Designing centralized marketplaces that work gracefully with pre-existing decentralized ones, in Management Science, by Benjamin Roth and Ran Shorrer

 In Management Science (online ahead of print):

Making Marketplaces Safe: Dominant Individual Rationality and Applications to Market Design

 Benjamin N. Roth , Ran I. Shorrer 

Published Online:8 Dec 2020 https://doi.org/10.1287/mnsc.2020.3643

Abstract: Often market designers cannot force agents to join a marketplace rather than using pre-existing institutions. We propose a new desideratum for marketplace design that guarantees the safety of participation: dominant individual rationality (DIR). A marketplace is DIR if every pre-existing strategy is weakly dominated by some strategy within the marketplace. We study applications to the design of labor markets and the sharing economy. We also provide a general construction to achieve approximate DIR across a wide range of marketplace designs.

Introduction: "Many marketplaces operate in a broader economic environment, and often participants cannot be forced to use a marketplace rather than the pre-existing institutions it was meant to displace. For instance, although most hospitals and residents use the clearinghouse known as the National Residency Matching Program (NRMP) to coordinate job offers, there is no legal barrier that prevents members of either side of the market from finding matches outside of the clearinghouse.1 In school choice, charter schools sometimes opt not to participate in clearinghouses, instead recruiting students in a decentralized manner. In the private sector, marketplaces that comprise the gig and sharing economies demonstrate the primacy of attracting participants who have many outside alternatives. In each of these settings marketplaces are actively engaging with the challenge of recruitment. In other words, these are marketplaces in which participation is not always safe.

...

"A designer may introduce a mediator (alternatively referred to as a marketplace), to which players may delegate their decision rights (i.e., participate in the marketplace). The mediator comprises a message space and a mapping from messages to outcomes (strategy profiles for the delegators). Players who delegate their decision rights select a message to send to the mediator, who then acts on their behalf according to the outcome mapping, as a function of the whole set of messages it receives. The mediator is voluntary in the sense that players may choose one of their original (outside) actions instead of sending it a message. And the mediator is restricted to condition the actions of participants only on the messages of other participants and not on the outside actions of nonparticipants.

"This framework highlights the endogeneity of the individual rationality constraint with respect to both the set of players who sign away their decision rights and the actions they take. We show by example that mediators that satisfy attractive criteria such as incentive compatibility and efficiency assuming that everyone participates may no longer do so in equilibria with partial participation. This motivates the search for mediators that can guarantee the safety of participation. In Section 3 we present our key desideratum: dominant individual rationality (DIR)."

Concerns about remote interviewing for the surgery match

 I don't doubt that every year people are nervous about the residency Match, and worries this year are related to the special situation of the Covid pandemic, in which interviews will be remote.

Irene Wapnir forwards the following:

From the AM College of Surgeons Bulletin: Interview crisis:

It May Be Too Late toAvoid a Crisis in the Surgery Match This Year

Ronald J. Weigel, MD, PhD, FACS; Steven C. Stain, MD, FACS; and L. Scott Levin, MD, FACS, FAOA

Are you hearing that outstanding medical students applying for surgical residencies are being wait-listed for an interview at top training programs? The problem may be yet another unfortunate consequence of the COVID-19 pandemic.

In normal years, programs have cancellations because there is a physical limitation for how many interviews a student can do. This year, the pandemic forced programs to go to virtual interviews, and a small group of top students nationally appear to be filling all the interview slots for the top programs. If this is true, then many of those programs may go unfilled in the match.

For example, if the average number of interviews offered by a program is 100, and these programs are all competing for the same pool of 100 intern applicants, the pool of top students interviewed may be too small to fill all the slots in these programs. Additionally, the current interview process may create disadvantages for minority applicants and students from schools that are not considered "top tier."

With virtual interviews allowing students to interview at a larger number of programs, we may need a different system nationally for the allocation of interview slots, such as rolling acceptances for interviews with students being required to commit only to a set number of programs, which would allow additional students the opportunity to be interviewed. The solution will require program directors and surgical leaders nationally to discuss this issue. It may be too late to avoid a crisis in the match this year.

Surgery Match: Considerations and Possible Solutions

In their article, "It May Be Too Late to Avoid a Crisis in the Surgery Match," Drs. Weigel, Stain and Levin highlight challenges with this year's surgery match. Regarding this, the ACS proposes that program directors, deans and chairs, as well as candidates, consider the following to ensure as fair and equitable a process as possible during this extraordinary time:

Program Directors, Deans, Chairs

• Review the consequences that oversubscribing to slots has to programs and other candidates with students
• Don't offer slots to more candidates until those offered have a reasonable time to respond
• Make lists of candidates of interest who are not interviewed to ensure slots are offered when available

Candidates

• Consider limiting the number of interviews scheduled to a reasonable amount. Consider the impact on your colleagues of taking up too many interview slots—be fair to other applicants
• Release interview slots if you know you will not use them
• Release slots when you have completed enough interviews and experienced reciprocal interest that you are confident you have a well-prepared rank list

 

NRMP conference on Transition into Residency: Oct 16-17

I'll be speaking  this morning at the opening session of the (virtual) NRMP conference on Transition into Residency: Conversations Across the Medical Education Continuum

My title will be "The Match as part of the larger system of transition to residency."

