The Match: A testament to the genius of central planning

My father who was a junior doctor in Britain’s National Health Service (NHS) in the seventies would have been grateful for the match scheme, an algorithm that places medical students in residency programs in the U.S. The training in the NHS was unstructured. Physicians carved their own training by joining a patchwork of hospital positions in disparate places.

Over a few years we lived in Yorkshire, East Anglia, Wales, East London and West London. The distances in Britain are trivial compared to the U.S. but the dialects are different. I had to change schools nearly every year. It’s not fun being an eight-year-old Indian kid with a stuttering Welsh accent in East London.

It was taxing for my parents to uproot annually. As disruptive as the fourth year is for U.S. medical students, I think my father would have preferred this concentrated disruption to the disruption he faced yearly.

Twenty odd years later when I graduated as a physician there was slightly more structure in the NHS but still a lot of disruption. In the first two years I changed hospitals every six months. I was not unusual in this regard. This was the norm.

Since junior doctors relied on hospitals for their accommodation, the move had to be in perfect sync. Someone was allotted your apartment just as you were allotted an apartment of a physician about to leave in another hospital. You couldn’t put off moving by a couple of days just because of your work schedule.

On one occasion I recall taking call the penultimate night of my position — someone had to as we were all moving — then loading my possessions in my car and moving to the new hospital only to be told that I was taking the first night’s call. I did not empty my suitcase for a week.

Scarcely would a job start that we would be looking at the British Medical Journal’s classified section (where training positions are advertised) for the next job. Rarely would one get the first job they interviewed. This meant that we had to take time off for multiple interviews. Where would this time come from? Our precious vacation, of course.

With the change in jobs there was disruption to the continuity of care. Just imagine having the July syndrome twice a year and en masse. Each hospital had its own quirks and turf nuances. For example, in some hospitals pyelonephritis was managed by medicine and in others by surgery. These were little details, but were annoying to master, and even more annoying to be shown to be ignorant about.

However, the job switching in the NHS took its main toll on relationships. I can’t count the number of relationships I knew of that ended because partners were careened to different parts of the country. One had no choice. They had to take the training position or be jobless.

No, before you ask, there was no “couples match.” This endearing concept, a remarkably pragmatic gesture crucial for the stability of marriages, is quintessentially American.

U.S. medical students who bemoan the imperfections of the match scheme may not be aware how lucky they are. Medical students from other countries would love to take some of their discomforts. It is understandable that some wish to improve the medical school experience, and the debts incurred by students that would leave Croesus in penury, suggests that much needs to be improved. However, the match scheme is one of its shining assets, a rare testament to the occasional genius of central planning.

Saurabh Jha is a radiologist and can be reached on Twitter @RogueRad

Comments are moderated before they are published. Please read the comment policy.

  • James O’Brien, M.D.

    You used “genius” and “central planning” in the same sentence.

    I tend to use “fatal conceit” and “central planning” in the same sentence.

    • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

      EHR is actually not centrally planned- in the NHS it is(and it was a fiasco worse than the one here), but in the US the government didn’t regulate the field at all for many years, and even now only has certain standards. Anyone is free to compete.

      EHR represents a failure of market incentives- they were bought by hospital administrators for the maximum convenience of the administration- clinical care was a distant second factor.

    • saurabh jha

      To be fair (to me) I did prefix it by “rare” and “occasional” later on.

      • James O’Brien, M.D.

        Fair point but a broken clock being right twice a day doesn’t make it a genius.

        • saurabh jha

          I would frame this a little bit differently.

          Given that healthcare, and all its components, departed the market long time ago, given the absence of price signals, given the absence of usual labor economics, where you neither want a surplus or shortage of physicians, would you give the Match credit for achieving what it has?

          Most arguments against the Match strike me as arguments against medicine being a gild, or derive from that argument.

          I’m pretty sure that Milton Friedman would not have singled out Match as the uniquely unmarket element of medicine. He would have started off with licensure and barriers to entry (see Capitalism and Freedom).

  • PoliticallyIncorrectMD

    I was wondering if the author would accept match-like program for finding his post-training position.

    • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

      A post-training position is a job. A residency is an educational opportunity.

      What’s to stop an orthopedics residency from telling person B that person A will work for $10 less? For that matter, what’s to stop residencies from charging residents in order to work there?

      Individuals do not go into residencies because they want the job. They go into residencies because they want training and future earning potential. That is the mistake in your analysis.

      The rules prevent exploitation of the residents- they do not protect the hospitals.

      Respectfully,
      Vamsi Aribindi

      • James O’Brien, M.D.

        “For that matter, what’s to stop residencies from charging residents in order to work there?”

        State labor laws for one thing, in addition to the fact that they would not be able to compete with other residencies that offered a salary.

        • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

          Even if every other residency spot which offered more money was filled, more than enough candidates (5000 IMGs) would kill for any residency that they’d work for whatever wage is given. We live in an employer’s market when it comes to residencies.

