Residents are fed up with pay and working conditions. Is the Match to blame?
Something is brewing in medical education.
Change in this profession doesn’t happen lightly. Medical training is steeped in tradition, and many seasoned physicians will defend the brutal working conditions – the long hours, the hazing – as necessary to ensure competence.??
But residents today have reached their breaking point, unionizing in record numbers at programs across the country and even holding an unprecedented strike at Elmhurst (N.Y.) Hospital, ground zero for COVID-19 cases when the city got pummeled by the virus in the spring of 2020.
They’re calling for higher wages, benefits like housing stipends and childcare, and improved working conditions, with the specifics varying from program to program. (Penn Medicine residents, for example, want call rooms without mice and roaches.)
The American Medical Association has identified one possible culprit for all this discontent: the Match.?
The group’s House of Delegates last month greenlighted a resolution to “study alternatives to the current residency and fellowship Match process which would be less restrictive on free market competition for applicants.”?
The current process is anticompetitive, the resolution notes, since hospitals set salaries for all residents. “Residents are using other means to obtain fair wages, safe working environments, and other benefits,” it states.
The AMA declined further comment, noting that the resolution hasn’t yet created new policy.?
But replacing the Match arguably would be one of the most significant shake ups to medical education since 2003, when the Accreditation Council on Graduate Medical Education (ACGME) moved to cap working hours for residents to 80 hours per week and no more than 24 consecutive hours each shift.
The National Resident Matching Program? (NRMP?) has been overseeing the process since 1952 – when, according to the not-for-profit, medical students wanted to create “an orderly and fair mechanism” for being matched into their preferred programs.
The group, however, emphasizes that it doesn’t play a role in setting and determining salaries.
“We’re literally only the matching mechanism for this very complex machine,” said Jeanette Calli , the NRMP’s chief of Match operations.?“Applicants can vote with their feet and their rank order list. They don’t have to rank programs that don’t offer what they want.”
The current process involves medical students ranking their top choices while residency directors do the same, and then leaving it up to a computer algorithm to handle the pairings. Medical students find out where they’re going in March of their fourth year, on what’s known as Match Day (and often amid much fanfare and celebration.)
It’s become a time-honored tradition for medical students. “The Match has been a rite of passage up to this point; there’s ceremonial significance, like the white coat ceremony,” said Michael Bass, M.D. , medical director of Oshi Health, in a comment on LinkedIn. “But it’s complicated; I never fully understood the methodology. Making the process more transparent would be helpful.”
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Some residents will go through the Match again if they apply for fellowship. Not every subspecialty participates in the Match, but Calli noted that every year, more programs want to offer it, and it has recently brought on sleep medicine, cancer rehabilitation and interventional cardiology, for example. “The reason they’re joining is because it works,” Calli said.
When I asked residents and program directors to weigh in, I got dozens of responses, both on my post as well as from those who reached out privately.?
Among the concerns raised: The Match effectively requires students to sign a binding contract before they even accept a spot. And it’s not easy to transfer programs; sometimes it can mean starting over entirely. Moreover, the process doesn’t allow a lot of leeway for programs to create diverse classes.?
Yet others questioned whether ending the Match would solve the underlying problems.
When it comes to issues that aren’t related to salary and benefits – like the amount of “scut work” residents are given or the aforementioned roaches – oversight is supposed to fall to the ACGME, which is responsible for ensuring that programs are in compliance with established policies.?
“The concerns raised in the AMA [resolution] are important but I think misdirected,” wrote Gil Lancaster, MD , program director for the cardiology fellowship at Yale New Haven Health’s Bridgepoint Hospital, in a comment on LinkedIn. “Instead of petitioning the NRMP, which is only concerned with pairing trainees with a teaching program, I suggest that these concerns be raised with the ACGME, which oversees those training programs.”
A new system could also create new problems.
Rather than leveling the playing field, doing away with the Match would give more leverage to stronger applicants compared with less competitive ones, Jordan Smith, MD , a pediatrics resident at Loma Linda University, commented.
