Wednesday, April 16, 2014

A medical student says to abandon the match

A blog post entitled "How a Nobel Economist Ruined the Residency Matching System for Newly Minted MDs" appeared on the Forbes website. In it, Amy Ho, the medical student author, lists all the things she considers wrong with the National Resident Matching Program (the "Match").

I would have commented about this on the site itself except that I have a lot to say, and in order to post a comment, I would have had to agree to allow Forbes to post tweets in my name. No, thanks.

The title of the post is misleading. As the author noted, the Match as been around since 1952. It was established to make the process of finding a residency position fair for all graduating medical students. Alvin Roth, the economist who shared a Nobel Prize based in part on his work with the Match algorithm, simply refined the process in the 1980s and 1990s to make it even more fair. Roth didn't ruin the Match; he made it better.

Ms. Ho blames the Match for the fact that 25% of those enrolled in 2014 failed to obtain a residency position. But even if the Match did not exist, there would still have been more than 34,000 people seeking some 26,000 positions, and 8000 doctors would not have found jobs.

She also says the system is wasteful because millions of dollars are spent on travel for interviews each year. I suppose applicants could be interviewed on Skype or FaceTime, but how would they meet residents, see the facilities, and assess the programs? I think most job applicants would prefer to take a look at the place they might be employed at for 3 to 7 years.

In a real stretch, Ms. Ho complains that the Match hampers dual degree applicants such as those with MD/JD, MD/MBA and MD/MPH degrees from negotiating higher salaries from hospitals. It's fine if a student wants to earn a combined MD/JD degree, but as a former program director, I question whether such a degree really provides more value for a residency program. She argues that mean earnings for 25-34-year-olds with doctorates or professional degrees are $25,000-$35,000 more than first-year resident salaries. Maybe not just dual degree graduates but all first-year residents should be given higher salaries since an MD degree is in fact a doctorate. And by the way, MBAs and MPHs are not doctorates.

She writes: "For hundreds of students a year, the Match means a change in career, as students who do not match in their preferred specialty are often forced into an alternate career specialty if they would like to practice as a physician. It also means a change in life circumstance, notably, for those with preferred location given family situations or with spouses unable to find a new job in the short two-three months between Match day and residency start dates in June."

How would that change if the Match disappeared? Everyone can't be a dermatologist, and everyone can't be a resident in San Francisco. There are only so many programs.

She concludes "it's about time to trash the Match," but doesn't say how she would replace it. Would she like to return to 1951 when an applicant had to decide whether to commit to the first offer he got or take a chance and interview at a few more hospitals? I don't think so.


pamchenko said...

reading this garbage infuriates me. it reminds me of an intern i had who constantly had grandiose ideas about how to improve surgical education or how to change it. an analogy would be a rookie on a football team telling the coach what to do.
don't get me wrong, I'm totally willing to consider change. when asked how I felt about the 80 hr work week I deferred to people who had more experience in medical/surgical education who were setting the tone for the country.
question is, what speciality did she match/not match? most people dont write crap like this unless they got effected somehow. this is not an article about how an underserved population got screwed, its about people who having projected earnings over 100k a year with ridiculous job security complain.
my guess is that she didn't get what she wanted. a primadonna like this could easily be a derm applicant. i would like to think crap like this doesn't come from a future surgeon but its very possible. I saw it at journal club the other day from one of my interns who was passionately talking about whether or not it was cost effective to take care of medicaid patients.
kids at this age need to focus on gaining the knowledge they need to help people. its why doctors still get respected alot over other professions. more of this type of number crunching attitudes at this age will inevitably dilute the public faith in our profession.
my guess is that she came from upper middle class to rich family in texas. prob went to great schools and this is the first time she has failed at something (like matching derm). she is also going to marry outside her race. this person has a bright future in administration.
80 hr work week isn't killing residency. her attitude/entitlement is.

pamchenko said...

and also for what its worth. i totally support the unionization of NCAA athletes.

Mike McInnis MD said...

A quick Google search says that Amy Ho is going into EM.

I would guess her animosity toward the Match has less to do with "entitlement" and disappointment with her results and more with her apparent frustration at the expense of the process. And possibly the anxiety she felt at not knowing where she was going to spend the next 3-5 years (and her lack of control over it).

