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This discussion started in another thread, with this post:
The match is one way to distribute students into residency slots. There certainly are others. Choosing a new path will create winners and losers, and hence assessing whether a different mechanism is "better" or not is complicated.
Let's take what's suggested here -- a free market. Each student just applies, interviews, gets offer(s), and picks what they want. For a student who has a clear #1 choice who gets to interview early at that program, get a spot, sign a contract, and done -- definitely a huge win. But not everybody wins. What tends to happen in such a system is that the best candidates get all of the offers up front -- middle of the road candidates and anyone in the bottom third get nothing while those hoarding offers at the top make up their minds. Someone applying to two fields might get an offer in their backup, and be stuck either taking it or hoping for something better. Contracts may include a financial penalty for cancellation - much like if you try to get out of a lease. Programs are extremely limited in the number of interns we can take -- if my program has 10 slots, I can take 10 interns -- I can't take 11, nor will I function well with 9. IMG's who require visas need offers early enough to get them, which is increasingly difficult with the current timeline as it is.
As mentioned in the other thread, we recently had this situation in the IM fellowship application process. Gastroenterology was the worst. One of my top resident applicants -- chief resident, lots of research, outstanding USMLE, etc -- applied to GI. He got an interview at a neighboring program and went, it was fine but he wanted to stay with us. Got a phone call while driving home from the PD -- offered him a position, take it or leave it. He begged for 24 hours to discuss with his wife, which they reluctantly gave him. He called our PD, told them that he was going to take the spot unless they offered him one in the next 24 hours -- and this was before our program had their first interview day. They interviewed him the next day and gave him the spot. He called the other program and declined -- they then called us and told us they would never give anyone 24 hours again. We then called all of the people we had invited for interviews and told them not to bother to come -- the spot was gone. They lost any airline or other travel fees they had paid. They then all panicked (as would be expected) and called all of their interview offers asking to move up their interview days. It was horrific.
That's another problem with a "free market" solution -- interviewing early is a huge advantage, spots disappear as time goes along. And, if you're couple's matching, a free market is a huge problem since the timeline of offers may not line up at all.
I think the calculations above (which are from the linked article) are also ridiculous for most people. Most people don't get a $300 flight to each interview -- many interview regionally and/or batch interviews together, although I admit that's not completely possible in some fields. Some fields help fund hotel costs. If you can find a cheap place to stay, you can interview at a bunch of programs in the same geographic area at a much lower cost.
Now, all that said, there are problems with the match and application process. If someone has a clear preference for a single program, they are stuck interviewing at a bunch of programs to ensure a match unless their chosen program volunteers to rank them at the top of their list and the applicant believes them. ERAS application inflation has created an increasing problem where programs get so many applications they need to either superficially review them, rely on easily assessed objective measures (i.e. USMLE scores, AOA), or make decisions on minor aspects of applications. Programs have no way of telling whom is serious, and whom is just applying.
I wonder if the NRMP match can be improved by adding an early decision option. You can apply to a single program, or perhaps 2-3 programs, and then they can offer you a spot. By limiting to a small number of programs, we would know that you're serious. if it was a single program, we could make it binding much like the early decision programs at many colleges. I'd limit programs to filling no more than 1/3 of their slots this way (somewhere between 20-40% seems right), that way not all the spots can be filled in an early round.
Would this help? Hard to tell -- as I mentioned, any change just generates new winners and losers. I expect that all residents would apply for an early position, even if we made it a single binding application. Students might agonize over whether they should use their early app to try to get a spot at their "dream" program, or whether that's a waste and they should use it at a "safety" -- exactly the problem the match is trying to prevent. If we have applicants apply to 2-3 programs, each program could offer 1/3 of their slots -- but if any applicants turn them down, then they don't get to re-offer, those slots just go into the regular match -- and again what might happen is that the best applicants get all of the offers. Not matching is relatively rare for US grads, but not getting an early spot would be the majority -- could make the process worse. Unlikely to save anyone application fees, unless the early applications were long before Sept 15th -- since you wouldn't know if you were going to get an early spot you'd still have to apply to a bunch of programs, so this won't help application inflation, although it might take 20% of the applicants out of the main match and free up more interview slots for those that are left.
