Why does the scramble exist?

[DeadCactus]

It seems idiotic at best.

"We're going to use an elaborate system of computer based matching to decide where people go for residency. But when that doesn't work, we'll turn it into the equivalent of a radio show giving a way concert tickets."

Do the residency programs just not care who they get by that point? Why not give a day for people to send their applications in and the just handpick the person?

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[Droopy Snoopy]

It seems idiotic at best.

"We're going to use an elaborate system of computer based matching to decide where people go for residency. But when that doesn't work, we'll turn it into the equivalent of a radio show giving a way concert tickets."

Do the residency programs just not care who they get by that point? Why not give a day for people to send their applications in and the just handpick the person?

Better a radio show giveaway for those few slots than a radio show giveaway for all the spots (which is how it used to be). Besides, the way you're suggesting would throw tremendous advantage to the programs, whereas the current system sucks equally for both parties. But yeah, the scramble stinks because by that point panic generally gets the better of everyone. I had a friend who was forced to scramble for a prelim gensurg spot. Our school allowed a friend to help the person phone around, fax, generally help do the legwork on scramble day. The atmosphere in that little room (there were 3 others) was extremely depressing.

These are usually not bottom of the barrel med studs; they're usually very good students who overestimated their worth and didn't interview at enough places or have a backup plan. You work hard for years, have massive debt, did well on exams and clerkships, imagine how big of an ego knock it is finding you might be working a Burger King in a couple of months. Everybody in your class is going to talk about you (in your mind), feel sorry for you, think differently about you, all this and you've been the sharpest pencil in the box for your whole life. Maybe you feel like you've let people down, let yourself down, etc.

Not surprising then that AOA, 230+ Step ENT-wannabees jump at the first malignant, across-country, inner-city prelim surg spot that gets thrown their way. The programs in turn sometimes knowingly hire substandard residents in order to cover their patient responsibilities and collect Medicare funding. Plus if a program doesn't fill it can get an unwarranted reputation as inferior or malignant.

 

[Knicks]

Better a radio show giveaway for those few slots than a radio show giveaway for all the spots (which is how it used to be). Besides, the way you're suggesting would throw tremendous advantage to the programs, whereas the current system sucks equally for both parties. But yeah, the scramble stinks because by that point panic generally gets the better of everyone. I had a friend who was forced to scramble for a prelim gensurg spot. Our school allowed a friend to help the person phone around, fax, generally help do the legwork on scramble day. The atmosphere in that little room (there were 3 others) was extremely depressing.

These are usually not bottom of the barrel med studs; they're usually very good students who overestimated their worth and didn't interview at enough places or have a backup plan. You work hard for years, have massive debt, did well on exams and clerkships, imagine how big of an ego knock it is finding you might be working a Burger King in a couple of months. Everybody in your class is going to talk about you (in your mind), feel sorry for you, think differently about you, all this and you've been the sharpest pencil in the box for your whole life. Maybe you feel like you've let people down, let yourself down, etc.

Not surprising then that AOA, 230+ Step ENT-wannabees jump at the first malignant, across-country, inner-city prelim surg spot that gets thrown their way. The programs in turn sometimes knowingly hire substandard residents in order to cover their patient responsibilities and collect Medicare funding. Plus if a program doesn't fill it can get an unwarranted reputation as inferior or malignant.

I might have lost a few years of my life-span just by reading that depressing piece of text.

 

[robrobbberts]

I might have lost a few years of my life-span just by reading that depressing piece of text.

I know! Something to look forward to.

 

[Superfrost]

I might have lost a few years of my life-span just by reading that depressing piece of text.

Why is it depressing? Don't be cocky. Apply broadly, keep your application in perspective and take the interview seriously. Things will work out nicely.

 

[ACSurgeon]

Why is it depressing? Don't be cocky. Apply broadly, keep your application in perspective and take the interview seriously. Things will work out nicely.

Because students are often faced with a tough decision: do they 'overshoot' and face the risk of not matching (depressing) or 'undershoot' and live the rest of their lives feeling like they could have done better (also depressing). It's not about being cocky, but the reality of it is that there is inherent risk in the match process that leaves many bright students with nothing or with a terrible spot of their second or third choice specialty. Finally, it's not as easy to double apply as you might think.

Things will work out nicely.

You are correct that statistically speaking, any student has a significantly higher chance of matching than not (P>0.05 )

 

[Superfrost]

Because students are often faced with a tough decision: do they 'overshoot' and face the risk of not matching (depressing) or 'undershoot' and live the rest of their lives feeling like they could have done better (also depressing). It's not about being cocky, but the reality of it is that there is inherent risk in the match process that leaves many bright students with nothing or with a terrible spot of their second or third choice specialty. Finally, it's not as easy to double apply as you might think.



You are correct that statistically speaking, any student has a significantly higher chance of matching than not (P>0.05 )

Sounds like you should just apply to urology AND gen surg then.

 

[Law2Doc]

Sounds like you should just apply to urology AND gen surg then.