“Even if there had been a competitive match process for the past decade, my gut tells me the drive towards unionization would still be in full swing,” he wrote. “After all, since there are more residents than slots, in theory hospital admins could pressure [program directors] to take the applicant willing to work lower wages vs. the higher quality applicant.”?
The uneven negotiating power between residency programs and medical students was actually core to why the current system was created in the first place.???
Before the Match, medical students had to participate in a process more akin to a “scramble,” noted Vineet Arora MD MAPP , dean for medical education at the Pritzker School of Medicine. Residency programs often would compel candidates to accept an offer in as little as 12 hours. “The uniform offer date was initially proposed by students to help students not feel pressured,” she wrote.
And residency programs still hold the cards today, as the number of available spots has failed to keep pace with the number of medical school graduates.?
In fact, the Match has gotten increasingly competitive, with only 47.7% of medical students matching into their first choice program this year – a decrease of 0.8 percentage points over 2022 and nearly ten percentage points lower than ten years ago, according to NRMP data. A total of 73.4% of students were accepted into one of their top three choices, a year-over-year decrease of 1.1 percentage points.?
“I like the language to ‘study alternatives’ – I look forward to seeing whether such alternatives can result in ensuring the maximal number of trained doctors,” Arora wrote on LinkedIn. “In the interim, let’s not forget that we are not training enough doctors in specialties of need and that the problem is multifactorial and cannot be fixed with match reform alone.”
CEO and Founder at Door Space Inc.
1 年Doctors:we're understaffed, lack the resources we need, and the leadership is never here helping solve problems or approving infrastructure upgrades so we're fed up! Healthcare leaders: the doctors are unhappy so it must be because of the match program.. ?????????????? Or maybe it is a leadership failure problem and the cure is to get new leaders and a lot better training for them so they fix the toxic workplace environment they have created across the US healthcare system...
Independent Business Owner at My Natural Calling Senior Services
1 年Its two parts to this change, first all the requests that this article mentioned should be revised and implemented but to whom? All workers or those who perform at the level of the demand? The time frame to import these changes realistically would take years to complete universally and not very long individually if a pay scale by experience education and training is considered. Not only has healthcare changed over the years, so has union representation, this is based on my own experience as a past CNA union member from 30 years ago. For future Healthcare Professionals there is a chance for a better work system that can be initiated by the current who while fighting for change will have to decide how long am I willing to wait before jumping ship from Healthcare business and choose alternative options such as Independent Healthcare Services. The workers themselves hold the ability to make the change.
Physician, Advocate and Entrepreneur
1 年Excellent article that sheds light into the matching process and resident working conditions. First, it could be implied from the writing that some degree of hazing is necessary, however, that's never true. There's a Socratic Method that can be functional or dysfunctional (hazing). Second, there's a revolution and/or evolution in the residency world. The new generation of doctors equipped with social media and a healthier perspective on doctor well-being and mental health are calling BS on the "old guard", exploitive and abusive way of training doctors. Combined that with a changing healthcare system where doctors are becoming more as employees rather than private practice/business owners, the new generation of doctors are realizing that they are laborers and thus need to advocate for their labor rights, hence unionizing. Third, the Match process is not fair to residents because applicants have to rank their programs before programs have to rank their residents. There's at least a one-week period between this. Program Directors at that time can speak with each other to compare applicants' ranking lists. Given how much egos some doctors have, you can only imagine the ramifications of that.
2x Author, Podcaster, Healthcare Advocate & Mentor
1 年So many have suffered, glad people are speaking up!
Faculty at Riverside Regional Medical Center OB/GYN Residency Program
1 年Halting the creation of new medical schools for profit should also be enforced. We need more residency program. When I was a medical student in the 1900s, there was a residency spot for each US medical student, may not have been your top program nor your specialty of choice, however at least you matched. Today, thousands of US medical students go unmatched. I can’t imagine the stress, depression and financial burden that’s put upon these students. I am faculty at a community-based OBGYN program and we had ~600 applicants for 3 positions!