          And state labor laws don’t apply to educational spots. Do colleges have to pay students minimum wage? There is nothing to stop a residency from declaring itself an educational enterprise- not a work one- except the traditions, regulations, and central planning of medicine that people propose scrapping.

          Respectfully,
          Vamsi Aribindi

          • James O’Brien, M.D.

            That is incorrect. The National Labor Relations Board ruled in 2000 that residents are employees, not students.

            http://www.nytimes.com/2000/04/18/health/essay-medical-residents-yes-but-workers-too.html

            I think you’re defining central planning all over the place.

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            The NLRB ruled in 2000 that residents as centrally regulated by the ACGME (the “central” organization that also runs the match) are employees. If the ACGME went away- a residency program can declare that it would stop paying it’s residents- and any resident wishing to work had to pay the hospital for malpractice coverage.

            If their contract dictated that they had to pay the hospital, would they still be employees? No. Hence I stand by my statement: the educational value and the inherent future income earning potential of residencies means that many hospitals can significantly screw over residents if they so wished.

            And even if minimum wage laws still applied- minimum wage plus overtime for extra hours worked up to 80 is still not particularly much to live on, especially for anyone in a New York or San Francisco residency program.

            Respectfully,
            Vamsi Aribindi

          • Eric Strong

            It’s not just the NLRB. The US Supreme Court has also ruled (unanimously) in 2011 that residents are full-time employees, and not students (Mayo Foundation v. United States). Through the decision’s omission of a reference to ACGME, it implies that the presence or absence of ACGME regulation is irrelevant. In the case, Mayo and the Univ of MN argued that the US Treasury Dept should refund payroll taxes to them that had been withheld on resident earnings, since residents were students and not employees. Predictably, the heart of the case was all about money, and all of the discussion about providing an education was just a smoke screen.

            You are also suggesting is that a hospital could convert a residency program into an unpaid internship. According to the US Dept of Labor, in order for an unpaid internship to be legal, all of the following 6 criteria must be met:

            1. The internship [residency], even though it includes actual operation of the facilities of the employer, is similar to training which would be given in an educational environment;

            2. The internship experience is for the benefit of the intern;

            3. The intern does not displace regular employees, but works under close supervision of existing staff;

            4. The employer that provides the training derives no immediate advantage from the activities of the intern; and on occasion its operations may actually be impeded;

            5. The intern is not necessarily entitled to a job at the conclusion of the internship; and

            6. The employer and the intern understand that the intern is not entitled to wages for the time spent in the internship.

            Reclassifying residents as unpaid interns would clearly violate requirements 3 and 4, and thus, doing so would be illegal.

            US medical residents are employees, not students. It is not a matter of opinion, but legal fact.

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            I said nothing about an unpaid internship- I meant status like a medical student. I will defend this minor point more in a moment, but you are missing the heart of my argument.

            Even if hospitals were obligated to provide minimum wage, that is ALL they would pay. The overall point is that because of the massive earning potential post-residency and the oversupply of people wanting each post, wages would actually go down, and residents would be abused in other ways to provide labor. You posit that wages would increase because medical students would be able to negotiate with hospitals. But how can they with zero bargaining power? The hospitals have the thing of value- a residency spot that will guarantee high future earnings. The graduating medical student can be replaced by five others who can do the same thing.

            Going back to this minor point-
            I said nothing about unpaid internships.

            I’m talking about residents becoming classified as students- like at colleges/other educational institutions. After all, if they’re paying money to undergo an experience- they’re no longer paid workers or unpaid interns, they are paying students- with the same status as medical students and the right to be charged for more debt.

            I’m not making this up out of thin air. After a radiology residency program was canceled in NYC, the residents solicited and accepted an offer which had them paying money to another ACGME accredited hospital for their malpractice insurance in order to be allowed to work and finish their residency. Fortunately, the original hospital reversed their decision, and they were able to finish. But for that reversal, they would have ended up paying money to work.

            The ACGME with it’s regulations prevents this from happening on a large scale, working in concert with housestaff unions. Currently, because hospitals can not easily poach residents away from other programs, they are forced to negotiate with groups like the SEIU-CIR, and pay higher resident salaries/grant other benefits in many cases.

            Ultimately, the match helps medical students more than it does hospitals.

            Respectfully,
            Vamsi Aribindi

          • James O’Brien, M.D.

            You’ve been presented facts with evidence and links, why are you persisting in this highly illegal fantasy about not paying residents?

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            Dr. O’Brien,

            I have been presented with legal theories and rulings. Here is an economic fact that actually happened:

            “One hospital, McLaren Macomb, in suburban Detroit, instead offered several residents slots in its “unfunded program,” in which most radiology residents essentially pay for their own positions through donations, typically from a spouse or parents: $65,000 a year to cover a $42,000 salary and $2,000 for expenses.

            “Obviously it would be your last choice, but if there are no open funded positions and you can scrounge up the funds, keep it in mind,” the program director, Dr. Eli Shapiro, wrote in an e-mail to Dr. Gerges.”

            http://www.nytimes.com/2013/03/28/health/trainees-in-radiology-and-other-specialties-see-dream-jobs-disappearing.html?pagewanted=all&_r=0

            A program was almost cancelled, and the residents were ready to accept a job where they pay for their training.

