NRMP Match: Good, bad or ugly?

[NotAProgDirector]

This discussion started in another thread, with this post:

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.

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[HemeOncHopeful19]

I don’t have anything to add other than that other GI program sounds ridiculous IMO, what a bunch of fatheads.

 

[BoardingDoc]

I don’t have anything to add other than that other GI program sounds ridiculous IMO, what a bunch of fatheads.

It wasn't just that one program. The GI application process, before it rejoined the match, was a universally escalating arms race for applicants. It got to the point where events like the one posted above weren't rare, they were the norm. This is what prompted GI to get back into the regular match so that the insanity would stop. There's a brief but interesting read on how GI initially ditched but later rejoined the match here: The Gastroenterology Fellowship Match: A Decade Later

 

[VA Hopeful Dr]

It wasn't just that one program. The GI application process, before it rejoined the match, was a universally escalating arms race for applicants. It got to the point where events like the one posted above weren't rare, they were the norm. This is what prompted GI to get back into the regular match so that the insanity would stop. There's a brief but interesting read on how GI initially ditched but later rejoined the match here: The Gastroenterology Fellowship Match: A Decade Later

And anything competitive outside the match would eventually end up just like that given a few years.

 

[Obnoxious Dad]

Why do residency applicants have to go to the expense of traveling to programs for interviews? Why don't programs use face time to interview prospective residents?

 

[smq123]

Why do residency applicants have to go to the expense of traveling to programs for interviews? Why don't programs use face time to interview prospective residents?

Because FaceTime doesn’t allow the applicants to see the hospital and to talk to current residents. The interview day, although expensive and cumbersome, benefits the applicant as well.

Because it’s easy to fake being polite and mature during an hour long Skype interview. It’s harder to fake it for an entire day. We definitely had applicants who interviewed very well, but showed their true colors during the tour or the post interview social hour.

 

[HemeOncHopeful19]

And anything competitive outside the match would eventually end up just like that given a few years.

I don’t necessarily disagree with you, but I think it is very important to point out that the linked article does not reflect a particularly competitive period for GI outside of the match. Interestingly, it actually seems to paint GI in the mid 90s as more akin to current day Nephrology (or Radiation Oncology) in that there were so few applicants to go around that programs became desperate to secure fellows from a limited pool.

 

[Obnoxious Dad]

Because FaceTime doesn’t allow the applicants to see the hospital and to talk to current residents. The interview day, although expensive and cumbersome, benefits the applicant as well.

Because it’s easy to fake being polite and mature during an hour long Skype interview. It’s harder to fake it for an entire day. We definitely had applicants who interviewed very well, but showed their true colors during the tour or the post interview social hour.

If it's all that important to programs to press the flesh with these interviewees, then maybe the program should pick up the travel costs.

 

[VA Hopeful Dr]

If it's all that important to programs to press the flesh with these interviewees, then maybe the program should pick up the travel costs.

Sometimes they do: when I interviewed I never paid for any hotels rooms or food.

 

[Raryn]

Sometimes they do: when I interviewed I never paid for any hotels rooms or food.

Specialty dependent. Between probably 22 or 23 interviews (total for residency and fellowship) a single one provided a hotel room. Maybe just over half had a dinner the night before.

 

[deleted814217]

What would be the issue with having residency offers work the same way as applying to medical school? Med school does not have an issue filling. Make offers standardized and in waves. This isn’t the 1950s anymore either things have changed since then. Have offers sent in waves with a two week time period or something g for acceptance. this can be regulated by the acgme in a more controlled manner.
I think the match has just been around for so long people are unable to accept change and trial something else. Medicine is conservative field in terms of this. But it doesn’t have to be this way.

 

[VA Hopeful Dr]

Specialty dependent. Between probably 22 or 23 interviews (total for residency and fellowship) a single one provided a hotel room. Maybe just over half had a dinner the night before.

That's weird, my wife is the same specialty as your primary and of the five interview she went on hotel and dinner were included in all of them.

Maybe it's a regional thing?

 

[ThoracicGuy]

That's weird, my wife is the same specialty as your primary and of the five interview she went on hotel and dinner were included in all of them.

Maybe it's a regional thing?

Of the 21 interviews I did, none paid for flights, but I did have more than a few pay for hotel rooms. I think every one had a dinner the night before.

 

[VA Hopeful Dr]

Of the 21 interviews I did, none paid for flights, but I did have more than a few pay for hotel rooms. I think every one had a dinner the night before.

Yeah I've definitely never heard of travel being paid for.

 

[GoSpursGo]

What would be the issue with having residency offers work the same way as applying to medical school? Med school does not have an issue filling. Make offers standardized and in waves. This isn’t the 1950s anymore either things have changed since then. Have offers sent in waves with a two week time period or something g for acceptance. this can be regulated by the acgme in a more controlled manner.
I think the match has just been around for so long people are unable to accept change and trial something else. Medicine is conservative field in terms of this. But it doesn’t have to be this way.

As pointed out in aPD's post, this is not necessarily a good thing for applicants.