One of the topics I expect to discuss is the proliferation of applications and interviews, in the NRMP and also in many of the fellowship matches.

Should residency program rank order lists be kept confidential from the Dean?

Here's the report of a survey of residency program directors in radiology. One issue, not confined to radiology, is the confidentiality of their rank order list for the resident match--confidentiality from their own administrative hierarchy.  The problem with having to show your rank order list to your dean is that it interferes with program directors' incentives to rank candidates in order of true preferences:   Thirty-seven percent felt pressure to match applicants from the top of the rank list in order to improve the perceived “success” in the match."  That is, some of these programs are refraining from ranking the most desirable applicants they interviewed because they worry these people will match to other programs.  This will make their program look bad to the dean (who will ask "how come you have to go so far down on your list?")

“What Program Directors Think” V: Results of the 2019 Spring Survey of the Association of Program Directors in Radiology (APDR) Academic Radiology,  8 August 2020, In Press, Corrected Proof

by Anna Rozenshtein MD, MPH1 Brent D. Griffith MD2 Priscilla J.Slanetz MD, MPH3 Carolynn M.DeBenedectis MD4 Jennifer E.Gould MD Jennifer R.Kohr MD6 Tan-Lucien Mohammed MD, MS7Angelisa M.PaladinMD8Paul J.Rochon MD9 Monica Sheth MD10Ernest F.Wiggins III MD11 Jonathan O.Swanson MD12   Academic Radiology Available online 8 August 2020, In Press, Corrected Proof 

"The Association of Program Directors in Radiology (APDR) surveys its membership annually on hot topics and new developments in radiology residency training. Here we report the results of that annual survey.

...

"Radiology Residency Match: Forty-nine percent of respondents reported that the final rank list is known only to the program administration (PD/APD) and the selection committee, while 27% disclosed the rank list to the department administration and 24% to the institution. Thirty-seven percent felt pressure to match applicants from the top of the rank list in order to improve the perceived “success” in the match."

Gender distribution of medical residents

 Surgeons are still less likely to be women (particularly orthopedic surgeons):

Bennett CL, Baker O, Rangel EL, Marsh RH. The Gender Gap in Surgical Residencies. JAMA Surg. Published online July 29, 2020. doi:10.1001/jamasurg.2020.2171

HT: Irene Wapnir

I join the NRMP board of directors

In the 1990's I worked closely with the NRMP on the resident match, and since then I've been following it from a distance.  Now I'll join their Board.  I imagine that during my term there may be an opportunity to look at how the overall system of applications, interviews and matching have co-evolved and adapted to each other.

Here's the NRMP press release:

 NRMP Board Of Directors Welcomes Outstanding Cohort Of New Members
Nobel Prize Recipient Dr. Alvin E. Roth Among Talented Slate of Elected Individuals
Washington, D.C., June 22, 2020 –

At its June meeting, the National Resident Matching Program® (NRMP®) Board of Directors elected five individuals for terms that begin July 1, 2020. The NRMP’s 19-member Board includes medical school deans, institutional officials, clinical program directors, resident/fellow physicians, medical students, and one public member. The appointment of Dr. Alvin E. Roth, the 2012 co-recipient of the Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel, highlights the quality of the slate of new members.

“The individuals recently elected to the NRMP Board of Directors will bring an impressive mix of professional experiences and fresh perspectives to the governance of the organization,” said NRMP Board Chair Dr. Steven J. Scheinman. “They were selected from a deep pool of accomplished applicants, and we look forward to working with them on an array of initiatives.”

The term for directors is four years, with a maximum of two terms. The term for resident/fellow and student directors is two years. Listed alphabetically, the new members include:

Ricardo J. Boccardo Bello, M.D., General Surgery resident at the University of Massachusetts Medical School. A graduate of the Universidad Central de Venezuela in Caracas, he earned a Master of Public Health from the London School of Hygiene and Tropical Medicine and completed his PGY-1 General Surgery residency and postdoctoral research fellowship in Microsurgery Outcomes at Johns Hopkins University. While at Johns Hopkins, he received the Core Surgery Clerkship Outstanding Junior Resident Teaching Award.

Sydney Miller, Michigan State University College of Osteopathic Medicine student. Elected President of her class, Ms. Miller serves alongside faculty leaders as a member of the Dean’s Executive Board, which deliberates the college’s undergraduate and graduate medical education programs and other strategic initiatives. She earned her undergraduate degree in Human Biology at Michigan State University. Her interests include increasing awareness and appreciation of osteopathic medicine.

