NRMP Antitrust Exemption

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exPCM

exPCM

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I think it is sad that the NRMP match process is basically one of only two entities (the other being major league baseball) in the entire country who have been exempted from the Sherman Antitrust Act which was passed in 1890 to prohibit abusive monopolies link: http://www.linfo.org/sherman.html

A. The Jung Case
A group of residents, interns, and fellows challenged the NRMP and
member academic hospitals alleging that the hospitals and the NRMP
violated § 1 of the Sherman Antitrust Act.
' The complaint was filed by aggravated residents and interns on May 5, 2002 in the District of
Columbia. The residents claimed that academic hospitals and the nonprofit matching program colluded to keep resident salaries artificially low and resident working conditions similarly taxing. The residents argued that the match program along with participating academic hospitals
perpetuated an anti-competitive program which constituted an unreasonable
restraint on trade. '
"The match" is responsible for the placement of 23,000 graduating medical students in residency programs across the country When medical students participate in the match program they agree to honor the match commitment, thereby locking them into whichever residency
program a computer selects for them. This program leaves interns and residents with little bargaining power. This Comment will not analyze the antitrust jurisprudence that relates
to the NRMP challenge, but instead will focus on the response of Congress to the Jung complaint. Generally, the complainants alleged that the match program involves horizontal restraints on price or salaries of residents. These particular restraints are generally regarded as per se violations of the Sherman Act 86 "because of their pernicious effect on competition and lack
of any redeeming virtue." '
However, few cases present such overtly anti-competitive effects as to trigger the per se illegality rule. For other cases, courts will apply the "rule of reason" test to an alleged anti-competitive industry. This rule analyzes "whether the restraint imposed is such as merely regulates and perhaps thereby promotes competition or whether it is such as may
suppress or even destroy competition. "Under this rule, after a plaintiff alleges anti-competitive effects of a particular industry, the court will then analyze the market to determine if the defendant's behavior provides any pro-competitive effects on the market.
Courts have developed a third test, known as the "quick look" test to evaluate a restraint that appears obviously anti-competitive. When courts apply the "quick look" test, a plaintiff does not have an initial burden of proving anti-competitive effects of a restraint, but the court presumes such effects. The defendant then has an opportunity to rebut the presumption
of unreasonable restraint on trade by proffering legitimate justifications or pro-competitive reasons for the restraint. If these justifications appear plausible, the court will use the full "rule of reason" analysis; otherwise, it will censure the practice.
The Jung court did not reach a full antitrust analysis of the NRMP. The court dismissed the action because Congress had secretly passed 15 U.S.C. § 37b(b)(2), retroactively preempting any
antitrust actions against the NRMP.
Congress titled 15 U.S.C. § 37b "Confirmation of anti-trust status of graduate medical resident matching programs. The legislation states as follows:
Antitrust lawsuits challenging the matching process, regardless of their merit or lack thereof, have the potential to undermine this highly efficient, pro-competitive, and long-standing process. The costs of defending such litigation would divert the scarce resources of our country's teaching hospitals and medical schools from their crucial missions of patient care, physician training, and medical research. In addition, such costs may lead to abandonment of the matching process, which has effectively served the interests of medical students, teaching hospitals, and
patients for over half a century.
The President signed this legislation into law as part of the Pension Funding Equity Act of 2004. The legislation thus formed a prime example of pork barrel legislation tacked onto a bill which was intended to update interest rates for the purposes of reducing employer contributions to pension funds.'' As the bill went into conference meetings, the above
rider did not exist.
In fact, a few senators objected staunchly to this seemingly unrelated rider. Senator Bingaman (D-New Mexico) who sits on the Health, Education, Labor, and Pensions Committee commented:
[T]here were provisions included in this bill-at least one provision that I think is highly objectionable.
Section 207 of the conference report creates an antitrust exemption for the graduate medical residency program that currently assigns medical students to hospitals where they are
required to work for 60 to 100 hours per week for an average of $9 or $10 an hour. To people who are not familiar with the way this place functions in recent years, they would be surprised to
find that we have written into the pension bill a retroactive exemption from the antitrust laws related to this issue of medical residency programs
That being said, the antitrust exemption that is established by subsection (b)(2) raises grave constitutional concerns. There has been no justification presented to this Congress, to any
committee of this Congress for depriving medical residents of the same protections under the antitrust laws that are enjoyed by other workers and other Americans. I do not see how it is
constitutionally permissible to take away the equal protection and the due process rights of medical residents without any showing that is necessary or beneficial.
Frankly, this is outrageous for Congress to be legislating in this way, without any hearings, without any testimony, without any knowledge of what it is doing.
The reason we have debate on the Senate floor is to allow Members to express views when we are getting ready to change the law. This is a time-honored process. It is one that was not
honored in this case. As far as I know, there has been no debate on the floor nor has there been debate in committee about this issue.
This is a provision that was added in a conference, without participation of Democratic Senators, and clearly it is contrary to good policy and to proper procedure here in the Senate.
Thus, controversy enveloped the passing of this legislation, and it is doubtful the rider would have existed without intense lobbying efforts from the NRMP, ACGME, and participating hospitals.
The AAMC, the representative body of all accredited medical schools in the United States and Canada, as well as over 400 teaching hospitals, vehemently opposed all resident unionization efforts. Coincidentally, the AAMC, named as one of the defendants in the Jung suit, stepped up its lobbying efforts after Jung filed suit and expressed uncompromising support for the above amendment. Allowing the unraveling of the match would greatly diminish the AAMC's power over post-graduate medical training. It comes as no surprise that the AAMC would oppose every effort
of house-staff to achieve more control over the process of resident placement. Offering more labor rights to medical residents would cost academic hospitals inordinate amounts of money. The cost of replacing one surgical resident with a "physician extender," or other physician, is
$210,000 to $315,000 a year. In addition, residents perform many responsibilities generally assignable to other hospital faculty, which allows hospitals to offer less privileges or compensation to some faculty members.'
http://www.law.upenn.edu/journals/jbl/articles/volume8/issue2/Geiger8U.Pa.J.Lab.&Emp.L.523(2006).pdf
Comment: The granting of the antitrust exemption helps to preserve a system of cheap (with CMS funding) and exploitable resident labor with no real bargaining power. I agree with Senator Bingamin's statement: "I do not see how it is constitutionally permissible to take away the equal protection and the due process rights of medical residents without any showing that is necessary or beneficial".
Members don't see this ad.
 
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What system would you propose to replace the match?

Gastroenterology went through a collapse of the match and it didn't return for many years. The consequence was that people were given "exploding" offers (ie you have 24 hrs to decide if you want to come here and if you don't answer , we'll offer it to the next guy). That system was even less fair than a match because you basically had to take the first good offer for fear that it was the last.

No match was worse than a match. The system above is not an antitrust violation nor illegal (in fact, its how most job offers work). Get rid of the match and that is what you are left with. Google gastroenterology match and read the economists' papers about the collapse of the match. Its an interesting read.

If you think there is a better system and a way that it could be enforced (since exploding offers are totally legal), lets hear it.
 
Gastrapathy said:
What system would you propose to replace the match?

Gastroenterology went through a collapse of the match and it didn't return for many years. The consequence was that people were given "exploding" offers (ie you have 24 hrs to decide if you want to come here and if you don't answer , we'll offer it to the next guy). That system was even less fair than a match because you basically had to take the first good offer for fear that it was the last.

No match was worse than a match. The system above is not an antitrust violation nor illegal (in fact, its how most job offers work). Get rid of the match and that is what you are left with. Google gastroenterology match and read the economists' papers about the collapse of the match. Its an interesting read.

If you think there is a better system and a way that it could be enforced (since exploding offers are totally legal), lets hear it.
Click to expand...