That said, I agree that the current Match system favors the applicant much more than a "free market" system (which she seems to favor) would. It puts the applicant in a much stronger position.

Anonymous said...

@pam. Are you OK?

I also think her analysis is wrong, but not because she is more likely to be a derm applicant than GS (your assumption).

Believe or not, many med students actually want to be endocrinologists, or anesthesiologists, or rehab, or even (gasp) primary care docs. It is not because they couldn't get into surgery.

Marrying outside her race? Where did that come from? So? The vast majority of her acquaintances are "outside her race". Who else is she going to marry?

This is prob. the most offensive post I have seen here.

pamchenko said...

im sorry if i offended you. I'm just trolling along in medicaid mill land right now getting frustrated by patients. the marry outside her race comment is way off topic.
I absolutely appreciate the high costs of traveling for interviews. With students graduating in so much debt it is a ton of money. nonetheless, most people would see it as an opportunity cost. is this a process that hurts poorer students? not necessarily...most students already accept that they are in debt around a quarter mil and another 8k is part of that. to spend a quarter mil in college/med school and not spend another 8k would be foolhardy. therefore the monetary argument doesn't make alot of sense.
most people who are med school will have left home and most dont have many choices...they will go where they are accepted / where it is the cheapest / best opportunity. the same applies at the residency and fellowship level as well.
her arguments about how the match puts people in different cities and specialities ... well those are choices those individuals have chosen. just like people choose to be in lifestyle specialities, they understand that if they match in plastic surgery/rad onc/peds surg, they would go anywhere. this is their opportunity cost.
ultimately in this type of free market no one is forcing the medical student to take these high costs. many of my classmates wanted to do family practice in their own hometown and as per facebook, have a great life doing it.
those kids that spend 8k are trying to chase a dream/vision. they have an idea of what they want. just like those kids who apply/interview to 20 different medical schools and spend an 8k 4 yrs prior.
so when she complains about the match system, its no different than the same process she went thru in the past, and no different than the one she has in the future. one would argue that the match system is the best system for her at this point. she doesn't realize that job hunting is more a crap shoot with tons of pitfalls i'm only beginning to fathom now.

Anonymous said...

reading the first garbage comment infuriates me. it reminds me of an arrogant surgeon I used to work with during third year who thought everyone should feel honored to kiss his a**
don't get me wrong, I'm totally willing to listen to rational opinions that where people aren't making crazy assumptions and racist comments.
question is, what happened in her life to make her say, "she is also going to marry outside her race" and how many rich successful people has she silently burned with jealousy against? most people dont write crap like this unless they got effected somehow. this is not a comment trying to propose a solution or even talk about a subject rationally. its about some person making crazy assumptions about a poor author, and who doesn't seem very happy about their own life.
my guess is that she didn't get what she wanted. she came from a poor family, struggled, went to a low tier medical school, and somehow matched beyond what she didn't expect. i would like to think crap like this doesn't come from a practicing doctor but its very possible.
doctors at this age need to focus on gaining the knowledge they need to help people. its why doctors still get respected alot over other professions. more of these type of low blows at this age will inevitably dilute the public faith in our profession.
my guess is that has some kind of odd hate against upper middle class to rich families in texas. prob went to crappy school and she cackles in delight when she sees when her peers do not achieve as much as her. she is going to have a hard time in her romantic relationships. this person has a bright future in having a title that's actually pretty meaningless.
Asking for residents to work hard isn't what makes residency suck. having superiors with her attitude/racism does that.

Skeptical Scalpel said...

I agree Pamchenko's comment about marrying outside her race was way out of line. I was away from my computer and moderating comments from my phone. I should have caught it anyway. Pamchenko is a frequent commenter and I did not expect something like that.

I don't consider "im sorry if i offended you" a real apology. It sounds like something a politician would say.

I appreciate the other comments. Let' stay on topic from now on.

Coleen said...

I had a close up view of interview season. My daughter had to fly from home to one region at least four separate times. After her very first far away interview her idea was to have a conference in each region in October. One week for each quadrant of the US. Everyone from residency locations in that region gathers in one place to conduct interviews. They still do the invites and all as normally is done.

What I liked about the idea is that she thought MS4s could then do their own visits on their own schedules. My daughter spent way too much money on the flights everywhere, sometimes it was three different states in a week, some places are expensive for travel, motels in cities, rental cars, complex and expensive.