Alvin E. Roth, Ph.D., Senior Fellow at the Stanford Institute for Economic Policy Research and a Professor, by courtesy, for the school of Management Science and Engineering. He is also the George Gund Professor of Economics and Business Administration Emeritus at Harvard University. Dr. Roth’s academic expertise is in game theory, experimental economics, and market design, and he was co-recipient of the 2012 Nobel Prize in Economics for work which focused in part on the NRMP’s matching algorithm. He earned a doctoral degree in Operations Research from Stanford University.

Morgan Swanson, M.D./Ph.D. student at the University of Iowa Carver College of Medicine and College of Public Health. She has served with the Association of American Medical Colleges’ Organization of Student Representatives (OSR), most recently as one of 12 students selected to its Administrative Board. Ms. Swanson graduated from Iowa State University and serves as a member of the Editorial Board of the U.S. Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

Christopher B. Traner, M.D., recent graduate of Neurology residency at Yale-New Haven Hospital and incoming Epilepsy/Neurophysiology fellow at Yale. He received the Yale Neurology Department’s Lewis Levy Award, presented to the PGY-2 resident who best exemplifies clinical excellence. He advised undergraduates as a Kaplan MCAT Advantage Plus Mentor while attending the University of Toledo College of Medicine. As a resident at Yale, Dr. Traner was a member of his program’s Interview Committee.

The newly elected Board members replace those whose terms conclude on June 30: Dr. Zaid Almarzooq, Cardiology fellow, Brigham and Women’s Hospital; Dr. Jessica Fried, chief resident, Diagnostic Radiology, Hospital of the University of Pennsylvania; Dr. Eriny Hanna, 2020 graduate of Vanderbilt University School of Medicine transitioning to an Emergency Medicine residency at Vanderbilt; Father Daniel Morrissey, O.P.; and Dr. Thomas Wickham, 2020 graduate of the University of New England College of Osteopathic Medicine transitioning to a Family Medicine residency at UMass Memorial Medical Center.

About NRMP
The National Resident Matching Program® (NRMP®) is a private, non-profit organization established in 1952 at the request of medical students to provide an orderly and fair mechanism for matching the preferences of applicants for U.S. residency positions with the preferences of residency program directors. In addition to the annual Main Residency Match® for almost 44,000 registrants, the NRMP conducts Fellowship Matches for more than 60 subspecialties through its Specialties Matching Service® (SMS®).

How will the pandemic affect the medical Match?

Some thoughts on the medical match in JAMA:

Potential Implications of COVID-19 for the 2020-2021 Residency Application Cycle
Maya M. Hammoud, MD, MBA1; Taylor Standiford, BS1; J. Bryan Carmody, MD, MPH2
JAMA. Published online June 03, 2020. doi:10.1001/jama.2020.8911

"Even before COVID-19, calls to reform the residency selection process were becoming more frequent.1,2 Many issues are related to the increasing number of programs to which applicants apply. In 2019-2020, applicants from US medical schools applied to an average of 65 programs, and international medical graduates (IMGs) applied to an average of 137 programs.3 This number of applications likely does not improve match rates and imposes a substantial cost on applicants and a potentially unmanageable load on program directors.

"It is possible that the disruptions caused by COVID-19 may result in an increase in the number of applications and further stress this already challenged system. Due to testing center closures, many applicants have been unable to take portions of the United States Medical Licensing Examination (USMLE). This is especially critical for IMGs, who must pass the Step 2 Clinical Skills Examination to obtain certification from the Educational Commission for Foreign Medical Graduates and apply to US residency programs. Additionally, medical schools have shortened clerkships, shifted to virtual rotations, and canceled away electives, all of which may reduce student opportunities to obtain meaningful faculty evaluations, letters of recommendation, and signal their interest to programs. Students will encounter significant uncertainty regarding how their applications will be evaluated and may respond by applying to even more programs.

Program directors may have difficulty identifying applicants to interview without use of traditional screening metrics. Yet, challenges will persist even after interviews are offered; if travel disruptions and social distancing persist into the interview season, programs may be unable to offer in-person interviews. Temporary solutions, such as conducting virtual interviews or waiving requirements for USMLE scores and letters of recommendation, will be necessary for the selection process to function. But these stopgap solutions may exacerbate existing problems with residency selection and lead to undesirable consequences. For instance, the use of virtual interviews could result in applicants participating in more interviews. Currently, the number of interviews an applicant attends is limited by time and travel expense, but these constraints will be less relevant with virtual interviews. Yet because many programs rely on the same screening metrics, many programs already overinvite the same pool of highly-qualified applicants, with just 7% to 21% of the applicant pool filling half of all interview slots in some specialties.4 The result of those applicants accepting more interview invitations could be an increase in both the number of unmatched applicants and unfilled programs.

