Selection of Dutch doctors by lottery

 Here's a recent article describing the once and future Dutch selection of medical students by lottery. (I believe that residency positions may also have or have had selection by lottery.)

Rationales for a Lottery Among the Qualified to Select Medical Trainees: Decades of Dutch Experience by Olle ten Cate, J Grad Med Educ (2021) 13 (5): 612–615. https://doi.org/10.4300/JGME-D-21-00789.1

"The Dutch Lottery for Medical School Selection

"A lottery, as a method to determine who will be admitted to medical school or residency, may sound an absurd proposition to many. A lottery appears to devalue motivation, disregard high effort and talent, and randomly block freedom of career choice. However, The Netherlands has decades of experience with this method. The Dutch government applied a lottery system nationally for admission to all medical schools in 1972. This system was abandoned in 2017 after an appeal but will now be reinstalled in 2023 as a legitimate procedure for the selection of students.

"Until 1972, the admission to Dutch medical schools, which have a 6-year program not preceded by baccalaureate education, was freely accessible for applicants with the proper secondary schooling (note that the Dutch government pays for most of medical education). When applicants increased in number and their costs became substantial, the Dutch government introduced a numerus fixus, a restricted total number of positions, derived from predictions of future physician need. After years of debate, politicians settled on a “weighted lottery” system for admissions. The average score on a national final secondary examination determined the weighting. Students with an outstanding score would triple their chances compared to those with a just-pass score. Declined candidates could reenter the lottery for 2 subsequent years. For decades schools and the public were generally satisfied with this procedure to determine the one-third of all applicants (on average across decades) for whom there was space at a Dutch medical school. The lottery procedure was smoothly conducted by a government agency, until 1996. That year an outstanding high school graduate was turned down 3 times and appealed the decision. Political and societal anger arose and led to a gradual replacement of the lottery, initially with a local qualitative selection process in parallel with a national weighted lottery. In 2 decades, the national lottery system was abandoned altogether; legislation prohibited medical schools from using a lottery as of 2017. Surprisingly, in 2020, a parliamentary majority voted to allow schools to use a lottery system, and thus reinstalled lottery processes as a legitimate method of selection. The law is effective in 2023."

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

Related:

Lottery Admissions System in the Netherlands, FL Meijler, J Vreeken - Science, 1975 - science.org

The weighted lottery in the admission to ‘restricted’ university studies in the Netherlands,      

Ben Wilbrink

The use of lottery systems in school admissions

C Stasz, C Von Stolk, R Europe, C Rand, TW Sutton - 2007 - researchgate.net

More on the UAE-Israel kidney exchange

If you're just tuning in, you can follow the story of the kidney exchange between the UAE and Israel here. The pairs who exchanged kidneys were an Israeli Arab husband and wife, a Jewish Israeli mother and daughter, and a mother and daughter who wish to be identified only as Arab residents of the United Arab Emirates.  (I joined their family at their home for a meal when I was in Abu Dhabi, but won't say more about them.)

It isn't a surprise that the donor in each pair couldn't donate to the intended recipient, because in each pair the recipient was a highly sensitized mother ( i.e. for whom it was hard to find a compatible kidney, because she had many antibodies against human proteins). During childbirth, mothers can develop such antibodies to the father's proteins that the children inherited. So the father and the daughters were incompatible donors, since the mother had antibodies against the paternal proteins (human leukocyte antigens) in their kidneys. Together with the fact that the mothers were quite hard to match, and that Israel and the UAE are both small, each with populations of around ten million, they had to look across national borders.

Cross border kidney exchange requires some diplomacy, particularly when the countries involved are getting together for the first time (and don't necessarily have a long history of cooperation). The key medical diplomats were Dr. Tamar Ashkenazi* the director of Israel Transplant and Dr Ali Abdulkareem Al Obaidli, Chairman of the UAE National Transplant Committee.  (Other key collaborators in the complicated logistics were Itai Ashlagi at Stanford and Atul Agnihotri and Mike Rees of the Alliance for Paired Kidney Donation.)  

So this was the plan:

And here's a picture of the Abu Dhabi kidney packed for shipping (masked in the picture are Sue and Mike Rees, who have a lot of experience with packing and shipping kidneys, another nurse whose name I don't know, and Dr. Muhammad Badar Zaman the UAE transplant surgeon who transplanted the  kidney that was on the way.