I am aware of some applicants in the NE who drive to most interviews, but if you are interviewing in the western US, you have a lot of flights as locations can be spread out.

The other issue is conflicting interview invites, there were some invitations that exactly conflicted with others and even interview emails which provided only a wait list option by the time she contacted the program. That meant both some early interviews that needn't have been done had she known she would be invited to more desirable options at a time she could attend and sometimes last minute flight arrangements for those last minute openings.

Instead, doing the campus visits on one's own schedule would allow for maximum efficiency both in time spent and money spent.

No sour grapes here, my kid matched #1, but certainly wishes she could have saved a lot of money and the stress of the timing, especially where interviews overlapped clinical rotations.

I cannot imagine an established program like match season being changed to address the cost to the med students! It's not like any other aspect of med school is sensitive to costs (Step II CK, anyone?) but it would be a kindness with loans at 6.8% accruing interest.

Skeptical Scalpel said...

Coleen, Thanks for the comments. I agree it's very costly. But I don't see how trashing the match would help. Your daughter would still have had to go places and interview.

As a former residency program director, I can tell you that we don't like the interview process much either. We could not possibly tailor our interviews to mesh with your daughter's and everyone else's personal schedules. Most programs plan a half to a full day to interview groups of applicants with time to meet some residents and show them the hospital. Some even do a dinner the night before. It is very time consuming.

Anonymous said...

I have written several articles on this topic. I actually agree the match should be change or discarded. Let me explain:

I remember "interviewing" at UK (Kansas) back in the late 80's. Lawrence Cheung, MD, walked into the cafeteria where about 300 "suits" were sitting--eagerly waiting for their chance to interview. As we waded into our hard rolls, water, and "chicken or beef" meal, he promptly walked to the podium and said, "If you are not in the top 90% of the boards, we will not rank you and you will not be considered." At that moment, about half the room got up, didn't finish their meals, and walked out. I stayed because I had nowhere to go: I'd paid for my air-fare, rental car, hotel, and dry-cleaning for this interview. The University of Kansas should have had to reimburse EVERY SINGLE APPLICANT for those expenses since they did not "weed out" their interviewees before they hopped airplanes and traveled to the Midwest to interview. In the "real world", if I'm invited for a job interview, the interviewER usually reimburses my travel expenses. Not so in "the match". It is a scam that allows hospitals to interview without any costs to them.

My next point: When I was a 3rd year resident, I was "sued" on a case, along with the Chief of Surgery; I had a State Medical License to moonlight in ER's. This became important, because, even though I was a "resident" and "not finished with my training", in the eyes of the law, because I had a State Medical License, I was "equally qualified physician and surgeon" as was my attending (with 30 years experience). When the case settled, I was held "equally" liable as my boss. Even though I was a "resident", was not even board-eligible, was "required" to scrub cases to "sit for boards", and rarely did cases on my own. If a resident can go to the NPDB and be held "equally" liable, in the eyes of the law, as a board-certified surgeon with 30 years experience, then residents must be PAID relative to that "legal" responsibility we share for the patient.

Third point: We ALL know the match is rigged. SS blogged about medical students receiving the "if you rank us highly we'll rank you highly" letters. We ALL know that if Dad is on the Board of Harvard, or if Dad was a resident at Mass General that his "son" has a better chance of "landing" a spot in, or out of, "the match."

I say we go back to the good old days where hospitals had to review applications, whittle them down to the 20 or so applicants they want, invite said applicants for interviews, pay their expenses, and after the interview offer, or don't offer the job. Just like the rest of America interview for jobs in the corporate world. And, if Harvard and Hopkins interview only "Daddy's son" so be it. It is still that way...just, now, it is "hidden" by the match.

Anonymous said...

continuing. . .

Interestingly, we are also told the "match" is "legally binding". If that is true, why does EACH matched intern receive, after the match, a "contract" with their program to sign? Shouldn't it be the other way around? How can you agree to have a contractor build your home--and as he's pouring the concrete, you come up to him with a document (20 pages) and say, "sign have've already poured the concrete." Each interns contract is different. Why? They've all gone through the "same match" why not the same exact wording in each contract for a "legally binding agreement" through the "legally binding match"? Why is their even a contract at all? The match should be made NON-binding, until that resident has read that contract and given the chance to walk away. Perhaps if program directors saw some of the crappy contracts I have (I wouldn't sign half of them now after 20 years of experience), and woke up to find their "matched" interns didn't show up for work on day one, it would cause change.

