Manipulation and the Match

The National Resident Matching Program (NRMP) was established in 1952 to remedy the increasingly competitive process of applying for internships, one in which high-pressure tactics essentially forced medical students to accept appointments as early as their second year of school.¹ Now, participants make decisions on a uniform schedule, without time pressure, and matches are made with an algorithm that allows participants to rank their actual preferences without affecting the probability of matches lower on their list. The NRMP requires that all members sign a Match Participation Agreement (MPA), which includes restrictions on persuasion. For example, applicants and programs may volunteer their interest in each other, but one party cannot solicit a commitment from the other or suggest that ranking is contingent on such a commitment. However, both my experience and the medical education literature suggest that this injunction is often violated.

As a former member of NRMP's Board of Directors applying in the 2009 Match, I expected to navigate the process easily. After all, I had spent two years reviewing the minutiae of NRMP policies. When I started on the Board, I felt out of place in a room full of senior academicians with intimidating titles, but I soon became comfortable representing the student perspective to the many deans and program directors there. We revised the MPA during my tenure, strengthening the language defining “persuasion,” and in the process I became intimately familiar with those regulations. Looking back, perhaps I overestimated the attention that these finer points would receive.

I was startled when my first interview with an assistant program director abruptly turned from an easygoing chat to an unfriendly challenge: “Why would you ever come here?” Throughout the rest of the season, other interviewers often pushed the MPA's boundaries, asking me, “How seriously are you considering our program?” or similar questions. Such inquiries are not violations, strictly speaking, but they still suggested that I had to make a commitment to be competitive. Worse, several interviewers did commit unambiguous violations: “If you want to match here, you have to let us know,” or “If we had a position for you, would you come here?” In all cases, it did not seem to matter whether the questioner was a central figure in the residency or someone on the periphery of the department.

I considered those violations unethical but felt uncomfortable taking action. Some of these interviewers seemed uninvolved with residency administration and probably did not know the MPA's specific injunctions against persuasion. I also did not want to publicly question a program's integrity if I might eventually match there. More practically, it would have been difficult to prove a violation had occurred without a record of the conversation. Although “whistle-blowers” may request anonymity, I could not imagine how to initiate a violation investigation without revealing my identity.

The atmosphere of gamesmanship extended beyond interviews. Some programs offered me formal “revisits” while others left it to me to request them. I wondered if it was necessary to travel to programs to improve my chances there. Soon after, program directors, faculty, or even residents I had met in passing started making recruitment calls, sometimes weekly. No matter how friendly these callers were, their overtures always seemed to end with awkward pauses inviting me to make a commitment. After each one finished, I gave my standard reply, which soon became rote: “I loved visiting your program and would be honored to train there.”

Throughout the process, my medical school friends and I debated “codes” like these, struggling to balance enthusiasm with honesty. For example, does saying “I will rank you at the top of my list” commit one to ranking that program first or just in the top few?

Only one of the ten programs that interviewed me had a stated policy that all postinterview contacts were voluntary and would not affect applicants' standing. (Another program director inveighed against gamesmanship on the morning of a visit, but later that day, an interviewer stated outright that in order to match there I had to make a commitment to them.) Without explicit statements from other programs, I assumed that visits, expressions of interest, and commitments would determine my competitiveness. As the ranking deadline approached, I felt compelled to tell my top-ranked program that it was first, and painstakingly crafted enthusiastic e-mails to others. Many of the other applicants I know did the same.

Most of us applicants were rewarded for participating in these courtship rituals. I was told I was “ranked to match” by a number of programs, and it was public knowledge that other students were receiving similar commitments. That said, whatever relief these assurances gave us was tempered by horror stories from years past. One student had been sent real estate clippings from his top-choice program, covered with breathless Post-it notes: “Looking forward to seeing you here!” Weeks later, he was shocked to match at a different program.

My experience is anecdotal, but the medical education literature suggests I am not alone in recognizing pressure and distrust in the residency application process. Only a handful of studies directly assess the Match, and they are often limited to one specialty, their sample sizes are relatively small, and many were conducted years ago. That said, the existing data are unanimous in suggesting that the pervasive contacts, insinuations, and frank violations I experienced are unfortunately common.