How about free competition as exists in all other industries and occupations. As an attending a group could make me an "exploding offer" tomorrow - SO WHAT? I can either accept it or not. The primary reason for the establishment of the match is:
In 1952, the hospitals and other entities employing resident physicians determined that the continuation of free competition in recruiting, hiring, employing and compensating resident physicians was undesirable because the number of available residency positions outpaced the number of available candidates. Employers determined that continued free competition would "bid up" compensation and other terms of employment by which employers commonly compete to attract employees. Creating the matching program enabled employers to obtain resident physicians without such a bidding war . . . .5
http://lsr.nellco.org/cgi/viewcontent.cgi?article=1068&context=upenn_wps
In aggregate free competition would provide more favorable working conditions (pay/benefits/hours) for residents.
Trying to defend the match as somehow doing med students a favor is a joke IMO. How much money would students save on travel costs alone if they could get and sign an offer after one interview. How nice would it be to find out before the middle of March where you will be working in July. Law students and engineering students get exploding offers and they somehow manage to make decisions. How much money does the NRMP rake in each year off the backs of thousands of students?
In a competitive market, a candidate's ability to seek employment with a competitor pressures the initial hospital to raise its wages, allowing the candidate to extract more of the surplus created through the employment relationship. Without this opportunity to negotiate, the resident's pay is not as high as it otherwise would be. A recent working paper by Jeremy Bulow and Jonathan Levin using a different matching model finds that when programs do not make individualized salary offers, salaries will be lower than in a competitive equilibrium, particularly for the most sought-after residents.
 
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Economic models show what the authors want them too. I suppose the market would also be able to determine that desirable residencies should be done for less (especially if desirable residents would get paid more). Want to do derm, how bout minimum wage?

The market is not necessarily the best way to handle education. Your other examples are people who have finished training and are looking for jobs. Residency is not a job, its where we learn to do this job. Exploding offers keep trainees from being able to compete anyway. Unlike job offers, where the candidate can just bail when he gets a better offer, continuity of training requires that people stay in one place for several years. Thus, exploding offers in people who can up and leave are much less effective than they are in limiting medical trainees. If you are advocating that residents be able to move around, I totally disagree. That would only serve to hide the dangerous trainees and keep anyone from being able to assess quality.

GI fellows just went through the process of transitioning from no match back to a match and people seem satisfied. In fact, most of the frustration I hear from applicants is that it hasn't been universally applied and programs are still offering a fair number of their positions outside the match.

Another bad part about exploding offers is that you don't get to know your options before putting together a list. This is a real drag when you have a professional spouse. Say you get an offer in Philly, she lives in NYC...lots of programs in NYC, but Philly is pretty close...you have to take it rather than risk not getting selected by an NYC program. Under a match, if that Philly program likes you enough to rank you to match, the fact that you listed all the NYC programs ahead of them won't cost you a slot in Philly.

It would have been better for me if there had been a match when I went through.

Oh, and GI fellow pay didn't improve when we went without a match for a decade.

I'm sure that the boys in charge didn't organize a match to help residents and I disagree with the ACGME on a number of policies (specifically, total lack of oversight of the disciplinary process and the work hour rules). However, IMO, the advantages of the match to the student outweigh the disadvantages. No joke.
 
Gastrapathy said:
Economic models show what the authors want them too. I suppose the market would also be able to determine that desirable residencies should be done for less (especially if desirable residents would get paid more). Want to do derm, how bout minimum wage?

The market is not necessarily the best way to handle education. Your other examples are people who have finished training and are looking for jobs. Residency is not a job, its where we learn to do this job. Exploding offers keep trainees from being able to compete anyway. Unlike job offers, where the candidate can just bail when he gets a better offer, continuity of training requires that people stay in one place for several years. Thus, exploding offers in people who can up and leave are much less effective than they are in limiting medical trainees. If you are advocating that residents be able to move around, I totally disagree. That would only serve to hide the dangerous trainees and keep anyone from being able to assess quality.

GI fellows just went through the process of transitioning from no match back to a match and people seem satisfied. In fact, most of the frustration I hear from applicants is that it hasn't been universally applied and programs are still offering a fair number of their positions outside the match.

Another bad part about exploding offers is that you don't get to know your options before putting together a list. This is a real drag when you have a professional spouse. Say you get an offer in Philly, she lives in NYC...lots of programs in NYC, but Philly is pretty close...you have to take it rather than risk not getting selected by an NYC program. Under a match, if that Philly program likes you enough to rank you to match, the fact that you listed all the NYC programs ahead of them won't cost you a slot in Philly.
Click to expand...

(1) Your first point is an empirical question. On the one hand, yes, the more desirable residencies might be able to pay people less, because they're desirable. But then again, desirable programs want desirable people, who have other competing offers--so desirable programs might have to pay more. Indeed, in academics, in general, the "brand name" places pay professors more than less "brand name" places, suggesting the latter effect dominates.

(2) More generally, what would be wrong with determining residency salaries in the market? I think it's a bit naive to imagine that this doesn't already occur to a large extent, certainly across programs.

(3) Exploding offers suck to an extent, but exist in other markets (such as again, the market for academics), that generally clear just fine. In the example you give, if I get an exploding offer from Philly, then I'll just inform the NYC programs of this and see what their reaction is. Presumably, if I'm a good candidate, they'll make an offer then as well.

I said this in another thread, but it's not the match algorithm itself that necessarily violates antitrust and costs applicants--I actually think the algorithm is useful because (at least for residencies, less so for fellowships), the numbers of people are involved are very large, so the algorithim eliminates some serious search costs. What really screws applicants *and* programs is the inability to make binding pre-match contracts ("I will rank you #1 and in return, you will rank me to match+/-give me some goodies).
 
I seem to recall a similar conversation a few years back. I would caution you to be careful what you wish for. Consider this unintended consequence of a free-for-all scramble:

Small, very desirable subspecialties, such as derm of direct plastics, could decide not to pay their residents at all -- or even require them to pay for training. They would still fill because of how lucrative they are post-residency. The same could hold true of Ophthalmology.

I'm with you on other grounds, however. Paying residents so little for so much work is BS. If forced to raise these salaries significantly, many would have great difficulty finding that money. A big med center may have 500 residents, given them a reasonable wage: double of 40L and you'd need another 20 million dollars. Many academic centers are just scraping by (or losing money) as it is.

Ed
 
staylor21 said:
(3) Exploding offers suck to an extent, but exist in other markets (such as again, the market for academics), that generally clear just fine. In the example you give, if I get an exploding offer from Philly, then I'll just inform the NYC programs of this and see what their reaction is. Presumably, if I'm a good candidate, they'll make an offer then as well.
).
Click to expand...

The major difference between the match and other markets is that you can't leave if a better offer comes along and there are so many simultaneously available slots (unlike academic jobs p training). Folks made the phone calls you suggest. They had no effect. The problem is that competitive specialties like GI have no reason to care. Don't want to come to our interview...fine, we have 100+ applicants for two spots. Doesn't matter how good you are, that was the reaction. The interview schedule was set and they had no incentive to change it. It sucked enough that the applicants wanted a match. Your presumption just isn't correct. The clear winners in this system were internal candidates (although they were limited to their own programs).
 
Gastrapathy said:
The major difference between the match and other markets is that you can't leave if a better offer comes along and there are so many simultaneously available slots (unlike academic jobs p training). Folks made the phone calls you suggest. They had no effect. The problem is that competitive specialties like GI have no reason to care. Don't want to come to our interview...fine, we have 100+ applicants for two spots. Doesn't matter how good you are, that was the reaction. The interview schedule was set and they had no incentive to change it. It sucked enough that the applicants wanted a match. Your presumption just isn't correct. The clear winners in this system were internal candidates (although they were limited to their own programs).
Click to expand...

(1) I'm fairly familiar with academic markets in the non-medical realm. Like the match, there's basically a large number of simultaneously available slots (because like clock work, every year, assistant professors either get promoted or denied tenure, which frees up their slot. This isn't necessarily the case for academic medical positions, where slots are more fungible, but it is the case in your more liberal-arts type departments). In addition, reneging (on either an applicant or a department) is *highly* frowned upon. So the differences aren't as big as you think, other than that numbers involved in the match are much larger. But that's why I said I think the match algorithim serves a useful purpose.