I prefer the good old days: Apply, interview, be paid well OR apply, interview (hospital pays), law says you can't sue residents, no NPDB reporting of low-wage earning residents, get the contract BEFORE you sign on the match-line...

Lots of room for improvement. LOTS. And, by the way, I grew up DIRT poor. Paid my own way through college and medical school, and when I graduated from medical school my credit cards were piled high with debt from flying around the country, living in hotels, renting cars, driving to YOUR program, hoping you'd like me.

What a joke.

Anonymous said...

Comment to Pamchenko:

Let's assume, just for a minute, that $8,000 isn't much money to you.

You argue, " nonetheless, most people would see it as an opportunity cost. Is this a process that hurts poorer students? Not necessarily...most students already accept that they are in debt around a quarter mil and another $8 is part of that. To spend a quarter mil in college/med school and not spend another $8,000 would be foolhardy; therefore, the monetary argument doesn't make alot of sense."

$8,000.00, in after tax dollars, would be 21 Medicare gallbladders ($750 each). Now, if you're sharing office space with me, and we split all the overhead, I say, "I'm going to charge you $8,000.00 dollars more this year because you already paid me $75,0000 in office shared expenses."

You'd come up for air.

I have no "generational wealth." Here's what your forgetting about the intern paying his own air fare and interview expenses:

Generational Wealth (in this scenario "Daddy" is a general surgeon who has been in practice for 20 years.):

Son: $150K in debt from Medical School + $8K interview expenses. Graduates and joins "Daddy's practice"...starts out $158K in debt.

Now, let's consider, no generational wealth:

Son: $150K in debt, + 8K interviews + $50K (office equipment) + $lease of office, etc.

It is a big deal. Because I'm doing 20 more gallbladders than the "other son" but the amount I must outlaw for my office, expenses, etc. that the "other son" doesn't have to.

Relevance: The poor kid, without money, pays $8,000 + credit-card interest. . .and flies around the country to "match"...while the "other kid" can see light at the end of the tunnel...the poor kid is in so much debt, chasing a dream...only to realize what a sick joke medicine is. Oh, and let's not forget: "tail coverage". . .

Now, I'd like to see how many "poor" doctors commit suicide vs. those who came from generational wealth.

No wonder everybody hates us. Whining, crying, kids? I think there is SOME truth to this.

Vamsi Aribindi said...

I disagree with Ms. Ho.

Fundamentally, her economic analysis is flawed- it's not a case of residents just getting screwed over their salary. In the match, both sides give up something. Hospitals and residency programs give up (largely) their ability to select individual residents. Especially mid-tier programs may have no idea who they have coming to them. Meanwhile, students give up their (already low) ability to negotiate salaries. In exchange, they get the ability to consider ALL offers before making a decision- something they would not have otherwise.

I am quite surprised Forbes printed this. It's really just her venting about the cost of flights.

In terms of improvement, I see as a model the current regional efforts to recruit medical students. At least in the Western US, all the EM programs send a few residents and a program director to a conference once a year (rotating between USC and UCI). There, they talk with 3rd and 4th years at a "residency fair", and give lectures and workshops to 1st and 2nd years about the specialty in general.

I don't see why in a similar manner, all the General Surgery programs in for example the Midwest couldn't get together in Chicago 4 times over the course of interview season. There, interviewees could go from room to room- for 30 minute interviews with the program director or a faculty member or designee. At the end of the night, a 2-3 hour social event at night with all the residents from the programs out in force.

I hear pediatric surgery is already moving to something like this, what with 30 spots in the nation that every applicant applies to.

Vamsi Aribindi

Skeptical Scalpel said...