NRMP Match Day (and corona virus precautions)

Today, Friday, is Match Day, the day when new American medical school graduates and others find out the residency programs to which they have been matched by the National Resident Matching Program (NRMP).

In a usual Match Day, the graduates of most American med schools would gather together, to learn all together where they would be heading later this summer.  However this year, many of us are working from home, with large gatherings discouraged if not banned, to prevent the spread of corona virus.

The AAMC put out this announcement earlier this week:

The Match®: 10 things to know as the day draws nigh
...

"A two-stage reveal: On Monday, students learned if they have been matched to a residency via emails that were sent out at 11 a.m. ET. On Friday, they learn specifically where their residencies will be during the Match Day ceremonies (either in-person or online), which start at noon ET across the country, or by emails from the National Resident Matching Program® that go out at 1 p.m. ET. Students can also learn about both results through a mobile device.

"Coronavirus impact: Many schools have made or are weighing changes to Match Day celebrations as the status of the virus outbreak changes in various regions of the country."

Interviews and matching--Echenique, González, Wilson, and Yariv

Interviews are an important feature of many matching markets. Here's a recent paper about that:

Top of the Batch: Interviews and the Match
Federico Echenique* Ruy González† Alistair Wilson‡ Leeat Yariv§ ¶
February 14, 2020

Abstract
Most doctors in the NRMP are matched to one of their most-preferred internship programs. Since various surveys indicate similarities across doctors’ preferences, this suggests a puzzle. How can nearly everyone get a position in a highly-desirable program when positions in each program are scarce? We provide one possible explanation for this puzzle. We show that the patterns observed in the NRMP data may be an artifact of the interview process that precedes the match. Our analysis highlights the importance of interactions occurring outside of a matching clearinghouse for resulting outcomes, and casts doubts on analysis of clearinghouses that take reported preferences at face value.

More proposals for reducing applications and interviews before medical resident matching

If the number of proposals for reform is an indicator of a brewing problem (and I think it is), it's time to think about the various application and interview processes that precede the NRMP resident match.  Here are three more...

J. Bryan Carmody (2020) Applying Smarter: A Critique of the AAMC Apply Smart Tools. Journal of Graduate Medical Education: February 2020, Vol. 12, No. 1, pp. 10-13.
https://doi.org/10.4300/JGME-D-19-00495.1

"Medical students today submit more residency applications than ever before. This trend is costly for students and imposes a substantial burden on program directors. Yet, despite a steady increase in the number of applications submitted per applicant, overall match rates have not improved.1 Put another way, applicants could collectively apply to fewer programs than they do now—and enjoy essentially the same overall match rate.

To assist students in determining the optimal number of residency programs to which they should apply, the Association of American Medical Colleges (AAMC) unveiled Apply Smart in 2016. The website notes that “there is a point where the relationship between the number of applications submitted and the likelihood of entry into a residency changes,” and suggests that students should consider limiting their applications at this point of diminishing returns.2 Responses to Apply Smart have been positive, with deans and program directors praising the tools and encouraging their use in counseling medical students.3–6

At first glance, the Apply Smart analyses seem highly informative. Yet, closer inspection reveals methodologic issues that introduce bias and suggest the need for improvements.
...
"Overapplication is costly, for applicants and programs alike. Given the incentives for medical students to overapply, it is unclear whether informational strategies alone can curtail overapplication. Until graduate medical education leaders are willing to support application caps or a fundamental restructuring of the Match to better allow signaling between applicants and programs,13 it is imperative that informational strategies present unbiased data that can aid students in applying to an appropriate number of programs. We cannot be satisfied for students to Apply Smart—we need to help them apply smarter."

************

Joseph G. Monir (2020) Reforming the Match: A Proposal for a New 3-Phase System. Journal of Graduate Medical Education: February 2020, Vol. 12, No. 1, pp. 7-9.
https://doi.org/10.4300/JGME-D-19-00425.1

"The National Resident Matching Program (NRMP) was originally devised in 1952 to bring order to the chaotic residency application process.1 It currently has 2 phases: The Match and the Supplemental Offer and Acceptance Program (SOAP). Applications are submitted through the Electronic Residency Application Service (ERAS). While this is a significantly superior system to its predecessor, it is not flawless. As both residency applicants and positions have become more competitive, the flaws of the current system are becoming increasingly problematic for all involved parties.