See his/her sentence about it not being easy to "doubly apply". It takes more interview time than most people have to adequately interview for multiple fields. Some people do it, but they spend thousands of dollars and go on a crazy number of interviews. Better to figure out what you want to go into and put all your horses onto one cart and apply as broadly as possible in that field. But you have to be realistic, and talk to lots of folks in the field. Most mentors will be honest with you and tell you if you are taking a million to one shot or something realistic.

 

[ACSurgeon]

Sounds like you should just apply to urology AND gen surg then.

haha... I should have seen that coming

You should also see the part where I talk about gen surg being the more interesting of the two (to me anyways), and urology really being tempting for the lifestyle and money, which to me was not worth the risk. Thanks for the advice, though

 

[Knicks]

Why is it depressing? Don't be cocky.

Huh? Wha?

what the hell are you blabbering about?, "cocky".

 

[mig26x]

in all honesty is pretty shocking that in the year 2010 the scramble is the best thing we have to fill unfilled programs.

its very primitive.

 

[countingdays]

The match and the scramble are set up to benefit the programs at the expense of med students. Without the match, you would interview for jobs and they would have to sell themselves to you and try to convince you to commit to working there. You'd be in a position of strength because there would be lots of other programs interested in having you (for all they know). You would interview at the best programs first and work your way down. If you got a job at a top program, you would take it and save lots of time and money by not traveling to and interviewing with lesser programs. If you didn't get a job right away, there would still be lots of jobs out there for you to apply to.

With the match, all the jobs disappear on the same day. If you don't have a spot on that day you are in trouble. It puts you in the weaker position when interviewing pre-match because you are desperate for the programs to rank you highly. You don't find out until it's too late whether you should have applied to more programs or less desirable programs. If so, you are totally screwed while the programs are just fine.

The scramble is a way to ensure that even terrible jobs get filled due to the despiration of unmatched medical students. The programs get as much money and as many cheap employees as possible.

 

[BlondeDocteur]

The match and the scramble are set up to benefit the programs at the expense of med students. Without the match, you would interview for jobs and they would have to sell themselves to you and try to convince you to commit to working there. You'd be in a position of strength because there would be lots of other programs interested in having you (for all they know). You would interview at the best programs first and work your way down. If you got a job at a top program, you would take it and save lots of time and money by not traveling to and interviewing with lesser programs. If you didn't get a job right away, there would still be lots of jobs out there for you to apply to.

With the match, all the jobs disappear on the same day. If you don't have a spot on that day you are in trouble. It puts you in the weaker position when interviewing pre-match because you are desperate for the programs to rank you highly. You don't find out until it's too late whether you should have applied to more programs or less desirable programs. If so, you are totally screwed while the programs are just fine.

The scramble is a way to ensure that even terrible jobs get filled due to the despiration of unmatched medical students. The programs get as much money and as many cheap employees as possible.

Unfortunately, that's not the way it works. Because of the nature of our training, residency is the only option for doing anything as a physician. Unlike, say, law grads who have the option of clerking, working for small firms, working for big firms, going nonprofit, etc, we've only got one thing going on. So the whole normal "weighing competing job offers thing" just doesn't work for us.

The pre-Match system was completely-- and I mean 100%-- in favor of the hospitals. Very desirable students (based on which med school they attended, mostly) were recruited by residencies as early as their second year of school, and they were given "exploding offers." Imagine the position that put you in as a top candidate-- you've done well in your preclinical years, and you think you might be interested in (say) Medicine, and along comes MGH saying "let's sign you up." You have a week to respond. If you say yes, you might find later that you have no aptitude for medicine and wish to become a pediatrician, but you're stuck-- and all the good peds spots are snapped up anyway. If you say no then you have no chance at matching at MGH, ever.

On the flip side poorer candidates would often graduate medical school with no job offers. They would literally be notified 1-2 days before residency began that there was a vacancy at a program and their candidacy was accepted. As you can see, it was total chaos, and applicants had almost no leverage.

The Scramble is changing next year to this weird quasi-match system they're calling the "managed scramble." I am very lamely interested in all of this and actually had a long email back-and-forth last year with Mona Singer, the woman at the NRMP in charge of changing this. I still think a second match-- minus in-person interviews-- would be beneficial to all parties, as it removes the dreadful time crunch and 'exploding offer' nature of the Scramble. Without the sensation that positions are literally disappearing from around you as the clock ticks (and 90% of open positions are filled within the first 4 hours) both programs and applicants can be sure they're making a reasoned choice and maximizing their utility curves.

I helped someone (an FMG with no one else in the US) scramble last year, and the radio call-in analogy is spot-on. It sucked donkey balls.

 

[Eta Carinae]

Because students are often faced with a tough decision: do they 'overshoot' and face the risk of not matching (depressing) or 'undershoot' and live the rest of their lives feeling like they could have done better (also depressing). It's not about being cocky, but the reality of it is that there is inherent risk in the match process that leaves many bright students with nothing or with a terrible spot of their second or third choice specialty. Finally, it's not as easy to double apply as you might think.



