Procedural-Based Specialties

Many of the specialties discussed are procedural-based. Whether it is surgery, a surgical subspecialty, or simply a specialty that performs a lot of in-office procedures, many medical students are attracted to the more active procedural-based specialties. 

I know that my own interest in urology certainly enjoyed (and continues to enjoy) the variety of procedures we can offer our patients. I enjoy working with my hands, and I find it fulfilling to solve a problem using my brain and my body.

Exploring the Most Difficult Residency Specialties to Match Into

Anesthesia

In 2024, there were 1,695 positions offered with a total of 3,034 applicants. 

Anesthesia as a specialty has become more and more popular over the past several years. For many, anesthesia is a fascinating field with an opportunity to deeply expand one’s understanding of physiology. Although many in anesthesia spend much of their time in the OR, others also work in the critical care unit or in pain management. Anesthesia offers significant financial compensation, but also offers the opportunity for shift work. The lifestyle in combination with the financial compensation have drawn many to the field of anesthesia over the past few years. (And many anesthesiologists are proud to have plenty of Sudoku time during the surgeries!:)) 

Cardiac and Thoracic Surgery

In 2024, 48 positions were offered in thoracic surgery with 114 applicants.

Cardiac and thoracic surgery involves long and complicated cases, and many are rightfully impressed by holding a beating heart in your hand. By treating some of the sickest patients, this specialty allows a surgeon to save lives, often in a high-paced and intense environment. Though this is a demanding specialty in terms of work hours, it is one of the few specialties that offer such an adrenaline rush. Considering that a lot of medical students were driven to become doctors based on the desire to save lives, it is not surprising that this desire influences their choice of specialty. Passion is one of the main reasons behind what makes this one of the most difficult residency specialties to match.

Vascular Surgery

In 2024, 139 students applied to 100 spots for vascular surgery.

For those medical students looking for diversity in their daily surgical work life, vascular surgery is an excellent choice. Vascular surgeons operate on every blood vessel in the body besides the heart and brain. So, as you can imagine, each day varies drastically. Procedures range from elective vein treatments to emergency aortic aneurysm rupture repairs. This specialty also provides the desired patient continuity, unlike most other surgical specialties. Often, vascular patients have many diseased blood vessels and require close follow-ups with their surgeon for many years. This allows a strong patient-physician relationship to form over many years. 

Dermatology

In 2024, 576 students applied to 916 dermatology positions.

Besides an excellent lifestyle and work-life balance, and high financial compensation, dermatology allows for both medical and procedural aspects. This is appealing for medical students who desire a mostly clinic-based practice while also being able to perform short, detail-oriented procedures. Oftentimes, the morbidity and mortality rates for dermatology patients are low helping to create a much lower stress environment. 

General Surgery

In 2024, 2,529 applicants applied to 1,717 general surgery positions.

General surgery has become one of the most competitive specialties in recent years. Its appeal lies in the wide range of diseases and organs treated. A residency in general surgery encompasses training in abdominal, cardiac, thoracic, vascular, hepatobiliary, transplant, breast, endocrine, colorectal, and minimally invasive surgeries. From complex exploratory procedures to quick laparoscopic cholecystectomies, cases vary greatly.

As a general surgeon, you receive training not only in surgery but also in medicine. Surgical services manage their patients comprehensively, including conditions like diabetes and hypertension during hospitalization. General surgery residents also gain experience in caring for critically ill patients. Although surgical residency is challenging, sub-specializations such as breast, endocrine, hepatobiliary, colorectal, and minimally invasive surgery offer a more balanced lifestyle. By specializing further, surgeons can pursue their passion without sacrificing all their time. Moreover, general surgery serves as a gateway to other specialties, such as plastic, vascular, and CT surgery. Integrated programs in these specialties are often more competitive to match into than general surgery, providing applicants with another route to their preferred specialty.

Neurosurgery

In 2024,  414 applicants applied to 241 neurosurgery programs.

Neurosurgery is appealing to those applicants who are fascinated with the human brain and nervous system and enjoy surgery. This makes it one of the most difficult residency specialties to match into. Neurosurgeons tackle diverse cases, each presenting unique challenges. This demands strong problem-solving and critical thinking skills under pressure. Aspiring neurosurgeons care for critically ill patients in fast-paced, high-pressure settings. Despite the lengthy seven-year residency, neurosurgery offers some of the highest financial compensation among physician careers.