"Despite evidence that applying to a greater number of programs does not improve Match rates,2 applicants feel pressured to apply to more and more programs to avoid going unmatched. In 2018, each applicant submitted a mean of 90.6 applications (mean of 60.3 for US graduates and 136.4 for international graduates).3 Applicants feel forced to accept interviews at programs which they have minimal interest in attending, to the detriment of other genuinely interested students. This, in turn, pressures other applicants to do the same lest they be disadvantaged. Whipple et al confirmed this vicious cycle using their computer model for competitive residencies, where they found that applying to the maximum number of programs “led to a poor result for the majority of students when all applicants undertook the strategy.”4

"As a result of this vicious cycle, residency programs are inundated with an average of 996 applications per program5 and have few reliable methods of identifying which of those applicants would seriously consider training there. Interviewing applicants who have no desire to attend that program is a costly endeavor. Gardner and colleagues found that, when accounting for both material and personnel costs, programs spent on average $18,648 ± $13,383 per open position and $1,221 ± $894 per interviewee.6

"Applying so broadly is costly for applicants as well. Fogel et al7 found that 84% of applicants believed residency interviews were too expensive, with 64% of applicants spending at least $2,500, and those entering competitive fields spending considerably more. In a study of orthopedic surgery applicants, for example, interview costs averaged $7,119 (range $2,500–$15,000).8 These figures do not include the cost of the applications themselves or externships, making the total residency application cost significantly higher.

"It is clear that the current system is fraught with inefficiency and that all involved parties would be better served by a system where applicants only apply to the programs they would seriously consider attending.

"The 3-Phase System
Transitioning the Match to a 3-phase process as outlined below could address the aforementioned problems.

"Phase 1
This phase would run from September through December and would function the same as the Match is currently. However, applicants would be limited in the number of positions for which they could apply. The results of Phase 1 would be e-mailed to applicants in the beginning of January. Most interviews already occur within this time frame, so most programs could continue using the systems they have in place. The majority of positions would be anticipated to fill in Phase 1.

"Phase 2
This phase would run from January through March. Those who do not match in Phase 1 would proceed to Phase 2. This would again function like the current Match, with applicants applying to open programs, attending in-person interviews, and submitting a rank list. There would be no cap on the number of Phase 2 applications, allowing applicants to apply broadly. The results of Phase 2 would be e-mailed to applicants in March. The majority of unfilled positions from Phase 1 would be expected to fill in Phase 2.

Phase 3
This phase would be the current SOAP week, with daily rounds of interviews and offers. The number of applicants and positions entering the SOAP would likely decrease significantly."
**********

Plast Reconstr Surg. 2019 Feb;143(2):634-639. doi: 10.1097/PRS.0000000000005254.
Solving Congestion in the Plastic Surgery Match: A Game Theory Analysis.
Molina Burbano F1, Yao A, Burish N, Ingargiola M, Freeman M, Stock J, Taub PJ.

Abstract
Plastic and reconstructive surgery is among the most competitive specialties in the residency match. Applicants seeking to maximize their chances of a successful match often submit numerous applications to the National Residency Matching Program. It is not uncommon for those applying to plastic and reconstructive surgery to apply to every program. The high application volume imparts significant time and financial burden for applicants and programs alike. Furthermore, it makes distinguishing between applicants with a genuine interest in a specific program and those who are merely hoping to improve their chances vastly more difficult. The authors sought to characterize trends in the match rate, as the number of integrated plastic and reconstructive surgery programs continues to increase. Furthermore, they reviewed the literature on game theory for possible solutions to residency application congestion. The authors propose the use of the game theory model to explain the observed results and show why an application limit is the most reasonable approach to address this issue.

Residency explorer (for new doctors)

Amidst all the concerns about the ballooning number of applications and interviews involved in preparing for the NRMP resident match, here's a site (still in test mode) from the AAMC, intended to help applicants explore residency programs before applying:

Residency Explorer

"Residency Explorer helps medical students and applicants to U.S. residency programs research programs in their specialty of interest and compare themselves to previous matched applicants at those programs.

...
"Residency Explorer delivers insights and information based on:
Residency applicant data from AAMC (ERAS)
Matched applicant data from NRMP
USMLE data from the USMLE Program
COMLEX-USA data from the NBOME
Residency program directory information from ACGME
Program characteristics from the National GME Census Survey, jointly administered by the AAMC and AMA, to which 95% of residency programs self-report information about their programs.
Purpose
The purpose of the Residency Explorer is to help residency applicants understand how they compare the applicants who previously matched at programs as well as explore program characteristics across many areas of interest."

Lovely short film about the resident match by Dr. Trisha Pasricha

Here's a charming and insightful 11 minute video by the remarkable physician-filmmaker Dr. Trisha Pasricha, about the experience of going through the residency match run each year by the National Residency Matching Program (NRMP). It includes some bits of an interview that Dr. Pasricha conducted with me.


: 

A PERFECT MATCH: The Selection Ritual to Become A Doctor from Trisha Pasricha on Vimeo.