Imagine your 4th favorite program accepts you on the first day they are allowed to--they're really interested in you and want to lock you down. However, you also interviewed at 3 programs you liked better, and they're still interviewing so you're not going to get an offer from them before you need to reply to program number 4. You either need to forgo the possibility of your 3 programs you like best, or risk losing your spot at program number 4.

Having to make a decision with incomplete information is objectively bad for applicants. The match is imperfect and expensive, but at the end of the day what people lose sight of is that it ultimately DOES favor the applicant. It gives you every opportunity to match at the program that you liked the best. Ultimately I think that's the most important thing.

That's weird, my wife is the same specialty as your primary and of the five interview she went on hotel and dinner were included in all of them.

Maybe it's a regional thing?

Definitely a regional thing. Programs in the midwest definitely tended to be more likely to pay for a hotel than coastal programs.

 

[VA Hopeful Dr]

Definitely a regional thing. Programs in the midwest definitely tended to be more likely to pay for a hotel than coastal programs.

I do love that the SE isn't considered coastal. I interviewed from GA up to VA and all paid for my lodging.

 

[GoSpursGo]

Somehow we can get into medical school without a match.
Somehow we can get jobs as an attending physician without a match.
Laughable to say that we can not allow residents to get positions without a match.
Somehow University of Maryland can get it done.
Application process: Although applicants must apply through ERAS, we do not participate in the Match. Those with competitive credentials are invited in mid-summer to interview during the months of August through October, and we have rolling admissions. The program currently offers 4 positions per year.

American College of Emergency Physicians

Didactics: The University of Maryland has partnered with Washington Hospital Center, Georgetown University, the National Institutes of Health, and the Walter Reed National Medical Center to provide a unique training course in the fundamentals of critical care during the first three weeks of the...

www.acep.org

Nice for a resident to know where they are going for fellowship 9 months in advance.

You're citing a relatively noncompetitive fellowship at one program with only 4 spots as evidence? Not sure how that is generalizable to large 50+ person IM programs, or competitive surgical subspecialty residencies.

 

[NotAProgDirector]

Why do residency applicants have to go to the expense of traveling to programs for interviews? Why don't programs use face time to interview prospective residents?

We have very seriously considered this for some applicants. As already mentioned, it has pluses and minuses. Residents in IM are committing to a 3 year training program, and it may be hard for applicants to really get a sense of what the place is like without visiting. On the other hand, we considered trying to replicate the interview day via a virtual interview -- applicants get time to video chat with some residents, interview with us, a virtual tour, perhaps participate in a teaching conference, etc. It;s hard to do well -- when I participate in a meeting via WebEx / Zoom, it's never the same as being there.

What would be the issue with having residency offers work the same way as applying to medical school? Med school does not have an issue filling. Make offers standardized and in waves. This isn’t the 1950s anymore either things have changed since then. Have offers sent in waves with a two week time period or something g for acceptance. this can be regulated by the acgme in a more controlled manner.
I think the match has just been around for so long people are unable to accept change and trial something else. Medicine is conservative field in terms of this. But it doesn’t have to be this way.

Somehow we can get into medical school without a match.
Somehow we can get jobs as an attending physician without a match.
Laughable to say that we can not allow residents to get positions without a match.
Somehow University of Maryland can get it done.
Application process: Although applicants must apply through ERAS, we do not participate in the Match. Those with competitive credentials are invited in mid-summer to interview during the months of August through October, and we have rolling admissions. The program currently offers 4 positions per year.

There are several differences that make the residency application process much more challenging to manage than medical school. One key problem is that residencies have an exact target to fill. If I run a medical school that takes 100 students per class, I can probably be just fine with 95 - 105. But with residency, I need my exact quota -- one more or less becomes a problem. A second problem is time to onboarding -- it takes much longer to get a resident licensed and onboarded than a student, so I need to know whom is starting much earlier.

The wave plan has been proposed and discussed. As mentioned already, it trades the match problems noted (cost, inefficiency) with new problems. First, I'm not sure it would really cut down on applications or interviews since you wouldn't know if you'd get a position in the first wave. I guess if the first wave was early enough and you were happy with your offer, you could cancel future interviews -- but only if the first wave is early enough. In a wave system, many people will get no offers in the first wave -- whether that will help or hurt applicants is hard to say, but I expect that many people will panic. If you allow people to accept a spot but still keep interviewing for something better, then the situation becomes more unstable -- programs won't know whether people whom have accepted a position will really be coming, people will be shifting around as they drop offers and new people get offers, and it's quite possible that people won't get settled until much later than the current match day. And this sort of system definitely benefits people who interview earlier in the system. Honestly, I don't think this will help solve the problem although some people will benefit -- someone who has a clear preference for a program could interview there early and get an early spot and be done, much like my early application suggestion above.

 

[rokshana]

If it's all that important to programs to press the flesh with these interviewees, then maybe the program should pick up the travel costs.

Some do in that they pay for accommodations and meals...dinner the night before, breakfast and lunch the day of...