You are correct that statistically speaking, any student has a significantly higher chance of matching than not (P>0.05 )

Overshooting would be the cause of many instances of not matching.

Which is why when people come on a PMB like this and ask about their "chances", knowing fully well that they're not competitive for a desired specialty (ie "I'm a team player and everyone likes me but my step 1 was 216...whaddaya think? Plastics?" ), it drives me nuts when responders paint a caricature, 'well-it-happened-for-me' picture that represents anything but the norm.

Your best assessment of your potential to match will always come from your dean. Not some anonymous guy who knows someone who has a cousin who's married to someone who hangs out with this guy that made <200 Step 1 and still matched derm.


PS: Pardon the run-on

 

[countingdays]

Unfortunately, that's not the way it works. Because of the nature of our training, residency is the only option for doing anything as a physician. Unlike, say, law grads who have the option of clerking, working for small firms, working for big firms, going nonprofit, etc, we've only got one thing going on. So the whole normal "weighing competing job offers thing" just doesn't work for us.

The pre-Match system was completely-- and I mean 100%-- in favor of the hospitals. Very desirable students (based on which med school they attended, mostly) were recruited by residencies as early as their second year of school, and they were given "exploding offers." Imagine the position that put you in as a top candidate-- you've done well in your preclinical years, and you think you might be interested in (say) Medicine, and along comes MGH saying "let's sign you up." You have a week to respond. If you say yes, you might find later that you have no aptitude for medicine and wish to become a pediatrician, but you're stuck-- and all the good peds spots are snapped up anyway. If you say no then you have no chance at matching at MGH, ever.

On the flip side poorer candidates would often graduate medical school with no job offers. They would literally be notified 1-2 days before residency began that there was a vacancy at a program and their candidacy was accepted. As you can see, it was total chaos, and applicants had almost no leverage.

The Scramble is changing next year to this weird quasi-match system they're calling the "managed scramble." I am very lamely interested in all of this and actually had a long email back-and-forth last year with Mona Singer, the woman at the NRMP in charge of changing this. I still think a second match-- minus in-person interviews-- would be beneficial to all parties, as it removes the dreadful time crunch and 'exploding offer' nature of the Scramble. Without the sensation that positions are literally disappearing from around you as the clock ticks (and 90% of open positions are filled within the first 4 hours) both programs and applicants can be sure they're making a reasoned choice and maximizing their utility curves.

I helped someone (an FMG with no one else in the US) scramble last year, and the radio call-in analogy is spot-on. It sucked donkey balls.

Just because the residency application process was flawed before the match does not mean that it is not deeply flawed with the match system in place.

The best system for medical students would have multiple rounds in the match with time in between rounds for continued application and interviewing. Top programs and top medical students would match each other in the first round. Lesser programs and lesser medical students would find each other with subsequent rounds. Unmatched students would be the weakest applicants not just those who lost the crap shoot. A managed scramble is a move in the right direction, but isn't enough because too many of the jobs, all of them for some specialties, disappear on the same day.

 

[Coastie]

Open the scramble to American grads (MD) first.

Then to American grads (DO).

Then to American citizens IMG.

Then FMG.

Before people flame my post with crying, remember this: in an ACGME (MD), government (United States) funded graduate medical education system, this is the most fair thing to do.

 

[BlondeDocteur]

Just because the residency application process was flawed before the match does not mean that it is not deeply flawed with the match system in place.

The best system for medical students would have multiple rounds in the match with time in between rounds for continued application and interviewing. Top programs and top medical students would match each other in the first round. Lesser programs and lesser medical students would find each other with subsequent rounds. Unmatched students would be the weakest applicants not just those who lost the crap shoot. A managed scramble is a move in the right direction, but isn't enough because too many of the jobs, all of them for some specialties, disappear on the same day.

Hey man, I never said it was perfect. I did say, however, that doing away with the Match would likely hurt applicants a lot more than hospitals since a) that's how it worked before, and b) the operating condition-- the fact that we all have to do a residency-- hasn't changed.

I like the idea of multiple iterations of the Match as well, though I think that would ramp up the stress level for everyone except the top people.

 

[badasshairday]

Open the scramble to American grads (MD) first.

Then to American grads (DO).

Then to American citizens IMG.

Then FMG.

Before people flame my post with crying, remember this: in an ACGME (MD), government (United States) funded graduate medical education system, this is the most fair thing to do.

spot on.

 

[deuce924]

Open the scramble to American grads (MD) first.

Then to American grads (DO).

Then to American citizens IMG.

Then FMG.

Before people flame my post with crying, remember this: in an ACGME (MD), government (United States) funded graduate medical education system, this is the most fair thing to do.

Very Good Idea

 

[NotAProgDirector]

The best system for medical students would have multiple rounds in the match with time in between rounds for continued application and interviewing. Top programs and top medical students would match each other in the first round. Lesser programs and lesser medical students would find each other with subsequent rounds. Unmatched students would be the weakest applicants not just those who lost the crap shoot. A managed scramble is a move in the right direction, but isn't enough because too many of the jobs, all of them for some specialties, disappear on the same day.