The little box taped to the top of the shipping container allows the kidney to be tracked in transit, via an app that gives you a picture of where it is at it travels:

And here's the swap of the two kidneys in shipping containers in the airport in Abu Dhabi (Tamar Ashkenazi and Dr. Ali are in the center, Atul and Mike are at the two ends...). Dr Ashkenazi was on both legs of the flight above--she flew in with the Israeli kidney and flew out with the UAE kidney.

On my last night in Abu Dhabi I had dinner with a lot of the docs. Across from me in the picture below are the two surgeons most actively involved in this exchange on the UAE side, transplant surgeon Dr. Zaman and the nephrectomy surgeon Dr. Hamid Reza Toussi.  Next to me is the nephrologist Dr. Mohamed Yahya Seiari.

Below is that whole dinner party. If you've been following these posts up til now, you've met all of them except the gentleman second from the left, Dr. Gehad ElGhazali, who is the head of the HLA lab, which is responsible for the data that allows the matching algorithm to predict which kidneys are compatible, and is responsible for the final 'crossmatch' tests that verify compatibility. Like all the other docs I encountered, he has a multi-international background. This reflects the UAE's very international population, which is why it seems a natural global hub for kidney exchange.

I only met the Israel participants in the exchange later, by Zoom: Shani Markowitz is the donor from the Jewish pair, and Walaa Azaiza is the recipient from the Israeli Arab pair.

The Israeli transplant surgeons are Dr Tony Karam at Rambam Hospital and Dr. Eitan Mor at Sheba Medical Center.

^^^^^^^^^^^^^^^^^^^

*As it happens, I've twice had the privilege of  being Dr. Ashkenazi's coauthor (concerning deceased organ donation):

1. Stoler, Avraham,  Judd B. Kessler, Tamar Ashkenazi, Alvin E. Roth, Jacob Lavee, “Incentivizing Authorization for Deceased Organ Donation with Organ Allocation Priority: the First Five Years,” American Journal of Transplantation, Volume 16, Issue 9, September 2016,  2639–2645. http://onlinelibrary.wiley.com/doi/10.1111/ajt.13802/full 

2. Stoler, Avraham, Judd B. Kessler, Tamar Ashkenazi, Alvin E. Roth, Jacob Lavee, “Incentivizing Organ Donor Registrations with Organ Allocation Priority,”, Health Economics, April 2016 online http://onlinelibrary.wiley.com/doi/10.1002/hec.3328/full ; doi: 10.1002/hec.3328. In print: Volume: 26   Issue: 4   Pages: 500-510   APR 2017

Doctors and guns

 Americans are divided about  guns, and so are American doctors. While the American Medical Association regards guns as a public health crisis (https://www.ama-assn.org/press-center/press-releases/ama-calls-gun-violence-public-health-crisis), a recent survey of the American College of Surgeons reveals that many surgeons are gun owners who store loaded guns unlocked at home.

Firearm Storage Practices of US Members of the American College of Surgeons  by Brendan T.CampbellMD, MPH, FACS, Deborah A.KuhlsMD, FACS, Cynthia L.TalleyMD, FACS, Eileen M.BulgerMD, FACS, Ronald M.StewartMD, FACS, Journal of the American College of Surgeons, Volume 233, Issue 3, September 2021, Pages 331-336  ttps://doi.org/10.1016/j.jamcollsurg.2021.05.024

Background: As a part of its firearm injury prevention action plan, the American College of Surgeons (ACS) surveyed the entire US ACS membership regarding individual members' knowledge, experience, attitudes, degree of support for ACS Committee on Trauma (COT) firearm programs, and degree of support for a range of firearm injury prevention policies. This survey included questions regarding members' prevalence of firearm ownership, type of firearm(s) owned, type of firearm(s) in the home, personal reasons for firearm ownership, and methods of firearm/ammunition storage.

...

Conclusions: A significant percentage of ACS members keep firearms in their home, and nearly one-third store firearms in an unlocked and loaded fashion. Safe storage is a basic tenet of responsible firearm ownership. These data present opportunities for engaging surgeons in efforts to improve safe firearm storage.

HT: Irene Wapnir

How many transplants could a transplant surgeon do if ...?

