Make residency fairer by removing The Match

As of noon on Friday March 19, more than 30,000 future physicians across the country and around the world will learn their professional destiny in residency programs for the next three to seven years.

At that time, medical students receive their results in The Match, officially known as National Resident Matching Program, which uses a popular computer algorithm to match medical students with the next part of their education – residency programs in hospitals and healthcare systems.

Medical schools and hospitals celebrate this moment. Public relations departments have a special affinity for the great drama of The Match: videos featuring ecstatic students reveling in their dream program, their dream specialty, their dream city. Before the pandemic, programs invited proud parents to watch and host wine and cheese parties. And while the Covid-19 restrictions may mean a more socially distant celebration this year, The Match’s message will remain as a happy transition from student to doctor.


But beneath the sparkle of champagne toast and Instagram posts lies a grim reality. Far from being a boon to new doctors, The Match has for decades maintained salaries in residency programs and shielded hospitals from pressure on key workplace issues such as parental and sick leave by banning future residents. serious negotiation with their future employers.

It marks a test for each new generation of residents and a tragedy for the medical system as a whole. Depressed wages and more paltry benefits afforded by this legally sanctioned monopoly make medicine a more off-putting place for those without wealth and for those who balance work and childcare. This makes medicine less racially and socio-economically representative at a time when it is becoming clear that representation can improve medical outcomes. In short, it affects not only the health of the residents, but yours.


It hasn’t always been that way. In the past, medical students and hospitals negotiated directly with each other. Competition for talent was fierce in a tight job market, with residency programs offering medical students up to two years before graduation. This process had significant drawbacks: students had to deal with explosive offers and felt compelled to commit to a program before they were sufficiently exposed to the different medical specialties.

Medical students, residents and hospitals all supported the reform. In the early 1950s, a precursor to today’s Match was approved, and it has since become virtually the only way to gain residency and become a licensed physician.

To participate, applicants must commit in advance to the residency program that the algorithm chooses for them from the programs they have chosen. Essentially their choice is this: accept the outcome of The Match or quit medicine.

It creates a striking power imbalance. Residents often feel they have little recourse to tackle punitive work hours, abusive environments, or little flexibility to accommodate pregnancy or child care. The private body that ostensibly accredits residency programs caps weekly hours worked at 80; in practice, many residents feel intense pressure to work longer hours and are content to lie on the forms that their programs submit to the accreditation body. At the height of the Covid-19 pandemic, residents’ risk premium requests have sometimes fallen on deaf ears; a head of department who, not by chance, made several times the salary of a resident, had the temerity to call this plea “not to become a compassionate and caring doctor.”

This statement is all the more infuriating when you consider the role resident physicians play in health care in the United States. They make life and death decisions about medications, work 24+ hours at a stretch, and write charts that hospitals rely on for billing. They perform lumbar punctures, drain abscesses and intubate Covid-19 positive patients. They answer pagers in the middle of the night and rush to the bedside. When patients’ hearts suddenly stop, they often try to revive them.

Yet they remain largely powerless to change critical aspects of their work environment. This decades-long power differential helps explain why salaries in residency programs remain low even though average medical school debt has declined. has exceeded $ 200,000, why many programs do not have a parental leave policy and why young doctors can be punished, formally or informally, for taking a sick day.

These hurdles are easier to overcome for people from wealthy backgrounds, and indeed, about half of American medical students grew up in the top income quintile, while only 5% come from the bottom quintile. Our country’s long history of racial discrimination means that Blacks, Hispanics, and Native Americans are disproportionately represented in the lower socio-economic strata. In addition to structural racism, these socio-economic barriers help to explain why people in these groups remain under-represented in medicine. And one growing number of searches indicates that this lack of representation can lead to worse outcomes for patients of color.

Correcting this will not be easy. The increasingly large hospital systems that benefit the most from these inequalities have clearly shown this. When The Match’s monopoly attracted a credible antitrust challenge in 2002, American hospitals and medical schools simply used their formidable lobbying arms to slip an exemption in an urgent and independent pension bill, which Congress dutifully passed.

If society is serious about creating a medical profession that resembles the patients it serves, it will need to level the playing field by removing The Match. Supporters of the current system argued that such moves could plunge the residency job search into the chaos that marked the pre-game days. But that doesn’t have to be the case. The law firm associate market has operated for decades, with schools simply imposing a set of rules defining maintenance periods and prohibiting explosive offers.

Perhaps more importantly, hospitals should stop hampering residents’ efforts to unionize. Some hospitals have attempted to torpedo union efforts by threatening interested residents and even to argue, laughable, that they do not qualify to unionize because they are students and not employees.

For too long, the House of Medicine has adopted a mercenary attitude towards its new doctors. To borrow a phrase, it just isn’t becoming a compassionate and caring profession.

Clifford M. Marks is a third year emergency medicine resident working in New York City.

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