I'm not certain this would be any better. Top students would clearly fare better -- they would apply to some top programs only, get interviewed, match, and be done. But it would be horribly painful for most medical students. They might be completely bypassed in the first few rounds. Each round you were bypassed or failed to match would be demoralizing and induce panic. Plus -- imagine you apply only to the best of programs in the first round, and don't get a spot. Maybe some second tier programs will fill in that round, and now you've lost any chance of getting a spot there instead. So, to avoid this, you'd need to interview at second tier (and by the same argument, third tier) programs also. So, you still need to interview at enough programs early, and then there's going to be large numbers of people who fail to match in round 1, then compensate by going on even more interviews for round 2. Plus, each round of apply/interview/rank/match has to take at least 2-3 weeks.

The problem is that the whole "job market" for residents is very strange. I hire people for 1 year (to be interns), then have to re-hire all those positions the next year. I can only hire from a very specialized subset of people. All of those people graduate from medical school at exactly the same time, so if I miss out I need to wait a whole year for a new crop (not necc true for IMG's). Usual supply/demand forces are highly skewed.

As mentioned above, doing away with the match is not a good option. You suggest that by doing so, programs will have to woo applicants. It's much more likely to be the other way -- applicants will be begging programs to take them, volunteering to have no salary, etc.

Also, it would all depend on how the system works. You (I think) are assuming that if you get a job offer from Program A, that you could keep looking at other offers. As mentioned, in the past (which is not that long ago for the IM fellowships, which recently entered the match) this was not true -- you were offered a spot and contract, and the offer expires in 24 hours. Take it or leave it, and once you sign a contract you can't simply change your mind.

If we were to try to enforce a "you can hold any one spot, and when/if you get a better offer give that spot up and keep the next" type of policy, programs would go insane. Medical schools work well with this type of system -- but there are two big differences. First, if a school is targetting a class of 100 students, it really doesn't matter much if they have 95 or 105. Second, if someone drops out at the last moment, the school has a waitlist of plenty of people -- someone will take a spot. Programs are highly regulated as to how many interns they can take, and we don't have a huge pool of people to take at the last minute. Such a policy will ultimately hurt students/residents -- imagine coming to work at a new program and finding out that, at the last minute, several of your colleagues took an offer from someone else. Now, you end up getting stuck with all the extra work they were going to do -- I know, sounds unfair (and it is), but that's often the way the system works since PD's can't just go and hire people.

In fact (and now this is stream of consciousness), if we had such a system I would have an incentive to "shoot low" -- if I took "really good" students I would worry that someone else might snatch them away from me. It would be safer for me to take "lower performers" because they'd be unlikely to get a better offer.

Honestly, I think the match is best for all. I agree the scramble should be fixed, and as others have mentioned it will be either next year, or 2012. I wonder if we could improve the match with some sort of "early decision" system -- for those people who are certain where they want to be, allowing them a chance to simply get a spot without interviewing at 10 places makes sense. But such a system will quickly degenerate the match -- programs will start to fill their spots with early decisions, applicants will panic that no spots will be left, applicants will decide that they have to apply early decision to get a spot at all, which will only create more early decisions and fill spots, which will leave less spots to fill, which closes the loop and feeds the frenzy. So, it won't work.

 

[dragonfly99]

The scramble needs to be fixed...it's ridiculous.
As for all those posting that nobody need risk not matching unless too "cocky", perhaps you shouldn't say anything until you and your friends have all already gone through the whole crazy process. There are people who don't have a crappy personality and don't way overshoot as far as where they apply, and still end up unmatched sometimes. There are people who stupidly apply to only a few places and shouldn't necessarily be that competitive but who still manage to match. It does happen.

 

[countingdays]

There are people who don't have a crappy personality and don't way overshoot as far as where they apply, and still end up unmatched sometimes.

Exactly. If they way overshoot, they wouldn't get interviews and would know to apply to more, less-competitive programs before the match. Lots of people (most of the 7-8% unmatched) interview at plenty of programs and lose the crap shoot. Now if they are lousy applicants and can't get interviews that's one thing, but that doesn't represent the majority of unmatched applicants.

6.3 percent of unmatched were AOA.
The USMLE 1 averages are somewhat lower for unmatched vs matched (216 vs 225) but the overlap is much greater than the difference.
http://www.nrmp.org/data/chartingoutcomes2009v3.pdf

It's a convenient lie to pretend that it has all that much to do with personality. It's part of it. I know plenty of applicants who we didn't rank because of personality, but they just put on a better 20-30 minute x 3-4 interview show and match somewhere else.