Here's a link on the NRMP web page:
Documentary “A Perfect Match” Follows Student Through The Match Process
"Directed by Dr. Trisha Pasricha (Massachusetts General Hospital) and produced by Dr. Michael Pilla (Vanderbilt University School of Medicine), A Perfect Match: The Selection Ritual to Become a Doctor follows a Vanderbilt University School of Medicine student as he experiences the medical residency match process. The 12 minute film was a finalist at the Nashville Film Festival,

Dr. Pasricha graduated from Harvard University with a B.A. in film production and went on to study at Vanderbilt University School of Medicine. She completed an internal medicine residency at Johns Hopkins and is currently a first-year gastroenterology fellow at Massachusetts General Hospital.."

And here's the direct link on vimeo.
******
Even short films can take a long time to produce; here's my earlier post:

Friday, September 2, 2016

A perfect match--documentary on the medical match by Dr Trisha Pasricha

*********
Perhaps I'll get a chance to chat with Dr. Pasricha again after she goes through the gastroenterology match.

NRMP Match Day, 2019

Today is match day, when imminent medical grads find out where they'll be starting residencies in July.

Here's the NRMP's press release:
Thousands Of Resident Physician Applicants Celebrate NRMP Match Results
2019 Main Residency Match is largest on record with 44,600 registered applicants and more than 35,000 positions offered

Here are some data tables, including this one on couples:

Here's an article in Stat reflecting on some current issues of marketplace maintenence, related to what certainly seems to have become excessive pre-match interviewing:

Ideas for easing medical students’ Match Day ‘frenzy’
By ALISON VOLPE HOLMES and MONA M. ABAZA MARCH 15, 2019

"The National Residency Matching Program is an admirable invention. Now more than 30 years old, it is the system through which medical students get their first paid, professional positions. It corrected past abuses that took advantage of students, often pressuring them to accept binding offers within 24 hours of a residency interview. The Match is sufficiently noteworthy that its creator, Alvin Ross, won a Nobel Prize in economics for his work on matching theory. His algorithm continues to place half of U.S. medical school graduates in their first-choice programs. Other professions and selection processes could be improved by using a similar matching system.

Yet the Match and what leads up to it are having growing pains. Medical students are applying to increasing numbers of residency programs, sometimes to all of the programs in a field. Residency program directors are flooded with applications, and have trouble identifying which students are truly interested.

...

"Otolaryngology (also known as ear, nose, and throat) offers a telling illustration of this problem, and a potential solution that failed. In 2010, the average student interested in an otolaryngology residency applied to 47 programs, and the average residency program received 200 applications from U.S. medical students — to fill just two to six positions. By 2015, this increased to 64 applications per student and 275 applications per program.

"The program directors attempted to exert some control over application inflation by asking students to write a paragraph about their interest in the program they were applying for. This reduced applications, but also backfired. In 2017, the number of applications fell back to 200 per program, but 10 programsfailed to get the number of residents they needed. The otolaryngology program directors removed the supplemental requirement and applications jumped back up to 278.

...

"The Match was once a brilliant solution that everyone in medicine was proud of. There are still lessons to be learned from it for other selection processes, including undergraduate admissions. But if we — students, advising deans, and residency program directors — do not come together and work on solutions, we risk losing the Match’s great many advantages."

Match Day for medical residents--NRMP results announced

Today is Match Day: later today, graduating American medical students, and quite a number of other young doctors will learn where they will work next year.

Here's one description: The Final Countdown: Match Day 2018.

Here's another:
NRMP Match Week will Reveal Future for Thousands of Resident Physician Applicants
NRMP Main Residency Match continues to grow, with 2018 Match expected to be largest in history.

And here's my all time favorite, courtesy of Hogwarts.

Applications and interviews for medical residencies

The computerized clearinghouse for the NRMP medical match solves the congestion problem for new doctors when it comes time to make offers, acceptances and rejections. But electronic applications make it easier to apply for lots of places, and this is coming to seem like a problem in both the resident match and in the later-career fellowship matches.

Residency Placement Fever: Is It Time for a Reevaluation?
Gruppuso, Philip A. MD; Adashi, Eli Y. MD, MS
Academic Medicine
Issue: Volume 92(7), July 2017, p 923–926

Abstract: The transition from undergraduate medical education to graduate medical education (GME) involves a process rooted in the final year of medical school. Students file applications through the Electronic Residency Application Service platform, interview with residency training (i.e., GME) programs from which they have received invitations, and generate a rank-ordered preference list. The National Resident Matching Program reconciles applicant and program rank lists with an eye towards matching students and GME programs. This process has effectively served generations of graduating medical students. However, the past several decades have seen an intensification of the residency placement process that is exemplified by an inexorable increase in the number of applications filed and number of interviews accepted and attended by each student. The authors contend that this trend has untoward effects on both applicants and departments that are home to GME programs. Relevant information in the peer-reviewed literature on the consequences and benefits of the intensification of the residency placement process is scant. The authors address factors that may contribute to the intensity of the residency placement process and the relative paucity of data. They propose approaches to reverse current trends, and conclude that any reevaluation of the process will have to include the generation of outcome data to afford medical educators the opportunity to explore changes in an evidence-based manner.
..............

