It’s time to make the Match disappear

Becoming a doctor takes time, but those outside of medicine do not always realize how convoluted the process can be. Central to the perversion is the National Resident Matching Program (or “the Match”).

After college and the two years of classroom-based training in medical school, students are ushered into clinical training through third year core rotations in predetermined specialties. In the spring of their third year, students must decide on their career specialty, often without rotating in their chosen specialty yet if it was not a “core” rotation of third year.

During their senior year, students spend the first few months doing from zero to three month-long “away rotations” at hospitals they are interested in for residency. In mid-September they apply to all residency programs that interest them, sometimes over a hundred programs, submitting a fee for each.

Starting in October, students interview around the country for three to four months, incurring significant travel costs and missing much of their senior year due. In late February, students and residencies both submit a “rank list” of one another for the NRMP algorithm to optimize.

Results of this optimization are released on Match day in late-March, when medical students around the country find out the residency program at which they “matched,” bound to the program and bound to a non-negotiable contract shown to them months prior. Many students either do not match at all or do not match at their first choice program; nonetheless their fate is sealed by the ivory tower algorithm of the Match.

This year, 5.6% of US allopathic (MD) seniors did not match, and 22.3% of US osteopathic (DO) seniors did not match. On the whole, 25.0% of applicants in the NRMP Match did not match — with a 25% unemployment rate, how successful is the Match, really?

This system is highly wasteful. It incurs massive costs for hospitals and students through the interview process, precludes contract negotiations that could optimize value for both parties and results in depressed wages for young physicians. Additionally, it incurs significant opportunity cost in trading interviews for educational senior year curricula, causes undue duress for applicants and their families and contributes to decreased quality of care in physicians unsatisfied with results of the Match.

An archaic system for changing times

The Match was established in 1952 when available resident positions vastly exceeded the number of graduating medical students. As a way to secure top students as residents, hospitals were: 1. Offering positions earlier and earlier, sometimes even prior to a student’s clinical years; 2. “Exploding” offers and demanding a acceptance or rejection of an offer within minutes.

The first problem was remedied by an agreement among medical schools to embargo student records until a specified date in fourth year. The latter was remedied by the Match.

Medical education today is nothing like it was 60 years ago. Today, many specialties have more US medical graduates than residency positions, and international medical graduates and physicians reapplying for residency also compete in the Match. Medical schools continue to increase, as have the birth of osteopathic schools and Caribbean schools.

Medicare, which funds residencies, is continually threatened. Medical education debt is rising while post-residency earning potential is declining and training time is increasingly extended with required fellowships.

The misbalance between residencies and students is no longer; and resources are tighter than ever, yet the archaic Match system continues to waste time and funds of students and applicants alike in the name of “tradition.”

$302 million wasted annually

Financially, the Match is devastating. Assume a student applies for 35 programs in one specialty, receives 20 interview offers and accepts 12; these are conservative estimates in competitive specialties, in applicants “couples-matching” with a spouse and in specialties requiring a separate “preliminary” year.

In application fees, this student will spend $465. The 12 interviews, each requiring a $50 motel, a $50 car rental, and a $300 flight, cost this student $4,800. All in, this student has spent $5,265 on the Match, against $250,000 in existing student debt. Assuming a Federal Stafford Loan with 6.8% interest paid in 10 years, $5,265 becomes $7,470.76.

With a 15% tax rate, $7,470.76 becomes $8,789.13 in pre-tax income. With 34,270 active applicants in the Match in 2014, $302 million is wasted annually, in the setting of tight graduate medical education funding, increasing student debt and decreasing physician reimbursement.

$35,000 lost in salary

In addition, the Match precludes an applicant from negotiating their salary or contract in any way. Dual degrees (MD/JD, MD/MBA, MD/MPH) are ever-increasing and many applicants will bring additional value to their hospital, yet are unable to be compensated for it. Additionally, it precludes less competitive applicants from accepting lower salary or early offers in exchange for a position.

Jung v. AAMC in 2003 challenged the Match on antitrust grounds, claiming that the collusion of hospitals within the Match artificially depressed wages. In response, Congress passed an explicit exemption for NRMP through the Pension Funding Equity Act of 2004, making legal challenges moot.

Nonetheless, labor statistics are daunting.  Per the 2012 US Census, mean earnings for 25-34 year olds with a doctorate or professional degree are $74,626 or $86,440 respectively. The AAMC mean first-year resident salary was $50,765 for 2013-2014.