First anonymous, thank you for the comments.
If your experience at the University of Kansas really happened, you have a right to be angry. I'm not sure what the legal case you were involved in was about, but your hospital should have covered you for malpractice. I don't think it's practical or feasible to expect residents to earn as much as a chief of surgery. I was a program director at three different community teaching hospitals. Not once was the match rigged. I'm sure there are deals made at times, but wouldn't they still be made if there was no match? Your plan to have the programs interview the 20 people they want sounds great, but what happens to people who only get invited to two or three places and get no offers?
I'll tell you how "legally binding" the match is. It's only binding on the programs. If you match to a program and then decide not to show up, your only penalty is that you will be barred from participating in the match for a year. This happened to me once. An applicant matched with my program and then disappeared for two months. She never returned the hospital contract we sent her. When she finally surfaced, she told me she had accepted a position in emergency medicine outside of the match. I then had to try to recruit a categorical resident in late May. The penalty issued by the NRMP meant nothing to her. If a program director reneged on the match, the program would be barred from participation, a much bigger problem for a program than for an individual like the one who bailed out on me.
"I prefer the good old days: Apply, interview, be paid well." You prefer the good old days? Perhaps you aren't aware that residents in the 1950s and before were not paid anything. They were given room and board at the hospital and maybe a few dollars per month. That's why they were called residents.

Second anonymous, I had a little trouble following your line of thinking. I will agree that the match process is very expensive. The previous anonymous commenter had a point that most corporations pay interviewees' expenses. Unfortunately, I don't see the current system changing. Once again though, this problem would exist with or without the match.

Vamsi, the idea of a residency fair works very well for the programs, but would you really want to take a job for five years without ever seeing the place where you were going to work and its environment? Also, I think it's very important that applicants at a chance to talk with the chairman of the department and the program director of the residency. Meeting a single faculty member and one or two residents is not enough.

Anonymous said...

I don't understand the math, but I thought that Roth proved (in a game-theoretic fashion) that the Match algorithm cannot be gamed on an individual basis. That is, the matching resident cannot do better on his/her own. It was the real-world application of game theory (not just the Match) which garnered him the Nobel.

I agree that interviewing at 25 programs across the country is crazy expensive for a
med student, but that is his or her choice regardless if the Match is involved.

Anonymous said...

Thank you for posting my comments, SS.

Yes, the University of Kansas experience was real. Very real.

You make a good point about "the Good 'ol days". . .in that they were paid nothing more than room and board. But history, and statistics of the profession, tell us there were no poor blacks, or poor whites in medicine at the time--because they couldn't afford tuition or "room and board" as the only salary. Interestingly, my point is also flawed in that military service used to be required of physicians, too. Not a bad idea, but, that too is not without issues. In those "good 'ol days" rich white boys became doctors. Not women. Not blacks.

I interviewed, also, in the midwest at the University of Oklahoma-Tulsa, where the "then" director told me point blank (after he'd just finished interviewing a woman), "I'll NEVER have a woman in this program. They get pregnant. . .take maternity leave and it screws up the rotational schedules and I have to re-do everything! They don't want to take call. NEVER I tell you, Never!" I wonder what the young lady who'd just spent her money traveling to that interview would have thought to have heard she wasted her money and was probably "selected" to interview to meet some kind of quota so the program could show they didn't discriminate against women.

Yes, my program did have malpractice insurance. And there is so much more to this story--and I do not want to put the details here for fear I'd give too much identifying information. Let's just say the attending did not go to the National Practtioner Data Bank and I did. Why? Because only the "insured" can go to the Data Bank. . .and the Program Director was insured as an employee under the "University". . .and you can't report a "University" to the databank...only the "insured"...(Mayo Clinic his able to umbrella many of their doctors this I'm told by attorneys and medical board members). "The Insured" is the "self-insured" entity. I was a resident "rotating" at that institution...and I had a "separate" policy covering "just me" (by name) as a "rider" to the policy with my name on it. As a non-employed physician, rotating to the University, from another institution (a rotation REQUIRED for me to complete my training), I was named to the DataBank.

Years ago, Josef Fischer, MD, from the ACS wrote several articles in the Bulletin of the ACS about this problem. He unfortunately failed to solve it.

But, I enjoy your blog and the back/forth input. We won't solve anything here, but it is good to hear others stories and arguments.

hope said...

