Hester, D. Micah PhD
Dr. Hester is assistant professor of biomedical ethics and humanities, Mercer University School of Medicine, Macon, Georgia.
I was pleased to see the above responses from Dr. Richard Elliott (a colleague of mine at Mercer University School of Medicine) and Drs. Blacklow and Beran (with the National Resident Matching Program) to my commentary on the Resident Matching Program. It should have been apparent that dialogue was my primary objective in the commentary, and though both letters are a bit more dismissive than I might have hoped, they do, regardless of where they stand on my specific proposal, take up the debate in a way that I hope does not let the entire issue simply drop. In the spirit of continuing dialogue, let me take a few lines to reply to some of their insights and remarks.
In his letter, Dr. Elliott rightly points out that several of my claims are “unfounded assertion[s].” I cannot deny this, and since my commentary was predicated on some of these “unfounded” contentions, it is right to raise questions about the commentary as a whole. What I find most striking, however, is that Dr. Elliott's concern for my “unsubstantiated opinion” is matched only with his own unfounded comments about a “reason to believe competition may improve the ability of medicine to improve health care.” It is true, I must confess, that I had only the “harsher side to competition” in mind while writing the commentary. I do not disagree that some competitive practices in any part of life can foster a strong work ethic, a responsible disposition, etc., but it is not clear that competitive means are the best way to do so. My, albeit unfounded, contention is that they may not be. Also, it is not clear that Dr. Elliott's example of Mercer's own ability to attract money and students (which is not directly related to the Match itself) does, in fact, successfully illustrate “competitive” advantages. That Mercer's mission to provide physicians for the medically underserved of Georgia through primary care specialties makes it unique does not entail that this places it in “competition” with other schools in Georgia. To characterize differences in terms of competitive characteristics may, in fact, be a problem rather than a benefit. Cooperative endeavors among the schools might be easier to forge if we saw ourselves as “in this thing together” rather than “us versus them.” Mercer's approach to medical education and its particular mission serve as an alternative—i.e., a novel option—in the field, and I would venture to say that Morehouse, Emory, and the Medical College of Georgia all provide novel options for students and legislators to consider. Is this “competition” or simply pluralism? Rather than “in competition with” other Georgia medical schools, why not look at Mercer's place in Georgia as supplemental, not adversarial?
Furthermore, though such comments as “medicine… [is] fundamentally about human beings… [with] human problems” do apply “equally well to many other professions and vocations” (I would go so far as to say all other professions), I do not agree that this fact makes the comment meaningless. It is no new insight to point to the plethora of written material, particularly since the 1960s, that has lamented medicine's turn to a focus on disease processes to the exclusion of what some have called “the patient as person” and others have called the “biopsychosocial” view of medicine. It is also not new to indicate that medicine must be even more acutely aware of this human dimension in its practices since, unlike most other professions and vocations, medicine deals with particular and deeply vital issues in human living, and does so in intimate ways that simply are not experienced in the same way for those seeking, say, educational, ministerial, or legal aid—to name but a few.
However, this being said, there are clearly fundamental problems with a lottery-based system, and I point out in the article the problems of ignoring “merit” and eliminating “choices” as at least two of them. The letters from both Dr. Elliott and the NRMP are correct to point out these flaws in my proposal as well, although the NRMP implies that my elimination of choice was, from my standpoint, a desirable outcome. Nothing could be further from the truth. Choice is important, but the suggestion to use the lottery is in response to what individual choice, as the Match currently operates, actually gets us—viz., chronically underserved geographic areas and specialties as well as the perpetuation of an elitist system of institutions to the detriment of many fine schools, residency programs, and, of course, students.
Oddly enough, neither Dr. Elliott nor the NRMP attends to my analogy with a sports “drafting” system, but much more importantly, neither expresses why the flaws with the current system are worth continuing without a thorough reconsideration. Presumably Dr. Elliott's appeal to the principle of autonomy is one attempt to do so, but no argument is given why such a principle trumps, say, the principle of justice that, it could be argued, supports an equitable distribution of resources—such as residents—to urban and rural community-based hospitals instead of the research institutions to which the spoils of the Match tend to go. “Them that's got shall get” is difficult to support using social justice criteria. Why should individual autonomy be more important than justice, especially in a field where the absence of medical expertise impacts not just individual patients but entire communities (this is one reason Mercer, for example, has the mission it does)? Whether or not changes to the Match in the way that I propose are, in fact, the best approach to these problems is, I admit, still an open question.
I wish to thank the editors of Academic Medicine for allowing me to put forth opinions that were obviously ripe with question-begging and unsubstantiated claims, and I also want to thank those who responded with Letters to the Editor concerning my commentary. I want to make clear that whatever the outcomes of this conversation, I do not ask, as might be inferred from the NRMP's letter, that we abandon the Match without regard to what it has positively contributed to the field, but instead suggest that we “rethink” it (as my title implies) for the 21st century. Of course, I would hope no one thinks me fool enough to believe that my comments were without obvious problems. Admittedly, the lottery system may err too much on the side of “social” concerns to be an acceptable alternative. However, my biggest concern, as I hope I stated plainly enough, was to jump-start a new discussion of the Match in light of the changes in medicine and society over the past 50+ years since its inception—e.g., to think not just in terms of “autonomy” and “choice” but “justice” as well. Any of my specific discussions of “competition” and “cooperation” (and this point I may not have made clearly enough in the commentary itself) should be seen in this light.