"In part, the intensification phenomenon is borne out by the aforementioned growth in ERAS-associated traffic. In the eyes of many, this “new normal” draws on the widespread perception that a successful match in highly competitive disciplines is contingent on the filing of applications with a large proportion of the relevant GME programs. For example, in 2015, senior U.S. medical students applied, on average, to 73 of the 163 orthopedic surgery programs and 47 of the 105 neurological surgery programs (based on data extracted from the AAMC 8 and the NRMP 9,10). What is more surprising is that even less competitive disciplines may now be seeing an ever-growing flood of applications. This contention is supported in part by recent observations according to which GME programs in nearly all disciplines have seen a marked increase in their application traffic. For example, the percentage of pediatric GME programs to which graduating U.S. medical students have applied on average increased from 9.8% to 13.7% during the five-year interval from 2010 to 2015.10 For internal medicine GME programs, the corresponding figures are 4.9% to 6.0%.8–10 In making these decisions, students appear to be keeping their own counsel against the advice of medical school advisers and mentors advocating moderation."
...
"First, consideration should be given to the possibility of coordinating the timing of the interviews and of the Match across all disciplines and GME programs, including the “early match” disciplines of ophthalmology and plastic surgery.32 Consolidation along these lines would address the disruption of fourth-year scheduling, thereby offering educators greater flexibility in designing the fourth-year curriculum. Implementing such changes will not be easy given the longevity, familiarity, and comfort associated with the extant construct. Voluntary action on the part of the relevant professional associations will be required should a realignment of current schedules ever come to pass. Second, reducing if not capping the number of interviews per student would go a long way towards stemming the time and resource drain on both applicants and GME programs. This, too, is not going to be easy given the near-universal presumption that “more is better” and the notion that the times in effect demand such. In this context, consideration might be given to a tiered “screen and schedule” system wherein initial online interviews with many or all eligible applicants would be followed by a limited set of on-site interviews with a select group of “finalists.” As envisioned, this approach, widely used in both the public and the private sectors, stands to rationalize the current residency placement process while maintaining its fundamental premises of excellence and compatibility. Limiting the final on-site interviews to a select number of candidates will also give rise to palpable economies of scale that are likely to be welcomed by applicants, GME programs, and medical schools alike."

The Nephrology fellowship match

Nephrology is a subspecialty that has required fellowship programs to participate in the match ("All In")

Perspectives on the Nephrology Match for Fellowship Applicants

1. Michael J. Ross, 
2. Gregory Braden, 
3. for the ASN Match Committee
4. 1. "
   In recent years, there has been a marked decline in applicants to United States nephrology programs (1). Although a multipronged approach is clearly needed to increase interest in nephrology, it is important that we ensure that our applicants/future colleagues are treated in the most fair and equitable manner possible, and we believe that 100% participation in the National Residency Matching Program (NRMP) is vitally important to achieving that goal. In this perspectives article, we will briefly review the evolution of the Match since it was implemented for appointment year (AY) 2009, the successes achieved, and the challenges ahead."
   
   
   

The Medical Physics Residency Match

Ethical violations and discriminatory behavior in the MedPhys Match

Kristi R. G. Hendrickson, Titania Juang, Anna Rodrigues, Jay W. Burmeister

Journal of Applied Clinical Medical Physics

First published: 20 August 2017 DOI: 10.1002/acm2.12135   

"Thirteen percent of 2015 respondents and 20% of 2016 respondents were asked by at least one program how highly they planned to rank them or which program they would rank first. Thirty-seven percent of 2015 and 40% of 2016 program directors indicated that candidates communicated to the program their rank intent, with 22.0% in 2015 and 12.5% in 2016 being told that their program would be ranked first. Twenty-three percent of 2015 respondents indicated being asked by at least one program during the interview about children or plans to have children; including 19% of males and 33% of females. In 2016, these values were 28% overall, 22% male, and 36% female. Fifty-seven percent of 2015 respondents who were asked this question indicated being uncomfortable or very uncomfortable answering, including 27.3% of males and 88.9% of females. In 2016, 42.9% of all respondents indicated being uncomfortable or very uncomfortable answering, including 10.0% of males and 80.0% of females.

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See also the editorial in the same journal: The Dark Side of the MedPhys Match
by John A. Antolak PhD, Timothy D. Solberg PhD

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Here are earlier posts on the medphysics fellowship match, and radiation oncology.