I am not a huge fan of the Match myself, however, I am a firm believer that harsh criticism should be followed up by well-argued suggestions for improvement. Without posing solutions to the problem, her arguments really lack a lot of strength. I'm actually an MD/PhD program graduate myself and in a specialized surgical residency. It's never occurred to me that residents with dual degrees should be paid more. My resident salary is actually quite a bit more than would be an entry-level post doc job at my institution, which is where I would have ended up without my MD. All of us dual degree residents were fully aware of the deferred gratification we were up for when choosing MD/PhD and when choosing surgery. The salary argument doesn't make much sense to me because, as Skeptical Scalpel has pointed out, having a JD (or even PhD) benefits day-to-day resident productivity very little. These degrees are useful for our destination jobs, and perhaps for giving us different ways of thinking and seeing the bigger picture, but honestly, in terms of resident job performance, there is probably little benefit to them (and thus no reason to be paid more, in my opinion).

The Match is not great in that many programs and specialties don't rank applicants's sometimes who you know and how much power they have. But tell me, which job ISN'T this way? No job search is really fair. Most jobs already have an internal candidate selected when the position is advertised. It's the real world. Success in this world will always be based to a certain degree on who you know and how you network. Medicine is no different. The outside world grapples with the problem of "more people than jobs" in a way that is often more critical than is the field of medicine.

I don't see a great solution to the problem. For now, the Match seems no better or worse than any of the other ideas about which I've read.

Anonymous said...

I don't know if other people have brought this up, but it seems to me that the biggest problem with the match currently is the fact that there are way to many applicants (34,000) for too few spots (26,000). Fact is that residency positions in this country are ridiculously underfunded by the government, and probably causes all the trouble in the firstplace.

The issues with the Match then follow inevitably. If you have a system that cannot provide for everyone, vicious competition, pointless bureaucracy, and a focus on meaningless attributes vs. competence of the applicant are bound to follow

hope said...

That's true Anonymous, but how is that situation different from the majority of fields out there? Engineering, marketing, social work, psychology, journalism, even finance. Freshly minted college graduates in many fields have difficulty securing jobs in the profession of their choice. They're lucky to find jobs at all. While the Match does bind two parties into a contract that appears less flexible than the average person trying to obtain a job, when you're looking for a specific job in your field that you were trained to do, well, I think everyone has problems securing their first few choices, not just doctors.

Skeptical Scalpel said...

Anon 1-I don't understand the math either, and I agree that Roth won the Nobel Prize for more than just the match. I also agree that getting rid of the match would not decrease the number of interviews that applicants feel they must schedule.

Anon 2-Thanks for following up. I'm sure there are still programs that don't want to take women and interview them just for show. I just read something somewhere that said only 4% of surgery programs have no women. I would point out that the match makes it difficult to completely balance the sexes. Even if a program ranked women in the first 10 on their list, it might not match with any of the women if they ranked another program higher. I agree that this has been a good discussion.

Hope-Thanks for agreeing with me about the lack of added value that a dual degree brings to a residency program. And you are correct that networking for jobs occurs in all fields and that many people in other occupations are working for companies that were not their first choice. Let's also not forget about the PhD's are working as baristas.

Anon 3-I wrote about the problem of insufficient numbers of residency positions last year. Here's the link As far as I know nothing has been done to address this problem. You are correct that the number of medical school graduates far exceeds the number of residency slots. Even if the match did not exist, the same number of medical school graduates would be unemployed.

Anonymous said...

I haven't look into the topic much. but if there are 26k residency positions, that is still much more than the number of American MD grads (18.5k).

The current rapid expansion of spots, and the curious position of DO's (unique to the US) complicates things, but at present and for the next few years an American MD is still pretty much a guarantee for a 6-figure job.

IMG's are of course in a much worse position.

Of course, we know things will get worse. It wasn't so long ago that a law degree from a no-name school usually led to a financially-lucrative, socially-prestigious career. It took only a few years for all that to crumble.

If you look at moderately successful engineers or financiers or even lawyers, you see a combination of academic credentials, technical expertise, client service, peer networking, managerial skills. and pure luck.

I suspect that purely having an MD won't be enough 10 years from now.

Anonymous said...

@hope "I don't see a great solution to the problem. For now, the Match seems no better or worse than any of the other ideas about which I've read."

Thanks for your insights; much appreciated.

My understanding of Roth's contribution is that *no* individual applicant can do better outside the match. He/she may do the same, but not better.

He or she may get together with others to get a sweeter deal, at the expense of those others. I don't know about the details, having not study game theory since college. But by that point, he/she should give up medcine and go for his/her own Nobel. : )

Skeptical Scalpel said...

