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Invited Commentaries

Assuring Integrity in the Residency Match Process

Chimienti, Sonia N. MD; DeMarco, Deborah M. MD; Flotte, Terence R. MD; Collins, Michael F. MD

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doi: 10.1097/ACM.0000000000002531
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Abstract

Participation in the residency program selection process (the Match) is a time-honored tradition in medicine. All medical students who wish to participate in accredited graduate medical education programs must register through the National Resident Matching Program (NRMP) Match or other specialty-specific matches, including the military,1 SF,2 and urology matches.3 In recent years, given that many medical schools have transitioned to pass/fail grading in their preclinical years, the United States Medical Licensing Examination Step 1 has become an increasingly important indicator of whether a student will be invited for a residency interview and ranked in a position that will result in a match.4,5 Furthermore, given that some programs may see it as desirable (or indeed essential) to match students without going very far down on their rank lists, some faculty members and even program directors have questioned students about their rank order lists prior to the creation of the programs’ rank order lists.

Moreover, improper postinterview communication with applicants has been documented in a number of specialty-specific survey studies, including studies in emergency medicine,6 dermatology,7 orthopedics,8 and urology.9 Although the survey questions were not identical, a comparison of these studies nonetheless shows a consistent pattern of observations. For example, a majority of survey respondents reported that they had received communications from programs after their interview and before the Match, at rates of up to 64% among orthopedics applicants.8,9 Fourteen percent of dermatology applicants7 and 30% of emergency medicine applicants6 felt that those interactions included outright violations of NRMP rules.10 Being pressured to reveal where they planned to rank a program was also reported to be quite common, ranging from approximately 8% among the emergency medicine applicants6 to approximately 20% among both dermatology and orthopedics applicants.7,8 Interestingly, for many applicants, the postinterview communications evoked a sense of pressure to attend a second look day, causing them to incur considerable additional expense.8,9

The Chaos of the Interview Process

Most physicians would agree that there are strong data to indicate that persistent attention to e-mail and the use of mobile devices during clinical work is distracting and can negatively impact the functioning of a team, affect attention to patient care, and even cause errors in patient care. It can also lead to personal dissatisfaction on the part of the provider. Yet, despite this knowledge, the residency interview process encourages students to be tied to their mobile devices so that they can immediately pounce on an interview offer when it comes in or else risk losing their spot to another applicant. Specifically, some programs overextend interview offers and then wait to see which students accept the offers first. Students who are not glued to their e-mail may lose an interview spot; if they reply a few hours after an offer is extended, they may be told that it is no longer available. Students have relayed to us that they give their mobile devices and even their e-mail passwords to friends and loved ones to monitor while they are in the operating room or patient exam room so that they do not miss an interview offer. This practice must stop. Our patients demand and deserve the attention and respect of their providers always. This practice must not be condoned or tolerated. Interviews should not be oversubscribed; a student who is extended an offer of an interview should be allowed a reasonable and designated amount of time to respond. Those students who fail to respond within the time frame should be offered a wait list spot and accommodated if an opening materializes later in the interview season. To do anything other than this is both offensive and inappropriate. The Electronic Residency Application Service issued a statement to medical schools during the 2019 Match season strongly encouraging programs to not overextend interviews and to allow a reasonable time to respond11; however, without a policy on this and enforcement of such a policy, this practice is likely to continue.

A Focus on Integrity During Interviews

During the interview process, students are often asked probing questions about what their rank order list might look like (e.g., “Is our program your first choice?”). Questions such as these, coming from someone in a position of power, are not only unfair but also cause significant discomfort for and pose ethical challenges to the applicants. Does the candidate speak truthfully and potentially affect their chances of matching at the program if it is not their number one choice? Or do they lie to protect their future training options? Furthermore, we are aware that many students are asked other inappropriate questions. From our own experience and from dialogues with faculty members from other institutions, we know that students in the most recent application cycle have been asked not only about their rank order lists but also about birth control, religion, and why they are pursuing residency training when they are married with a partner to support them. Clearly, these questions are inappropriate. Yet, we encounter students each year who are subject to these and other such inquiries.