(2) I'm sure the phone calls matter for some people, and less for others, just like the academic market. When a candidate gets an exploding offer, they typically do make those calls--and efforts are made to accomodate, if the candidate is desirable.

(3) Your statement that competitive specialties have no reason to care isn't 100% true, as presumably there are top candidates that programs care about. Personally, I've had several friends whom i believe to a large degree had some ability to negotiate things when applying for residency (of course, the match means that any commitment made is non-binding, so they took it all with a grain of salt). But at the end of the day, it's an empirical question. Again, why not keep the match algorithim but let programs and applicants enter into binding pre-match contracts?
 
Teddy%20Trust%20Buster%20Roosevelt.JPG


Where is Teddy the Trust Buster when you need him :laugh:
 
exPCM said:
How about free competition as exists in all other industries and occupations. As an attending a group could make me an "exploding offer" tomorrow - SO WHAT? I can either accept it or not. The primary reason for the establishment of the match is:
In 1952, the hospitals and other entities employing resident physicians determined that the continuation of free competition in recruiting, hiring, employing and compensating resident physicians was undesirable because the number of available residency positions outpaced the number of available candidates. Employers determined that continued free competition would “bid up” compensation and other terms of employment by which employers commonly compete to attract employees. Creating the matching program enabled employers to obtain resident physicians without such a bidding war . . . .5
http://lsr.nellco.org/cgi/viewcontent.cgi?article=1068&context=upenn_wps
Click to expand...

First, thanks for the really nice link above. I hadn't seen that before. It's quite long and I read parts, but not all of it.

Several thoughts:

1. The quote above is taken from the lawsuit. It's quoted in the article, which then goes on to explain how this is almost certainly not true. As discussed in the article, the match was created by medical school deans to prevent the "unraveling" of the whole residency placement process. If the match was actually created by programs to prevent "bidding up" of contracts, there would be no pre match spots. We would want everyone in the match -- prematches simply would give some applicants a way to "bid up" salaries. The reason that only 4th year US grads are required to use the match is because it was created by the med school deans, and they could only force their own students.

2. Just wondering if you've read the whole paper. You're a frequent poster here, and very well spoken and knowledgable. The paper concludes that the anti-trust exemption was valid and required. The author suggests some minor changes for the match, most of which have already been implemented.

3. I do have to agree that adding the anti-trust exemption into a bill in conference without any discussion is really slimy. It's the way politics is done in this country, and it sucks. Even if I agree with the exemption, it should have been discussed.

4. As I have said before, I agree that residency salaries are probably too low. However, the match is not the problem. Make the match go away, and you will have the same salaries. It's not the problem.

The problem is that, with an MD/DO alone, you cannot do anything. You must do a residency in order to get a license to practice. This makes medicine different from law, business, NP/PA's, and essentially most other fields. Salaries are low because MD graduates really have no choice but to do one. Any effect that the match has on salaries (which might be the case) is small compared with this. (Note: This is discussed in depth in footnote #265 of the paper)

staylor21 said:
Indeed, in academics, in general, the "brand name" places pay professors more than less "brand name" places, suggesting the latter effect dominates.
Click to expand...

? if you are talking about non-medical academic positions. In my experience, the better the "brand name" academic center, the lower the pay was (and often the higher the cost of living).

-----
My summary:

1. Several things make the residency placement process different from most other job situations. First, an MD without a residency is useless -- so all grads must do a residency. In almost every other field, you can go and work on your own if you want. Hence, this is a high stakes process with a huge downside for students.

Second, the pool of candidates that programs can hire from is very limited. Students all graduate at the same time, so if you don't fill a spot there is limited availability of applicants off cycle, and only highly qualified (i.e. went to medical school) candidates can apply.

Third, programs are specifically limited in how many residents they can have. If I'm approved for 10, I can't have 11. This makes offering spots on a rolling basis very complicated.

Fourth, programs are vitally dependent on residents. If I have slots for 10 residents, my program doesn't function well with 9. This is our fault, and I'm happy to accept my portion of the blame. This plus the above means that I have to get my exact compliment of residents, which highly skews the employment market.

2. The match is the most efficient and accurate way to distribute applicants and spots for the majority of people. Although it may seem painful to wait until mid March to know where you are going, it's much less painful than applying to programs and having no idea when you might get an offer. Remember back a few months, applications are in, and people are going crazy wondering when (and if) they are going to get an interview. You hear of others getting interviews. You start to panic. Now, imagine this is happening with offers. It would be horrible.

3. The match specifically favors those applicants who are more flexible, are undecided, or are less academically strong. The former two groups benefit from the ability to visit multiple programs, review their options, and explore their interests. The vast majority of the latter group simply matches on match day -- in a rolling admissions type system, they would be left to the end which could be miserable (anyone ever the last kid picked in gym for sports teams?)

3. The match somewhat disfavors those who have a known strong preference that is unlikely to change, are geographically limited, etc. Strong applicants will get multiple offers quickly and early, and hence might be better off without a match. Those who know exactly where they want to go, or are otherwise limited, would want to apply to 1-2 programs and get a spot, and only spend more time/money exploring further if that failed (although this assumes that their first choice places would make decisions before other programs are filled, else they too would do better with a match).

4. Adding some way for US grads to prematch might help with #3, but would completely unravel the match.

5. Having non-US grads able to prematch destabilizes the match. Until recently it didn;t matter, since there were so many more spots than US grads. As exPCM mentions, that era is coming to an end. We have already had one push for an all-in match which failed. It's interesting why it failed -- it failed because PD's were unwilling to support it, mainly because it weakens their position. From my viewpoint, it would clearly be the right thing to do for students. Then again, I'm a match believer.
 
aProgDirector said:
First, thanks for the really nice link above. I hadn't seen that before. It's quite long and I read parts, but not all of it.

Several thoughts:

1. The quote above is taken from the lawsuit. It's quoted in the article, which then goes on to explain how this is almost certainly not true. As discussed in the article, the match was created by medical school deans to prevent the "unraveling" of the whole residency placement process. If the match was actually created by programs to prevent "bidding up" of contracts, there would be no pre match spots. We would want everyone in the match -- prematches simply would give some applicants a way to "bid up" salaries. The reason that only 4th year US grads are required to use the match is because it was created by the med school deans, and they could only force their own students.

2. Just wondering if you've read the whole paper. You're a frequent poster here, and very well spoken and knowledgable. The paper concludes that the anti-trust exemption was valid and required. The author suggests some minor changes for the match, most of which have already been implemented.

3. I do have to agree that adding the anti-trust exemption into a bill in conference without any discussion is really slimy. It's the way politics is done in this country, and it sucks. Even if I agree with the exemption, it should have been discussed.

4. As I have said before, I agree that residency salaries are probably too low. However, the match is not the problem. Make the match go away, and you will have the same salaries. It's not the problem.

The problem is that, with an MD/DO alone, you cannot do anything. You must do a residency in order to get a license to practice. This makes medicine different from law, business, NP/PA's, and essentially most other fields. Salaries are low because MD graduates really have no choice but to do one. Any effect that the match has on salaries (which might be the case) is small compared with this. (Note: This is discussed in depth in footnote #265 of the paper)



? if you are talking about non-medical academic positions. In my experience, the better the "brand name" academic center, the lower the pay was (and often the higher the cost of living).

-----
My summary:

1. Several things make the residency placement process different from most other job situations. First, an MD without a residency is useless -- so all grads must do a residency. In almost every other field, you can go and work on your own if you want. Hence, this is a high stakes process with a huge downside for students.

Second, the pool of candidates that programs can hire from is very limited. Students all graduate at the same time, so if you don't fill a spot there is limited availability of applicants off cycle, and only highly qualified (i.e. went to medical school) candidates can apply.

Third, programs are specifically limited in how many residents they can have. If I'm approved for 10, I can't have 11. This makes offering spots on a rolling basis very complicated.

Fourth, programs are vitally dependent on residents. If I have slots for 10 residents, my program doesn't function well with 9. This is our fault, and I'm happy to accept my portion of the blame. This plus the above means that I have to get my exact compliment of residents, which highly skews the employment market.