NRMP dodged the legal attack in Jung, but numbers don’t lie and a $23,861-$35,675 difference in salary is robbery.

An economist’s quantity, not a patient’s quality

Assume for a moment that the double-binding match is the most efficient mechanism for filling the residency labor market (which, notably, was not the intent of the Match).

For hundreds of students a year, the Match means a change in career, as students who do not match in their preferred specialty are often forced into an alternate career specialty if they would like to practice as a physician. It also means a change in life circumstance, notably, for those with preferred location given family situations or with spouses unable to find a new job in the short two-three months between Match day and residency start dates in June.

Ultimately, the Match translates into thousands of physicians training in an undesired specialty, in an undesired city and in a undesired situation split from their families. These physicians, lives forced by the Match, cannot be assumed to perform at the same quality and motivation as those that matched into their ‘dream job’.

Of this population, do they end up leaving the profession prematurely?  Are their career trajectories as successful as their first-choice Match counterparts? Are their satisfaction rates the same? What about their suicide rates, addiction rates and wellness?

Time for a change

Legislation exonerated the Match from legal attacks in Jung v. AAMC, but that does not prove it is good policy. Economist Dr. Alvin Roth won a Nobel Prize in economics for his theory in a double-binding labor market match underlying the NRMP — but notably, academic economists like Dr. Roth himself acquire their positions on the free market, not through a match.

Few other professions utilize this double-binding match, and in explaining the Match to those unfamiliar with medical training, the closest relatable comparison is sorority rush. However, the stakes are a bit higher than selecting Greek letters, and we are physicians, not teenagers. For the good of our profession, our patients, and our future protégés, it’s about time to reassess the Match.

Amy Ho is a medical student.  This article originally appeared on Forbes.com.

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  • PoliticallyIncorrectMD

    Match must go! Finding residency should be no different from applying for any other job. Let the market work – it will be a winning scenerio for everyone ( except, of course, for bureaucrats how run the match – but let the market work for them too ; )

  • azmd

    O.K., there appears to be some dissatisfaction among medical students with the match process…what are your suggestions for an alternate method? How would having medical students interview and compete for residency spots in an open market address any of your concerns?

    • PoliticallyIncorrectMD

      Well… Without the Match hospitals would be able to immediately offer positions to candidates of their choice and strong candidates would be able to bargain for better contracts. This does not increase the number of residency spots but it may simplify the process, make it more flexible, allow to select for better candidates, improve working conditions and eliminate the uncertainty.

      • SCFP

        That is how things used to be an is exactly why the Match exists. Talk to some of the older subspecialists whose fellowships operated that way until the last 15 years about how much the process would suck without the Match.

        • Amy Ho

          @SCFP – no current physicians have ever operated in a Match when the # of graduates have so outnumbered the # of residency spots…fellowships are a different animal just given the difference in the tightness of the labor market. Also, fellowship salaries are determined by residency salary most of the time (on the PGY scale), so it’s not compelling to compare fellowships w Matches v. w/o Matches because they are all influenced by the residency Match.

      • azmd

        That sounds like it would be great for all of the top candidates for any given specialty…what about the middle-range and the bottom candidates? How would they not end up in “an undesired specialty in an undesired city in an undesired situation?” Does Ms. Ho think that the Residency Fairy would come and wave a wand and create more ophthalmology residency spots if we had an open market? Also, how would the process of interviewing and negotiating be any less time consuming? Right now the students don’t have to negotiate…

        • Amy Ho

          Middle-range and bottom candidates are no longer competing with the SUPER competitive applicants who are using programs as safeties. I.e. the NY-bound Dermatologist is interviewing in Alabama IM as a “safety”…as such he is taking a spot away from someone who ACTUALLY wanted to go there.

          I don’t understand why you assume No Match=No Competition. Free Market is definitionally competiton…

          The interview process is less onus by having LESS interviews. At the end of the day, it is just not realistic to try to compare 15 programs head to head anyways (but 3 to 4 is okay). Yet we rank them as if we were going to get an offer. Negotiations don’t need to happen in person.

      • Amy Ho

        Yes, numbers are numbers. Nothing is going to change that until we fix GME funding, which is in the hands of Congress (and us…saveGME.org). But it’s silly that we are IN CONTROL of the Match process (which is exacerbated by the lack of GME funding and also exacerbates the problems caused by lack of funding), yet have not reexamined this.