Gotta love how PDs try to see the match as being something good. The match forces students to spend big bucks doing multiple interviews. Compare this to my fellowship where there was no match and I went on one interview and got the job the same day.
As stated above:
"The Court finds that plaintiffs adequately have alleged a common agreement to displace competition in the recruitment, hiring, employment and compensation of resident physicians and to impose a scheme of restraints that has the purpose and effect of fixing, artificially depressing, standardizing and stabilizing resident physician compensation and other terms of employment among certain defendants"
Although most medical school graduates accept that participating in the match and a residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME) is the only way to become a licensed physician, a small group of physicians sought to challenge this system through legal action starting in 2002 with Jung v. Association of American Medical Colleges (AAMC)—a case that ultimately led to the legal solidification of this system for the foreseeable future .
Anticompetitive claims. The resident plaintiffs argued that the organizational and institutional defendants, through the match, had imposed anticompetitive restraints on medical residency placement and hiring by quashing the prospective residents’ ability to negotiate the terms of their employment contracts, resulting in fixed and depressed compensation packages [4]. The legal basis for the residents’ claim was that it violated Section 1 of the Sherman Antitrust Act, which holds that “Every contract…or conspiracy, in restraint of trade or commerce among the several States, or with foreign nations, is declared to be illegal” [5]. The Sherman Act is one of three core federal antitrust laws that regulate commerce in the United States, but some violations of the act may not necessarily be deemed illegal if the parties involved in the suspect activity can demonstrate that the restraint on trade is reasonable [6].
The legal challenge to the match and accredited residency programs was a bold attempt at reshaping a critical stepping stone in medical education and training in the United States. It revealed not only the frustrations many medical students and physicians experience with the current system but also the staunch resistance of those who oversee that system to substantial alteration of a process that has been in place for more than 60 years.
Challenging the Medical Residency Matching System through Antitrust Litigation
The legal challenge to the residency training system and the match by which medical school graduates are assigned to residency programs alleged that they impose anticompetitive restraints on medical residency placement, hiring, and salaries. The challenge was dismissed in federal court in 2004.journalofethics.ama-assn.org
Financially, the Match is devastating. Assume a student applies for 35 programs in one specialty, receives 20 interview offers and accepts 12; these are conservative estimates in competitive specialties, in applicants ‘couples-matching’ with a spouse and in specialties requiring a separate ‘preliminary’ internship.
In application fees, this student will spend $465. The 12 interviews, each requiring a $50 motel, a $50 car rental and a $300 flight, cost this student $4,800. All in, this student has spent $5,265 on the Match, against $250,000 in existing student debt. Assuming a Federal Stafford Loan with 6.8% interest paid in 10 years, $5,265 becomes $7,470.76.
With a 15% tax rate, $7,470.76 becomes $8,789.13 in pre-tax income. With 34,270 active applicants in the Match in 2014, $302 million is wasted annually, in the setting of tight graduate medical education funding, increasing student debt and decreasing physician reimbursement.
$35,000 lost in salary
In addition, the Match precludes an applicant from negotiating their salary or contract in any way. Dual degrees (MD/JD, MD/MBA, MD/MPH) are ever-increasing and many applicants will bring additional value to their hospital, yet are unable to be compensated for it. Additionally, it precludes less competitive applicants from accepting lower salary or early offers in exchange for a position.
Jung v. AAMC in 2003 challenged the Match on antitrust grounds, claiming that the collusion of hospitals within the Match artificially depressed wages. In response, Congress passed an explicit exemption for NRMP through the Pension Funding Equity Act of 2004, making legal challenges moot.
Few other professions utilize this double-binding match, and in explaining the Match to those unfamiliar with medical training, the closest relatable comparison is sorority rush. However, the stakes are a bit higher than selecting Greek letters, and we are physicians, not teenagers. For the good of our profession, our patients, and our future protégés, it’s about time to trash the Match.
How A Nobel Economist Ruined The Residency Matching System For Newly Minted M.D.'s
This year, 5.6% of US allopathic (MD) seniors did not match, and 22.3% of US osteopathic (DO) seniors did not match. On the whole, 25.0% of applicants in the NRMP Match did not match – with a 25% unemployment rate, how successful is the Match, really?www.forbes.com
The match is one way to distribute students into residency slots. There certainly are others. Choosing a new path will create winners and losers, and hence assessing whether a different mechanism is "better" or not is complicated.