2. The match is the most efficient and accurate way to distribute applicants and spots for the majority of people. Although it may seem painful to wait until mid March to know where you are going, it's much less painful than applying to programs and having no idea when you might get an offer. Remember back a few months, applications are in, and people are going crazy wondering when (and if) they are going to get an interview. You hear of others getting interviews. You start to panic. Now, imagine this is happening with offers. It would be horrible.

3. The match specifically favors those applicants who are more flexible, are undecided, or are less academically strong. The former two groups benefit from the ability to visit multiple programs, review their options, and explore their interests. The vast majority of the latter group simply matches on match day -- in a rolling admissions type system, they would be left to the end which could be miserable (anyone ever the last kid picked in gym for sports teams?)

3. The match somewhat disfavors those who have a known strong preference that is unlikely to change, are geographically limited, etc. Strong applicants will get multiple offers quickly and early, and hence might be better off without a match. Those who know exactly where they want to go, or are otherwise limited, would want to apply to 1-2 programs and get a spot, and only spend more time/money exploring further if that failed (although this assumes that their first choice places would make decisions before other programs are filled, else they too would do better with a match).

4. Adding some way for US grads to prematch might help with #3, but would completely unravel the match.

5. Having non-US grads able to prematch destabilizes the match. Until recently it didn;t matter, since there were so many more spots than US grads. As exPCM mentions, that era is coming to an end. We have already had one push for an all-in match which failed. It's interesting why it failed -- it failed because PD's were unwilling to support it, mainly because it weakens their position. From my viewpoint, it would clearly be the right thing to do for students. Then again, I'm a match believer.
Click to expand...

aprogdirector,
Thanks for your post.
I am aware that the author concludes that the exemption is valid.
I do not agree with that conclusion.
I concede that there are pros and cons to the match.
However the current match system (where one group of students must participate in the NRMP and other students can use prematches to bypass the NRMP) is inherently unfair. The PDs have showed that they will not support a more equitable "all-in" match.
When given the choice between supporting a fatally flawed NRMP system or eliminating the NRMP entirely, I come down on the side of eliminating the NRMP entirely.
I realize that eliminating the match is not without problems but it eliminates the current inequalities of the NRMP.
The argument that derm and other popular specialties would offer unpaid positions for residents if the match was eliminated is not a valid argument since the ACGME has banned unpaid residents in accredited residency slots.
 
exPCM said:
aprogdirector,
Thanks for your post.
I am aware that the author concludes that the exemption is valid.
I do not agree with that conclusion.
I concede that there are pros and cons to the match.
However the current match system (where one group of students must participate in the NRMP and other students can use prematches to bypass the NRMP) is inherently unfair. The PDs have showed that they will not support a more equitable "all-in" match.
When given the choice between supporting a fatally flawed NRMP system or eliminating the NRMP entirely, I come down on the side of eliminating the NRMP entirely.
I realize that eliminating the match is not without problems but it eliminates the current inequalities of the NRMP.
The argument that derm and other popular specialties would offer unpaid positions for residents if the match was eliminated is not a valid argument since the ACGME has banned unpaid residents in accredited residency slots.
Click to expand...

Fatally flawed? With all due respect, did you even read what aPD wrote?
 
aProgDirector said:
We have already had one push for an all-in match which failed. It's interesting why it failed -- it failed because PD's were unwilling to support it, mainly because it weakens their position. From my viewpoint, it would clearly be the right thing to do for students. Then again, I'm a match believer.
Click to expand...

Surely, the majority of PDs wouldn't be too concerned with weakening their position. I know that it is nice to be able to lock up outstanding FMGs, IMGs and DO's prior to the match, but typically isn't it weaker programs that are seeking out these candidates and giving them the "sign the pre-match contract or we won't rank you" schpiel? I would think that most PDs would be in favor of lumping everyone together in an effort to keep this kind of practice from happening, since now all the PDs have an equal shot at these candidates. I suppose, given my extremely limited understanding of the process, I don't understand how it weakens the position of the majority of PDs.
 
Resident unions are one counter-balancing force against hospitals. CIR doesn't seem to be gaining much in-roads around the country but I suppose that's to be expected. How do you expect to organize already overworked interns to unionize on top of an 80 hour work week?
 
aProgDirector said:
First, thanks for the really nice link above. I hadn't seen that before. It's quite long and I read parts, but not all of it.

Several thoughts:

? if you are talking about non-medical academic positions. In my experience, the better the "brand name" academic center, the lower the pay was (and often the higher the cost of living).
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The AAUP has an annual survey of salaries at universities:

http://chronicle.com/stats/aaup/index.php?action=result&year=2009&withRanks=1&sort=professor

The top 10 are pretty much brand name universities (harvard, princeton, yale, Univ of Chicago, Stanfordm MIT, etc). I also have experience with the non-medical side of things, and can confirm that generally speaking, the brand name programs pay more.

With regards to medicine, I'm less familiar, but would imagine there are two groups of people: the "stars" upon whom an institution's reputation is based, and the non-stars who are there to fulfill service requirements. I can see that in the latter case, salaries might be lower at brand name programs, as the non-stars are accepting bragging rights in lieu of financial compensation. But for the stars, I imagine compensation is higher at brand name programs, simply because it's the stars that make them "brand name."
 
aProgDirector said:
First, thanks for the really nice link above. I hadn't seen that before. It's quite long and I read parts, but not all of it.

Several thoughts:


1. Several things make the residency placement process different from most other job situations. First, an MD without a residency is useless -- so all grads must do a residency. In almost every other field, you can go and work on your own if you want. Hence, this is a high stakes process with a huge downside for students.

Second, the pool of candidates that programs can hire from is very limited. Students all graduate at the same time, so if you don't fill a spot there is limited availability of applicants off cycle, and only highly qualified (i.e. went to medical school) candidates can apply.

Third, programs are specifically limited in how many residents they can have. If I'm approved for 10, I can't have 11. This makes offering spots on a rolling basis very complicated.

Fourth, programs are vitally dependent on residents. If I have slots for 10 residents, my program doesn't function well with 9. This is our fault, and I'm happy to accept my portion of the blame. This plus the above means that I have to get my exact compliment of residents, which highly skews the employment market.

2. The match is the most efficient and accurate way to distribute applicants and spots for the majority of people. Although it may seem painful to wait until mid March to know where you are going, it's much less painful than applying to programs and having no idea when you might get an offer. Remember back a few months, applications are in, and people are going crazy wondering when (and if) they are going to get an interview. You hear of others getting interviews. You start to panic. Now, imagine this is happening with offers. It would be horrible.

3. The match specifically favors those applicants who are more flexible, are undecided, or are less academically strong. The former two groups benefit from the ability to visit multiple programs, review their options, and explore their interests. The vast majority of the latter group simply matches on match day -- in a rolling admissions type system, they would be left to the end which could be miserable (anyone ever the last kid picked in gym for sports teams?)

3. The match somewhat disfavors those who have a known strong preference that is unlikely to change, are geographically limited, etc. Strong applicants will get multiple offers quickly and early, and hence might be better off without a match. Those who know exactly where they want to go, or are otherwise limited, would want to apply to 1-2 programs and get a spot, and only spend more time/money exploring further if that failed (although this assumes that their first choice places would make decisions before other programs are filled, else they too would do better with a match).

4. Adding some way for US grads to prematch might help with #3, but would completely unravel the match.

5. Having non-US grads able to prematch destabilizes the match. Until recently it didn;t matter, since there were so many more spots than US grads. As exPCM mentions, that era is coming to an end. We have already had one push for an all-in match which failed. It's interesting why it failed -- it failed because PD's were unwilling to support it, mainly because it weakens their position. From my viewpoint, it would clearly be the right thing to do for students. Then again, I'm a match believer.
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Aprog,

You many many good points, but again, I would contest that residency is unique. The market for assistant professors (in non medical settings) is very similar:

1) In many fields, a PhD without an assistant professorship is useless--e.g., if you're an English PhD, there's not a whole lot available for you employment wise other than an assistant professor job.