In 2015, the ACGME will consider DO graduates equivalent to MD graduates which accounted for about 20,000 graduates in 2014. That number will rise sharply as expanded classes and new med schools pump out more doctors.

I agree that it does not look good for IMGs, US or otherwise.

Anonymous said...

I think the real frustration expressed by the author stems from a lack of choices arbitrated by the match. There are about 40,000 medical school applicants each year for 19,000 MD spots (see AMCAS data, 2013). The DO data is separate. The difference here is that medical school applicants often have several schools to choose among after shelling out $$ for traveling and interviews, holding several offers and with a final date to decide on one school to attend. While this system arguably is less efficient, with some schools only filling in their last couple of spots within days of starting medical school, somehow (miraculously) those 19,000+ MD spots are always filled. Roth's Match system isn't necessary to "fill residency positions" - we do it every year in a non-match system with medical school applicants. I think the author of the Forbes article laments the lack of choices among residency applicants - just as other professions often have many job offers (along with the free market opportunity to negotiate better salaries, benefits, etc among the offers the applicant receives). Even down-the-totem-pole medical students get to negotiate with their medical school acceptance offers - I know many, many students who came out on top with better financial aid packages because other, less competitive programs offered better scholarships to woo them.

We don't "need" the NRMP match system - we do the same thing, each year, with filling the numerous medical school spots with diverse candidates, all without the match.

Skeptical Scalpel said...

Anon, you make some good points. I'm not sure the match and the med school application process are so similar. It is possible that outstanding students could negotiate higher salaries, but why would that be fair? Since the work of a resident is comparable across all hospitals, why should some residents make more money? But even more unfair would be that the top hospitals could easily pressure their residency applicants to take less money. Wouldn't you take less to train at MGH?

Again, even if the match disappeared, the expenses and time associated with interviewing would still exist. Med schools don't pay applicants' expenses. I doubt residency programs would either.

TDintheED said...

After the Twitter exchange I had with Amy Ho last night, I understand her much better. Her Twitter profile had the quote: "The opposite of Tweet is tw*t. That is how I feel about people on Twitter sometimes. Understand the * is not an i, it was the more vulgar term. This is a twitter profile linked directly to her name, not a pseudonym. I tweeted her that using vulgarity in a twitter profile is unprofessional. She responded "Stop the personal attacks." I explained that calling her the vulgarity is a personal attack, pointing out its improper use is not. She told me I was being "a Mean Girl" From a movie of the same name, popular with young girls.

The fact that she would use such a term in a public profile while at the same time having a published article in Forbes, shows a gross misunderstanding of the public nature of social media and how one should conduct herself in a professional setting.

Further, it is a failure of her medical education that she is about to graduate, yet has the maturity of a middle school girl and very thin skin. How on earth can you make it through medical school if you respond to criticism as a personal attack? Was she so difficult to deal with that they just mollycoddled her through? God help her future colleagues.

To sum up Amy Ho: I want to go to residency where I want to. I want you to pay me what I want to. I don't want to interview anywhere I don't want to work. Don't tell me I am wrong.

Skeptical Scalpel said...

TD, thank you. I can confirm that her Twitter profile was as you said. Despite her apparent feelings about your comment and her profile, she has deleted the vulgar reference from it. I share your concern about her lack of insight.

The best of the best said...

I am happy that a primadonna like Amy Ho, as flawed as some of her assertions are, has made a public denouncement of the artificial match process.

I have a solution that, being so obvious, will boggle the minds of those who read it, because its obviousness should have been..well...obvious to everyone!

MDs should be able to practice competently, without ANY residency training.

Years ago, you could be a general practitioner (now called the lame term "family doctor") once you finished medical school. The training was rigorous, the standards and expectations were astronomical, and the curriculum was arranged in such a way as to be useful.

Fast forward to now. Medical school is useless. Too many cooks are in the kitchen, pushing their left-wing ideals onto the students - the mandatory classes are all ethics and handholding seminars. Technology has changed the way we practice, yet we are still using the Flexner model from 100 years ago. Clerkship has devolved into a shadowing game where kissing up and shutting up is the way to an A. Medical students don't actually know anything anymore when they graduate, and as such, residency selection is more about how well one kissed butt than about how accomplished they are as physicians. It seems medical schools are just fine with using an outdated educational model and leaving real medical training to occur in residency.