        • PoliticallyIncorrectMD

          I am curious (and this is a question for everybody): if a particular facility agrees to start a program without Medicare $$$, can that be ACGME approved?

          • Amy Ho

            Nothing in ACGME says that $ has to come from Medicare that I know of. In fact, the amount of $ that comes from Medicare is based on the # of residents a program has in its first 3 years of existence…after that if they want to expand (they almost always do), the programs put in private $.

    • Amy Ho

      I advocate free market…I actually do think it solves all the issues of forced front-loading and more than anything I advocate Transparency and Autonomy in the process. However, people much smarter than me have great policy papers (email me if interested – amyfaith DOT ho AT gmail DOT com). Among those, Match with a “pre-match” (early offer) option [like what TMDSAS does in Texas for medical schools], Match with individualized contingency contracts (so establish a range of wage and negotiate from there), Match with capped # of programs you can apply for (I do not advocate this, but a Urology paper did), Match w/transfers (advocated by some economists when looking at misbalanced markets), Match w/multiple offers, Match w/non binding offers, etc.

      I answer above how free-market would solve. Rather than HAVING to do 15 interviews in the name of “better safe than sorry” and front-loading them the moment ERAS opens, you can adapt your strategy and as you get interviews/offers decide to exit the process early (take an offer) or continue. As such, the spots I ended up occupying (14 interviews I didn’t need), those can go to applicants who would love them. Also allows residency programs to interview fewer ppl (since only interviewing applicants truly interested, not using them as a safety), and also to craft in diversity and cohesion/personality for their class of residency.

  • PoliticallyIncorrectMD

    Central planning has no credibility… China, Russia etc. are prime examples. Having signed contract off Match (back when foreign graduates could do that) I can testify to the benefits of the process…was offered position during my clerkship year, signed as soon I graduated, no headache, no uncertainty : )

    • KMarton

      Hold on there! The match is simply designed to optimize the choices of both the applicant and the residency program. There is nothing in it that resembles Chinese or Russian central planning. You may not like the match, but don’t denigrate it with misinformation.

      • PoliticallyIncorrectMD

        I am not the one who mentioned “central planning”. Also, unlike in China and Russia, here in US we are allowed to have difference in opinion ; )

        • Amy Ho

          Because there is no “agreement” because the applicant has no options. You HAVE to participate in Match to get a job…and that Match precludes negotiation of any type. Also, it’s double-binding so you HAVE to go with the results of the Match. Docs most complain about loss of autonomy when they talk about lack of satisfaction with their practices…this is the ultimate lack of autonomy.

      • Amy Ho

        The Match algorithm is designed to optimize, but it has upstream effects of over-applying/over-interviewing that skews the process before it even goes into the algorithm. That being said, there are economist papers that say that the Match may only produce a 50% “optimal Match” with only 29% of those preferring the applicant…http://www.pitt.edu/~alistair/papers/Matching.pdf

        I have other papers too if interested…amyfaith DOT ho AT gmail DOT com

  • Skeptical Scalpel

    Here are some of the many things wrong with Ms. Ho’s post. http://skepticalscalpel.blogspot.com/2014/04/a-medical-student-says-to-abandon-match.html

  • Amy Ho

    Open market allows you to ADAPT your strategy as you see how interview season plays out rather than front-loading ALL your optios on Sept 15 (regions, back-up specialties, etc). Also allows you to exit the process early (and take an offer) if it makes sense to your situation. Lack of transparency/autonomy in the system breeds fear and forces you over-apply, which skews even how programs know which applicants are really interested and which ones are just using them as a safety — and that translates into mis-allocated interview offers and interviewees having to spent interview time discussing not just their merit but also spin social ties to a region…going to an interview is no longer enough committment when programs KNOW you’re all doing 15 interviews.

    I went on 14 interviews I didn’t “need”, based on my very successful match. Without Match, those spots could’ve gone to someone who actually needed/desired them. Top RANKED program is NOT the Top DESIRED program (as you can only rank your interviewed programs). As such, your #1 RANKED may be like your #15 overall. I say that over-application means competitive applicants are stealing interviews from less competitive applicants and that means that latter group doesn’t even get to rank the program.

    Additionally, Scramble throws kids into specialties they did not choose. And by March when you find out, it is too late to pursue alternative careers (MBA, MPP, JD, consulting/pharma) which may be preferential to being a doctor in a field you didn’t choose.

