Portal de Periódicos da CAPES

Rethinking the Residency Matching Process and Questioning the Value of Competition in Medicine

2001; Lippincott Williams & Wilkins; Volume: 76; Issue: 4 Linguagem: Inglês

10.1097/00001888-200104000-00009

1938-808X

D. Micah Hester,

Healthcare Policy and Management

The residency matching process appears at first glance to be a successful method for most programs and candidates. From the standpoint of residency programs, the National Resident Match Program (NRMP, “the Match”) contains costs, maximizes visibility, and, where matches are made, “guarantees” housestaff. Analogously, the NRMP can also reduce costs and maximize visibility for candidates while allowing them to make informed ranking decisions without institutional pressures, and, again, where matches are made, be guaranteed positions. Those who have raised questions about the Match process have tended to focus on the algorithm used,1–4 or on possible discriminatory practices on the part of institutions.5–8 And though these concerns are not unimportant, what of the value system on which the Match—and the U.S. educational system in general—is based? Does that value system reflect or discourage the values espoused by the medical profession? CONTROL AND COMPETITION Two overriding aspects of the matching process in particular, and, for that matter, medicine in general, are control and competition. From a candidate's perspective, the Match itself controls the outcome of the process, an outcome that is experienced as uncertain. Without direct control over the final results, candidates agonize over rank-order lists (ROLs), hoping to “rig” the process in their favor. The competition among candidates for “choice” positions is high, and this competitive atmosphere fuels stress and heightens the desire for control over outcomes. Reactions by candidates to the lack of control within the Match itself manifest themselves in at least two ways. First, prior to the February ROL deadline, candidates will often court multiple institutions, making strong (though sometimes vague) overtures concerning intent to rank them highly (let's just say it: “first”) in return for similar promises from the institutions. Second, if the Match does not provide an institution that is acceptable to a candidate, he or she may decide to ignore the outcome and scramble to find an unmatched position at another institution. Of course, programs themselves are not immune from the problems created by a lack of control and a competitive marketplace. They too go through a courting process and make promises to students. One might be more inclined to believe that the programs are apt to keep those promises, but without direct control over the final match, the specific character of those promises is very important. Ironically, the NRMP has only “one cardinal rule,” which is “neither [party] must ask the other before the Match to make a commitment as to how one will be ranked.”9 Of course, there is no authority to back this up any more than with most ethical edicts. Ethics is concerned with what our actions should be, how actions affect our habits and character, and what consequences follow in the socio-natural environment if we act in particular ways. Competitive acts breed a competitive environment. Competitions place individuals at odds and treat their ends as incompatible and each other as impediments to individual ends. Unfortunately, the entire institution of medicine breeds and supports competition in testing, ranking, selecting, granting, etc. Our environment and how we act help to shape our habits and characters, and if medicine and its practices are fundamentally about human beings working together to solve very real human problems, why is it that we do not treat the processes of training and hiring medical practitioners in the same way? To put it another way, if the ends of medicine are healthy individuals in healthy communities and environments, then why don't our means mirror our decidedly positive, even moral, ends? Competition as overwhelmingly manifested in medicine in general and in the matching process in particular is incompatible with the ends of medicine itself. While it must be noted, of course, that the Match was designed to give every applicant a fair chance to gain a residency position, so long a competitive practices run rampant in institutionalized activities such as residency matching, medicine simply will never fully meet the concerns of the people who need its help and a society that needs its comfort. EXPLORING AN ALTERNATIVE What, then, is the alternative? How might we change the residency matching process to account for these concerns? What practices, instruments, and algorithms might help to make the matching process less competitive? I would suggest we consider a radical alternative—if only to force us to reflect on the value system on which the current Match system is based. What if the Match were conducted using a straightforward lottery system, in which candidates and programs were randomly matched? In such a system, all PGY-1 candidates in pediatrics (for example) would be placed into one pool and all PGY-1 programs placed into another; a name would then be drawn from each pool, and a match would be made. This system has the decided advantage of providing