            That is why I am arguing so hard. I did not explicitly state this earlier, but I remember this case and from it I KNOW that medical students will do anything for a residency spot.

            And FYI- I’m actually a moderate libertarian, not a Marxist- but that philosophy does not work in healthcare. Do you want every nurse practitioner and PA to be able to do surgery? (To the patient: “I watched a ton of these, and I assisted on even more. I’ll do it for half the cost of that general surgeon.”) To prescribe any drug, with no supervision? Or for that matter, why don’t we let EMTs read some stuff online, and prescribe antibiotics to whoever needs it? No need for anyone to be evaluated by a physician.

            The medical system runs on trust- no patient knows what they’re really buying (save for plastic surgery patients). It is on us to regulate that system to prevent perverse outcomes like the above.

            Respectfully,
            Vamsi Aribindi

          • James O’Brien, M.D.

            No, you stated as a fact that residents have status only as students. Then when presented with boatloads of evidence that in fact they are fully recognized by law as employees, you tried to reposition your argument that they should be students, never owning up to your original error. Then you tried to reframe the argument based on hypotheticals.

            If that arrangement would have gone through it would have been highly illegal for the reasons we have discussed.

            So even the hypothetical is flawed because the law is the law. You can’t give an example in reality where residents worked for free and if such a program were discovered, there would be major labor law violations.

            It’s fairly obvious for some reason you dig the Dickensian idea of residency as chattel apprenticeship and I am curious why.

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            Dr. O’Brien,

            My original error was being unclear in my wording, and I’ll admit to that.

            I’ll get to your point in a moment. First:

            You made a throwaway comment earlier that is quite illustrative:

            “I could make a better argument that third and fourth year medical students should be paid as employees based on the DOL criteria noted above.”

            Indeed, why not? Why aren’t med students paid for the labor they do on the wards, filling out paperwork, looking at patients, etc.? Especially by 4th year and sub-I when they are doing somewhat real work and functioning partially as an intern. Why in fact do med students pay to work during their 3rd and 4th years?

            In economic theory, there is a transaction taking place, and the med students are being ‘paid’. They are laboring, and paying tuition, and being paid with an MD degree. The degree is the compensation, and the med students work for it because of the earning potential that they will get with the MD degree.

            I also never said that residents “should” be students. What I have always been saying is that from an ECONOMIC perspective they ARE in fact “students” for the purpose of analysis. No amount of legal technicalities can change the economic fundamentals in the scenario. You are making the error of relying upon laws as opposed to analyzing the economic fundamentals at stake to determine what will happen- before relying upon those same fundamentals to argue that residents’ wages will rise.

            Residents’ salaries are not the primary “compensation” they are receiving in exchange for their service. What they are really working for and getting is board-certification/board-eligibility status that will enable them to bill insurances and make a lot more money. In other words, they are providing their work in exchange primarily for training- not for the wages they are being paid.

            The hospital/residency programs have the most valuable good- the ability to confer this status upon any med student. They can dictate terms to anyone who shows up, and this means that without centralized regulation through the match and other ACGME mechanisms, residents will be exploited by hospitals.

            Respectfully,
            Vamsi Aribindi

          • Eric Strong

            Whether or not you want to call it this, what you’ve described is an unpaid internship. Reclassifying a traditional residency as a student experience to avoid having to pay residents would be destroyed in the court of public opinion, and would have no chance at surviving a legal challenge.

            And if a hospital changed the residency experience enough such that residents could legally be considered students, it would no longer satisfy ACGME accreditation criteria, and thus, no one would be willing to go to it no matter how desperate they were.

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            Dr. Strong,

            I am arguing this point (which, as I said before, is minor) because it actually happened:

            “One hospital, McLaren Macomb, in suburban Detroit, instead offered several residents slots in its “unfunded program,” in which most radiology residents essentially pay for their own positions through donations, typically from a spouse or parents: $65,000 a year to cover a $42,000 salary and $2,000 for expenses.

            “Obviously it would be your last choice, but if there are no open funded positions and you can scrounge up the funds, keep it in mind,” the program director, Dr. Eli Shapiro, wrote in an e-mail to Dr. Gerges.”

            http://www.nytimes.com/2013/03

            A program was almost cancelled, and the residents were ready to accept a job where they pay for their training.

            Respectfully,
            Vamsi Aribindi

          • Eric Strong

            I don’t know McLaren Macomb hospital, but from what you’ve said yourself, what the article talks about didn’t actually happen. When a residency program describes a position as “unfunded”, it means that the program is not getting money from the government to train the resident in that position; it does not mean the resident will not be paid. Any program which truly has a resident performing duties similar to a conventional residency, but does not pay them, is violating the law and should be sanctioned and/or loose accreditation.

