At the stroke of noon on Friday, March 19, more than 30,000 doctors-to-be across the country and around the world will learn their professional fates in residency programs for the next three to seven years.
At that moment, graduating medical students receive their results in The Match, officially known as the National Resident Matching Program, which uses a much-feted computer algorithm to pair medical students with the next part of their training — residency programs in hospitals and health systems.
Medical schools and hospitals celebrate this moment. Public relations departments have a particular affinity for The Match’s high drama: videos featuring ecstatic students reveling in their dream program, their dream specialty, their dream city. In pre-pandemic times, programs invited proud parents to watch and hosted wine-and-cheese receptions. And though Covid-19 restrictions may mean a more socially distant celebration this year, the message will remain of The Match as a joyous transition from student to doctor.
But beneath the glitter of champagne toasts and Instagram posts, there lurks a sinister reality. Far from being a boon to new doctors, The Match has for decades held down wages in residency programs and shielded hospitals from pressure on key workplace issues such as parental and sick leave by barring future residents from meaningful negotiation with their employers-to-be.
This marks a hardship for each new crop of residents and a tragedy for the medical system as a whole. The depressed wages and stingier benefits permitted by this legally sanctioned monopoly make medicine a more forbidding place for those without wealth and for those balancing work with child care. It makes medicine less racially and socioeconomically representative at a time when it’s becoming clear that representation can improve medical outcomes. In short, this affects not just residents’ health, but your own.
It wasn’t always this way. Medical students and hospitals once negotiated directly with each other. Competition for talent was fierce amid a tight labor market, with residency programs extending offers to medical students up to two years before graduation. This process had significant downsides: Students had to deal with exploding offers and felt pressure to commit to a program before getting sufficient exposure to different medical specialties.
Medical students, residents, and hospitals all backed reform. In the early 1950s, a precursor to today’s Match was approved, and it has since become virtually the sole means of gaining a residency slot and becoming a credentialed physician.
In order to participate, applicants must commit in advance to the residency program the algorithm chooses for them from programs they picked. Their choice is essentially this: accept the outcome of The Match or leave medicine.
That creates a striking power imbalance. Residents often feel they have little recourse to address punishing work hours, abusive environments, or little flexibility to accommodate pregnancy or child care. The private organization that accredits residency programs ostensibly caps weekly hours worked at 80; in practice, many residents feel intense pressure to work longer hours and simply lie on the forms their programs submit to the accrediting body. At the height of the Covid-19 pandemic, resident requests for hazard pay fell at times on deaf ears; one department chair who, not incidentally, made several times a resident’s salary, had the temerity to call this plea “not becoming of a compassionate and caring physician.”
That statement is all the more galling when you consider the role resident physicians play in U.S. health care. They make life-and-death decisions about medications, work 24 hours and more at a stretch, and write the charts that hospitals rely on for billing. They perform spinal taps, drain abscesses, and intubate Covid-19-positive patients. They answer pagers in the middle of the night and rush to patients’ bedsides. When patients’ hearts suddenly stop, they often direct the effort to revive them.
Yet they remain largely helpless to change critical aspects of their work environments. This decadeslong power differential helps explain why salaries in residency programs remain low even while average medical school debt has soared past $200,000, why many programs lack parental leave policies, and why young doctors can be punished, formally or informally, for taking a sick day.
These obstacles are easier to weather for those from wealthy backgrounds, and indeed, roughly half of U.S. medical students grew up in the top income quintile, while just 5% come from the bottom quintile. Our nation’s long history of racial discrimination means Black, Hispanic, and Native American people are disproportionately represented in lower socioeconomic strata. In addition to structural racism, these socioeconomic barriers help explain why people from these groups remain underrepresented in medicine. And a growing body of research indicates this lack of representation can lead to worse outcomes for patients of color.
Fixing this will not be easy. The increasingly large hospital systems that benefit most from these inequities have made that clear. When The Match monopoly drew a credible antitrust challenge in 2002, American hospitals and medical schools simply used their formidable lobbying arms to slip an exemption into an unrelated and urgent pension bill, which Congress dutifully passed.
If society is serious about creating a medical profession that looks like the patients it serves, it will have to level the playing field by scrapping The Match. Supporters of the current system have argued that such moves could throw the residency job search into the chaos that marked the pre-Match days. But this need not be the case. The market for law firm associates has functioned for decades with schools simply imposing a set of rules defining the periods for interviews and prohibiting exploding offers.
Perhaps most importantly, hospitals should stop impeding efforts by residents to unionize. Some hospitals have sought to torpedo union efforts by threatening interested residents and even arguing, laughably, that they don’t qualify to unionize because they are students, not employees.
For too long, the House of Medicine has adopted a mercenary attitude toward its newest doctors. To borrow a phrase, this is simply not becoming of a compassionate and caring profession.
Clifford M. Marks is a third-year emergency medicine resident working in New York City.