 

[countingdays]

I'm not certain this would be any better. Top students would clearly fare better -- they would apply to some top programs only, get interviewed, match, and be done. But it would be horribly painful for most medical students. They might be completely bypassed in the first few rounds. Each round you were bypassed or failed to match would be demoralizing and induce panic. Plus -- imagine you apply only to the best of programs in the first round, and don't get a spot. Maybe some second tier programs will fill in that round, and now you've lost any chance of getting a spot there instead. So, to avoid this, you'd need to interview at second tier (and by the same argument, third tier) programs also. So, you still need to interview at enough programs early, and then there's going to be large numbers of people who fail to match in round 1, then compensate by going on even more interviews for round 2. Plus, each round of apply/interview/rank/match has to take at least 2-3 weeks.

The problem is that the whole "job market" for residents is very strange. I hire people for 1 year (to be interns), then have to re-hire all those positions the next year. I can only hire from a very specialized subset of people. All of those people graduate from medical school at exactly the same time, so if I miss out I need to wait a whole year for a new crop (not necc true for IMG's). Usual supply/demand forces are highly skewed.

As mentioned above, doing away with the match is not a good option. You suggest that by doing so, programs will have to woo applicants. It's much more likely to be the other way -- applicants will be begging programs to take them, volunteering to have no salary, etc.

Also, it would all depend on how the system works. You (I think) are assuming that if you get a job offer from Program A, that you could keep looking at other offers. As mentioned, in the past (which is not that long ago for the IM fellowships, which recently entered the match) this was not true -- you were offered a spot and contract, and the offer expires in 24 hours. Take it or leave it, and once you sign a contract you can't simply change your mind.

If we were to try to enforce a "you can hold any one spot, and when/if you get a better offer give that spot up and keep the next" type of policy, programs would go insane. Medical schools work well with this type of system -- but there are two big differences. First, if a school is targetting a class of 100 students, it really doesn't matter much if they have 95 or 105. Second, if someone drops out at the last moment, the school has a waitlist of plenty of people -- someone will take a spot. Programs are highly regulated as to how many interns they can take, and we don't have a huge pool of people to take at the last minute. Such a policy will ultimately hurt students/residents -- imagine coming to work at a new program and finding out that, at the last minute, several of your colleagues took an offer from someone else. Now, you end up getting stuck with all the extra work they were going to do -- I know, sounds unfair (and it is), but that's often the way the system works since PD's can't just go and hire people.

In fact (and now this is stream of consciousness), if we had such a system I would have an incentive to "shoot low" -- if I took "really good" students I would worry that someone else might snatch them away from me. It would be safer for me to take "lower performers" because they'd be unlikely to get a better offer.

Honestly, I think the match is best for all. I agree the scramble should be fixed, and as others have mentioned it will be either next year, or 2012. I wonder if we could improve the match with some sort of "early decision" system -- for those people who are certain where they want to be, allowing them a chance to simply get a spot without interviewing at 10 places makes sense. But such a system will quickly degenerate the match -- programs will start to fill their spots with early decisions, applicants will panic that no spots will be left, applicants will decide that they have to apply early decision to get a spot at all, which will only create more early decisions and fill spots, which will leave less spots to fill, which closes the loop and feeds the frenzy. So, it won't work.

In a multi-round match, the rules would be more or less the same as in the current match- no offers outside the match, match is binding, etc. The difference is that there would be three of four match days instead of one. Each round of the match would have to be binding, otherwise it would be too hard on the programs to replace lost residents in the middle of the match process, and it would be too complicated to keep an accurate list of available positions.

 

[staylor21]

Aprogdirector,

You bring up interesting points. The only issue I'd bring up is that the labor market system/requirements for residents and programs isn't really all that unique. I think it's quite similar to the job market for academic positions in departments with fixed slots.

I know the job market for econ assistant professors reasonably well, so let me explain. Every year, an opening(s) comes up for an assistant professorship in most department (bc the previous occupant(s) has left, either 2/2 promotion or 2/2 being denied promotion!). Like you, departments face the hurdle of (a) needing to fill those slots with the highest quality candidates possible and yet (b) there is typically little flexibility in terms of adding additional sports.

It's interesting then, how this market clears--how do programs give out offers? The answer is that it typically clears top down, with the "better" programs giving out offers earlier, and the "lesser" programs giving out offers earlier. You might wonder why "lesser" programs don't give out offers earlier, and in some cases they do--sometimes, a lesser program will jump ahead and give out an "exploding offer" (as BlondeDocteur referenced), which it expires in a few weeks. This is usually done to attract "better" candidates. But there's not as much incentive to do so as you might think, because the "better" candidates know who they are, and are unlikely to accept an exploding offer. And if there's any doubt, they can (and do) tell the "better" programs about the exploding offer and see if those programs can hurry the process up. If they can, great, if not, well, the "better" candidate may be overestimating how attractive he really is.

Overall, I think the process works fairly well. It's costly for a program to make an offer to a person who will ultimately turn them down (because this keeps them from making an offer to the next preferred candidate who might accept), so programs have a good incentive not to shoot too high when making offers, but then, there is a cost as well to take lower quality candidates. Having known people who've gone through the process for 5-6 years now, I'd say people generally don't get screwed or lucky (i.e., few bad people going to good places and vice versa).


