The Nrmp Let The Computer Decide Your Fate

To bring an end to the chaotic free for all, a group of five organizations (including the American Medical Association and the Association of American Medical Colleges) joined forces in 1952 to cosponsor the formation of the National Resident Matching Program (NRMP). It is a private, nonprofit corporation. Through the shared use of a rank order list, medical students and residency programs submit a list of preferences from among those interviewed. A master computer in Washington, DC, running a 6-minute algorithm, generates a single Match between applicants and hospitals. Both parties learn of a mutually acceptable appointment on a common date and time.

With this new system, the NRMP seemed to have achieved its purpose: uniformity and impartiality. For the first time, both applicants and residency programs could explore their options without intense pressure for early decision-making. Medical students now were given a great deal of choice in deciding which residency program they would prefer. However, because both parties were still anxious over the relative uncertainty of the final Match outcome, students and program directors began to exploit other avenues that compromised the integrity of the Match, such as outside-the-Match contracts, pre-Match promises, audition electives, and second visits.

Despite these ethical violations, the NRMP does not stringently enforce its own rules. The result is that today the participants in the residency appointment system no longer believe each other. Nearly one third of students felt that the residency program administrators had lied to them during the process, and 21% believed that program directors encouraged their unethical behavior in order to match.1 Even the NRMP states that "the success of the match depends on a high level of trust among all participants." Apparently, a lot of people — medical students and program directors alike—seem to have missed reading the NRMP's Statement on Professionalism.

Take the out-of-Match contract, for example. During the application season, residency programs are not supposed to offer these binding commitments to US seniors. They are intended only for any highly desirable independent applicants, a large group that consists of anyone who is not currently a US senior, like foreign-trained graduates, US graduates, osteopathic students, and Canadian students. If a medical student accepts a position outside the Match, the applicant commits himself to that program and is officially required to withdraw from the Match. Yet, some US seniors are even offered these under-the-table contracts. Certain specialties, particularly extremely competitive ones like radiation oncology and dermatology, are more likely to engage in this behavior. In either case, these agreements have a detrimental effect on the application process for the average medical student. Any residency program that signs applicants outside the Match is supposed to contact the NRMP and reduce the number of positions (its quota) published in its on-line directory. Most programs, however, do not. For the average candidate, it becomes much more difficult to plan an application strategy for positions that may not even exist!

Pre-Match promises and informal commitments, which will be discussed again later in this chapter, also add to the unethical gamesmanship of the residency appointment process. Program directors and applicants frequently send letters that imply, but do not guarantee, a commitment to each other. In addition, many institutions promise scarce residency spots to their own medical students, who then rank the program #1 and receive that desired Match. As positions become more competitive, this type of behavior undermines the integrity of the whole system. The two dermatology positions at a particular hospital, for example, may have already been promised to its own medical students and therefore be unavailable for the common applicant. The misleading numbers create uncertainty and insecurity and make it very difficult for advisors to counsel their students on how to obtain positions.

With this greater emphasis on networking and contacts, the residency Match game has become more and more unfair. Some students end up left on the sidelines. The NRMP has finally responded to the rampant unprofessional behavior and widespread policy violations. At some point in the near future, there will be new stricter rules. Residency programs participating in the NRMP will have to register and attempt to fill all their positions in the match. They cannot have some positions in the NRMP and at the same time fill other slots with independent applicants (outside the match). Programs will have to update their advertised quota of available positions. For now, however, the current NRMP system is here to stay.

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