Correspondence
Is the Match Illegal?
N Engl J Med 2003; 348:2259-2262May 29, 2003
- Article
To the Editor:
Chae (Jan. 23 issue)1 raises several interesting and important points in his analysis of the lawsuit attacking the matching process of the Accreditation Council for Graduate Medical Education (ACGME). He suggests, however, that the Match has resulted in programs' being “deterred from increasing salaries to compete.” This is probably not entirely true. Prospective residents are informed of their potential salary even before they apply. When deciding how highly to rank programs on their Match list, students may take salary into account — along with other known attributes of programs such as location, workload, and academic reputation. Would not a program offering a salary of $80,000 be more desirable to an applicant than a similar program offering $40,000?
A nearly exact parallel may be drawn to the application process for medical specialties. Fellowships in cardiology, pulmonology, and critical care, for example, use the Match, whereas training programs in other disciplines, such as gastroenterology, do not. The salaries of gastroenterology fellows are not higher than those of their colleagues in cardiology. Trainees are paid moderate salaries not because of the Match, but because of market forces.
1 ReferencesDaniel P. Morin, M.D., M.P.H.
Tufts–New England Medical Center, Boston, MA 02111
daniel@massmed.org 1
Chae SH . Is the match illegal? N Engl J Med 2003;348:352-356
Full Text | Web of Science | Medline
To the Editor:
“Is the Match Illegal?” leaves the misimpression that the Match somehow determines or affects how much residents are paid, which it does not. Under the rules of the Match, students apply separately to residency programs and determine which ones they prefer on the basis of whatever factors are important to them. These factors typically include the prestige of the program, the quality of the medical education, and the program's location. For students, unlike professional engineers,1 the Match does not restrict the negotiation of residency terms, including stipends.
The Match's sole purpose is to match students with programs on the basis of their preferences. U.S. students are typically matched with one of their top four choices.2 Unlike professional football players,3 students are not assigned; they are matched with programs they have selected, and they receive a graduate medical education of substantial value in addition to their stipend.
From an antitrust perspective, the Match provides a fair, efficient means of bringing together students and residency programs. Thus, it operates in the best interest of students, residency programs, and the public.
3 ReferencesStephen H. Miller, M.D.
National Resident Matching Program, Evanston, IL 60201To the Editor:
I graduated from medical school in 1952, the year the National Resident Matching Program was initiated. As a medical student, I spent five months working on the Match, which was initially unworkable. A group of my medical-school classmates and I were determined to change it, and we succeeded. It has endured for 50 years and has been adopted by most specialties. I have saved all the archival notes on these deliberations.
The Match was designed to assist medical students in choosing the best possible internship. It matched the candidate with the best hospital on the applicant's list that had also listed the candidate. It did not address issues of work hours, salary, or antitrust or anticompetitive practices by hospitals.
A residency is chosen for educational opportunity, not work hours or salary. In 1952, an internship at the Massachusetts General Hospital paid $25 per month. The hours in surgery were every other night and weekend — that is, 100 to 120 of the possible 168 hours. The jobs were eagerly sought. The training lasted eight years — much longer than in some other specialties — but the education was worth it. It would be a giant step backward into anarchy to end the matching program.
W. Hardy Hendren, M.D.
Children's Hospital, Boston, MA 02115
hardy.hendren@tch. harvard. edu To the Editor:
Success of the lawsuit challenging the legality of the Match would take us into an unknown swamp. Economics aside, someone should make clear what arrangements are likely to emerge if the suit is successful. Physicians of my era (I attended medical school from 1948 to 1952) remember seeing senior students sleeping in phone booths waiting for a call from their first-choice hospital but having to respond to the rest of their choices by a deadline that was only days or hours away — typically, 72 hours.
The Match was initiated in 1952 by my class, led by Hardy Hendren, now a professor emeritus at Harvard Medical School.1 The medical students — not the hospitals — arranged the Match. Without the Match, we would presumably be back to a free-for-all, rife with all sorts of special deals and favoritism, followed inevitably by federal civil-rights oversight to ensure fair play and diversity. Would this really be progress? Or does somebody have a better alternative plan?
1 ReferencesJames A. Pittman, Jr., M.D.
University of Alabama School of Medicine, Birmingham, AL 35294-0007
jpdoc@aol.com To the Editor:
The Sounding Board article by Chae, in seeking to present a balanced legal view of the resident matching program, unnecessarily intertwines the Match with residency reform, resulting in an underestimation of the benefits of the Match to students, residents, and hospitals and an underappreciation of the chaos that would ensue if the Match were eliminated.