2) Just like residency, the pool of candidates is limited--every year, there's a graduating crop of PhDs (just as there is a graduating crop of MDs), most of whom are graduating in June, as opposed to off cycle.

3) Similarly, every year a bunch of assistant professor slots open (as their previous occupants are either given or denied tenure), and just like residency, departments face a fixed cap when offering positions--if there is 1 slot for an assistant professor, they can't have 2 people.

4) It's a matter of debate, but departments are pretty dependent on the assistant professors too--especially in a small department, if one isn't hired, then everyone else's teaching and administrative responsibilities get large.

These other markets clear just fine without a match. The only real difference is that with residency, the numbers involved are much larger--for this reason, I think the match algorithm is an efficient way to place candidates.

However, for me, it's not the match algorithm that causes antitrust issues (and hurts candidates), it's the prohibitions on negotiation and the inability to make binding contracts. And I don't see how lifting these prohibitions would hurt the match. As is, we all know that pre-match communications go on, where applicants (sometimes less than truthfully) tell programs "you're my number 1," and programs (again, sometimes less than truthfully) tell applicants "you're ranked to match,"--and, in the case of my friends, sometimes offer concessions ("if you come here, we will guarantee you a fellowship/research time/etc). But since under the NRMP, these pre-match communications are non-binding, *both* applicants *and* programs are worse off, bc neither can trust the other's communications.

Allowing programs and applicants to enter into binding contracts ("You will rank us #1 and in return we will rank you to be guaranteed to match and give you 3 months of research time, etc.") would simply formalize what goes on anyhow--and more importantly, would insure that programs (and applicants!) communicate truthfully, which can't be a bad thing. Moreover, by allowing concessions to be made, it would at least make stronger applicants better off than the current system.
 
Physio Doc 2 Be said:
Surely, the majority of PDs wouldn't be too concerned with weakening their position. I know that it is nice to be able to lock up outstanding FMGs, IMGs and DO's prior to the match, but typically isn't it weaker programs that are seeking out these candidates and giving them the "sign the pre-match contract or we won't rank you" schpiel? I would think that most PDs would be in favor of lumping everyone together in an effort to keep this kind of practice from happening, since now all the PDs have an equal shot at these candidates. I suppose, given my extremely limited understanding of the process, I don't understand how it weakens the position of the majority of PDs.
Click to expand...

The full story is this: The NRMP tried to institute an all-in policy. Unfortunately, they tried to make the "all-in" attach at the institution level -- i.e. all slots in all programs at a single institution had to agree to use the match, or all would be excluded. I assume they hoped that programs that liked using only the match would pressure programs using prematches, or that if they made "all-in" attach at the program level, that some programs which take mostly prematches would pull out altogether. In any case, PD's became worried that some programs would not agree and pull the whole institution out of the match.

The other concern raised was about visas and orientation. They argued that when you have many IMG's it's hard to get all the license and visa processing done, so they need to prematch to have some extra time.

As for "weakening positions", I have to admit that's probably my own feelings rather than based on any facts. If you take prematches and then are forced into the match, I would think that PD's might lose people who otherwise would have prematched -- i.e. they wouldn't have "risked the match" and would take the safe, but "inferior", prematch. On the other hand, it's possible that some programs could do better in the match than with prematches. It's hard to tell -- but change is always scary.

staylor21 said:
With regards to medicine, I'm less familiar, but would imagine there are two groups of people: the "stars" upon whom an institution's reputation is based, and the non-stars who are there to fulfill service requirements. I can see that in the latter case, salaries might be lower at brand name programs, as the non-stars are accepting bragging rights in lieu of financial compensation. But for the stars, I imagine compensation is higher at brand name programs, simply because it's the stars that make them "brand name."
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Assistant profs in medicine, would almost all fall in the "non-stars" category. I can only tell you that in my experience, the salaries paid by the Harvard hospitals, UCSF, etc, seem much lower than those paid by less prestigious places -- people are willing to trade "name brand" for salary.

staylor21 said:
Aprog,

You many many good points, but again, I would contest that residency is unique. The market for assistant professors (in non medical settings) is very similar:

1) In many fields, a PhD without an assistant professorship is useless--e.g., if you're an English PhD, there's not a whole lot available for you employment wise other than an assistant professor job.

2) Just like residency, the pool of candidates is limited--every year, there's a graduating crop of PhDs (just as there is a graduating crop of MDs), most of whom are graduating in June, as opposed to off cycle.

3) Similarly, every year a bunch of assistant professor slots open (as their previous occupants are either given or denied tenure), and just like residency, departments face a fixed cap when offering positions--if there is 1 slot for an assistant professor, they can't have 2 people.

4) It's a matter of debate, but departments are pretty dependent on the assistant professors too--especially in a small department, if one isn't hired, then everyone else's teaching and administrative responsibilities get large.

These other markets clear just fine without a match. The only real difference is that with residency, the numbers involved are much larger--for this reason, I think the match algorithm is an efficient way to place candidates.
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Sounds reasonable.

However, for me, it's not the match algorithm that causes antitrust issues (and hurts candidates), it's the prohibitions on negotiation and the inability to make binding contracts. And I don't see how lifting these prohibitions would hurt the match. As is, we all know that pre-match communications go on, where applicants (sometimes less than truthfully) tell programs "you're my number 1," and programs (again, sometimes less than truthfully) tell applicants "you're ranked to match,"--and, in the case of my friends, sometimes offer concessions ("if you come here, we will guarantee you a fellowship/research time/etc). But since under the NRMP, these pre-match communications are non-binding, *both* applicants *and* programs are worse off, bc neither can trust the other's communications.

Allowing programs and applicants to enter into binding contracts ("You will rank us #1 and in return we will rank you to be guaranteed to match and give you 3 months of research time, etc.") would simply formalize what goes on anyhow--and more importantly, would insure that programs (and applicants!) communicate truthfully, which can't be a bad thing. Moreover, by allowing concessions to be made, it would at least make stronger applicants better off than the current system.
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It's an interesting idea. It could potentially help residents. As I mentioned, there are some things that probably can't be negotiated for -- guaranteed fellowship slots for example. Salary may also not be negotiable. But when your vacation is, research time, research in a specific lab, etc all could be negotiated.

But, could this actually hurt residents? Perhaps. It would help residents if they are in a "stronger negotiating position" -- i.e. if the program really wants Resident A, they might be willing to offer something. But, what if the opposite is true? What if Program X has 30 people applying for each spot? Then, they could come to person A and say "You rank us #1, and we'll rank you at the top. You don't, and we won't rank you at all. Sign this contract, or walk away." I guess you could try to write rules about this to prevent it, but it seems like it would be difficult.

The honest problem here is that most residents are not in a good negotiating position. If an outstanding resident is applying for an non-competitive field / program, then they might be able to work a good deal. Otherwise, the programs hold the better hand. Without a resident in the match, I can always scramble, sign someone off cycle, or live without. Without a spot, students are screwed.
 
aProgDirector said:
The full story is this: The NRMP tried to institute an all-in policy. Unfortunately, they tried to make the "all-in" attach at the institution level -- i.e. all slots in all programs at a single institution had to agree to use the match, or all would be excluded. I assume they hoped that programs that liked using only the match would pressure programs using prematches, or that if they made "all-in" attach at the program level, that some programs which take mostly prematches would pull out altogether. In any case, PD's became worried that some programs would not agree and pull the whole institution out of the match.

The other concern raised was about visas and orientation. They argued that when you have many IMG's it's hard to get all the license and visa processing done, so they need to prematch to have some extra time.

As for "weakening positions", I have to admit that's probably my own feelings rather than based on any facts. If you take prematches and then are forced into the match, I would think that PD's might lose people who otherwise would have prematched -- i.e. they wouldn't have "risked the match" and would take the safe, but "inferior", prematch. On the other hand, it's possible that some programs could do better in the match than with prematches. It's hard to tell -- but change is always scary.
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Thanks for the back story.