            I appreciate that we are not going to agree on any of this, so I just ask that you keep an open mind about it. In 6-7 years, after you’ve tried to squeeze in 15 interviews into your 2 week vacation between busy ward months in 4th year, and as you watch your college classmates make 6 figures directly out of law or business school, and as you slave away for 80 hours a week in the ICU for ~$14/hr, you may start to reconsider whether you feel like a student or an employee, and whether or not the Match is a fair system after all.

          • James O’Brien, M.D.

            Wait, he’s a pre-med? Is that true?

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            Dr. O’Brien,

            I’m an MS3 in clinical rotations (it should say that on my profile.)

            I have a minor in public policy (including economics) from my undergrad.

            Respectfully,
            Vamsi Aribindi

          • James O’Brien, M.D.

            The moral masochism is astounding. A future doctor two years removed from residency who likes the idea of working for less or free. Because he’s learning something and earning a basic wage doesn’t matter.

            Is it any wonder that attorneys and business have their way with us?

            Please get back to us after the consequences of your idealism play out.

          • Guest

            Dr. O’Brien,

            It is not self-flagellation to realize that while the current system is not ideal, what you and others propose will be far worse.

            I did not say that I liked the idea of working for free- but that working for free may be a consequence of the system that you propose.

            I say this as someone who has more to lose in the process than you, since I have more years and the match left to go, and as someone who has a background in economics and public policy analysis.

            Respectfully,
            Vamsi Aribindi

          • James O’Brien, M.D.

            “as someone who has a background in economics and public policy analysis.”

            And yet with that background you somehow conclude that using something other than the NRMP will drop resident salaries by 50% even though that makes no sense from a supply demand basis (supply and demand do not change either way) and such a salary would violate state minimum wage laws.

            You have provided no evidence that what I propose (which is getting rid of the monopoly) will lead to working for free…because it can’t…because residents are employees…because it’s the law.

            I think in your head you still believe it is possible for residents to legally work for free. Was critical thinking part of the econ background?

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            Dr. O’Brien,

            You are laboring under a misunderstanding of my position. When have I ever said that I wanted to work for free? I want the same thing you do- a fair, living wage. I would love for that wage to be as high as possible. I just happen to have very different view of how to get there and why the wages are so low now.

            What do you think of my alternative plan? (Posted above, but the double post made things confusing)

            ——————————-
            A better plan may be to actually move somewhat to the British system: establish a two year psuedo-internship, after which all doctors earn a certification to practice as a GP. All doctors must take this course before any residency. Thus, you force all residencies beyond these two years to compete harder for residents- because those residents can just say “good bye!” and go into practice.

            Or, pass laws allowing all medical school graduates to practice as PAs.

            Give medical students more options to earn money in lieu of residency, diminish the desire for all medical students for residency spots, and that is how you raise salaries.

            ———————————–

            Respectfully,
            Vamsi Aribindi

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            Dr. O’Brien,

            It is not self-flagellation to realize that while the current system is not ideal, what you and others propose will be far worse.

            I did not say that I liked the idea of working for free- but that working for free may be a consequence of the system that you propose.

            I understand where you are coming from. Residency pay is laughable and horrible- but getting rid of the match is not the answer. A better plan may be to actually move somewhat to the British system: establish a two year psuedo-internship, after which all doctors earn a certification to practice as a GP. All doctors must take this course before any residency. Thus, you force all residencies beyond these two years to compete harder for residents.

            Or, pass laws allowing all medical school graduates to practice as PAs.

            Give medical students more options to earn money in lieu of residency, and that is how you raise salaries.

            Respectfully,
            Vamsi Aribindi

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            Dr. Strong,

            Fair enough. I think the system has many problems as well.

            Which is why I propose that we move to something akin to what Family medicine does, where program directors recruit medical students at a big AAFP conference in Kansas or somewhere like that.

            Every program in a given specialty in a given region should gather in a central location. (Say, every EM Program in California, Oregon, Washington, and Hawaii should meet in San Francisco). Then, the medical students can show up, and over the course of one 3 day weekend, interview at any of the programs during the day. During each of the nights, there should be 2 social hours with groups of residents from each program. Over three nights, that’s six programs whose social hour you can attend.

            Everyone saves money on flight and hotel costs, everyone still meets the residents and program directors. Take three to four of these weekends, and you should cover every program you’re interested in in the country.

            Respectfully,
            Vamsi Aribindi

  • Eric Strong

    Is this post a joke? I’ve got news for you – the U.S. match system is terrible and was never meant to serve the purpose that everyone assumes (i.e. it was not designed for the benefit of graduating students). Instead, the match is the most essential component of the ongoing conspiracy (yes, conspiracy) by training programs to violate the spirit of antitrust law in order to keep housestaff salaries artificially low. With so little control in the system, graduating students are unable to negotiate salaries and contracts individually, and it is extremely difficult to change programs midway, especially mid-year. This reduces motivation for programs to treat their trainees fairly and with respect, and increases the stranglehold a finite collection of training programs have on their employees, severely reducing motivation for residents to unionize and attempt collective bargaining.

