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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.

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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.

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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.

  • This is asinine and takes into zero consideration the cause for existence of the match — to improve the things that the author suggests it implements. The Match primarily benefits the students rather than the programs themselves based on 1) how the algorithm works in rank-choices and 2) prevents the significant power dynamic of “take it or leave it” job offers. It would further significantly put at a disadvantage programs or regions of the country who could not compete with larger powerhouse organizations and academic centers (which already exists). The Match provided some semblance of balance within the chaos.

    Inequality and socioeconomic diversity are not factors of the Match; those issues predate the Match and are moreso inequities of medical school admissions. The point of having to participate in the Match or the Supplemental Offer and Acceptance Program (SOAP) program (which the author fails to accurately name after the “Scramble” moniker was scrapped) is to prevent rogue institutions from doing what they want with their contract negotiations.

    The Match really doesn’t have any bearing on the point of unionizing and collaborating on wages either. The biggest challenge about the aforementioned is that residents are essentially rented workers for 3-7 years or so and the time it takes to develop a cohesive plan for a union structure with lawful representation and negotiations on an institutional basis which may take several years to develop and then the interested/active parties graduate and go on to the real world of medicine and don’t have time. That’s not to say such a notion is bad, it just has zero to do with the Match.

    The author should really be talking to the ACGME and AAMC about how there should be a strong focus on quality of life and care for resident physicians, including parental leave, adequate sick days, etc. The focus on the Match misses the mark.

  • The match rates for US seniors is incredibly high (>90%). While I agree with the residents lack of ability to negotiate, removing the match will not help representation. That has to occur at the medical school acceptance level, and medical schools must provide the resources for these students to succeed.

  • The match evens the playing field much more than conventional interviewing does. Hospitals are as much susceptible to the almighty algorithm as medical students are. It’s what forces hospitals to interview dozens of people and put people in their coveted “top 10” instead of hiring on the spot. If anyone would like to know what the match process would be like without the current match structure, they would only need to learn about The Scramble. Scramble is the brief event that takes place from the Monday that Match results are decided, and the Friday that Match results are announced. As the author surely knows, it’s exactly what it sounds like. Don’t imagine that the “advantaged” aren’t benefitting from having friends and family spam cold calls to open hospital positions.

    That’s not to say that the entirely separate issue of resident abuse is nonexistent. The author raises fully valid points about the continued archaic system of resident abuse that is rampant in a broken medical education system.

    • The Scramble was replaced with the Supplement Offer and Acceptance Program (SOAP) in, I believe, 2012 or 2013. It is essentially a smaller scale Match, giving students who didn’t match in the first round a chance to find another slot.

  • Prior to the match there were no “negotiations” with what were regarded as top tier programs because the quality of the program determined the demand in a time of demand greater than supply. For lower tier programs who could not attract as many residents in the 70’s they could offer more money. The ACGME that accredits residency sets standard for the length of the program, how much time per year (adjusting for vacation and meeting times) and surgical numbers. Any prolonged absence, for instance, for parental leave would result in the resident not making their surgical numbers or spending enough time with their resident responsibilities to meet those standards. To expect a resident to “make up” deficiency by extending the training increases costs and penalizes training of the next residency group if they have to decrease their training for the catch up resident. Finally, most major academic centers are actively working for inclusion by ignoring results of the USLME testing results and college or medical school reputation and evaluating real life experience and personal qualities when ranking applicants in the match.

  • Among the things that Dr. Marks will learn when he moves into the real world is that complaining ≠ improving. Furthermore, dismantling the Match and relying on one-on-one negotiations would inevitably advantage those most advantaged. Something that Dr. Marks’ politically-correct and buzzword-compliant missive appears to miss.

    There may be a system better than the Match- however, it can not be found in this editorial.

    • Is it your opinion the match doesn’t already favor “advantaged” applicants — legacies, those with pre-existing personal or professional connections, students with the financial capabilities to do away rotations or research years, etc?

    • @Hallie B. The match actually alleviates some of the problem you raised. Programs will receive the same number of applicants without the match, but the match forces them to interview more students to ensure they can have a large enough list with a high probability of matching. This is particularly important in specialties that do not fill all their positions such as EM, Rad Onc, and IM. If programs offer less interviews, less advantaged students have a lower possibility to share their personal experiences that are critical to their persona before USMLE, GPA, and Research count filter their application.

  • What’s missing here is a discussion of how the market for resident physicians has changed since the Match started.

    In 1951, there were fewer than 6000 applicants for 10,500 positions. This is what led to the intense competition between hospitals for residents (and the early, high-pressure, and ‘exploding’ offers that followed).

    In contrast, in 2020, there were ~42k applicants for ~34k positions. It’s hard to imagine that a prospective resident could negotiate a better contract when there are multiple similar applicants waiting in the wings.

    The problems with resident working conditions are real and demand solutions – but basic forces of supply and demand tell us that just removing the Match won’t solve them.

    Unions, on the other hand, have much greater promise. This, of course, is the way that workers in other industries in which easily-replaceable individual workers that can collectively leverage and bargain with their employer for better working conditions. And once hired, residents do have real leverage – because the services they provide are nearly indispensable to the hospitals that employs them.

    Other reforms not mentioned in the article are helpful, too. Whether a resident obtains their job through the Match or on the open market, ACGME restrictions make it nearly impossible to transfer from one position to another. This has the effect of making an initial contract permanent, regardless of the working conditions. A system in which residents could move between programs would allow the market to punish programs with poor working conditions. Without the ability to ‘vote with their feet,’ demands for improvement are an empty threat.

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