 

[rokshana]

Specialty dependent. Between probably 22 or 23 interviews (total for residency and fellowship) a single one provided a hotel room. Maybe just over half had a dinner the night before.

Must be regional...I applied mostly in the SE and almost every residency/fellowship interview paid for hotel and meals..only my NE residency and fellowship programs didn’t pay for hotel but still did meals.

 

[Dr. Death]

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.

A lot to unpack here.

The cost part of this is probably more in line than you think. Very few applicants are applying to only 35 programs. Thus far in my interview season I've spent $2400 on ERAS fees for 99 programs plus the racket that is the $85 USMLE transcript fee. I've attended 11 interviews thus far and with 8 more to go I anticipate spending around $7000 in travel costs, which includes driving to interviews whenever possible and a handful of programs providing hotel rooms. I applied broadly but the majority of my interviews to this point have not been in my region. So when you say that the numbers are completely ridiculous, I disagree. I know plenty of people in my class that have spent more than myself. $5000 is a conservative estimate for match season.

I think you can provide anecdotes explaining where various applicants get screwed in the current system and anecdotes where other applicants get screwed in an alternate system. The most compelling argument to me is that we don't need a match system to fill a medical school or a match system to fill attending positions. You could argue that an alternative system would benefit the best applicants but I would argue that the current system hurts the best applicants. You have top applicants being put through an expensive and stressful process when things would be so much simpler if they could just accept an offer early in the season and cancel the rest of their interviews. These would trickle down to the lesser applicants and programs would adjust to make sure they got the best applicants in their building as early as possible, much like the med school application process. The system would work a lot better if the best applicants only went on 3-4 interviews instead of clogging up 15-19 interview spots when they really would never match below their 3rd rank. Your argument includes this idea of the applicant "making up their mind." This is easily remedied by telling the applicant they have 72 hours to accept or decline the offer. Furthermore I think most applicants have an idea what programs they want to end up at before the season even begins. Obviously programs can't fill more or less spots than they have funding for, but programs can easily control this by only offering as many contracts as they have spots at a given time. If at the end of the season there are unfilled spots, they can be filled through a SOAP-style system

 

[NotAProgDirector]

A lot to unpack here.

The cost part of this is probably more in line than you think. Very few applicants are applying to only 35 programs. Thus far in my interview season I've spent $2400 on ERAS fees for 99 programs plus the racket that is the $85 USMLE transcript fee. I've attended 11 interviews thus far and with 8 more to go I anticipate spending around $7000 in travel costs, which includes driving to interviews whenever possible and a handful of programs providing hotel rooms. I applied broadly but the majority of my interviews to this point have not been in my region. So when you say that the numbers are completely ridiculous, I disagree. I know plenty of people in my class that have spent more than myself. $5000 is a conservative estimate for match season.

I think you can provide anecdotes explaining where various applicants get screwed in the current system and anecdotes where other applicants get screwed in an alternate system. The most compelling argument to me is that we don't need a match system to fill a medical school or a match system to fill attending positions. You could argue that an alternative system would benefit the best applicants but I would argue that the current system hurts the best applicants. You have top applicants being put through an expensive and stressful process when things would be so much simpler if they could just accept an offer early in the season and cancel the rest of their interviews. These would trickle down to the lesser applicants and programs would adjust to make sure they got the best applicants in their building as early as possible, much like the med school application process. The system would work a lot better if the best applicants only went on 3-4 interviews instead of clogging up 15-19 interview spots when they really would never match below their 3rd rank. Your argument includes this idea of the applicant "making up their mind." This is easily remedied by telling the applicant they have 72 hours to accept or decline the offer. Furthermore I think most applicants have an idea what programs they want to end up at before the season even begins. Obviously programs can't fill more or less spots than they have funding for, but programs can easily control this by only offering as many contracts as they have spots at a given time. If at the end of the season there are unfilled spots, they can be filled through a SOAP-style system

Perhaps my comment that the costs were "ridiculous" was a bit cavalier. It's a "worst case scenario", which some/many applicants can probably minimize to some extent. But some will spend that amount, and some more.

Applying to 99 programs seems like it's part of the problem. Even in a match-free system, not sure how to improve this (other than decreasing the cost of each application).

I agree that a match-free system would benefit top candidates. Whether there would be trickle down benefits for mid and lower tier candidates is debatable. I could imagine you'd go on an interview, and then if you don't get an offer within the first 48 hours panic would start to set in.

What's happened in the past is that lower tier/competitive programs start offering spots early. I'm OK with a 48-72 hour window to make a decision. But in this system, once you sign a contract are you "done", or if someone else then offers you a spot can you change your mind?

Perhaps comparing to the medical school application process is helpful. Imagine that you get an offer from a medical school that is only good for 48-72 hours, and is binding. What if the school you really want's interview is 3 weeks away?

 

[differentiating]

A lot to unpack here.