    Look at law school clerking as the most comparable market. It’s a TIGHTER and MORE competitive market than residencies and works on the open market (their attempt at centralized system was a HUGE failure). Match or No Match doesn’t change the # of spots/applicants, but No Match would solve a great deal of waste of over-applications/interviews. Rather than 15 interviews, I would’ve done maybe 3 and ended up in the same place. 1/5 the cost/time with more opportunities to less competitive folks.

  • Amy Ho

    Interesting thought. But remember the REASONS the match was initiated (Residency spots>>>graduates) has been REVERSED…so the fundamental reason for it existing is gone. Tech interviews would be a SUPER interesting idea…love it.

  • PoliticallyIncorrectMD

    Agee… Also, why not allow those who want to go outside of Match to do it?

    • Amy Ho

      NRMP has a functional monopoly on the application process. If ANY program wants to participate in the NRMP, EVERY program has to participate at that hospital…(per new rule in 2004). Jung v. AAMC tried to address this idea of collusion, but failed after Congress snuck the legislative exemption through (literally SNUCK it in…a couple Senators issued statements appalled that it passed w/no discussion)

  • T H

    The only thing I would add to this is

    5. Permit each residency to keep a certain # of slots out of the Match: that way they can offer ‘Their Star Prospect’ a job right then, right there AND sign the contract.

    • Amy Ho

      @T H Actually, NRMP made a rule in 2004 that if a hospital has ANY residency program in the NRMP, ALL the residencies at that hospital MUST participate in NRMP…effectually, it forces anyone who wants to practice ever to go through NRMP.

      @Jimmy, I like the suggestions and encourage the discussion (that’s the point to the article in the first place!). My comments:
      1. The flat fee would probably end up incentivizing further over-applications…which would be problematic again in how interviews are offered (and subsequently worsen the issue I try to address). Also, would put a burden on programs that already have to over-interview. Nonetheless, you’re right…$ needs to be controlled.
      2. Love it. The other problem too is when you’re ranking 15 programs…it’s just not possible to mentally compare them head-to-dead. Another reason I think less interviewing/applications is key (but the existence of a non-transparent front-loaded centralized system makes it a necessity to overinterview for “safety”). But yes…I think an initial tech screening would REALLY help how programs allocate interviews to just applicants they’d feasible give “offers” to (or rank).
      3 & 4. I can’t really speak to either as I’m not knowledgeable enough on those issues…but I do encourage the discussion for those w/more experience in those matters!

      As always, thanks to everyone for being civil and focusing on solution not insults! amyfaith DOT ho AT gmail DOT com for any discussion through email as well!

      • T H

        Thank you for making my point about holding a slot or two separate from the Match: NMRP should not be so all-powerful. It should not BE ABLE to be so all powerful. The fact that all these residencies have abdicated this power is a bit dismaying to me.

        Do I want a free-for all? No. But I also think that the residency programs should (if they so desire) have some flexibility.

  • Amy Ho

    saveGME.org. I ABSOLUTELY agree that residency funding needs to be addressed. However, the issue of GME gets more complex with DGME being a set amount given to hospitals and IME being production-based. Additionally, to compensate for the abysmal failure of Congress to prioritize physician training, almost every residency program puts in private $ to fund residents (knowing that as an investment, residents will produce and create $ from their services). I focus on the Match because it exacerbates the imbalance of spots v. graduates and it is WHOLLY in the control of physicians..whereas GME funding is in the hands of Congress unfortunately.

    In a free market system, though, competitive applicants end up in competitive spots…elimination of the match does not change the # of spots or # of graduates, it just makes it so that competitive applicants who see a program as a “safety” are NOT competing with less-competitive applicants who may see the program as a “dream”. Competitive applicants probably only need to interview at a couple places…but in the name of “safety” (given the lack of transparency or early offers), they go on 10-12 interviews and “steal” spots they didn’t need that could’ve gone to less competitive applicants. Medical school application rates are actually quite good and the free market system hasn’t been a problem historically…competition is a good thing, the Match just forces a weird front-loading of waste that creates an artificial competition among applicants who are not truly interested in spots they are applying for. OR who are “forced” into spots they do not want through the Scramble (but have no other options to do…given that by March it is too late to look into non-residency track careers like pharma/consulting/graduate degrees).

    As always, thank you for being civil and having meaningful discussion. I say that now seeing how many ridiculous comments are just rants or personal insults/speculation. amyfaith DOT ho AT gmail DOT com too if I can ever be of help.