Defending the residency Match and its algorithm

KevinMD.com recently published the article “It’s time to make the Match disappear” written by medical student Amy Ho. I firmly agree with her that the current match system is wildly inefficient and needs fixing. However, she is throwing the baby out with the bath water in abandoning the algorithm which yields an extremely effective system.

Firstly, when one examines her data, which in itself is correct, one also needs to examine what comprises the data. Her argument that 25% of DOs and IMGs don’t match is neither representative nor fully accurate. Being a DO myself, I recognize that the match was created with the focus of training U.S. MDs. While inconvenient for me, it is simply the premise for which the NRMP was created. Whereas my unmatched DO colleagues retroactively seize unfilled spots in the DO match, the U.S. MDs have no backup plan. Yes, Caribbean trained MDs have an even tougher time but, unfortunately this has always been the case. While this route was possibly their only option to bring their dream of becoming a physician to fruition, the responsible ones understood the enormous risk of training outside US.  Thus, the 5% non-match rate of U.S. MDs is actually very impressive, and the only real relevant statistic.

Other parts of her data regarding salaries and dual degrees are also oversimplified. She is correct that some postdoctoral graduates make as much as $35,000 more but this is ignoring the truth that most JD and PhD graduates face an even fiercer job market and are quite often unemployed (or “underemployed”) many months after graduation. These postdoctorals often will never receive the enormous salary jump physicians earn upon leaving residency.

Furthermore , I will humbly admit that I am nowhere near ready to practice medicine without supervision. I can handle writing off the $35,000 to understanding that residency is still a learning process, at least for the humble. In regards to dual degree compensation, free markets do not compensate for being inappropriately overqualified. You get compensated for the relevant attributes you bring for the position. I have a difficult time seeing how a JD or MBA produces a more qualified intern. While a post-residency job may utilitize dual degrees, I surmise that most program directors regard it impressively, but ultimately as nothing more than a feather in the hat during residency. Too many times, we stay in academia so long we forget that initials do not necessarily make you a better employee. Not to mention that our efforts to correct these financial issue are far less valuable compared to impending larger issues we face, or more appropriately, from which we’re currently burying our heads in the sand. Medicaid’s SGR and lack of inflation based reimbursements both come to mind.

After all this, she makes several arguments about students’ dreams being shattered, whether it is due to location or matching to a different specialty. Our parents may have told us we could be anything we wanted to be but unfortunately that is not how even the free market works. Competitive spots go to those with the highest qualifications which is the same as in the real world. The most qualified candidates apply to very few places and are not forced to abandon their desired specialty. Having a free market does not automatically mean every applicant will interview for their dream spot as she implies. There are still the same spots and the same number of qualified applicants. Even with a degree from MIT one cannot work for Google simply because one desires. In real life, non-medical people still face immense obstacles and often sacrifice locations and job specialties with higher unemployment rates.

Finally, in the financial regards to her article, she claims free market tactics would lower interview costs and increase resident salaries. While there are ways to reduce costs, I will save them for a future article. The algorithm itself is practically free and thus, the problem lies elsewhere in the entire process. As she mentions, the interviews are where the costs are, but she is wrong to assume a free market simply cures this.

A free market will still require many interviews, especially if programs are allowed to delay their final decisions weeks to months after the interview. As mentioned, the best candidates will still have fewer programs to which they need to apply in order to have their choice of residency. Likewise, less competitive candidates will still need to go on many interviews and may have to sacrifice location or specialty. A free market does not mean you are free to do what you want, you are simply free to try and often fail. Even after having personally spent $10,000 on the interview trail, I cannot complain because I know my non-medical friends have spent similar amounts of money on their own career paths. If she is contending that over-applying and over-interviewing are the culprits of reducible costs then she is correct. However, there are far easier fixes for this problem without abandoning the algorithm.

While her complaints would still exist (or worsen) in a free market, if her underlying point was that both medical school and the match are wildly inefficient, then she is spot on. However, switching to a free market is the epitome of throwing the baby out with the bathtub. The system’s basic construct still yields the best realistic outcomes for all parties involved. The two years that I worked in the free market before medical school helped me learn how correct Mick Jagger was when he said, “You can’t always get what you want”.

Life is not about being happy with every situation. It is about rising above the unexpected detours and finding happiness in spite of them. I firmly agree there are ways to increase the NRMP’s efficiency for both involved parties. However, a free market is not one of them.

Jeremy J. Robbins is a medical student.

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