The cost part of this is probably more in line than you think. Very few applicants are applying to only 35 programs. Thus far in my interview season I've spent $2400 on ERAS fees for 99 programs plus the racket that is the $85 USMLE transcript fee. I've attended 11 interviews thus far and with 8 more to go I anticipate spending around $7000 in travel costs, which includes driving to interviews whenever possible and a handful of programs providing hotel rooms. I applied broadly but the majority of my interviews to this point have not been in my region. So when you say that the numbers are completely ridiculous, I disagree. I know plenty of people in my class that have spent more than myself. $5000 is a conservative estimate for match season.

I think you can provide anecdotes explaining where various applicants get screwed in the current system and anecdotes where other applicants get screwed in an alternate system. The most compelling argument to me is that we don't need a match system to fill a medical school or a match system to fill attending positions. You could argue that an alternative system would benefit the best applicants but I would argue that the current system hurts the best applicants. You have top applicants being put through an expensive and stressful process when things would be so much simpler if they could just accept an offer early in the season and cancel the rest of their interviews. These would trickle down to the lesser applicants and programs would adjust to make sure they got the best applicants in their building as early as possible, much like the med school application process. The system would work a lot better if the best applicants only went on 3-4 interviews instead of clogging up 15-19 interview spots when they really would never match below their 3rd rank. Your argument includes this idea of the applicant "making up their mind." This is easily remedied by telling the applicant they have 72 hours to accept or decline the offer. Furthermore I think most applicants have an idea what programs they want to end up at before the season even begins. Obviously programs can't fill more or less spots than they have funding for, but programs can easily control this by only offering as many contracts as they have spots at a given time. If at the end of the season there are unfilled spots, they can be filled through a SOAP-style system

What were you applying to that required 99 applications? I applied last year and 5000 was what I budgeted for apps because it was obviously excessive (most of my classmates thought I was being ridiculous)- I came in around 2500 for the entire cycle, iirc. Most people will be less than 5000, easily.

Personally, I think the match system sounds infinitely better than the alternative. Yes, it’s costly, but you get much more choice as an applicant this way. If you’re spending 3-7 years at a program, it’s nice to have a say.

 

[rokshana]

A lot to unpack here.

The cost part of this is probably more in line than you think. Very few applicants are applying to only 35 programs. Thus far in my interview season I've spent $2400 on ERAS fees for 99 programs plus the racket that is the $85 USMLE transcript fee. I've attended 11 interviews thus far and with 8 more to go I anticipate spending around $7000 in travel costs, which includes driving to interviews whenever possible and a handful of programs providing hotel rooms. I applied broadly but the majority of my interviews to this point have not been in my region. So when you say that the numbers are completely ridiculous, I disagree. I know plenty of people in my class that have spent more than myself. $5000 is a conservative estimate for match season.

I think you can provide anecdotes explaining where various applicants get screwed in the current system and anecdotes where other applicants get screwed in an alternate system. The most compelling argument to me is that we don't need a match system to fill a medical school or a match system to fill attending positions. You could argue that an alternative system would benefit the best applicants but I would argue that the current system hurts the best applicants. You have top applicants being put through an expensive and stressful process when things would be so much simpler if they could just accept an offer early in the season and cancel the rest of their interviews. These would trickle down to the lesser applicants and programs would adjust to make sure they got the best applicants in their building as early as possible, much like the med school application process. The system would work a lot better if the best applicants only went on 3-4 interviews instead of clogging up 15-19 interview spots when they really would never match below their 3rd rank. Your argument includes this idea of the applicant "making up their mind." This is easily remedied by telling the applicant they have 72 hours to accept or decline the offer. Furthermore I think most applicants have an idea what programs they want to end up at before the season even begins. Obviously programs can't fill more or less spots than they have funding for, but programs can easily control this by only offering as many contracts as they have spots at a given time. If at the end of the season there are unfilled spots, they can be filled through a SOAP-style system

So of those 99 application you put out, your 99th choice gives you the first interview and the tells you you have 48 hours to accept their offer...you going to be happy with that? And what if your interview with your first choice program is 96 hours away?

That is what happens without the match...and you do t have to go through the match...there are programs that still do a prematch/outside the match.
Why not do those?

Because they tend not to be the better programs and people like to know that they took the best shot at getting the best program.

 

[deleted814217]

Yet again medical schools do not give you 48 hours to accept their offer. I know this is what happened when there was no match. However that was decades ago at this point. There is really no way for the ACgMe to regulate it? LCME does for medical schools? Can they not handle that role or something? I don’t understand why this is tossed about as such a definitive when this is not what happens with things like say med or professional school acceptance which is what I would suggest would be a better model.
I also think it would be better to have the ability to consider multiple offers as well (as with schools).

 

[LucidSplash]

I think there are many interest perspectives and good points made in this thread. I also think there are a lot of extremes: either The Match as it currently stands or the system in place before the The Match. Certainly the system prior to The Match was broken, with students forced to committ to positions earlier and earlier while still in school, as early as the beginning as 3rd year. But now that The Match as a system is over 65 years old, although it has been modified during its lifetime, its not unreasonable to consider alternatives without assuming that would mean going back to the system pre-1952.