We also know from our own experiences that during or following their residency interviews, students are often contacted by program directors, interviewing faculty members, home medical school department chairs, chief residents, and residents that they know or know of (who are often from their home medical school) and asked about their rank order. These contacts are particularly frequent with highly competitive residencies or home school programs and aimed at revealing the student’s rank order preference list. For example, here is a communication from an institution to a student that the student shared with us:

[Name of applicant], Just thinking of you as we get our rank list together. I know a lot goes into the formulation of your rank list, but please know how much we would love to welcome you to [name of program] for [specialty choice]. You would be GREAT here and I would love to support the next steps in your career as it unfolds. —[Name of interviewer]

The applicant matched at this program.

Conversely, students often ask whether, to help them with a possible match, they should send a thank you note to programs indicating their enthusiasm for the program. One student was counseled by a resident at a program that he/she should definitely contact the program director or he/she would run the risk of not being ranked by the program.

Students also often feel obliged to inform the program that they choose to rank first that this program is their number one choice. Programs will respond to applicants to acknowledge receipt of this information regardless of whether they have ranked that applicant, which can lead to awkward communications such as this:

Hi [name of applicant]—I am so glad you had a wonderful experience at [name of hospital]. I am thrilled with your decision. You made my day! —[Name of program director]

The applicant did not match at this program.

Additionally, the chair or program director of a student’s home medical school will often ask a student to inform them about their rank order list. This is often done under the guise of a mentoring visit, yet the program director then has information that could favorably or unfavorably impact the student’s match. Another observation we have made is that often program directors or interviewers will ask students what they might know about the rank order preference of another student who they have been seen with on the interview trail. Whether inadvertently or not, information about another student’s rank order preferences may then be conveyed to those who inquire.

Due to practices like the ones mentioned above, the Match experience seems to be the only place in medicine where it is “acceptable” to bend the truth or to speak less than honestly. We should not model for applicants that it is acceptable to be less than honest during the Match process. Both programs and applicants should not, as a way of influencing the other’s rank order list, try to nuance their views on a program or applicant, as can be seen in the following statements:

We could definitely see you in our program!

I know that I would be comfortable in your program!

In these cases, neither the program nor the applicant intends to match with the other. They are simply looking for a polite way to respond.

The ethical lapses and outright abuses described here are strikingly reminiscent of those experienced in another recruiting process that puts young, talented individuals in a position where both their empowerment and their integrity may be compromised. The recruitment of competitive athletes from high school to major National Collegiate Athletic Association (NCAA) athletic programs has come under heavy scrutiny recently and ultimately led, in the fall of 2017, to the federal prosecution of 10 individuals for fraud and corruption.12 Based on that particular incident, the NCAA created a Commission on College Basketball to reexamine their recruitment policies and facilitate the enforcement of NCAA rules.13 In a parallel fashion, we would propose certain reforms to the residency program selection process.

Proposal to Enhance the Integrity of and Promote Order in the Match Process

Steps should be taken to ensure the highest possible standards of integrity in the Match process. By NRMP policy,10 no interviewer, program director, or anyone else affiliated with a residency program is permitted to ask an applicant about the order in which he/she is ranking programs on his/her list. Similarly, programs should refrain from asking applicants about other applicants’ preferences. Furthermore, programs must not inform a student of its rank order. Programs and students should be prohibited from any postinterview correspondence, and second look days at residency programs should be eliminated. Finally, the process by which interviews are granted and accepted must be addressed (as indicated above).