Even before 1952, when the “Boston pool” method was adopted nationwide to create the Match, students did not seek out a residency on the basis of the highest salaries; rather, they sought out programs on the basis of their reputations and the quality of the educational experience offered. At that time, they were more often than not basing their decisions on incomplete information, because the system fostered premature decision making and reliance on an “old-boy” network of privilege. Before choosing their Match priorities, today's students have detailed information about the educational options available to them. Now more than ever, with board eligibility being a requirement for malpractice insurance in most settings, the full term of residency should be considered to be part of the continuum of medical education and not part of the traditional “job market,” as Chae contends that it is.
The Match algorithm has been adjusted over the years to ensure that it functions to protect students' choices for their resident education.1 In fact, the Match is configured so that students' choices trump hospitals' choices.
Duty-hour changes and other aspects of residency reform can be carried out without reconsideration of the essential components of the Match. Meaningful residency reform is occurring nationwide now. I believe that the duty-hours reform that takes effect on July 1 is only a first step reflecting the larger commitment of academic medicine to adjust residency education so that it reflects the postgraduate training needs of students in the current health care environment. I have agreed to chair an advisory task force on medical-education reform for the Association of American Medical Colleges, and although our main focus will be on undergraduate medical education, we cannot address this first half of the training of new physicians without also looking at the other half, graduate medical education; the two are too intertwined today.
1 ReferencesJoseph B. Martin, M.D., Ph.D.
Harvard Medical School, Boston, MA 02132
joseph_martin@hms.harvard. edu 1
Roth AE . The effects of the change in the NRMP matching algorithm. JAMA 1997;278:729-732
CrossRef | Web of Science | Medline
Author/Editor Response
As Dr. Miller points out, programs may advertise salary, training, and prestige, but his commentary misses the critical point that the Match prohibits direct offers by forbidding communications such as “verbal or written contracts prior to . . . the Match.”1 This prohibition operates as an anticompetitive restraint on trade because it “impedes the ordinary give and take of the market place,”2 eliminating market pressure on salaries. Students may factor in prestige, education, and location, but they will not factor in salary, because the salaries are roughly the same. The most prestigious programs, such as those at Massachusetts General Hospital and Johns Hopkins, pay about $40,000, whereas Albany Medical Center pays $36,000, Staten Island University Hospital $42,200, and the University of Arkansas $35,250.3 This emphasis on competition in variables other than salary in the face of roughly flat salaries does not satisfy the antitrust laws, as the appellate court in U.S. v. Brown University noted. “[B]y eliminating price competition . . . [schools] channeled competition into areas such as curriculum [and] campus activities . . . naturally focus[ing] on attributes other than price. This is not the kind of pro-competitive virtue contemplated under the [Sherman] Act, but rather one more consequence of limiting price competition.”4
Although it is tempting to draw an analogy between the fellowship process and the Match for residency, as Dr. Morin has done, the comparison is inappropriate, because the underlying economics are strikingly different. A labor shortage characterizes the residency market, forcing many residency programs to hire graduates of foreign medical schools. By contrast, there is a labor surplus for fellowships. There are more residents seeking fellowships in cardiology or gastroenterology than there are spots. A labor shortage should drive up salaries for residencies, whereas low salaries in the fellowship market might reflect the high demand for these positions.
As Drs. Hendren and Pittman note, the Match was probably a novel and effective solution in the 1950s. Residencies and medical education have changed substantially since then. In 1952, debt was unheard of. Now, the average student owes $103,000. Furthermore, the workload for residents has changed, as the emphasis has shifted from learning to labor. According to Dr. Ron Arky, a professor at Harvard Medical School, “Residents work much harder now than they did 10 to 15 years ago. The `service' component or labor component of a residency has exploded because of technology, patient turnover, and the pressures on hospitals. Residents do many more workups [and much more] scheduling and paperwork . . . and there is less time for learning.”5
Hence, the Match may have become dated. Antitrust concerns provide an opportunity to address issues that have arisen over the past 50 years. Although few desire a return to “anarchy” and chaos, business and law students with similar levels of debt apply for jobs under a more open system. One wonders whether they would prefer the acquisition of positions that pay $40,000 for 80 hours of work per week through a mechanism like the Match over anarchy and chaos.
5 ReferencesSanders H. Chae, M.D., J.D.
Columbia University College of Physicians and Surgeons, New York, NY 10032
sanderschae@post.harvard. edu 1
Policies of the NRMP. (Accessed May 9, 2003, at http://www.nrmp.org//res_match/policies.html.)
2
National Society of Professional Engineers v. United States, 435 U.S. 679, 692 (1978).
3
FREIDA Online: fellowship and residency electronic interactive database. Chicago: American Medical Association, 2003. (Accessed May 9, 2003, at http://www.ama-assn.org/ama/pub/category/2997.html.)
4
United States v. Brown University, 5 F.3d 658, 675 (3d Cir. 1993).
5
Ludmerer KM. Time to heal: American medical education from the turn of the century to the era of managed care. Oxford, England: Oxford University Press, 1999.