So, for those that think The Match is not the best solution, but agree that most people shouldn't be forced into choosing a residency before they've had clinical exposure, lay out some feasible ideas of alternatives.

 

[LucidSplash]

For anyone who hasn't read it, this is a good primer on the history of The Match and why it came into being.

The Origins, History, and Design of the Resident Match

In the early 1900s, competition among hospitals for interns and among medical students for good internships led to increasingly early offers of internships to students. By the 1940s, appointments were often made as early as the beginning of the junior year of medical school. Hospitals thus had...

jamanetwork.com

 

[Franzd'Epinay]

Yet again medical schools do not give you 48 hours to accept their offer. I know this is what happened when there was no match. However that was decades ago at this point. There is really no way for the ACgMe to regulate it? LCME does for medical schools? Can they not handle that role or something? I don’t understand why this is tossed about as such a definitive when this is not what happens with things like say med or professional school acceptance which is what I would suggest would be a better model.
I also think it would be better to have the ability to consider multiple offers as well (as with schools).

Please explain in detail the benefits that system will have over the match. The only thing you mentioned is "the ability to consider multiple offers", which is already the case in the match. You consider multiple offers and create a rank list.

 

[2021Doctor]

There are now large numbers of PA and NP residency/fellowship positions.

https://appap.org/wp-content/uploads/2019/10/APPAP-Postgraduate-PANP-Program-Membership-Roster-by-Specialty-as-of-Oct-2019.pdf

Nurse Practitioner Residency Programs & Fellowships [2021]

Nurse Practitioner Residency Programs & Fellowships By Specialization & State for 2021 | Find the best residency program for you!

www.graduatenursingedu.org

How do PAs and NPs survive without a match yet somehow eliminating the match would be the end of the world for medical students?

 

[NotAProgDirector]

Medical schools give out more offers than they have spots. If more accept than they expected, then they either have a bigger-than-expected class, or sometimes they get some students to defer a year. Residency programs don't have this type of flexibility.

NP/PA residencies are optional. Most don't complete them, and just start working.

Although I agree that the profit the AAMC makes in the application process is obscene, comparing it to rape is insensitive.

As mentioned earlier, I could imagine improving the process with an early acceptance program of some sort. The simplest option would be to allow students to apply to a single program. Another option would be 3-5 early apps -- early applicants who did not get spots would then also have an advantage for the regular spots as using one of your early apps would show increased interest in the program. But I do worry that in some fields / programs, they won't look at non-early applications.

 

[rokshana]

The match is hurting poor med students while the AAMC rakes in huge $$$$ in ERAS fees. Meanwhile we have program directors defending this rape of med students by the AAMC.
View attachment 287224

This is not rape... and apparently you have never known anyone who has been raped...otherwise you would not have made such a comparison.

 

[2021Doctor]

This is not rape... and apparently you have never known anyone who has been raped...otherwise you would not have made such a comparison.

Revised. AAMC is using their monopoly power to forcibly take advantage of medical students. What alternatives do medical students have other than to pay the ERAS fees? What are PDs doing about it? ZIP. ZERO. Because generally PDs do not spend any effort fighting against this gouging of med students. Instead PDs spend their time arguing that making fellow human beings work 28 hours in a row without sleep is not abuse.

 

[hamstergang]

Revised. AAMC is using their monopoly power to forcibly take advantage of medical students. What alternatives do medical students have other than to pay the ERAS fees? What are PDs doing about it? ZIP. ZERO. Because generally PDs do not spend any effort fighting against this gouging of med students. Instead PDs spend their time arguing that making fellow human beings work 28 hours in a row without sleep is not abuse.
View attachment 287250

You're hurting your argument about the Match by being all over the place. It sounds like you are just angry with PDs. Perhaps you can take your other gripes to another thread.

 

[Dr. Death]

What were you applying to that required 99 applications? I applied last year and 5000 was what I budgeted for apps because it was obviously excessive (most of my classmates thought I was being ridiculous)- I came in around 2500 for the entire cycle, iirc. Most people will be less than 5000, easily.

Personally, I think the match system sounds infinitely better than the alternative. Yes, it’s costly, but you get much more choice as an applicant this way. If you’re spending 3-7 years at a program, it’s nice to have a say.

This is my best chance to get a job as a physician. I'm not going to cut costs and risk going unmatched. I way over-applied and got 31 interview invites, but I'd rather be in that position than wondering if 7 interviews is going to be enough to match. But instead of putting the onus on me as an applicant to choose a program, I'm flying all over the country to 19 interviews because none of them can put pen to paper and say "you're one of our top choices, please sign." Maybe 48-72 hours isn't enough time, but the match is a 12 month cycle, there are timelines that exist where applicants can wait and make an educated decision without holding programs hostage.

 

[Dr. Death]

So of those 99 application you put out, your 99th choice gives you the first interview and the tells you you have 48 hours to accept their offer...you going to be happy with that? And what if your interview with your first choice program is 96 hours away?