The only point I'm making is that there's nothing intrinsic about the residency market which necessitates the current match process, as other similar markets fare well without it. However, there is one crucial difference, which is why I think a match is necessary int he case of residency: size. The residency market is obviously many orders of magnitude larger than the market for academic jobs, so the match process is likely a whole lot cheaper/easier logistically.

 

[staylor21]

The match and the scramble are set up to benefit the programs at the expense of med students. Without the match, you would interview for jobs and they would have to sell themselves to you and try to convince you to commit to working there. You'd be in a position of strength because there would be lots of other programs interested in having you (for all they know). You would interview at the best programs first and work your way down. If you got a job at a top program, you would take it and save lots of time and money by not traveling to and interviewing with lesser programs. If you didn't get a job right away, there would still be lots of jobs out there for you to apply to.

With the match, all the jobs disappear on the same day. If you don't have a spot on that day you are in trouble. It puts you in the weaker position when interviewing pre-match because you are desperate for the programs to rank you highly. You don't find out until it's too late whether you should have applied to more programs or less desirable programs. If so, you are totally screwed while the programs are just fine.

The scramble is a way to ensure that even terrible jobs get filled due to the despiration of unmatched medical students. The programs get as much money and as many cheap employees as possible.

It's not the match per se that benefits programs at the expense of medical students, it's the inability to make binding contracts due to some of the rules of the match (which in my mind, could be repealed pretty easily).

I disagree with BlondDocteur's assessment that candidates have no bargaining power with programs--in my (and friend's) experiences, I think some candidates would have the ability to negotiate things from programs. The problem is that the match prevents both parties from making binding contracts prior to the match

For example, suppose I like program A a lot, and vice versa. As part of enticing me to come, they'd like to offer me a guarantee in a fellowship program there (conditional on satisfactory advancement of course). The match rules prevent us from entering into a binding contract that says (a) I promise to rank program A #1 and (b) in exchange, program A will rank me so that i am guaranteed to match and explicitly promise me a fellowship conditional on satisfactory residency performance.

If these kind of contracts could be made, then candidates could receive the kind of benefits that you talk about--the match doesn't allow this, but there's nothing intrinsic to the nature of the match (or specifically, the matching algorithm) that prohibits this.

 

[gutonc]

The only point I'm making is that there's nothing intrinsic about the residency market which necessitates the current match process, as other similar markets fare well without it. However, there is one crucial difference, which is why I think a match is necessary int he case of residency: size. The residency market is obviously many orders of magnitude larger than the market for academic jobs, so the match process is likely a whole lot cheaper/easier logistically.

You got it. Size, and timing are the reasons why the Match is needed in this situation. When you have 35,000 people looking to get one of 31,000 jobs that all start on the same day, there's no way that a simple "apply/interview/offer/accept" system would work.

 

[NotAProgDirector]

In a multi-round match, the rules would be more or less the same as in the current match- no offers outside the match, match is binding, etc. The difference is that there would be three of four match days instead of one. Each round of the match would have to be binding, otherwise it would be too hard on the programs to replace lost residents in the middle of the match process, and it would be too complicated to keep an accurate list of available positions.

This would certainly work. However, can you imagine how horrible it would be as a student not to get a spot in the 1st round, or the 2nd. You'd start to panic. This is exactly what happened in England a few years ago -- they didn't have a match but they started a "uniform offer date". What happened was that some small percentage of the students got all of the offers (each student got multiple offers). While they were deciding, everyone else was going crazy.

Each round would take several weeks -- reviewing applications, interviewing, etc. If applicants did all of their interviewing at the beginning, might as well have one big match as we do now. The point of multiple rounds would be to interview at a few spots, try to match, if you fail interview at more, etc. I guess we could start the first round really early -- let's say end of november -- else the final round might be much later than mid March. Programs could put as many spots into the match as they wanted and see what they get. Still, it would create all sorts of problems -- perhaps in round 1 I would only rank "really strong candidates". Some people who interviewed early might not make the early rank list, and hence not match. They'd have to understand that even though they didn't match in the first try, that they should rank us again in round 2. Applicants might feel a need to rank programs in Round 1 that really would be low on their lists, but are afraid will fill up early (but I guess as long as you make all of this public up front, applicants could see for themselves). If a program fills completely in an early round and then tells people who had scheduled interviews later that they are simply "out of luck", you will generate a run on the bank -- people will want the earliest interviews possible, and programs are likely to step their interviews earlier in the season.

The only point I'm making is that there's nothing intrinsic about the residency market which necessitates the current match process, as other similar markets fare well without it. However, there is one crucial difference, which is why I think a match is necessary int he case of residency: size. The residency market is obviously many orders of magnitude larger than the market for academic jobs, so the match process is likely a whole lot cheaper/easier logistically.

As mentioned already, the size and absolute timing required (i.e. it doesn't matter if, as an assistant prof in Economics, that you start on July 1st exactly) make this difficult. Also, the other idfference is the vast array of different fields. If you're looking for an Economics academic spot, chances are you don't want to be a Physics prof also. But someone looking for Ortho might also be looking for Gen Surg.