The  Indy Star carried this story about Dr. William Goggins at Indiana University, on the occasion of his 2000th kidney transplant (which happened to be through kidney exchange):

1 doctor, 2,000+ kidney transplants. If surgeons kept stats, he’d be LeBron James

"Goggins stands out, having notched more kidney transplants than some transplant programs as a whole. Last year Lutheran Hospital of Fort Wayne did 13 transplants, St. Vincent Hospital about 50. Goggins might do 10 to 12 in a week.
...
"To Goggins, there's nothing more interesting than kidney transplants. And the more complicated the surgery, the better.
...
"A typical kidney transplant will take Goggins from two to three hours, although more complicated procedures may go longer. It's demanding, physical work that requires bending over, delving deep into a patient's abdominal cavity, and doing the painstaking job of sewing the donor kidney into the recipient.
...
"[Patient 2000's] kidney came earlier this year, as part of what's known as a paired kidney exchange. How that worked: A friend of hers donated a kidney on her behalf; the organ went to another donor who was a match. Then, Brophy was matched with a kidney from a different donor.
...
“You put in a good kidney, you do a nice operation, and they get healthy very quickly and they’re like a new person within 24, 48 hours and it’s just, an awesome experience,” Goggins said.       
...
"At one point, he recalled, he performed 365 transplants over two years, each one taking two to three hours. That adds up to every other day for two years straight.
...
"patients over 60 are the fastest-growing group of kidney transplant patients, Goggins says. Studies have shown that people in this age range with a life expectancy of five to 10 years will do better with a kidney transplant than they would staying on dialysis.
...

When an academic conference can save lives (market for interventional cardiologists)

The Chronicle of Higher Ed has the story:
Academic Conferences May Save Lives — by Keeping Big-Name Doctors Busy

Here's the medical paper on which it is based:
Acute Myocardial Infarction Mortality During Dates of National Interventional Cardiology Meetings
Anupam B. Jena, Andrew Olenski, Daniel M. Blumenthal, Robert W. Yeh, Dana P. Goldman, John Romley,
Journal of the American Heart Association. 2018

"Thousands of physicians attend national scientific meetings annually. Within hospitals, the composition of physicians who attend scientific meetings may differ from nonattendees who remain behind to treat patients, potentially resulting in differences in care patterns and outcomes for patients hospitalized during meeting dates. A quasi‐experimental evaluation of outcomes of patients hospitalized with acute cardiovascular conditions during the American Heart Association (AHA) and American College of Cardiology (ACC) annual meetings compared with identical nonmeeting days in the surrounding weeks found that, within teaching hospitals, patients admitted with cardiac arrest or high‐risk heart failure during meeting dates had lower adjusted 30‐day mortality compared with similar patients on nonmeeting dates"

Solidarity between doctors and nurses in Quebec

Canadian doctors--at least some of them--are different.
The Washington Post has the story.

Hundreds of Canadian doctors demand lower salaries

"In a move that can only be described as utterly Canadian, hundreds of doctors in Quebec are protesting their pay raises, saying they already make too much money.

"As of Wednesday afternoon, more than 700 physicians, residents and medical students from the Canadian province had signed an online petition asking for their pay raises to be canceled. A group named Medecins Quebecois Pour le Regime (MQRP), which represents Quebec doctors and advocates for public health, started the petition Feb. 25.

“We, Quebec doctors who believe in a strong public system, oppose the recent salary increases negotiated by our medical federations,” the petition reads in French.

"The physicians group said it could not in good conscience accept pay raises when working conditions remained difficult for others in their profession — including nurses and clerks — and while patients “live with the lack of access to required services because of drastic cuts in recent years.”

"A nurses union in Quebec has in recent months pushed the government to address a nursing shortage, seeking a law that would cap the number of patients a nurse could see. The union said its members were increasingly being overworked, and nurses across the province have held several sit-ins in recent months to push for better working conditions."

Medical careers as investments

From Statnews.com:

How much do doctors really make? Compare your salary to various specialties 

What do immigrant doctors affected by the travel ban bring to America?

"What do immigrant doctors bring to America" is the question asked (and answered) by The Immigrant Doctors Project, a website compiled by a team of youthful looking scholars in response to the six country travel ban reinstated by the White House after an earlier version was found illegal by the courts.