That is what happens without the match...and you do t have to go through the match...there are programs that still do a prematch/outside the match.
Why not do those?

Because they tend not to be the better programs and people like to know that they took the best shot at getting the best program.

No because I would know what interviews I have coming down the pike and could make a decision if I wanted to attend more interviews and take the risk of not being offered a spot or play it conservative and take the bird in the hand. After an interview an applicant should able to say, "yes this is somewhere I want to be" or, "no, this is my 99th preferred choice"

Also I don't think pre-match offers exist anymore. If they do they are so rare that I have not heard of them occurring in the last 2 match years.

 

[Dr. Death]

Perhaps my comment that the costs were "ridiculous" was a bit cavalier. It's a "worst case scenario", which some/many applicants can probably minimize to some extent. But some will spend that amount, and some more.

Applying to 99 programs seems like it's part of the problem. Even in a match-free system, not sure how to improve this (other than decreasing the cost of each application).

I agree that a match-free system would benefit top candidates. Whether there would be trickle down benefits for mid and lower tier candidates is debatable. I could imagine you'd go on an interview, and then if you don't get an offer within the first 48 hours panic would start to set in.

What's happened in the past is that lower tier/competitive programs start offering spots early. I'm OK with a 48-72 hour window to make a decision. But in this system, once you sign a contract are you "done", or if someone else then offers you a spot can you change your mind?

Perhaps comparing to the medical school application process is helpful. Imagine that you get an offer from a medical school that is only good for 48-72 hours, and is binding. What if the school you really want's interview is 3 weeks away?

I completely agree that applicants over-applying is a part of the problem. PDs and PCs are wading through mountains of applications and LOI from students that are desperate for invites, even to programs they aren't particularly interested in. Everyone is chasing the magic number of 12 (+/- for some fields). If applicants had the flexibility to make their decision early on, their applications would get removed from the pool.

I also agree that lower tier programs would start offering early to try and snag better applicants that might be playing things conservatively. Applicants would have to quantify what level of risk they are willing to live with in order to achieve the best fit for them. Perhaps an early signing date would have to be enacted where no offers could be officially made or accepted before Halloween. That would give programs and applicants an opportunity to see one another and make a more educated decision. They could field multiple offers at one time and accept one or decline all and hope to get another offer from a later interview.

 

[rokshana]

No because I would know what interviews I have coming down the pike and could make a decision if I wanted to attend more interviews and take the risk of not being offered a spot or play it conservative and take the bird in the hand. After an interview an applicant should able to say, "yes this is somewhere I want to be" or, "no, this is my 99th preferred choice"

Also I don't think pre-match offers exist anymore. If they do they are so rare that I have not heard of them occurring in the last 2 match years.

There are ...programs that are not participating in the match do exactly that, interview and offer a contract...but not many programs do this...why? Because programs want the chance to get the best students.
If this was what most students wanted to do, then they would interview at those places...but they don’t... because again students want the opportunity to get the best possible spot for training.

Maybe a limit on the number of programs would help allow students to apply to the programs that are realistic and then programs wouldn’t need to plow through thousands of applications and could more realistically give interviews to appropriate candidates.

 

[Franzd'Epinay]

could make a decision if I wanted to attend more interviews and take the risk of not being offered a spot or play it conservative and take the bird in the hand.

The only scenario in which this is a reasonable choice is if you got an offer at one of your top programs early on in the interview cylce. This scenario would be the exception, not the norm. We shouldn't change the system for exceptions.

 

[GoSpursGo]

You could argue that an alternative system would benefit the best applicants but I would argue that the current system hurts the best applicants. You have top applicants being put through an expensive and stressful process when things would be so much simpler if they could just accept an offer early in the season and cancel the rest of their interviews.

Doesn't the current system already have plenty of benefits built in for the strongest applicants? Nobody is arguing that the costs associated with interview season are fair to anyone, but I think I care much more about making sure that everyone can make a fully-informed decision rather than allow minor convenience for the uber-competitive applicants who are already going to land at a good program under the current system.

Yet again medical schools do not give you 48 hours to accept their offer. I know this is what happened when there was no match. However that was decades ago at this point. There is really no way for the ACgMe to regulate it? LCME does for medical schools? Can they not handle that role or something? I don’t understand why this is tossed about as such a definitive when this is not what happens with things like say med or professional school acceptance which is what I would suggest would be a better model.
I also think it would be better to have the ability to consider multiple offers as well (as with schools).

As aPD stated earlier, the time required to get a resident licensed and credentialed is much longer than it takes to do whatever background checks are necessary for med school. They can't sit around for multiple months waiting for the top applicants to decide from multiple offers; if their top choices don't accept, they need to move on to the next set of applicants in relatively quick order. No matter how you slice it, you're going to wind up with a subset of applicants needing to decide to accept an offer from a mediocre program before they hear back from their top choices. I would find this unacceptable as an applicant.