It's not the match per se that benefits programs at the expense of medical students, it's the inability to make binding contracts due to some of the rules of the match (which in my mind, could be repealed pretty easily).

I disagree with BlondDocteur's assessment that candidates have no bargaining power with programs--in my (and friend's) experiences, I think some candidates would have the ability to negotiate things from programs. The problem is that the match prevents both parties from making binding contracts prior to the match

For example, suppose I like program A a lot, and vice versa. As part of enticing me to come, they'd like to offer me a guarantee in a fellowship program there (conditional on satisfactory advancement of course). The match rules prevent us from entering into a binding contract that says (a) I promise to rank program A #1 and (b) in exchange, program A will rank me so that i am guaranteed to match and explicitly promise me a fellowship conditional on satisfactory residency performance.

If these kind of contracts could be made, then candidates could receive the kind of benefits that you talk about--the match doesn't allow this, but there's nothing intrinsic to the nature of the match (or specifically, the matching algorithm) that prohibits this.

Interestingly, that's the same conclusion that the paper referenced in the other thread (about the Anti-trust exemption) concluded. Problem is, there is very little I can actually control as a PD. I cannot promise people fellowship spots -- those are controlled by others, and they are unlikely to be willing to put them up for sale for medical students who are largely untested in clinic skills (some exceptions for research programs). I can't really control salaries, since they are controlled by GME (although I guess that perhaps GME could give me a total budget and I could divide it up. However, that creates winners and losers -- presumably if I pay one resident more then some other resident (maybe you) would get less).

 

[Eta Carinae]

Which is why when people come on a PMB like this and ask about their "chances", knowing fully well that they're not competitive for a desired specialty (ie "I'm a team player and everyone likes me but my step 1 was 216...whaddaya think? Plastics?" ), it drives me nuts when responders paint a caricature, 'well-it-happened-for-me' picture that represents anything but the norm.

Your best assessment of your potential to match will always come from your dean.

I knew it wouldn't be long before someone illustrated my point-

Here's a classic example of an ortho hopeful:

"Current 3rd year
step 1: 211
class ranK: top half
3rd yr clerkships: 2 PC+ and 2 H so far, currently on surg
inspiration: scholarship collegiate athlete- basketball (mvp of team, voted player of the year in conference)
non-ortho research (case reports, chart reviews, etc)
volunteer: lots of time spent at Shriner's and working sports events at my school"




Actual post

thread

 

[Eta Carinae]

I don't have stats for matching into ortho these days, but something tells me a 211 might not cut it?

I fully expect someone to respond with recommendations for blowing Step 2 out of the water, taking it early, talking up faculty, busting your chops on away rotations, shake, mix twice, add some sprinkles and angel dust and as long as people like working with you, you'll match into ortho

Hence the perpetuation (certainly not in all cases) of the scramble.

 

[raptor5]

I tried to upload an academic paper from Alvin Roth in the Journal of Political Economy (1984) titled "The Evolution of the Labor for Medical Interns and Residents: A Case Study in Game Theory" concerning the algorithm and rationale for the match but it is a tad too large. 891KB. If interested, PM me or have a moderator post it.

I have been working on a paper with a some other economists that examines the residency labor market from ERAS application to market clearing (end of scramble). Looking at market failure, its causes, and possible solutions that may be more pareto optimal.

The important item so far has been the causes of market failure (ie why the match cannot clear either the spots or the applicants). There have been over a hundred identified variables so far. Currently we are in the process of developing instruments to measure some of these variables but it involves the use of surveys that must be filled out by applicants and residency programs during different timeframes. As you can imagine this is difficult.

 

[Rabbit Hole]

I tried to upload an academic paper from Alvin Roth in the Journal of Political Economy (1984) titled "The Evolution of the Labor for Medical Interns and Residents: A Case Study in Game Theory" concerning the algorithm and rationale for the match but it is a tad too large. 891KB. If interested, PM me or have a moderator post it.

I have been working on a paper with a some other economists that examines the residency labor market from ERAS application to market clearing (end of scramble). Looking at market failure, its causes, and possible solutions that may be more pareto optimal.

The important item so far has been the causes of market failure (ie why the match cannot clear either the spots or the applicants). There have been over a hundred identified variables so far. Currently we are in the process of developing instruments to measure some of these variables but it involves the use of surveys that must be filled out by applicants and residency programs during different timeframes. As you can imagine this is difficult.

Here is a link to the paper:

"The Evolution of the Labor for Medical Interns and Residents: A Case Study in Game Theory" - Roth, A.

 

[countingdays]

I knew it wouldn't be long before someone illustrated my point-

Here's a classic example of an ortho hopeful:

"Current 3rd year
step 1: 211
class ranK: top half
3rd yr clerkships: 2 PC+ and 2 H so far, currently on surg
inspiration: scholarship collegiate athlete- basketball (mvp of team, voted player of the year in conference)
non-ortho research (case reports, chart reviews, etc)
volunteer: lots of time spent at Shriner's and working sports events at my school"




Actual post

thread

That guy will probably match in ortho because of the college sports.