    Also, the Match results in minimal variation in salary across all fields and across different geographic locations, irrespective of extreme differences in cost of living, desirability, and in physician need. As an example, consider intern 1, working in the highly competitive field of dermatology, in the highly desirable location of San Francisco. And intern 2, working in a non-competitive field of internal medicine, in the highly undesirable location of North Dakota (sorry ND, but you know it’s true…). In a free market, intern 2 should receive far more compensation (2-3x, probably) than intern 1, appropriately so. Due to the Match however, these 2 interns receive salaries that probably don’t vary by more than 10%. This is because the applicants for intern jobs are unable to negotiate a fair contract. An underappreciated side effect of nearly identical salaries among residents across all locations and all disciplines, is that there is no incentive for students to go into fields such as family medicine and pediatrics, which are simultaneously less competitive and in great need in the more remote parts of the country. Without a match and with the ability for applicants to negotiate, after a few iterations, housestaff compensation for these non-competitive fields would increase (and thus, make them more desirable) until an equilibrium was established. Simple economics.

    In addition, because of the Match, most graduating students travel across the country multiple times to interview at over a dozen programs (at significant personal cost and inconvenience), while in the absence of a Match, most would probably interview at only 2-3 before finding a mutually agreeable relationship.

    Lawyers and MBAs would never tolerate a employment matching scheme in which the employers had such a disproportionate control of the process. This largely explains why lawyers and MBAs receive much fairer compensation immediately coming out of school.

    And when some students sued the National Residency Matching Program 10 years ago on the grounds that they were violating antitrust law, because the NRMP was clearly going to loose, they (along with self-serving professional societies) lobbied Congress to pass a minimally debated and publicly invisible law specifically exempting the NRMP from the same legislation that all other private companies and organizations must abide by.

    The Match is perhaps the most anti-American establishment currently in America, as it perfectly exemplifies the seemingly contradictory philosophies of being simultaneously antilabor and anticapitalism.

    The only thing genius about the Match is how the NRMP has convinced a sizable portion of the American medical establishment that it’s for our own benefit.

    • PoliticallyIncorrectMD

      Very much agree! See my question to the author below. I wonder if he would accept match-like system for finding a job for himself after finishing training as salaries offered through such monopoly would be quite disappointing. But, I guess, when it comes to residents, they should be ecstatic about it.

      • Eric Strong

        Totally agree with your point!

    • James O’Brien, M.D.

      Great post. And I learned something.

      I did not know NRMP had an antitrust exemption.

      Hope the NBME does not get one.

    • Eric Strong

      In the above post, I probably should have included something like: “The opinion included herein belongs solely to the author, and do not necessarily reflect the official position of his institution”.

      So much for that open assistant program director position…

    • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

      “In addition, because of the Match, most graduating students travel across the country multiple times to interview at over a dozen programs (at significant personal cost and inconvenience), while in the absence of a Match, most would probably interview at only 2-3 before finding a mutually agreeable relationship.”

      Seriously? You think a program is going to say yes to a candidate when there are 50 others they can look at coming along? And if that candidate is so good, why let them go on more interviews? Why not say “take this offer in the next 10 minutes, or it’s withdrawn”?

      The only ones who benefit from getting rid of the match are the top of the top candidates- who can go anywhere they want and get an offer. Everyone else is screwed. Oh, and programs will feel free to put deadlines on the offer: “Get back to us in 2 days or the deal is off. We have a position to fill”

      Your idea about resident salaries assumes that it is a good thing to change them based on desirability. Do you realize that there are 5,000 IMGs who would be MORE than happy to work for free for the next five years in exchange for a residency? And what’s to stop an ortho residency from telling candidates: “person A will work for 30k a year- are you willing to work for 10k? If so, academics be damned, you have the spot.”

      As it is, resident salaries fluctuate based on cost of living. In North Dakota, it is a lot easier to survive on 50k a year than it is in Manhattan. Wages are changed accordingly to give residents a reasonable living wage while they train.

      Your mistake is to treat residencies like jobs. They are not. They are educational opportunities leading to future jobs. The rules and regulations in place prevent exploitation of the residents.

      • Eric Strong

        “Seriously? You think a program is going to say yes to a candidate when there are 50 others they can look at coming along? And if that candidate is so good, why let them go on more interviews? Why not say “take this offer in the next 10 minutes, or it’s withdrawn”? (This happened before the match, during the anarchy that you want to go back to)”

        Every other profession is able to handle the post graduation job matching process without the supposed chaos that the NRMP claims will happen to physicians without the Match. Every June, there is a sudden influx of lawyers, MBAs, teachers, nurses, social workers, programmers, and investment bankers into the job market. Those graduates are able to negotiate the market and negotiate their jobs without experiencing anarchy. Not everyone gets hired, but that’s because there are more grads than jobs. That’s not true with medicine – hence IMGs. The internet has brought with it enough transparency that any program that tells its applicants something like “you need to accept this offer in the next 10 minutes” would quickly be publicly identified. And an intelligent applicant should
        realize that if they are presented with such an ultimatum, that probably won’t be a supportive work environment in which they would want to find themselves anyway.

