The Match is broken. Can it be fixed?

Every summer medical school seniors are faced with the daunting task of completing applications for residency programs.  This requires completion of the “common application” through the Electronic Residency Application Service (ERAS), among other things.  This ultimately becomes a compilation of medical school and USMLE transcripts, letters of recommendation, personal and biographic information, a personal statement, and a resume composed of work, volunteering, and research experiences.

Countless hours are spent on its completion prior to submission to residency programs in early September.  Over the ensuing months, applicants receive interview invitations and rejections from programs.  At the conclusion of interview season, applicants and programs will both submit their “rank order lists” to the NRMP.  The NRMP then inputs those lists into an algorithm that matches applicants to the program of their highest ranking.  Those who do not match have the opportunity for a second chance through the Supplemental Offer Acceptance Program (SOAP) to interview for unfilled positions prior to match day.

According to the 2016 Results and Data for the Main Residency, the first “main residency match” took place in 1952 during which 6,000 applicants applied for 10,400 residency positions.  Over time the number of graduating seniors has significantly outgrown the number of offered positions.  In 2016, 42,370 applicants registered for the match with only 27,860 residency positions available.  Thus, each year nearly half of all graduating seniors do not reach the next step in becoming a licensed physician.  However, this crude reality doesn’t always signify the end of the road for applicants.  Many will choose to reenter the match in the following year, but the odds will be against them.

Initially, this problem (i.e., not matching) never used to exist.  Students would finish medical school, and go onto residency without a problem.  However, in response to the physician shortage, multiple efforts have been made to increase the number of graduates entering primary care residencies.  This push exponentially increased the number of medical school seats across the nation without proportionally increasing residency positions.  It also had no way of guaranteeing that students occupying those newly added seats would even become primary care physicians.  And let’s not forget about the thousands of international medical graduates (IMGs) who enter the match each year.  This created a major problem, and as a result, the Match has become a bottleneck that narrows each year.

So who’s to blame for this tragedy?  Is it medical students, residency programs, or perhaps the government?  I don’t think there’s truly a correct answer, but the finger could be pointed at all parties.  Years ago, before the emergence of electronic applications, medical students filled out residency applications individually with pen and paper.  This incentivized applicants to fill out only a small number of applications, and only to those programs in which they were genuinely interested.  Although primitive, it was highly effective, and essentially eliminated any subjectivity involved interview selection processes.  Handwritten applications signified to programs that you were very interested in them, and didn’t simply apply just to increase your number of interviews.

However, as the new electronic application system has emerged, the process is streamlined for applicants.  Applicants fill out one “common application,” and then scroll through a list of programs in their desired specialty while selecting all to which they wish to apply.  Although highly efficient, it has also created a match nightmare, and caused programs to question why certain applicants even applied to their program in their first place.

Residency programs are flooded with thousands of applications to sort through, and identify those applicants whom they wish to interview.  This can be approached in many different ways (i.e., USMLE scores, medical school grades, etc.), and often takes weeks to complete.  When the dust settles, usually a couple hundred applications remain.  On average, most programs interview ten applicants per position.  And if they are offering six positions, then it would be foolish to interview a couple hundred.  Thus, selection committees are faced with narrowing down the final pile even further to select applicants for interview invitations, and those who will be waitlisted.

Inevitably there is great variability in this step of the selection process.  It is complex, inconsistent, and generally lacks any form of objectivity.  It is this very step that we the applicants have created, and it’s solely a creation of our own neuroticism.  Understandably, medical students are known to be chronically anxious and worried about the future.  Even in spite of a strong resume, we will still send out far more applications than is necessary.

For example, programs might question why someone from California is applying to a program in Minnesota where it’s blistering cold eight months out of the year, or why someone from New York City is applying to a program in a small rural town in the middle of nowhere.  These are all fair and appropriate questions, but they shouldn’t carry any weight in selecting which applicants to interview.  What ever happened to an application signifying an applicant’s genuine interest in a program?

There are other additional hurdles for applicants, and each takes away from the Match’s true intended purpose.  Some programs will primarily match their own students, or students from other institutions who completed an away rotation with them.  There are also programs who simply will not interview students from select programs due to a prolonged bitter quarrel going on between their departments. These are real problems, and although many refuse to confirm their existence, it’s happening, and it is hurting applicants.

I’ll leave you with this, the million dollar question. Can this problem be fixed, or was it simply inevitable?  Maybe we need to return applications to pen and paper.  It would not only decrease the number of applications, but also eliminate any questions regarding an applicant’s interest in that program, especially if applications involved handwriting personal statements.  Should ERAS set a max number of applications per applicant?  That would be effective, but it also would never happen, because programs like ERAS would then lose thousands of dollars each year.  As the number of applicants continues to grow in lieu of a steady number of residency positions, this problem will persist and unfortunately further worsen.

Having said all of this, as I move onto residency in a few short months my heart goes out to all those left behind on this battlefield littered with broken dreams, and matches that never came to be.

Mitch Obey is a medical student.

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