It's interesting they tried to make it an all-or-none with regard to hospitals, when they would have had (IMO) a better chance going to it at the program level. IM doesn't effect GS's decision and vice versa.
 
aProgDirector said:
It's an interesting idea. It could potentially help residents. As I mentioned, there are some things that probably can't be negotiated for -- guaranteed fellowship slots for example. Salary may also not be negotiable. But when your vacation is, research time, research in a specific lab, etc all could be negotiated.

But, could this actually hurt residents? Perhaps. It would help residents if they are in a "stronger negotiating position" -- i.e. if the program really wants Resident A, they might be willing to offer something. But, what if the opposite is true? What if Program X has 30 people applying for each spot? Then, they could come to person A and say "You rank us #1, and we'll rank you at the top. You don't, and we won't rank you at all. Sign this contract, or walk away." I guess you could try to write rules about this to prevent it, but it seems like it would be difficult.
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(1) I suppose it'd be an empirical question whether salary or guaranteed fellowships are negotiable. I'd point out that right now, in anesthesia and internal medicine (and perhaps other fields), there exist formal "research" tracks at many programs which promise higher salaries and/or guaranteed fellowships. So there's certainly room for programs to make these promises, and indeed, I think (to some extent), the formal existence of these programs is to allow programs to make commitments to candidates re: higher salary and guaranteed fellowships.

(2) If a program is acting rationally (perhaps a big if), a threat to "rank us #1 or we won't rank you at all" is a non-credible threat. Since the offer to rank me #1 is binding (if I accept, the program must do it), by virtue of the fact that the program is making the offer, I know they view me as their #1 candidate. Suppose I choose not to rank them #1. They now have two options:

(a) Choose not to rank me at all (or rank me lower). This makes the program worse off, as it increases the probability that I will not match there and be replaced by someone whom they preferred less to me--granted, the differences between me and the other person may not be large, but they are running the risk of replacing me with a less preferred candidate.

(b) Rank me #1 anyway. This option is costless to the program--the worst that can happen is that I don't match there, and of course, in ranking me #1, they maximize the probability that I appear. The only potential cost is that they slip further down their rank list (which does matter for some PDs, but I'd argue this is part of behaving non-rationally).

So the program is no worse off for ranking me #1, and worse off (even if only a little bit) if it follows through on its threat--so the threat isn't a credible one. Just like candidates should rank programs based on preference, not the probability that they will get in, programs should do likewise.
 
exPCM and I agree that the match is anti-competitive and the 11th hour Frist amendment ended Jung's action, else there would be no need for the Frist amendment.

The problem is that the entire residency system is anti-competitive and aPD is absolutely correct: the students/residents get screwed. Programs, attempting to attract students, have a tremendous incentive to be dishonest. Non-binding deals become mere words without substance. Any representations are non-binding, thus may be as untruthful as necessary. On both sides. Except that the graduating students are likely more naive and less jaded than the PDs hiring. Advantage: PD

Dishonesty in the process has no penalty except potential loss of reputation by the program. The potential loss of reputation of a dishonest program can be easily squelched for many years by their PDs through intimidation, threats and termination of residents who protest. And post-residency physicians will need the dishonest PD's reference letters every time she/he seeks new credentials for the balance of their careers.

Honesty may have the penalty of sending stars to the dishonest programs, only to have the star find out they've been had after the match, bound by the match to the unscrupulous program, and forced to sign a contract nothing like what was promised and agreed. In business, we call this fraud in the inducement and is sufficient to void a contract and in some circumstances invoke treble damages.

The present system does a disservice to both the students and the programs with integrity.

The arguments about the match process aside, it is the binding of an applicant to a program without the possibility of change for a period of 3 or more years that is disastrous to highly qualified who are duped by these programs/institutions.

If the match is not fatally flawed (and this writer argues that it is indeed fatally flawed), then what is fatally flawed is that residency programs that snag a resident through the match have captured the resident for the entirety of the program. The snagged has no choice but to do whatever it takes to complete the program and get out, no matter how deceived, until the paper is in hand. Therein lies the problem.

If the (in my opinion) fatally flawed NRMP is to continue, anti-competitive as it is (else there would be no need for secret exemption amendments) then what need to happen is the following:
1.) Standardize resident rotation evaluations across all Program/PGYx.
2.) On at least a quarterly basis, require programs to deposit certified copies of all residency evaluations with a central repository, thus insuring that evaluations are complete, accurate and available to residents, and unalterable by unscrupulous institutions. [That this central repository is not only feasible, but also desirable is borne witness by ERAS (LOR, transcripts, etc) the FSMB CVS, NPDB, etc.]
3.) These standardized residency evaluations may then be used by residents desiring to seek their next year at a different program as fully recognized credit for work performed in a prior training.
4.) Eliminate the NRMP/RRC "expectation" that a resident must finish at a program she/he started but create the expectation that a resident should finish a residency.

This will help reduce the rampant dishonesty in the "courting" phase of the ERAS/NRMP. Unfortunately, this dishonesty all too often flows over into subsequent programmatic actions when residents who have been deceived protest, the net result is fear and silence which allows the system to continue.
 
3dtp said:
The problem is that the entire residency system is anti-competitive and aPD is absolutely correct: the students/residents get screwed. Programs, attempting to attract students, have a tremendous incentive to be dishonest. Non-binding deals become mere words without substance. Any representations are non-binding, thus may be as untruthful as necessary. On both sides. Except that the graduating students are likely more naive and less jaded than the PDs hiring. Advantage: PD
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Now wait a second. I never said that the students/ residents get screwed by the match process. On the contrary -- the vast majority of residents benefit from the match IMHO. I won't repeat all of those arguments here.

As far as dishonesty is concerned, most of what has been talked about in these threads is applicants feeling like they were going to be ranked higher than they were. Let's say someone is on the bottom 1/3 of my rank list. There is some chance I may match them -- I've gone down to that level in the past, let's say. But I may not. They email me and thank me for an interview. I send them back an email saying "We would be thrilled if you matched with us". What I mean by this is: if you match with us, I'd be thrilled to work with you. I want the "last person matched on my list" to be just as happy as my #1 pick.

What you may think you hear is: I'm ranked at the top of their list.

Honesty may have the penalty of sending stars to the dishonest programs, only to have the star find out they've been had after the match, bound by the match to the unscrupulous program, and forced to sign a contract nothing like what was promised and agreed. In business, we call this fraud in the inducement and is sufficient to void a contract and in some circumstances invoke treble damages.
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This would be a match violation, if the contract was truly vastly different from what you were shown prematch.

The arguments about the match process aside, it is the binding of an applicant to a program without the possibility of change for a period of 3 or more years that is disastrous to highly qualified who are duped by these programs/institutions.

If the match is not fatally flawed (and this writer argues that it is indeed fatally flawed), then what is fatally flawed is that residency programs that snag a resident through the match have captured the resident for the entirety of the program. The snagged has no choice but to do whatever it takes to complete the program and get out, no matter how deceived, until the paper is in hand. Therein lies the problem.
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You seem to be arguing something different from the match here. You're suggesting that there are malignant programs out there that, after you start working there make all sorts of changes / switches / etc, and then tell you that if you don't do them, they;ll fail you out and ruin your reputation so that you don't get another spot.

Sadly, I'm certain some programs like this exist. Luckily, I think they are rare. Also, malignant can be in the eye of the beholder. I think I'm a reasonably good PD, run a quality program, and treat people fairly. Still, I've had a few residents who would swear I'm a vindictive tyrant. We had some disagreements, and they didn't like my decisions.

If the (in my opinion) fatally flawed NRMP is to continue, anti-competitive as it is (else there would be no need for secret exemption amendments) then what need to happen is the following:
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I love someone who, instead of just complaining, has ideas!

