Friday, March 15, is Match Day. It’s a big deal in the medical community: At schools across the nation, fourth-year students who will get their medical degrees in a few short weeks learn their hospital assignments for the next three to seven years.
The National Residency Matching Program is an admirable invention. Now more than 30 years old, it is the system through which medical students get their first paid, professional positions. It corrected past abuses that took advantage of students, often pressuring them to accept binding offers within 24 hours of a residency interview. The Match is sufficiently noteworthy that its creator, Alvin Ross, won a Nobel Prize in economics for his work on matching theory. His algorithm continues to place half of U.S. medical school graduates in their first-choice programs. Other professions and selection processes could be improved by using a similar matching system.
Yet the Match and what leads up to it are having growing pains. Medical students are applying to increasing numbers of residency programs, sometimes to all of the programs in a field. Residency program directors are flooded with applications, and have trouble identifying which students are truly interested.
The ensuing Match frenzy benefits neither students or residency programs. Anxious students who are already debt-ridden pay $26 for each additional application, and each interview can cost them hundreds of dollars for travel and lodging. Program directors cajole faculty colleagues away from overburdened clinical, teaching, and research responsibilities to review stacks of applications and conduct more interviews.
As a program director (M.A.) and student-advising dean (A.V.H.), we represent both sides of the problem. Here we collaboratively outline the problems and propose potential solutions to maintain the strengths of the Match while controlling the “frenzy.”
The main problems
We see three main problems contributing to the dysfunction.
An overabundance of applications. Otolaryngology (also known as ear, nose, and throat) offers a telling illustration of this problem, and a potential solution that failed. In 2010, the average student interested in an otolaryngology residency applied to 47 programs, and the average residency program received 200 applications from U.S. medical students — to fill just two to six positions. By 2015, this increased to 64 applications per student and 275 applications per program.
The program directors attempted to exert some control over application inflation by asking students to write a paragraph about their interest in the program they were applying for. This reduced applications, but also backfired. In 2017, the number of applications fell back to 200 per program, but 10 programs failed to get the number of residents they needed. The otolaryngology program directors removed the supplemental requirement and applications jumped back up to 278.
Stressful for students. Twenty years ago, U.S. medicals students typically applied to 10 to 20 programs, interviewed at five to 10, and felt some control over the process. If students applied, residency directors knew they were interested in their programs. With students now regularly applying to more than 50 programs, they have little ability to indicate their real interest, even to the few they are most excited about. When one of us (A.V.H.) counsels a student who really wants to head home to California for residency, she still needs to recommend that the student apply to many programs in other regions just to be assured of having a job after graduation.
With the emergence of new traditional medical schools that grant medical degrees, increased class sizes, the single accreditation process for osteopathic programs, and meager growth in residency slots, the number of unmatched students is increasing, especially in competitive fields. In 2019, 1.7 graduates from U.S. medical schools are applying for every available position in orthopedic surgery. This creates pressure to complete an increasing number of visiting or “audition” rotations, in which students spend a month of fourth year in their chosen field at an institution where they want to match for residency. Such rotations and interviews to secure a match take far more time, money, and effort than was needed in the past.
The time expended on matching takes away from meaningful efforts to improve the senior year curriculum that could potentially provide residency programs with better-prepared residents.
Stressful for residency programs, too. Graduate medical education programs have limited resources. When the director of an orthopedic surgery program receives 600 applications for four positions, how can she determine who to interview? The standard, generic application offers program directors little information about who truly wants that program, and they don’t typically have the faculty resources to increase their interview numbers. When a student who didn’t really want to come to one of our (M.A.) residency programs canceled at the last minute, there often wasn’t enough time to offer the slot to a student who was seriously interested. That scenario makes it hard for many programs to pass up the temptation to offer more interview slots than they can actually conduct. Students are then left excusing themselves from clinical experiences to answer email and quickly secure wanted interviews before all the spaces are taken.
Potential solutions
Although residency programs have suggested placing a cap on the number of programs a student can apply to, this type of strict limitation would be vulnerable to litigation as restraint of trade. But there are other things that can be done to restore sanity to the Match, lest we lose one of the best inventions in medical education.