Let's take what's suggested here -- a free market. Each student just applies, interviews, gets offer(s), and picks what they want. For a student who has a clear #1 choice who gets to interview early at that program, get a spot, sign a contract, and done -- definitely a huge win. But not everybody wins. What tends to happen in such a system is that the best candidates get all of the offers up front -- middle of the road candidates and anyone in the bottom third get nothing while those hoarding offers at the top make up their minds. Someone applying to two fields might get an offer in their backup, and be stuck either taking it or hoping for something better. Contracts may include a financial penalty for cancellation - much like if you try to get out of a lease. Programs are extremely limited in the number of interns we can take -- if my program has 10 slots, I can take 10 interns -- I can't take 11, nor will I function well with 9. IMG's who require visas need offers early enough to get them, which is increasingly difficult with the current timeline as it is.
As mentioned in the other thread, we recently had this situation in the IM fellowship application process. Gastroenterology was the worst. One of my top resident applicants -- chief resident, lots of research, outstanding USMLE, etc -- applied to GI. He got an interview at a neighboring program and went, it was fine but he wanted to stay with us. Got a phone call while driving home from the PD -- offered him a position, take it or leave it. He begged for 24 hours to discuss with his wife, which they reluctantly gave him. He called our PD, told them that he was going to take the spot unless they offered him one in the next 24 hours -- and this was before our program had their first interview day. They interviewed him the next day and gave him the spot. He called the other program and declined -- they then called us and told us they would never give anyone 24 hours again. We then called all of the people we had invited for interviews and told them not to bother to come -- the spot was gone. They lost any airline or other travel fees they had paid. They then all panicked (as would be expected) and called all of their interview offers asking to move up their interview days. It was horrific.
That's another problem with a "free market" solution -- interviewing early is a huge advantage, spots disappear as time goes along. And, if you're couple's matching, a free market is a huge problem since the timeline of offers may not line up at all.
I think the calculations above (which are from the linked article) are also ridiculous for most people. Most people don't get a $300 flight to each interview -- many interview regionally and/or batch interviews together, although I admit that's not completely possible in some fields. Some fields help fund hotel costs. If you can find a cheap place to stay, you can interview at a bunch of programs in the same geographic area at a much lower cost.
Now, all that said, there are problems with the match and application process. If someone has a clear preference for a single program, they are stuck interviewing at a bunch of programs to ensure a match unless their chosen program volunteers to rank them at the top of their list and the applicant believes them. ERAS application inflation has created an increasing problem where programs get so many applications they need to either superficially review them, rely on easily assessed objective measures (i.e. USMLE scores, AOA), or make decisions on minor aspects of applications. Programs have no way of telling whom is serious, and whom is just applying.
I wonder if the NRMP match can be improved by adding an early decision option. You can apply to a single program, or perhaps 2-3 programs, and then they can offer you a spot. By limiting to a small number of programs, we would know that you're serious. if it was a single program, we could make it binding much like the early decision programs at many colleges. I'd limit programs to filling no more than 1/3 of their slots this way (somewhere between 20-40% seems right), that way not all the spots can be filled in an early round.
Would this help? Hard to tell -- as I mentioned, any change just generates new winners and losers. I expect that all residents would apply for an early position, even if we made it a single binding application. Students might agonize over whether they should use their early app to try to get a spot at their "dream" program, or whether that's a waste and they should use it at a "safety" -- exactly the problem the match is trying to prevent. If we have applicants apply to 2-3 programs, each program could offer 1/3 of their slots -- but if any applicants turn them down, then they don't get to re-offer, those slots just go into the regular match -- and again what might happen is that the best applicants get all of the offers. Not matching is relatively rare for US grads, but not getting an early spot would be the majority -- could make the process worse. Unlikely to save anyone application fees, unless the early applications were long before Sept 15th -- since you wouldn't know if you were going to get an early spot you'd still have to apply to a bunch of programs, so this won't help application inflation, although it might take 20% of the applicants out of the main match and free up more interview slots for those that are left.