And the difference between weighing multiple offers an creating a rank list is really semantics. If you have already determined that you would choose your number 1 program over all others, does it really matter if you actually get an offer from programs 2-10?

Revised. AAMC is using their monopoly power to forcibly take advantage of medical students. What alternatives do medical students have other than to pay the ERAS fees?

You COULD apply to fewer programs.

Please elaborate why PDs are doing nothing about this obscenity.

What do you suggest they do?

This is my best chance to get a job as a physician. I'm not going to cut costs and risk going unmatched. I way over-applied and got 31 interview invites, but I'd rather be in that position than wondering if 7 interviews is going to be enough to match. But instead of putting the onus on me as an applicant to choose a program, I'm flying all over the country to 19 interviews because none of them can put pen to paper and say "you're one of our top choices, please sign." Maybe 48-72 hours isn't enough time, but the match is a 12 month cycle, there are timelines that exist where applicants can wait and make an educated decision without holding programs hostage.

1) Nobody is making you go on 19 interviews. It's difficult for me to feel a ton of sympathy when you are choosing to spend money on way too many interviews.
2) It is not a 12 month cycle. ERAS opens on 9/15 because you need a couple of months to do sub-I's and aways, and as stated multiple times you can't run all the way up until 6/30 because of licensing and credentialing. Being generous, it's a 6 month cycle.

Applicants would have to quantify what level of risk they are willing to live with in order to achieve the best fit for them.

The clear alternative is that you could decide that you're willing to live with a slightly higher risk by applying to fewer programs/go on fewer interviews.

 

[Dr. Death]

Doesn't the current system already have plenty of benefits built in for the strongest applicants? Nobody is arguing that the costs associated with interview season are fair to anyone, but I think I care much more about making sure that everyone can make a fully-informed decision rather than allow minor convenience for the uber-competitive applicants who are already going to land at a good program under the current system.

As aPD stated earlier, the time required to get a resident licensed and credentialed is much longer than it takes to do whatever background checks are necessary for med school. They can't sit around for multiple months waiting for the top applicants to decide from multiple offers; if their top choices don't accept, they need to move on to the next set of applicants in relatively quick order. No matter how you slice it, you're going to wind up with a subset of applicants needing to decide to accept an offer from a mediocre program before they hear back from their top choices. I would find this unacceptable as an applicant.

And the difference between weighing multiple offers an creating a rank list is really semantics. If you have already determined that you would choose your number 1 program over all others, does it really matter if you actually get an offer from programs 2-10?


You COULD apply to fewer programs.

What do you suggest they do?

1) Nobody is making you go on 19 interviews. It's difficult for me to feel a ton of sympathy when you are choosing to spend money on way too many interviews.
2) It is not a 12 month cycle. ERAS opens on 9/15 because you need a couple of months to do sub-I's and aways, and as stated multiple times you can't run all the way up until 6/30 because of licensing and credentialing. Being generous, it's a 6 month cycle.

The clear alternative is that you could decide that you're willing to live with a slightly higher risk by applying to fewer programs/go on fewer interviews.

It's very easy for you to sit where you are and tell applicants to apply to fewer programs and go on fewer interviews. But the reality is that if we don't match we're saddled with hundreds of thousands in student loan debt and the prospect of SOAPing or reapplying next year with far worse odds of matching.

 

[gutonc]

It's very easy for you to sit where you are and tell applicants to apply to fewer programs and go on fewer interviews. But the reality is that if we don't match we're saddled with hundreds of thousands in student loan debt and the prospect of SOAPing or reapplying next year with far worse odds of matching.

If the data weren't available to let you know the point of diminishing returns on the rank list side of things, then I'd agree with you. But that data is easily available. I certainly wouldn't suggest riding the ragged edge (i.e. only interviewing/ranking whatever # of programs will statistically give you a 95%+ chance of matching), but unless you're an IMG going for integrated plastics and couples matching with another IMG shooting for ortho, 19 ranks is well beyond where that curve flattens out.

 

[Dr. Death]

The only scenario in which this is a reasonable choice is if you got an offer at one of your top programs early on in the interview cylce. This scenario would be the exception, not the norm. We shouldn't change the system for exceptions.

I think this describes more applicants than you think. When applying for medical school I know plenty of people, including myself, that went on 3-4 interviews, got an offer from a "good enough" school, accepted it and cancelled the rest. There are plenty of low or mid-tier programs and applicants that would be thrilled to get an offer early in the season, save themselves the stress and cost and commit to a program. As currently constituted the system primarily benefits ERAS and the NRMP who collect boatloads of money from individuals whose futures are at stake and no alternatives.

 

[Dr. Death]

If the data weren't available to let you know the point of diminishing returns on the rank list side of things, then I'd agree with you. But that data is easily available. I certainly wouldn't suggest riding the ragged edge (i.e. only interviewing/ranking whatever # of programs will statistically give you a 95%+ chance of matching), but unless you're an IMG going for integrated plastics and couples matching with another IMG shooting for ortho, 19 ranks is well beyond where that curve flattens out.