1.) Standardize resident rotation evaluations across all Program/PGYx.
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This could certainly be done. Each rotation evaluation needs to be individual, but PD's could be required to complete an overall evaluation of each resident on some sort of a standardized form. In fact, in IM we already do this -- every year we have to summarize for the ABIM how each resident is doing. The evaluations are not very helpful -- we simply rate residents on a 1-9 scale in several domains, there are no comments or narratives but that could be changed.
2.) On at least a quarterly basis, require programs to deposit certified copies of all residency evaluations with a central repository, thus insuring that evaluations are complete, accurate and available to residents, and unalterable by unscrupulous institutions. [That this central repository is not only feasible, but also desirable is borne witness by ERAS (LOR, transcripts, etc) the FSMB CVS, NPDB, etc.]
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This also could be done. The only argument against it is that it seems to be a lot of work for potentially a small number of programs that may be malignant. The ACGME is working on a portfolio -- it's possible this could be part of it. I agree it would not be expensive nor very time consuming.
3.) These standardized residency evaluations may then be used by residents desiring to seek their next year at a different program as fully recognized credit for work performed in a prior training.
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This isn't as easy. First, many people who want to move do so in the middle of the year. Hence, you'd need to have reports like this filed more often then annually. If you were suggesting in #1 that all evaluations from all rotations be filed in some unalterable central repository, that's not going to work. Each program needs the flexibility to evaluate itself -- tools from one program often don't work well in another.

Even if there were these work reports, when you're looking at hiring someone into a complex and highly skilled position like a physician, references are key. To think that you could use some standardized form to go get a residency spot is not realistic.

Also, performance changes. Just because your performance was fine 3 months ago doesn't mean that it's fine now -- so you'd always need an updated reference.

4.) Eliminate the NRMP/RRC "expectation" that a resident must finish at a program she/he started but create the expectation that a resident should finish a residency.
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Actually, this expectation is there for residents' benefit. The idea is that programs are supposed to graduate most of those they start training. Otherwise, we could simply pick up a bunch of PGY-1's and decide to discard the bottom 50% every year.
 
aProgDirector said:
Now wait a second. I never said that the students/ residents get screwed by the match process. On the contrary -- the vast majority of residents benefit from the match IMHO. I won't repeat all of those arguments here.
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I stand corrected. What you did say was that without a spot students are screwed, and where there is no match, and no real opportunity outside The Match, they are screwed. And since the match is an exempted monopoly, the match, the LCME and the COTH do have hall the control.


aProgDirector said:
As far as dishonesty is concerned, most of what has been talked about in these threads is applicants feeling like they were going to be ranked higher than they were.
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While that is true, the OP's thesis is that the monopoly accomplishes exactly what monopolies have historically accomplished: control of supply of a vital commodity or resource, in the present instance, mandated post medical school training positions, and leverages that control into artifically lower wages for both faculty and residents and unreasonable working conditions that may not be acceptable/available in an unrestricted (ie un-monopolized) market.

Any discussion concerning the rank order list is technically off topic.



aProgDirector said:
This would be a match violation, if the contract was truly vastly different from what you were shown prematch.
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True. But, contracts incorporate by reference other documents, and those documents may not be shared, and as I have found out from direct personal experience, these referenced documents are changed, making the contract vastly different and the NRMP will not take action against an institution.


aProgDirector said:
You seem to be arguing something different from the match here. You're suggesting that there are malignant programs out there that, after you start working there make all sorts of changes / switches / etc, and then tell you that if you don't do them, they;ll fail you out and ruin your reputation so that you don't get another spot.
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I am not only suggesting this, I am stating it directly. I have seen it happen. The match monopoly allows it to continue. In defense of honest programs, at a meeting, one PD on hearing about one such program, demanded the RRC take definitive action, stating, "these guys need to be stopped because they make us all look bad." No action was taken despite clear and convincing evidence.

aProgDirector said:
Sadly, I'm certain some programs like this exist.
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They do and there is objective evidence. (JHU's and other's whose programs were threatened by the ACGME for violations, and retaliatory action taken against the reporting residents are a matter of public record.)

aProgDirector said:
Luckily, I think they are rare. Also, malignant can be in the eye of the beholder. I think I'm a reasonably good PD, run a quality program, and treat people fairly. Still, I've had a few residents who would swear I'm a vindictive tyrant. We had some disagreements, and they didn't like my decisions.
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I think you may be right, but there is no objective evidence published one way or another that these programs are rare. First the truly malignant programs can hide pretty well, again due to the nature of the present GME structure. From what I've read, although we disagree on perspective, nearly everything you've written, that I've read indicates that you are not a vindictive tyrant. But, they do exist. Unfortunately, some of them have played the political fiddle well enough to rise to program directorships, and use the nearly absolute power to exercise that tyranny.

When this happens in other professions, the solution is quite simple. Go home, update your CV, send it to the competition and change jobs. When this happens in GME, the outcome is equally simple: resident gets terminated/forced to resign under duress and goes to work stocking shelves at wal-mart. . .at least for a few years until another PD is willing to take a chance, then some, at least, prosper.


aProgDirector said:
I love someone who, instead of just complaining, has ideas!
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Thanks. A supervisor once told me, "Son, never tell me what's wrong without telling me how to fix it." He was an Admiral.


aProgDirector said:
This isn't as easy. First, many people who want to move do so in the middle of the year. Hence, you'd need to have reports like this filed more often then annually. If you were suggesting in #1 that all evaluations from all rotations be filed in some unalterable central repository, that's not going to work. Each program needs the flexibility to evaluate itself -- tools from one program often don't work well in another. Even if there were these work reports, when you're looking at hiring someone into a complex and highly skilled position like a physician, references are key. To think that you could use some standardized form to go get a residency spot is not realistic.
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I disagree. I know the ABIM is a rather simplistic model, but that can be amplified. And source documents, in the modern era can be readily and easily scanned and digitized, so hand written notes on evaluations can be included. Flexibility is reasonable, but the ultimate goal of mandatory residency should be to produce competent, independent thinking physicians. Evaluations should be significantly standardizable to insure relatively uniform outcomes by independent skilled evaluators.




aProgDirector said:
Also, performance changes. Just because your performance was fine 3 months ago doesn't mean that it's fine now -- so you'd always need an updated reference.
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It can, but usually there is an objective reason for that. There's the rub. Did performance really change? Or did someone irritate someone at some point on a bad day, and now is unredeemable?

Or as one PD told me on evaluating a potential resident, "He is competent, but he just couldn't get evaluated fairly at our program." This resident finally did go on to another program and has prospered.
 
You think that the match is a monopoly which artificially depresses wages, allows for inferior working conditions, and prevents residents from changing programs.

I agree that the match is a monopoly. Hard to argue with that -- there's one match, and everyone has to use it. But, I don't think the match has anything significant to do with low wages, working conditions, nor lack of portability. Those are created by other forces -- federal funding for GME positions, a cap on total GME positions created by the ACGME and funding, the regimented nature of residency schedules, the artificial "PGY" level system (rather than progression based upon competency), and the high stakes nature of running a program which makes PD's wary of taking transfers unless fully supported by their PD. All of these forces have nothing to do with the match, and removing the match would not fix any of them.

I think we're simply going to have to agree to disagree on that.

As far as your other points are concerned, I agree that it would be great to have a better way to allow residents to transfer -- a better way to tell the difference between a resident who simply can't do the work (which certainly exist) and those that get caught up in politics / cycle of poor evaluations / etc. You suggest a clearinghouse that would maintain records to prevent vindictive PD's from altering them. Or, perhaps a way for residents to have open access to the "raw data" of all of their evaluations, which once signed can be amended but not changed. Much like a medical record.

The best way to do this is to have the ACGME develop a web based evaluation system. We all use one now -- whether it's E*Value or New innovations or MyEvaluations.com or whatever. It would be really smart for whomever is behind in market share in these companies to partner with the ACGME, and then offer the service free to programs (presumably making money from the ACGME). Although this wouldn't capture all of the eval data, it would get a good share of it.
 
aProgDirector said:
But, I don't think the match has anything significant to do with low wages, working conditions, nor lack of portability. Those are created by other forces -- federal funding for GME positions, a cap on total GME positions created by the ACGME and funding, the regimented nature of residency schedules, the artificial "PGY" level system (rather than progression based upon competency), and the high stakes nature of running a program which makes PD's wary of taking transfers unless fully supported by their PD. All of these forces have nothing to do with the match, and removing the match would not fix any of them.
Click to expand...