Provide reliable competitiveness information. If students had a better way to gauge programs in their range (based on their grades, test scores, and medical school ranking), they could put together a more streamlined application list. The Texas STAR database (Seeking Transparency in Application to Residency), which any medical school can join, is an excellent start to remedying this issue, but requires individual students to enter personal information on grades, test scores, and research and volunteer experiences. Having residency programs release their data into a central system would be more reliable.
Other sources of data, such as Apply Smart from the Association of American Medical Colleges, have tried to provide reasonable guidelines for the number of programs to apply to, but we have found that students do not believe the numbers. A single comprehensive and verifiable information system would help applicants and programs.
Indicate interest. Students and programs would like a way to indicate interest in each other earlier in the application process. Since some students have a strong desire to be in a certain city, a “token” or tiered ranking system could give a student three platinum tokens to express a strong interest in Philadelphia, for example. The next 10 programs would get gold tokens, followed by 10 silver and 10 bronze. Residency directors could then tell which students are most interested, and this could help them figure out who to interview. This would allow some display of student interest without fully revealing how applicants rank their choices of residency programs.
Applications tiered by timing also have potential. For example, students could apply to 20 programs in a specific week and be either offered interviews or rejected within a five-day window. They could then apply to 20 more programs the next week, etc., stopping when they have received a reasonable number of interview offers.
Fix times and processes. Interview offers are currently made anywhere between mid-September and late January. That’s a problem. During this period, students pay attention to their email instead of their patients. One alternative is to have interview offers arrive on fixed days for each specialty, in cycles. For example, pediatric interviews could be offered each Monday, Wednesday, and Friday for three weeks starting in late September. Surgery might choose to offer on Mondays and Thursdays for four weeks starting Nov. 1. Applicants should be allotted a minimum of 24 hours to respond, and never be shut out of offers because the all the spots are full. To help with the overall interview process, students should be encouraged to accept no more than 10 interview offers for individuals, or 15 for couples, so that there sufficient spots available.
These are just a few of the ideas for reforming the Match. Others are out there. Something must be done soon. Medical education is already stressful enough, and doesn’t need the addition of more stress from the process for applying to residency programs.
The Match was once a brilliant solution that everyone in medicine was proud of. There are still lessons to be learned from it for other selection processes, including undergraduate admissions. But if we — students, advising deans, and residency program directors — do not come together and work on solutions, we risk losing the Match’s great many advantages.
Alison Volpe Holmes, M.D., is an associate professor of pediatrics and the residency advising director at the Geisel School of Medicine at Dartmouth. Mona M. Abaza, M.D., is a professor of otolaryngology and directed the otolaryngology residency program at the University of Colorado School of Medicine for 18 years.
I read with interest the article by Drs. Holmes and Abaza. As a former member of the NRMP Board and President for two years, I have several comments to make. First, some factual ones: The NRMP was started in the 1950’s, not 30 years ago and was originally only for “Internship” year. Modifications over the years have added specialties to the match, couples matching, and have incorporated several “Independent Matches” which were in such programs as ENT and Ophalmology. We engaged Roth to look into whether a hospital-based match rather than a student/applicant-based match favored hospitals’ choices and was biased against students. Roth’s report was the basis for changing to a student-based match. (Over several years’ data, Roth found less than a small number of choices that would have been changed!)
Once again, the match is being made the problem in a way: it is merely the messenger. Residencies have the right to release data about their selection criteria, but many of the them are reluctant to do so; I agree that students should not be the ones to release theirs. Residency programs already have the ability to inform students they are favorably inclined to an applicant . What they are NOT allowed to do is expect a reply from the applicant, though I believe the informed student may feel under pressure to reply, and “fudge” an answer. Having fixed days for interviews sounds interesting, but various schools have different fourth year schedules. Finally, to say that any program is flooded with an overabundance of applicants flies in the face of the fact that colleges and medical schools never seem to complain about that! Good counseling and a weeding out process should cut down the need to interview all.
In summary, these are never-ending problems which existed in the past, and we still struggle to solve them. NRMP has always tried to be the impartial messenger. Now, as then, it is up to Medical Schools and Residency Programs to be the messengers and craft the proper message.