Your implication that unmatched applicants are underqualified is baseless and false. People go unmatched with all kinds of credentials in all the specialties, competitive or less-competitive. When programs can get like 600 applications for 5-10 positions, it's easy for quality applicants to get passed over. In that group of 600 there will always be some stellar applicants and some lousy applicants, but most of the applicants are pretty similar. The programs are likely indifferent between many of the applicants but have to rank them exactly as if they really had a specific order of preference. If you've ever been to a rank list meeting and if ours are typical, the program's rank list is partly intentional but mostly random. No one at the meeting very clearly remembers a large portion of the applicants, with only unusually good or unusually irritating applicants being particularly memorable. Most of them are more or less the same and their placement on our rank list has a lot to do with chance (except for the top 5-10 ranks and the bottom/unranked applicants).

 

[Eta Carinae]

That guy will probably match in ortho because of the college sports.

Your implication that unmatched applicants are underqualified is baseless and false. People go unmatched with all kinds of credentials in all the specialties, competitive or less-competitive. When programs can get like 600 applications for 5-10 positions, it's easy for quality applicants to get passed over. In that group of 600 there will always be some stellar applicants and some lousy applicants, but most of the applicants are pretty similar. The programs are likely indifferent between many of the applicants but have to rank them exactly as if they really had a specific order of preference. If you've ever been to a rank list meeting and if ours are typical, the program's rank list is partly intentional but mostly random. No one at the meeting very clearly remembers a large portion of the applicants, with only unusually good or unusually irritating applicants being particularly memorable. Most of them are more or less the same and their placement on our rank list has a lot to do with chance (except for the top 5-10 ranks and the bottom/unranked applicants).

You should read both of my posts again and understand both.

Also if you study the "Charting outcomes in the Match" from the NRMP for the past several years, the step 1 means of matched applicants across every specialty is uniformly and consistently lower than that for unmatched applicants. These are means and there will always be outliers and a few unlucky applicants who either interview poorly, fail to establish rapport with residents/faculty (however that's determined) on interview day (the "chemistry"/fit factor) or who do not apply widely enough.

In addition certain specialties are notorious for applying strict USMLE score filters that would preclude some applicants from getting interviews. Ortho is one of them, and most programs use 230 as a filter for non-rotaters.

Furthermore, I never insinuated that underqualification was the sole reason for every case of an applicant going unmatched. There are many factors and combination of factors that contribute to the phenomenon.

And yes, I have been privy, several times over to the proceedings of rank list meetings. I have seen a few slide shows and have a fair understanding of at least some of the factors that influence the ordering of a program's rank list.

FINALLY, the aforementioned applicant is clearly underqualified, AS MOST PROGRAMS DETERMINE QUALIFICATION. I don't determine what makes an applicant more qualified than another- programs do. And unfortunately, most programs rely heavily on board scores as a measure of qualification for a residency spot and believe they (board scores) are a good indicator of performance in their specialty boards (which step 1 has shown fair correlation to), performance in residency in general (which has been shown to correlate to step 2 scores) and, believe it or not, surgical prowess (which has been shown to correlate to step 1, of all things, scores).

There are many applicants with 211's who have far more expertise in athletic injuries or joint biomechanics or in reducing dislocated hips and shoulders than their counterparts with 260's who (applicants with 211) WILL NOT MATCH regardless of their professed expertise.

Nevertheless, it has not been given to me to attempt to stop anyone from applying. Anyone whose heart is set on a specialty is welcome to apply. All I can do is point to stats that reliability predict their chances of matching and provide an assessment based on those stats.

 

[RKNY]

Open the scramble to American grads (MD) first.

Then to American grads (DO).

Then to American citizens IMG.

Then FMG.

Before people flame my post with crying, remember this: in an ACGME (MD), government (United States) funded graduate medical education system, this is the most fair thing to do.

If you and the others think it's fair then stop bitching like everyone else and write your congressman about it. If writing doesn't work gather as many people as you can that share the same views and make it known to the people that can change things. If that fails then tough luck. Life ain't fair. Instead of complaining about the system and what you feel you're entitled to why don't you try to work the system to your advantage?

Otherwise those same FMGs + IMGs will be laughing their way into match positions that they chose first and everyone will be complaining about why they didn't get their first choice. People should have known about this terrible match program before they got into medicine.

 

[countingdays]

Also if you study the "Charting outcomes in the Match" from the NRMP for the past several years, the step 1 means of matched applicants across every specialty is uniformly and consistently lower than that for unmatched applicants.

The difference in USMLE averages between matched and unmatched is about 9 points. The standard deviation is 21! The difference is relatively minor compared to the similarity overall. Almost half the matched applicants had lower USMLE scores than the average unmatched applicants' scores. Don't be fooled by a difference in averages. (This is also true when people talk about competitive and noncompetitive specialties.)