all programs with housestaff (so long as there are as many or more candidates as there are positions) and all candidates with equal chances for even the “top-level” placements. The best students from the Harvards, Columbias, Baylors, Vanderbilts, UCSFs, etc., might find themselves in what they consider to be less desirable inner-city hospitals or rural settings. These programs, and the populations they serve, however, would benefit from having fully supplied medical staffs and residents from an array of educational backgrounds, and the diverse residents could learn from each other while providing care for otherwise underserved patients. On the flip side of the equation, if it is in fact the case that some residency programs are better than others, these so-called “top” programs would have the opportunity to work with a variety of residents from different schools and backgrounds, residents who might not otherwise have had the opportunity to learn from the “best.” Of course, such a system would have its share of problems—not the least being that, because it flies in the face of our culture's “merit-based” values, it is not likely to be adopted. Also, while a lottery system would in principle eliminate competition, it would completely eliminate personal choice. The uncertainty that exists in the current NRMP would be taken to an extreme in a lottery-based approach. If ROLs do nothing else, they do allow candidates to limit their options to only those programs they wish to join and those places they wish to live. Programs, too, can use ROLs to limit candidates to those with whom they are willing to work. A lottery system would be likely to engender resentment among those who were placed in situations or geographic locations that are perceived to be undesirable. (My own institution is a good example: many Mercer students would prefer to stay in Georgia, since all Mercer students are from Georgia—a lottery system could scatter them to the “four corners,” away from family, friends, and the populations they are being trained to serve, viz., the rural and underserved populations in Georgia itself.) Also, the lottery system would have to provide a rationale for either including or excluding U.S.-trained students, foreign-trained students, and independent candidates, since the number of candidates far exceeds the number of positions. But before we discount the whole notion of a lottery system, we might consider an analogy from professional sports. Professional sports teams use a drafting system in order to hire players. Whether out of high school or college, potential professional athletes are chosen to populate teams across the country (and even Canada) without much say in the matter. Baseball, for example, drafts players who can be sent to any number of locations, from big metropolitan areas to small rural communities, playing in the minor or major leagues. Of course, they can opt out of the system entirely, choosing to wait for another year or moving to other countries to participate, but so long as they want to get paid to play immediately and in North America, they must go where they are told by the clubs who draft them. This is the price athletes pay to become professionals with the potential to make good money and garner at least a modicum of fame. Analogously, physicians have an enviable status in Western culture, and their opportunities to make good money and have a secure future are quite great. However, physicians have a duty to society that professional athletes do not. As Edmund Pellegrino has eloquently argued, medicine, like any activity worthy of the title of “profession,” is a moral calling of the highest order: “It is the heart of the act of ‘profession,’ the declaration that one will help.”10 The service component of the profession demands of physicians their care and concern for others, requiring ethical practices that are constitutive of the very nature of medicine itself. In the face of the obvious social and economic benefits physicians still enjoy, how much medical education is subsidized by U.S. taxpayers, and the moral nature of medicine, is it unreasonable to ask that residents submit to a lottery system for the benefit of the programs, populations, and the profession itself? Like the draft for athletes, a lottery-based matching system could be considered the “price to pay” in order to become a physician. Eliminating the competitive Match system would provide residency programs and candidates with the resources to work on other more pressing issues. More time, energy, and money could go to support such concerns and activities as better salaries and hours for residents, outreach programs, deeper professionalism, and ethics and humanities education—concerns and activities that go to the heart of moral medical care. Can my proposal hold up to further scrutiny? I open that up for debate. At the very least, I hope my proposal will reopen discussions of the process of residency matching and the generally unquestioned value system on which it is based. Whether or not a new system comes of such discussions, all of us involved in medical education should continue to ask ourselves two fundamental questions: What kind of physicians do we want to produce? And are our current education and training systems likely to produce them?