Postinterview contact may be almost universal. Between 69% and 95% of program directors follow-up with applicants, and 47% say their primary purpose is recruitment.^{2 - 3} Students are getting the message that these contacts matter, as 94% reported contacting programs after interviews.⁴

Violations may be frequent, as one survey found that one-third of students were asked how they planned to rank programs.⁴ Fifty-seven percent of students were told to keep in touch if they wanted to match at a particular program, suggesting that borderline cases are common, too.⁴

Not surprisingly, applicants and programs distrust each other. Between 31% and 90% of applicants and program directors believe that they are lied to during the application process.^{2 - 5} Thus, applicants' “voluntary” commitments are simultaneously valued and doubted. Programs seem to distrust one another as well; for example, 51% of radiology fellowship program directors believe that others are not abiding by the rules.⁵

Regardless, recruitment practices appear to be effective at influencing ranking decisions. Studies suggest that 10% to 35% of applicants are vulnerable to changing their rank order list in response to recruitment contacts.^{4 ,6} Programs, too, appear to respond to postinterview communication, as 36% of family practice program directors stated that hearing they will be ranked “high” or “No. 1” improves an applicant's ranking.²

Professionalism demands that all parties involved in the Match work harder to prevent violations. Program directors must take responsibility for educating faculty about restrictions on persuasion, and applicants must adhere to standards of professional conduct themselves. Educators should ensure that applicants understand Match guidelines, while professional organizations could help to disseminate these regulations or issue their own supporting recommendations.

However, the NRMP's rules are only minimum standards, and residency administrators in particular could do much to relieve the pressure on applicants. Program directors should establish transparent communication policies; the best practice would be to inform applicants that post-interview communication does not affect their standing in programs' rankings. Programs could also relieve the stress of recruitment telephone calls, most simply by refraining from this practice altogether. Some programs have already instituted such “no-call” policies out of respect for the subset of applicants whose ranking preferences are vulnerable to recruitment contacts.⁶ At the very least, callers should explicitly restate NRMP policy by stating that their purpose in calling is not to gauge applicant interest.

These changes at the program level need not be dictated by other organizations. While the NRMP should continue to revise the MPA to clarify restrictions on unprofessional behavior, outlawing all statements of interest would be too restrictive and might raise anti-trust concerns.⁷ Instead, programs could take initiative themselves, engaging in the responsible self-regulation that is so central to medical professionalism. Committed programs could even band together in smaller numbers to adopt uniform policies against manipulative practices, which might mitigate the competitive disadvantage of reducing recruitment. This process could be facilitated by professional organizations and organizations of program directors.

The members of the NRMP Board used to bemoan program directors' fixation on “number needed to fill,” a common bragging right among residencies. This crude metric of competitiveness says little about program quality, and it is certainly less important than protecting applicants from recruitment pressures. Fundamentally, the Match works best when both applicants and program directors rank each other according to their true preferences.

The application process that selects new physicians has evolved to encourage misrepresentation and mutual distrust, and the impact of this gamesmanship is far-reaching. The pressure on applicants exploits and magnifies a power differential that originates in medicine's inherent hierarchies and persists throughout residency training. By the end of the application season, I had no sense of being welcomed into the profession as a colleague. Rather, I felt manipulated, ashamed of having given in to pressure to ignore flagrant violations and to exaggerate my enthusiasm. My current program had acted ethically, having demonstrated restraint throughout interviews and follow-ups. However, had my program director not called me in for a post-Match session to get feedback on how to improve applicant experiences, I would likely still be bitter about the overall process.

I suspect that program directors and other faculty members—who clearly have the best intentions—do not appreciate the extent and negative impact of the culture of the Match. Ultimately, commitments to violation prevention and transparency could free everyone from the pressures to overplay their interest in one another, dispelling distrust, improving collegiality, and bringing us closer to the original purpose of the Match: to protect applicants from undue persuasion.