I propose the following:

1. Medical schools change their damned curricula to be congruent with modern medical practice (we do 6 weeks of psychiatry but NO anesthesiology, radiology or orthopedics - how does that make sense?)
2. Didactic, non-MD medical school be shortened to 3 years: Two schools in Canada do this and frankly it works. We all know that the fourth "interview" year is a complete waste of time.
3. Everyone does a 2 year internship afterward, in the same thing: a general rotating internship. Once they come out, they can practice medicine as a GP. All medical students would have this behind their belts, and this would be a boon to society and to medical education.
4. Residency applications would be just like applying for jobs. None of this wasteful match process.

Dentists are always ready to go be dentists when they finish training, and their school is no less rigorous than ours. Why can't we make medical school one where physicians are trained, not just rubber stamped into a residency?

artiger said...

I agree with "the best", although to a lesser degree. I have written on Scalpel's blog elsewhere that I don't find much of medical school to be useful these days, save anatomy, some physiology, and some pharm. It could certainly by compressed in my opinion.

I also agree it's time for a "new Flexner Report".

Skeptical Scalpel said...

Best, thanks for commenting. Your description of clerkships is spot on. I agree with you about med school curricula being way outdated. I've written about that in a previous post. [See:] Do you think the shrinks will every give up even a single week to ortho or rads? Not a chance.

Your suggestion #2 will never happen. Do you think that med schools would give up a year of tuition, which by the way costs the schools nothing but some administrative work? [See:]

Your suggestion #3 is of course a great idea. Unfortunately, it will never happen. If you were the American Board of Orthopedic Surgery or Dermatology or any other highly competitive specialty, why would you ever agree to change the system?

I've said all I want to say about the match.

Best of the best said...

There are far more non-competitive specialties than competitive ones. I can't see why the doldrums of medicine like pathology and anything primary care couldn't band together to push this through.

But I don't think it would be the ABOS or the AAD who'd get in the way - as long as the pay is high they're still gonna attract "the best". It'd be the AAFP. Making "everyone" into a general practitioner would remove the "specialty" designation from "family medicine". I for one think that family medicine is an artificial concept that has no meaning, and that such a field is not a specialty but what medical school should be like for everyone. They're not paid like specialists and produce no worthwhile research. Family is not a specialty.

Med schools could charge the same tuition over three years that they do over four. It might be even better for them since they'd be getting bigger sums at once.

You're right about the shrinks. My school used to have an anesthesia rotation in clerkship, until the moronic psychiatrists banded together to have it removed in favor of more psychiatry, since no students were interested in psych and they thought that more exposure would help. Well, it didn't. More students saw what kind of whiny, incompetent halfwits went into psych at my institution, and the match rate for psych dropped even more than before!

The match is necessary only because the medical education system is extremely flawed.

Were I some bigwig academic, I'd be riding the horse on this one. Yet I went into medicine to help patients, not do meaningless research and claw at academic appointments, so people will not experience the best ideas from the Best of the Best. What a sad world.

Skeptical Scalpel said...

Best, the situation you describe in psychiatry reminds me of one of my first blog posts [] in which I described my plan to increase the number of med students going into family practice.

I offered to help set my plan in motion, but the phone never rang.

Anonymous said...

I agree that "family medicine" is not a real specialty, and stating otherwise has not encourage students in the field.

A couple of years ago, I attended a week-long FM update course at a high-profile med school. All but 2 of the sessions were given by non-FM specialists. One of them was about unusual vaginal secretions, the course director's hobbyhorse, and I completely forgot the other topic.

You can't be a medical specialty if you are completely dependent on others for knowledge.

Skeptical Scalpel said...

Anon, that is a very interesting observation. I wonder what the people running family medicine would have to say.

Anonymous said...

Please explain this to me: A 4th-year medical student ranks a program as #1; another 4th-year medical student, from the SAME medical school, ranks that same program #25. The "program" has ranked both applicants (we don't know their list/rankings). The student who ranked the program #25 matches there. The other future intern matches at his 8th choice somewhere else. If the match "favors the student", how did this happen?

Skeptical Scalpel said...

How do you know the program ranked both applicants? That information is not public knowledge.

Here's how the process works

This reddit thread offers more detailed explanations

Assuming what you described actually happened, the first program ranked the second applicant higher than the first applicant.

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