In summary, we propose that the Match, residency programs, and applicants consider the following remedies to ensure integrity and promote order in the residency program selection process:

  • Interviewers, program directors, or anyone else affiliated with a residency program must not ask an applicant about where programs are to be ranked on that student’s rank list. Similarly, they must be prohibited from asking an applicant about other students’ preferences. Current NRMP rules10 regarding these behaviors should be enforced.
  • Programs must not inform a student as to what their rank order will be (e.g., “You are in a sure-to-match position!”). As with the previous item, current rules10 should be enforced.
  • As many students have mentors from their home medical school’s specialty department, these faculty members will need to hold in confidence information that they receive about their mentee’s rank preference and must not transmit this information to those who are making the program’s rank order lists. There also needs to be separation of mentoring and rank order list responsibilities to ensure that students are not adversely affected during the process.
  • Programs and students must be prohibited from any postinterview correspondence, including thank you letters, e-mails, or texts.
  • Second look days, which are an extra expense for students, should be eliminated.

Although several of these behaviors are already prohibited, the enforcement of norms surrounding communications appears to us to be very inconsistently adhered to. Thus, we suggest that the NRMP, which is responsible for this process, provide both an anonymous reporting system for violations of these rules and an unaffiliated ombudsman function for learners who find themselves caught in the middle of “match games.”

Conclusion/Summary

Given the central role that the Match plays in a physician’s future specialty choice and location of training, it is essential that program directors, faculty members, and students model the high ideals of the profession during this most critical process. The integrity of the Match, as a process for placing applicants in programs they desire and ensuring that residency programs are filled with capable learners, should be reinforced. We believe that the remedies we have proposed in this Invited Commentary will assist in the reduction of anxiety among student applicants and support the integrity of the Match, while also ensuring that students and programs alike are treated fairly throughout the process.

References

1. Medicine + the Military. Residency + Match Day. https://www.medicineandthemilitary.com/officer-and-medical-training/residency-and-match-day. Accessed October 23, 2018.
2. SF Match. SF Match homepage. https://www.sfmatch.org. Accessed October 23, 2018.
3. Americal Urological Association. Urology and specialty matches. https://www.auanet.org/education/auauniversity/education-and-career-resources/for-residents/urology-and-specialty-matches. Accessed October 23, 2018.
4. National Resident Matching Program. Interactive charting the outcomes in the Match. http://www.nrmp.org/interactive-charting-outcomes-in-the-match. Accessed October 23, 2018.
5. National Resident Matching Program. At-a-glance program director survey. http://www.nrmp.org/at-a-glance-program-director-survey. Accessed October 23, 2018.
6. Thurman RJ, Katz E, Carter W, et al. Emergency medicine residency applicant perceptions of unethical recruiting practices and illegal questioning in the match. Acad Emerg Med. 2009;16:550–557.
7. Sbicca JA, Gorell ES, Kanzler MH, Lane AT. The integrity of the dermatology National Resident Matching Program: Results of a national study. J Am Acad Dermatol. 2010;63:594–601.
8. Brooks JT, Reidler JS, Jain A, LaPorte DM, Sterling RS. Post-interview communication during application to orthopaedic surgery residency programs. J Bone Joint Surg Am. 2016;98:e84.
9. Sebesta EM, Lipsky MJ, Nunez M, Cooper KL, Badalato GM. The National Resident Matching Program code of conduct: What is the perceived degree of compliance during the urology Match process? [published online ahead of print June 21, 2018]. Urology. doi: 10.1016/j.urology.2018.04.046.
10. National Resident Matching Program. Match communication code of conduct. http://www.nrmp.org/communication-code-of-conduct. Accessed October 28, 2018.
11. ERAS Communications, Association of American Medical Colleges. E-mail communication, October 22, 2018.
12. Henning PJ. Taking a new strategy to court in N.C.A.A. case. N Y Times. October 4, 2017. https://www.nytimes.com/2017/10/04/business/ncaa-coaches-payments.html. Accessed November 9, 2018.
13. NCAA. Committed to change. http://www.ncaa.org/about/committed-change. Accessed October 28, 2018.
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