In his commentary “Rethinking the Residency Matching Process and Questioning the Value of Competition in Medicine,” Dr. Hester asks that consideration be given to practices, instruments, and algorithms to make the resident matching process less competitive. He suggests a straightforward lottery system as a possible mechanism for filling residency positions, noting that a lottery system would eliminate personal choice.
The ability of programs and applicants to rank-order their preferences is central to the matching process. Applicants' preferences for program types and geographic locations; couples' preferences for geographic proximity; and programs' preferences for the best candidate matches for their programs are the critical drivers in the construction of rank-order lists. While competition is clearly a factor in the events surrounding the development of preferences, the rank-order list process itself represents a seminal example of personal choice.
The interest of programs and applicants in each other—particularly when more than one program and/or applicant is interested in the same individual or position—will result in “preferences.” The verbal courting that precedes the final certification of the rank-order list is part of the process of showing one's interest in one's “preferences.” However, it is when courting progresses to “promising” that one begins to witness the adverse effects of competition noted by Hester. It is important to point out that applicants who match to an institution do not have the option (as indicated by Hester) to ignore the outcome.
The NRMP and its five sponsoring organizations work collegially with specialties to encourage maximum participation in the Match. The NRMP's policies and procedures are designed to minimize or neutralize the adverse effects of competition. Similarly, the NRMP has been strengthening its follow up on issues of applicant and program compliance with match policies and procedures. Violations of the Match are no longer “inconsequential.” Confirmed violations by either applicants or programs will be reported to such organizations as the medical schools, the Accreditation Council for Graduate Medical Education, and the appropriate Residency Review Committee.
The specter of having the first year of residency training determined by a lottery is fundamentally opposite to the concept of choice and also is not in line with the practices observed by other professions. While one can take issue with the value system in medicine, the NRMP believes the present emphasis on “professionalism” in our schools, in graduate medical education, and in the NRMP represents a reasonable and sound strategy in the education and training of future physicians. One needs only to recall the residency selection process prior to the development of the Match to understand the meaning of the term “adverse effects of competition.”