Elliott, Richard L. MD, PhD
Dr. Elliott is professor of psychiatry and medicine, Mercer University School of Medicine, Macon, Georgia.
I am writing in response to Dr. Micah Hester's commentary “Rethinking the Residency Matching Process and Questioning the Value of Competition in Medicine.”1 In this he suggests that the current system for matching students to residency programs be replaced by a lottery. My concerns with this proposal are several, and include the assertions made about the role of competition as well as the consequences of such a proposed lottery system.
Dr. Hester takes as his central thesis that “medicine and its practices are fundamentally about human beings working together to solve very real human problems…” This unfounded assertion applies equally well to many other professions and vocations, and is therefore a relatively meaningless statement. Therefore it is difficult to see how the author can distinguish the selection process used for residency programs from processes used to gain admission to other programs and institutions. Should there also be lottery systems to determine admissions to undergraduate institutions, graduate programs, medical schools, and law schools? Perhaps employment of physicians itself should also be based not on merit but on a lottery, so as to provide patients with greater diversity among physicians in their communities. Perhaps patients should not choose their physicians but should be assigned “providers” as, sadly, has become the case in some HMOs.
The logic of the piece continues similarly, with the statement “Competition as overwhelmingly manifested in medicine in general… is incompatible with the ends of medicine itself.” Where is the support for this sweeping generalization? Certainly some competition is necessary in a desirable profession, and certainly unhealthy competitive practices exist, but few physicians can practice successfully without much cooperation with patients, other physicians, and other health care providers. Learning how to compete fairly is one, but only one, aspect of becoming a doctor, or, for that matter, a lawyer, teacher, or biomedical ethicist. A program responsive to the needs of its consumers also teaches other values, including the need for cooperation.
Dr. Hester goes on to assert another unsubstantiated opinion, that with such competition, medicine will never fully meet the needs of society. In fact, there is reason to believe competition may improve the ability of medicine to improve health care by providing the appropriate rewards for innovation and industry. For example, the author's and my own school, Mercer, is able to compete with other medical schools in Georgia for funding and students by virtue of its unique focus on training primary care physicians for Georgia, a competitive position that benefits the state and its citizens. A lottery system such as that proposed by Dr. Hester would undermine the ability of schools such as Mercer to attract students similarly interested in rural medicine, and would also poorly serve schools with other special missions and capacities, whether in research, clinical areas of expertise, or interests in serving special populations.
I found myself wondering as I read his commentary whether Dr. Hester sees only the harsher side to competition and fails to see the value of competition in bringing out the strongest work ethic and encouraging programs to find niches that increase program diversity. If such a lottery system were to receive support, then perhaps an important lesson of failed socialism—the need to foster healthy competition—may be in danger of becoming lost.
My final concern with this commentary is the lack of consideration of fundamental ethical principles, of which I will mention only one, the principle of autonomy. In an age where autonomy is of paramount importance in medicine, it seems inconceivable to consider a system that would limit a student's ability to compete for and to select, within the limitations of a fair match process, the best position for which he or she is qualified.
I have touched on only several of the flaws in the commentary, and leave to others to discuss the political problems inherent in removing from our best training programs the ability to select students best qualified to take advantage of the opportunities they offer. I hope we can put Dr. Hester's proposal to rest, and that future discussions on selection for residency programs will focus on more substantive issues, issues that will improve the fairness of the system without sacrificing ingredients essential to its success.