Orthopedic Surgery

In 2024, there were 916 positions offered for 1,492 applicants to orthopedic surgery. 

Orthopedic surgery requires a deep knowledge and appreciation of the musculoskeletal system. One of the best parts of this field is helping patients recover and getting to see them return to their active lifestyle. This is appealing to many applicants who live an active lifestyle themselves and those who love surgery and want to see their patients from the start to the finish line. This specialty also allows for working with a variety of patients of all ages and performing a variety of surgeries, ranging from the repair of traumatic fractures to elective knee replacements. There is also a lot of ongoing innovation in this field, allowing room for research and creativity.

Ophthalmology

In 2024, 779 students applied to 520 positions. This data is not reported by NRMP, but rather is reported by AUPO as ophthalmology is considered “outside of the match.”

Ophthalmology, one of the most difficult residency specialties to match into, offers a remarkable work-life balance. It minimizes call duties, and weekends are usually free, even during residency. What sets ophthalmology apart is the instant gratification it provides. Patients experience immediate relief and swift recovery after surgeries. With shorter procedure durations, ophthalmologists can care for a large number of patients. Attention to detail is crucial in this specialty, given the delicate nature of the operative field. Medical students who choose ophthalmology enjoy this meticulous work.

Otolaryngology

In 2024, 513 people applied to 382 otolaryngology spots.

Besides being another surgical specialty that offers a great lifestyle, otolaryngology is a great field for those who love head and neck anatomy. This specialty also allows for the use of a wide variety of operative techniques, including large open operations, endoscopic procedures, and surgeries using microscopes. Along with a wide variety of operative techniques comes a broad range of conditions that are treated by otolaryngologists. These include cancers of the head and neck, hearing loss, and diseases of the vocal cords. Often, otolaryngologists have the opportunity to develop long-term relationships with their patients. 

Plastic Surgery

In 2024, 362 people applied to 213 plastic surgery spots.

For those who enjoy the technically demanding aspect of surgery but also want to employ their creativity at work, plastic surgery is the perfect field. Very few specialties in medicine and surgery offer the chance to be creative. Plastic surgeons operate on nearly every part of the body. A large field of plastic surgery is reconstructive surgery, which is very appealing to many students. There is a particular accomplishment that is derived from reconstructive surgery that is unlike that of regular procedures. Plastic surgery has the power to make a substantial impact on patients’ quality of life. Though it is possible to have a great lifestyle with plastic surgery, especially if doing private practice, this specialty can require long hours and calls. 

Urology

Urology, like ophthalmology, is considered “outside the match.” The AUA reports urology statistics. In 2024, 500 students applied to the 394 urology positions offered.

To be fair, as a urology resident myself, I might be a bit biased when it comes to urology. BUT, urology is a delightful field with a unique balance of clinic, clinic-based procedures, endoscopic procedures, and major surgeries. They take care of any conditions that impact the urinary tract in both females and males. A lot of the conditions that urologists treat impact patient’s lives significantly and results can be obtained rapidly. Urology is amongst the top innovative fields, using lasers and robots in practice. Because urologists take care of patients’ most intimate problems, they often develop genuine patient-physician relationships and have the opportunity to offer a dramatic improvement in a patient’s quality of life.

Interventional Radiology

In interventional radiology, applicants must match both a prelim spot and a PGY2 spot for IR. In 2024, 349 applicants applied to 137 PGY2 integrated positions.

The unique aspect of interventional radiology is being able to perform valuable and sometimes life-saving procedures in the most minimally invasive way possible, usually through a tiny incision. IR integrates imaging and procedures and is perfect for those who love both. This specialty includes a broad spectrum of practice, ranging from biopsies to peripheral arterial disease intervention. Interventional radiologists could tailor their practice and specialize further, or practice a wide range of procedures.

Embrace the Challenge and Good Luck!

Residency is tough! Make sure that you pursue a specialty that you are genuinely interested in and excited to learn about for 3, 5, or even 7 years. And certainly, don’t be discouraged from applying to competitive specialties if you’re interested in them. Seek mentors in your desired specialty during medical school to gain insights and strengthen your application. Look for research in these specialties, and be sure to shadow as much as possible. Shadowing can be a great way to get to know if a specialty is the right fit for you! For additional assistance with your residency application, consider consulting an Elite Medical Prep residency advisor. Schedule a complimentary consultation to discover how we can support your success. Best of luck!