Apart from federal funding per capita (which is more than generous based on our salaries!!), I don't see how the regimented nature of residencies, PGY system, etc. would all create low wages, poor working conditions, etc.

If the rules were lifted that tied us down to a match, then residents would be free to go to the places with the best conditions, and programs would have the incentive (pressure?) to behave and continually pay their employees well.

Anyway, I was doing some research on how our friendly neighbors up North do residency systems. All their residents are unionized. They've managed to negotiate strict hourly limitations, many statutory holidays off, a mandatory "5 day contiguous leave" block somewhere during Christmas/New Years for EVERY resident that has to include one of the "major" days then, wages that are about $5-10k higher, better benefits, and more. AND, they get a stipend every time they are on call. Can you imagine getting $100 extra, q4, every time you had to be at the hospital overnight? $50 for home call? On top of your salary? Interestingly they also run a multi-tiered match, allowing Canadians to have first crack, then IMG's for whatever's left.

www.pairo.org - very interesting and informative example of one such Canadian union.

Downsides: it seems much more difficult to moonlight in Canada... plus, it's also Canada. I'm sure others know more downsides.
 
Speculatrix said:
Apart from federal funding per capita (which is more than generous based on our salaries!!), I don't see how the regimented nature of residencies, PGY system, etc. would all create low wages, poor working conditions, etc.

If the rules were lifted that tied us down to a match, then residents would be free to go to the places with the best conditions, and programs would have the incentive (pressure?) to behave and continually pay their employees well.

Anyway, I was doing some research on how our friendly neighbors up North do residency systems. All their residents are unionized. They've managed to negotiate strict hourly limitations, many statutory holidays off, a mandatory "5 day contiguous leave" block somewhere during Christmas/New Years for EVERY resident that has to include one of the "major" days then, wages that are about $5-10k higher, better benefits, and more. AND, they get a stipend every time they are on call. Can you imagine getting $100 extra, q4, every time you had to be at the hospital overnight? $50 for home call? On top of your salary? Interestingly they also run a multi-tiered match, allowing Canadians to have first crack, then IMG's for whatever's left.

www.pairo.org - very interesting and informative example of one such Canadian union.

Downsides: it seems much more difficult to moonlight in Canada... plus, it's also Canada. I'm sure others know more downsides.
Click to expand...

This mostly proves my point. According to your post, and reviewing the contract I agree, residents in Ontario have what appears to be much better working conditions than their US counterparts. Yet, there is still a match in Canada. Hence, it does not appear to be the match that is the issue, but the presence of a union.

Although I am not an expert at this, it appears that all residents in Ontario are hired by the same, merged GME office. Hence, all residents in all hospitals get exactly the same salary and benefits. One resident union negotiates with a single GME office. Since US systems are fragmented, the same model would be hard to implement.

Interestingly, there are some really interesting ideas in the Ontario contract.

The one I am most intrigued by is the creation of a stepwise process for addressing resident grievences -- including first a meeting of a union rep with the PD/CEO, and then binding arbitration by an outside arbitrator.

There are some other things which are interesting / complicated:
11.6 - Apparently vacations can be taken in any block. Really? Gee -- I'm on night float, perhaps I'll take vacation then? There are vague statements that the Department can delay vacation for service needs, and it's not clear what that means.

If I had to do this, it would potentially completely change the way we make schedules. Currently, we build a year-long block schedule. By the end of next month, all of my PGY-2+3 residents will have their entire 2010-11 schedule -- all calls, all electives, etc. Addressing someone deciding 4-8 weeks in advance that they want vacation while they are assigned to the ICU would be a nightmare. But, why don't I make the schedule 3-4 months in advance. People could choose vacations 3-4 months out, and then we could simply roll the schedule along. It would also address the problem of what happens if someone drops out of the program -- since the schedule hasn't been preset, you simply build it as you go.

15.2 - Parental leave -- full pay and benefits for 37 weeks if you're a father, if I'm reading it correctly (and ? extends to 52 weeks). Wow.

Hard to completely compare salaries, as tax structures are much different in Canada. In general, the tax rates are much higher there but pay for health care and better benefits (like 37 weeks of paid leave to be with a kid)
 
aProgDirector said:
You think that the match is a monopoly which artificially depresses wages, allows for inferior working conditions, and prevents residents from changing programs.

I agree that the match is a monopoly. Hard to argue with that -- there's one match, and everyone has to use it. But, I don't think the match has anything significant to do with low wages, working conditions, nor lack of portability. Those are created by other forces -- federal funding for GME positions, a cap on total GME positions created by the ACGME and funding, the regimented nature of residency schedules, the artificial "PGY" level system (rather than progression based upon competency), and the high stakes nature of running a program which makes PD's wary of taking transfers unless fully supported by their PD. All of these forces have nothing to do with the match, and removing the match would not fix any of them.

I think we're simply going to have to agree to disagree on that.

As far as your other points are concerned, I agree that it would be great to have a better way to allow residents to transfer -- a better way to tell the difference between a resident who simply can't do the work (which certainly exist) and those that get caught up in politics / cycle of poor evaluations / etc. You suggest a clearinghouse that would maintain records to prevent vindictive PD's from altering them. Or, perhaps a way for residents to have open access to the "raw data" of all of their evaluations, which once signed can be amended but not changed. Much like a medical record.

The best way to do this is to have the ACGME develop a web based evaluation system. We all use one now -- whether it's E*Value or New innovations or MyEvaluations.com or whatever. It would be really smart for whomever is behind in market share in these companies to partner with the ACGME, and then offer the service free to programs (presumably making money from the ACGME). Although this wouldn't capture all of the eval data, it would get a good share of it.
Click to expand...

I like the final thought. It is a good idea and will certainly help.
I hope the vendors are interested enough and the ACGME likewise.

I think we agree on much more than we disagree about.

As for the closed/monopolistic nature of GME, I agree it is not just the NRMP that is the problem, but the whole way we fund/use residents. Before HCFA/CMS became involved in funding, Allen Lichter, then of the NCI/ROB now Executive Director of ASCO and former dean at UMich advocated HCFA payments for residents in response to the then new concept of capitated payments or DRGs. Allen's and other's arguments were that capitated payments shortchanged teaching hospitals, and therefore, Medicare should pay teaching hospitals more. The idea took root and institutions began getting payments from HCFA which led to university training programs adding more residents. To stop the free for all, HCFA (I'm not sure if it was CMS by this time or not) put a cap on the number of residency slots it would pay for, and later imposed payment limitations based on the present "you start a program, you finish a program," concepts.

To end this, we end the caps, we end federal funding, we end the match. Then, union or no, institutions will determine what price/working conditions etc will be required to fully staff their models of operation. Likewise, newly minted MDs will be willing to work at whatever they can get, knowing that they've just spent 4 years and a tonne of money to get a degree that is worthless without a few years of residency, due to the extremely high barriers to entry into the profession. In fact, it might work out that the institutions are better off than the desperate, given a truly free market approach.

When the ACGME in response to congress' increasing agitation for work hour limits, actually did start cracking down on serious abusers, PDs at Duke began lobbying for a PA residency, arguing not that additional training would make better PAs, but rather, the cost of MD residents would go up by 40% (loss of hours at the same pay rate), and the institutions would be better off financially if the PA residency became mandatory, thus PAs would not be subject to the caps, and they could be worked whatever hours required, at half the cost of hiring PA-Cs. Fortunately for the PAs, the PA board held their ground and refused to go along with mandatory residencies, making them optional.

It is about economics as much as it is about training, perhaps more so. That's my opinion having watched this process for better than two decades now. The only reason this system has survived as long as it has is that it is limited to 3-5 years and the financial rewards on the backside are enough to placate those who have made it through the gauntlet. As soon as that changes, and I suspect it will as AT&T and GE both today announced multi-billion dollar charges against profits in the coming quarters to pay for the new health care system taxes, squeezes on physician payments will become much greater (to wit the present SGR medicare cuts). This system will collapse unless it is fixed. The only question is when?
 
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