The gastroenterology fellowship match is thriving

The journal of Digestive Diseases and Sciences reports that the state of the Gastro match is good:

The Gastroenterology Fellowship Match: A Decade Later 

• Robert J. Huang
  • 1
• George Triadafilopoulos
  • 1
• David Limsui
  • 1

1. 1.Gastroenterology and Hepatology Stanford University Medical Center  

Fellows and Young Gis Section

First Online: 

04 May 2017

DOI: 10.1007/s10620-017-4593-z

Cite this article as:

Huang, R.J., Triadafilopoulos, G. & Limsui, D. Dig Dis Sci (2017). doi:10.1007/s10620-017-4593-z

Abstract: Following a period of uncertainty and disorganization, the gastroenterology (GI) national leadership decided to reinstitute the fellowship match (the Match) under the auspices of the National Residency Matching Program (NRMP) in 2006. Although it has now been a decade since the rebirth of the Match, there have been limited data published regarding progress made. In this piece, we discuss reasons for the original collapse of the GI Match, including most notably a perceived oversupply of GI physicians and a poor job market. We discuss the negative impacts the absence of the Match had on programs and on applicants, as well as the impetus to reorganize the Match under the NRMP. We then utilize data published annually by the NRMP to demonstrate that in the decade since its rebirth, the GI Match has been remarkably successful in terms of attracting the participation of applicants and programs. We show that previous misguided concerns of an oversupply of GI physicians were not realized, and that GI fellowship positions remain highly competitive for internal medicine applicants. Finally, we discuss possible implications of recent changes in the healthcare landscape on the GI Match.

Match Day and the medical match as an economic game by Moblab

Not only is the medical Match important for doctors, now there's an in-class game from Moblab which econ instructors can use to introduce matching. Here's a post about it:

A Personal Note on Match Day and our KR Matching Game.
17 Mar 2017/ by Doug Norton 

Match Day for American doctors and foreign medical grads

Today is Match Day for the National Resident Matching Program. Congratulations to all the newly matched residents.

Here are some articles in honor of match day, concerning difficulties in the interviewing process that proceeds the formal match, and some other things (including the US travel ban that is once again being adjudicated):

Match Day is coming up. Here’s how medical students game the residency system
"Writing love letters

This is the most common way to game the match. Applicants send emails to residency program directors expressing their interest in the program, hoping to influence how the director ranks them. Applicants sometimes end up writing multiple letters professing their love to different programs. Sometimes, they tell more than one program director that their program is their first choice.

While programs often say that they don’t adjust their rankings based on “love letters,” some do. For one of my friends, a residency director for surgery told her, “the love letter could be a deciding factor in how we rank you.”

So, we’re stuck: If you don’t send one, it might look like you’re not interested."
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Am Surg. 2016 Dec 1;82(12):1163-1168.

Behind the Match Process: Is There Any Financial Difference Lurking Below the Specialty of Choice?

Oladeji LO1, Raley JA, Smith S, Perez JL, McGwin G, Ponce BA

Abstract: The Match was developed in response to a chaotic residency selection process. While the match has remained relatively unchanged since it was introduced, the number of medical school graduates has increased at a rate outpacing the number of residency positions leading to a more competitive process for applicants. In May 2014, an 18-question mixed-response questionnaire was distributed to fourth year allopathic medical students via an E-mail distribution list for student affairs representatives. The individual surveys were accessible via SurveyMonkey and available for completion over the course of a 4-week period. Approximately 65.1 per cent of students performed at least one audition rotation and documented average expenditures of $2494 on housing, food, and transportation. The average applicant applied to 32 programs and attended 12 interviews while spending $4420 on the interview trail. Applicants for surgical programs applied to approximately 42 programs and attended 13 interviews compared with primary care applicants who averaged 23 programs (P < 0.001) and attended 12 interviews (P = 0.002). Surgical applicants averaged 20 days on the interview trail while spending $5500 ($423/interview) on housing, food, and transportation compared with primary care applicants averaged 19 days away from home (P < 0.05) and spending $3400 ($283/interview) on these same items (P < 0.001). The findings in our study indicate that the "Match process" contributes to the financial burden of graduating medical students and it is more expensive and time consuming for the candidates interested in surgical specialties.

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No Heart Surgeon Match Day for Major Medical Center
Columbia University missed deadline to submit residents' ranking list
"Medical students hoping to train in cardiothoracic surgery at New York-Presbyterian/Columbia University Medical Center in New York City got some bad news over the weekend: The center will not be able to select residents in Match Day for cardiothoracic surgery.
The center confirmed Monday that it missed the deadline to submit its ranking list for residents in the specialty."
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And this:( 
Travel Ban Adds Stress To 'Match Week' For Some Doctors

Here incidentally is the NRMP statement on the travel ban:

NRMP Statement On The Executive Order On Immigration

February 3, 2017

NRMP has released a statement on the Administration’s Executive Order on immigration. We ask the medical education community to support all international medical graduates and their families during these difficult times. Please be assured that NRMP will do all it can to address the uncertainties the order has created. As for the current Match cycle, we hope that applicants and programs will continue to rank each other in the order of true preference, based on the qualifications and qualities each seeks in the other.

NRMP statement

Maria C. Savoia, M.D., Chair
Mona M. Signer, President and CEO