        “The only ones who benefit from getting rid of the match are the top of the top candidates- who can go anywhere they want and get an offer. Everyone else is screwed.”

        When you state “everyone else is screwed”, do you mean that compensation will simply become more fair? The strongest candidates should get paid more than less desirable candidates. Sorry, but that’s the way the real world works. Also, everyone will benefit since the consequence of eliminating the match is that resident salaries across the board will increase; it’s just that it would increase more for some candidates, and more for some specialties than others. The NRMP is anti-competitive, and as such, its consequence (whether are not you believe this is intentional) is necessarily lower housestaff salaries.

        “Your idea about resident salaries assumes that it is a good thing to change them based on desirability. Do you realize that there are 5,000 IMGs who would be MORE than happy to work for free for the next five years in exchange for a residency?”

        First, minimum wage restrictions should apply to residents. So an IMG offering to work for free would be a non-issue. Second, the number of non-citizen IMGs given work visas for residency each year should be set slightly higher than the number of available spots minus the number of new US medical grads + US-citizen/perm. resident IMGs. (Slightly higher because some US medical grads choose not to do residency, and it would give a shot to the strongest IMGs to still take a spot from a less qualified US med grads )

        “And what’s to stop an ortho residency from telling candidates: ‘person A will work for 30k a year- are you willing to work for 10k/year? For that matter, are you willing to take out more loans and pay us 10k/year? If so, academics be damned, you have the spot.’ ”

        Recruitment within other professions seem to work fine without this becoming a larger issue than the antitrust problems the NRMP creates. Also, as above, minimum wage restrictions apply to housestaff, such that as a rough estimate, 30-35k would be the lowest a program could offer, even for the most highly sought positions. 30-35k is too low, even for something highly competitive and desirable like ophthalmology at Harvard or Penn, however, it would help the very high supply of ophtho applicants better meet the more limited demand.

        “As it is, resident salaries fluctuate based on cost of living. In North Dakota, it is a lot easier to survive on 50k a year than it is in Manhattan. Wages are changed accordingly to give residents a living wage while they
        train.”

        The differences in cost of living are not negligible, but clearly do not make up for the differences in geographic desirability. And there is no significant difference in resident wages based on cost of living. The overwhelming majority of graduates from top tier med schools apply to residencies on the two coasts, and skip most of the middle of the country, despite top quality programs there.

        “Your mistake is to treat residencies like jobs. They are not. They are educational opportunities leading to future jobs.”

        Residencies are jobs, and residents are employees. Both in concept and in law. Otherwise, if the law treated residency as an educational opportunity, Congress would not have needed to pass an exemption to antitrust law in order for the NRMP to continue to exist. Residents are provided financial compensation in exchange for profit-earning work that benefits their employer. A job. It may be true that as a resident, you are supervised by someone more experienced, and you are required to attend educational conferences. However, that’s the way most jobs work. In fact, as an assistant professor, I’m technically supervised by someone more experienced than I (e.g. chief of inpt medicine, chief of the division of GIM, medicine dept. chair, etc…) and I’m required to attend educational conferences too (e.g. CME).

        “The rules and regulations in place prevent exploitation of the residents.”

        I could not disagree more. The rules and regulations
        enable the continued exploitation of residents by fixing inexcusably low salaries, preventing competition, disenfranchising medical school grads, disincentivizing the formation of unions and collective bargaining, and severely punishing anyone who dissents with the system (since the only way to get a job is to use the system one is fighting against).

        • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

          I think the heart of our disagreement is this:

          “Residencies are jobs, and residents are employees. Both in concept and in law.”

          I agree that residencies are currently jobs in concept, and in law, but they are not jobs in economic terms. Which means that their definitions in law and concept are open to change.

          Consider this:
          Would anyone work as a resident without hope of becoming an attending? Granted, desperate medical students do go for pre-lim spots, but even then- most are praying for a transfer to a categorical position.

          If you look at jobs that are like residencies in the real world, you find police and fire departments that hire rookies and train them to become an officer. Both institutions restrict their training to their individual department. With rare exceptions, if you go through the training for one department in one geographic locale, your seniority and pay will not transfer if you go to another department. In effect, the department provides both training and pay on the job- but in return, you can only leave with great difficulty.

          Residencies on the other hand do confer a transferable good. The resident can be trained, and leave the hospital the next day, fully able to earn a lot of money wherever else they go. What is this most similar to? College. How much would students give up to go to MIT or Harvard? A whole lot (50k per year to be precise).

          In other words, residencies may be hard work- but their value to the resident is far greater than the value of any one resident to a hospital. Thus, the situation is ripe for exploitation of the resident by the hospital.

          Respectfully,
          Vamsi Aribindi

          • Eric Strong

            I only raise the issue of minimum wage to argue against your suggestion that a program could demand a resident work for 10k a year. Of course it wouldn’t be desirable to pay an ortho resident in Manhattan minimum wage, but it’s not like Manhattan-based residencies offer a fair living wage as it is.