You're right. But I'm not trying to be in the 5% or 1% that has their career goals ruined by not matching. If I had an offer right now I'd cancel the rest of my interviews and those could go to other applicants.

 

[Giovanotto]

These are the type of posts that bring me to SDN. Thank you for sharing your thoughts on the matter and starting this discussion aProgDirector!

 

[Giovanotto]

If the data weren't available to let you know the point of diminishing returns on the rank list side of things, then I'd agree with you. But that data is easily available. I certainly wouldn't suggest riding the ragged edge (i.e. only interviewing/ranking whatever # of programs will statistically give you a 95%+ chance of matching), but unless you're an IMG going for integrated plastics and couples matching with another IMG shooting for ortho, 19 ranks is well beyond where that curve flattens out.

Why not? Why even look at the data if you're not going to use it to your advantage then.

 

[mvenus929]

Specialty dependent. Between probably 22 or 23 interviews (total for residency and fellowship) a single one provided a hotel room. Maybe just over half had a dinner the night before.

I think about 2/3 of programs I interviewed at (for residency and fellowship) put me up in a hotel and took me out to eat somewhere. The rest took me out to eat, but made me find my own housing. Interestingly, the programs out west were more likely to not give me a hotel room. One of my fellowship interviews even compensated $300 in travel expenses.

GI fellowships are not comparable to most fields. People here are attempting to use one hypercompetitive field (GI) and portray it as representative of fellowships in general.

I think there are many interest perspectives and good points made in this thread. I also think there are a lot of extremes: either The Match as it currently stands or the system in place before the The Match. Certainly the system prior to The Match was broken, with students forced to committ to positions earlier and earlier while still in school, as early as the beginning as 3rd year. But now that The Match as a system is over 65 years old, although it has been modified during its lifetime, its not unreasonable to consider alternatives without assuming that would mean going back to the system pre-1952.

So, for those that think The Match is not the best solution, but agree that most people shouldn't be forced into choosing a residency before they've had clinical exposure, lay out some feasible ideas of alternatives.

Peds Endo just entered the fellowship match a few years ago (like, 2017, I think). I wasn’t in it before the match, but I’ve heard lots of stories about how people would be signing contracts for fellowship in the middle of their second year of residency (granted, half of peds fellowship matches were spring matches, meaning you applied in January of your second year). And Peds Endo is remarkably non-competitive—there are about 20-30 more positions than there are applicants every year.

Also I don't think pre-match offers exist anymore. If they do they are so rare that I have not heard of them occurring in the last 2 match years.

They exist, but I think for residency, it’s all or nothing in the match. So if you’re applying in the match, that program doesn’t do pre-match offers, but there are others who are not in the match and exclusively do ‘pre-match’ offers.

 

[GoSpursGo]

It's very easy for you to sit where you are and tell applicants to apply to fewer programs and go on fewer interviews. But the reality is that if we don't match we're saddled with hundreds of thousands in student loan debt and the prospect of SOAPing or reapplying next year with far worse odds of matching.

I’m not THAT old—I’ve applied through ERAS twice this decade, once for residency and once for fellowship and am still living on a training salary. Both times I interviewed at more programs than I needed to and spent a painful amount of money. Heck, for one of my residency interviews I flew there, checked into my not-paid-for hotel, and then had to cancel my interview because I woke up with a 104 fever and uncontrollable vomiting (they didn’t even reschedule me).

So I have plenty of empathy for this process. But for the reasons I’ve said, I can’t really get behind anything that gives FURTHER advantage to applicants who are already highly qualified..

 

[gutonc]

You're right. But I'm not trying to be in the 5% or 1% that has their career goals ruined by not matching. If I had an offer right now I'd cancel the rest of my interviews and those could go to other applicants.

19 doesn't guarantee a match either. Just sayin'.

 

[gutonc]

Why not? Why even look at the data if you're not going to use it to your advantage then.

My point was simply that a little buffer is reasonable. If 7 programs gives you a 95% chance of matching, going to look at 10 is not unreasonable. If OTOH you go on 19 and then b***h about how much it costs, you're being disingenuous and a bit of a princess.

 

[differentiating]

This is my best chance to get a job as a physician. I'm not going to cut costs and risk going unmatched. I way over-applied and got 31 interview invites, but I'd rather be in that position than wondering if 7 interviews is going to be enough to match. But instead of putting the onus on me as an applicant to choose a program, I'm flying all over the country to 19 interviews because none of them can put pen to paper and say "you're one of our top choices, please sign." Maybe 48-72 hours isn't enough time, but the match is a 12 month cycle, there are timelines that exist where applicants can wait and make an educated decision without holding programs hostage.

But, as others have said, applying to 99 programs is grossly excessive unless you’re an IMG or couples matching into competitive specialties. There’s data on the point of diminishing returns for applicants in various specialties, plus you can get an idea as to what to aim for by looking at prior matched applicants from your school and talking with advisors. I applied to 15 programs based on the aforementioned information and safely matched, and didn’t ever feel like I’d applied to too few.