What is wrong with the Match?

On March 15^th, 2019 another group of poor medical students went through the archaic and brutal gauntlet that is known simply as the Match.  The Match is more formally known as the National Resident Match Program. It has existed in virtually the same manner for decades, matching medical students to hospitals with residency programs.  There are some really great things about the Match, and some other things that are problematic.  I thought it would be worthwhile to discuss some of these today. 

The Match began in 1952. (1) Prior to the Match, senior medical students around the country would work all year to secure an internship. They were looking for a hospital that had a good reputation and clinical mentors that would teach them.  Often these connections were made from their mentors in medical school.  But honestly, the hospitals had all the power in this situation. They were paying little to nothing to the interns. There were no regulations on duty hours or work conditions. And the hospitals had very little responsibility to the interns. Sometimes a medical student would show up to a hospital expecting an intern position only to find out that their position had been given to someone else.  It was in this environment that the Match was created. 

At its simplest, the Match allows medical students to rank the residency programs where they have interviewed and residency programs to rank the medical students that they have interviewed. Afterwards a computer algorithm "matches" the students and the programs.  Every student in the nation finds out their match on Match Day in the middle of March. 

Over the years, the Match has had issues. Medical students have complained on multiple occasions that the algorithm favors the hospitals. In fact, a detailed analysis of incomplete Match data reported that the algorithm favored hospitals and that the NRMP had misrepresented that knowledge to medical students for years. (2) In 2002, a group of medical students filed a class-action lawsuit against the NRMP and several large teaching hospitals. The suit claimed that the Match unfairly kept residency wages low because of the lack of competition for residency positions. This suit was dismissed in 2004, after the US Congress passed a law that gave the NRMP anti-trust protection. (3) In 2015 an MIT Professor published an analysis of 2003 to 2011 Match data in the American Economic Review. He concluded that the Match lowered resident salaries by an average of $23,000 per year. (4)

But overall, I believe that the NRMP has worked hard to make the Match fair and accessible to everyone-students and residency programs, but there will always be questions when the stakes are this high.  The Match determines where a medical student / resident will spend the next three to eight years of their life. The medical student is moving to a new city, finding a place to live, and uprooting their spouse and/or family.  They may be joining a training program after spending one day interviewing and meeting program faculty and the other residents. And to top this all off, their peer residents are completely unknown to them until after the Match. They do not even know who their residency classmates will be, their partners if you will, until Match Day. Imagine that. You take a job, not even knowing who you will be working with, for up to 80 hours a week.  That takes some faith!

And there is some data that shows that the quality of the hospital that a resident trains in will affect the quality of care that they deliver to their patients for decades. (5) In a study of Obstetrics & Gynecology residency graduates, those who trained in hospitals in the bottom quintile for risk adjusted complications such as laceration, hemorrhage, and infection had 33% higher complication rates once they were practicing physicians when compared to physicians who trained in higher quality of care hospitals. It is not just in obstetrics. A 2016 study of General Surgery residency graduates found that patients operated on by surgeons who were trained in high quality residency programs (top tertile for adverse outcomes) were less likely to experience an adverse event than were patients operated on by surgeons trained in residency programs that were ranked in the bottom tertile. Adverse events included death, complications, and increased length of stay. (6)

So, I guess my bottom line is that Match Day remains an important milestone for physicians.  The Match is not perfect but this year it brought my institution  a crop of new resident physicians.

Our first residents as a new Sponsoring Institution.  I hope we were their first choice!

References

(1)   Roth AE. The Origins, History, and Design of the Resident Match. JAMA  2003; 289 (7): 909-912.

(2)   Williams KJ. A reexamination of the NRMP matching algorithm. National Resident Matching Program. Acad Med 1995; 70 (6): 470-6.

(3)   Robinson S. Antitrust Lawsuit Over Medical Residency System Is Dismissed. New York Times. Published 8/14/2004

(4)   Agarwal N. An Empirical Model of the Medical Match. American Economic Review 2015; 105 (7): 1939-1978.

(5)   Asch DA, Nicholson S, Srinivas S, et al. Evaluating Obstetrical Residency Programs Using Patient Outcomes. JAMA  2009; 302 (12): 1277-1283.

(6)   Bansal N, Simmons KD, Epstein AJ, et al. Using Patient Outcomes to Evaluate General Surgery Residency Program Performance. JAMA Surg 2016; 151 (2): 111-119.