            Also, if the point of regulation in the form of the Match is truly an attempt to “protect residents”, this whole line of argument in favor of the Match falls apart if the ACGME required a standardized minimum resident salary (something close to current resident salaries) in order for programs to remain accredited. Therefore, if the Match is eliminated, no one’s salary will end up falling.

    • James O’Brien, M.D.

      I didn’t mind the match so much when I did it and I suppose it was a useful information clearinghouse.

      However, that was before the Internet. Now it is completely obsolete.

  • saurabh jha

    Remarkably, I agree with every sentiment expressed here.

    I still believe the Match is the least worst system and its greatest beneficiaries are medical students, although hospitals clearly benefit as well.

    A lot of folks want more market forces to operate. The market might not give medical students an answer they would like, particularly, as pointed out by Vamsi Aribindi, there are numerous FMGs willing to do the residency for free.

    Be careful what you wish for.

    • James O’Brien, M.D.

      They may be willing to do it for free but it is illegal. So this is a silly argument.

      I did not know there were so many people out there who really dig the idea of a career in medicine as a form of chattel servitude.

      • saurabh jha

        ok, but it’s not illegal to undercut US residents by 50 %.

        “I did not know there were so many people out there who really dig the idea of a career in medicine as a form of chattel servitude.”

        You’ll be surprised. Welcome to the market.

        • James O’Brien, M.D.

          Are you talking about “the market” or what you would like to see happen?

          • saurabh jha

            “This has nothing at all to do with “the market” unless you dismiss the idea of nationhood altogether.”

            Nationhood! That’s cute. Free market proponents from Bastiat to Hazlitt to Friedman would squirm at protectionism (even by another name).

            Concern about the working condition is all very chic moral grandstanding, but a bit late in the day when manufacturing has been outsourced to China and Bangladesh (or did you not know that?) and everyone is enjoying the low costs of their labor.

            The FMGs I’m talking about are not from the deep dark slums of Mumbai who “would gladly pick up trash or do any menial task in the US for free.”
            They are here and present, picking up spots US medical graduates don’t want to fill. But there are a lot of them. Biding their time doing research. Hungry for residencies.
            Want to compete with them in the free market? No not with the billions in India but the thousands here?
            Go on. I dare US medical students to embrace the free market.
            It’s easy to advocate a la carte free market from the safety of the guild.

          • James O’Brien, M.D.

            He says, while embracing the legal monopoly (since 2004 by law) that is the Match. And neither Friedman nor Adam Smith embraced monopolies. In fact, here’s Friedman on the subject:

            “The great danger to the consumer is the monopoly — whether private or governmental. His most effective protection is free competition at home and free trade throughout the world. The consumer is protected from being exploited by one seller by the existence of another seller from whom he can buy and who is eager to sell to him. Alternative sources of supply protect the consumer far more effectively than all the Ralph Naders of the world.”

          • saurabh jha

            “He says, while embracing the legal monopoly (since 2004 by law) that is the Match.”
            Sorry, but I’m not the one making tall claims about how the Match violates free market principles! Particularly when everything else in medicine violates free market principles.
            Like you, I am enjoying the safety of the guild. I acknowledge it. I do not have selective market pretentions.
            BTW, Milton Friedman called for abolition of medical licence and open competition with mid level providers.
            Will you march in DC with NPs and pharmacists for equal prescribing and admitting rights?
            Have you read Bastiat’s Candlemakers’ Petition? How about Hazlitt’s Economics in One Lesson?
            You will know how they felt about guilds and barriers to entry.
            I know a lot of people who love the market, so long as it doesn’t interfere with the guild.

          • James O’Brien, M.D.

            Since no one else in healthcare, especially government and hospitals, seem to be playing by free market rules, it would be unilateral disarmament to give up the safety of licensure. And since there is no widespread clamor for it elimination of it politically in most specialties, there is no point in proposing it on a practical basis.

            However, you do raise a point. Primary care is on its last legs because PAs and NPs will be clamoring for it. And they will prevail because there will be a shortage.

            Surely as a radiologist living in the US, you’re not for pure free market worldwide capitalism. Given that anything that can be imaged can be captured and read by anyone anywhere.

          • saurabh jha

            “Surely as a radiologist living in the US, you’re not for pure free market worldwide capitalism.”

            You’re right. I’m not. And it serves as a constant cognitive dissonance for me, as I am seeped in the Austrian School of Economics.

            So, you’re right I don’t have a free market leg to stand on, neither do I wish to.

            “And let’s not forget that your idea of cutting resident salaries would also hurt FMGs in the US”
            Neither you nor I make the rules of the market. So having ideas is all great but the market has the last say.

          • James O’Brien, M.D.

            Right now politics, not the market, has the last say, but in principle I think we are not that far apart.

            Medicine is under siege. I’m not saying we can be “pure”. What I am saying is that we can be united against monopolies that do not have our best interests at heart.

            Personally, MOC and EHR are much bigger fish to fry than residency matching, which I consider to be more obsolete than tyrannical. I got my first choice in my match.

            But I still don’t like monopolies.

          • saurabh jha

            “Medicine is under siege”
            It is.
            And the biggest argument against MOC is that its utility is very very questionable. Regardless of where one is on the political spectrum utility (or lack thereof) is not something you can argue against.
            The problem is politics for sure. But I’d go a step further. It’s an internal power struggle between physicians who wants to regulate and physicians who are regulated.

          • James O’Brien, M.D.

            That we agree on.

            And the physicians being regulated have stupidly elected the former type to head medical organizations for the last 50 years.

          • James O’Brien, M.D.

            Thank you for having the intellectual honesty to admit the cognitive dissonance. We all have practical limits on how far we can embrace an ideology. Here’s one of mine…I think the war of drugs is a waste and I support pot legalization (admitting all the problems with that) but I can bring myself to favor legalization of meth…because…well meth.

            One of the biggest problems with MOC is that we are beta testing it. It’s efficacy is unproven. It’s imposition is counter to rational thinking in medicine and evidence based analysis. On principle it should be rejected outright. Yet, I would just go ahead and do it for practical reasons against principle if it were just a test and CME validation.

          • saurabh jha

            Thanks.
            Yes, I think the Austrians (Hayek, Mises, Rothbard, Hazlitt) were right and will be proven right, in the long run.
            I haven’t been terribly enarmoured by the data proponents of MOC have presented. For one, these tests do not measure subtractive medicine, something which comes from experience, and something healthcare desperately needs.

          • Eric Strong

            I think you are greatly overestimating the value of an FMG willing to work for less money. While there are obviously talented candidates and outstanding schools in other parts of the world, it is substantially more difficult for a US residency program to separate out the outstanding FMG candidates from the others. Program directors are busy people and, with the exception of remediation, residency applications are generally their least favorite responsibility. They don’t have the time or patience to find the superstar FMGs in their applicant pool, which is why, with few exceptions, top and middle tier residency programs in the US don’t rank FMGs highly (or in some case, rank them at all). Even with a willingness to work for less, it still wouldn’t be worth it for the program directors and their hospitals since the headache and legal liability of inadvertently offering a spot to a terrible candidate greatly outweighs any cost savings from paying them less.

          • saurabh jha

            “I think you are greatly overestimating the value of an FMG willing to work for less money.”
            No. But I think you are on to something. Healthcare is one of the sectors in which efficiency wages operate. That is hospitals would not necessarily pay less to secure labor. They’d probably not pay more either. But I don’t think it will be a race to the bottom.
            It will be classic supply side economics with one difference. The benefit of the labor surplus will go to the hospitals.
            Exactly what effect that will have is uncertain. You could draw multiple permutations and combinations.
            The point is that accumulating FMGs in an even footing labor pool will make searching for a residency less of a picnic than it is now.

    • Eric Strong

      In addition to free labor being illegal as JO points out, the common reference to FMGs upsetting a free market model of residency matching is also a non-argument because the US government controls the number of work visas offered to FMGs. Since a huge influx of FMGs working for pennies would clearly not be in the best interest of anyone other than hospital CEOs, visas would be reduced to a level that optimizes filling of available spots.

      Also, residency program directors want to attract the best candidates, not save the hospital money. Thus, they would be inclined to argue for higher salaries in order to meet counteroffers by applying residents, and would serve as a check on any motivation of the hospital’s financial people to cut salaries in response to a free market approach.

      • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

        Dr. Strong,

        I’ve said this in another comment below, it is not illegal to work for free because it happened.

        http://www.nytimes.com/2013/03/28/health/trainees-in-radiology-and-other-specialties-see-dream-jobs-disappearing.html?pagewanted=all&_r=0

        “Residency directors want to attract the best candidates”

        True- but what do hospital administrators want to do? After all, right now they just accept Medicare money for each residency, and call it a day- doesn’t matter who they get. But all of a sudden, they can save money by paying residents less. What are they going to order the program director to do?

        The point isn’t about FMG supply. FMG supply just ensures that EVERY resident is screwed over in a market. If there is no FMG supply, then only those residencies which are valuable (Derm, Ortho, Rads, Plastics, Anesthesia) get screwed. If there are 2-3 other medical students ready to take your spot for $10k less, then there is downward pressure on wages (perhaps only to minimum wage levels, if your legal theory holds up). And there will always be that pressure so long as the post-training pay for Ortho is 5 times that of Family Medicine. And correcting that problem is a whole other ballgame.

        Respectfully,
        Vamsi Aribindi

  • James O’Brien, M.D.

    I agree with you on the definitions and clarified that point.

    EHR as a mandate is for cloud or server based centralization of records. It is a horrible idea. What patients need is electronic records on an encrypted thumb drive, not on a cloud.

    Based on the Wikileaks experience, just assume medical information on a cloud will eventually become public.