One of the authors, Jonathan Roth, is quoted at length in a news article on the particular effect this ban may have in Los Angeles: Hundreds of doctors in LA County could be affected by new travel ban

"The executive order, which is due to go into effect on Thursday, temporarily blocks visas from being issued to citizens of Iran, Libya, Somalia, Syria, Sudan and Yemen to "to protect the Nation from terrorist activities by foreign nationals." The ban does not include permanent residents and those who already have visas, but doctors applying for new visas or seeking to renew expired ones would require a waiver. Several states are challenging the order's constitutionality in court.

"Los Angeles is actually the metro area in the United States which has the highest number of doctors from the banned countries," according to Jonathan Roth, a Harvard PhD student and one of the researchers who worked on the Immigrant Doctors Project.  

Roth, along with other researchers from Harvard and MIT, used the location of the medical school where a doctor was trained as a way to calculate a doctor's country of origin. Since many doctors train abroad, Roth says it's likely that the number of doctors affected by the ban is much larger than their estimates. 

More than 900 doctors in Los Angeles went to medical school in one of the six countries listed in the executive order, more than three-quarters of them in Iran, he says. "

**************
You can here a brief interview with Jonathan R. here: http://www.byuradio.org/episode/01e0c780-5621-4307-ba99-954c81776308?playhead=2440&autoplay=true
*************

Tomorrow is Match Day for new medical residents and fellows, and we have yet to hear how the immigration ban may have affected this year's match. (See earlier post: Travel bans and rank order lists for the resident match)

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

Here's a description of a forthcoming documentary on the National Resident Matching Program (NRMP), the resident match : A Perfect Match. And here's a piece on the doctor-filmmaker behind it, Dr. Trisha Pasricha, who graduated from Vanderbilt's medical school and went through the 2016 match: The Envelope, Please.

Apparently the film is scheduled for release around the time of the 2017 match, so look for it in March (Match Day will be March 17, 2017).

Results of the 2015 Medical School Enrollment Survey

Results of the 2015 Medical School Enrollment Survey

"Key findings include:
 • Medical school enrollment has grown 25 percent since 2002–2003, and 30 percent growth should be achieved by 2017–2018. In 2006, in response to concerns of a likely future physician shortage, the AAMC recommended a 30 percent increase in first-year medical school enrollment by the 2015–2016 academic year (over 2002–2003 levels). Using the baseline of the 2002–2003 first-year enrollment of 16,488 students, a 30 percent increase corresponds to an increase of 4,946 students. The survey results indicate that the 30 percent goal will likely be attained by 2017–2018. Enrollment growth could be accelerated if any of the seven applicant or candidate schools in the Liaison Committee on Medical Education (LCME) pipeline attains preliminary accreditation.

• Schools are increasingly concerned about the availability of graduate medical education opportunities for their incoming students. Medical schools reported concern about enrollment growth outpacing growth in graduate medical education (GME). Half of medical schools reported concerns about their own incoming students’ ability to find residency positions of their choice after medical school, up from 35 percent in 2012. Concern about GME availability at the state and national levels declined somewhat since 2013, yet it still remained high.

• There has been a large increase in the percentage of schools experiencing competition for clinical training sites from DO-granting schools and other health care professional programs. In 2015, 85 percent of respondents expressed concern about the number of clinical training sites and the supply of qualified primary care preceptors. Seventy-two percent expressed concern about the supply of qualified specialty preceptors. There has been a large increase in the percentage of schools experiencing competition from DO-granting schools and other health care professional programs, from about a quarter of schools in 2009 to more than half of schools in 2015. Forty-four percent of respondents reported feeling pressure to pay for clinical training slots, though the majority of schools currently do not pay for clinical training.
...
• Enrollment increases at DO-granting schools continue to accelerate. First-year enrollment at DO-granting schools in 2020–2021 is expected to reach 8,468, a 185 percent increase from 2,968 students in 2002–2003. Combined first-year enrollment at existing MD-granting and DO-granting medical schools is projected to reach 30,186 by 2020–2021, an increase of 55 percent compared with 2002–2003. "

The supply of American doctors

American medicine is a market with tightly restricted entry, at all levels. Proposed legislation offers a glimpse: Bill Would Create More Medical-Residency Slots, Potentially Easing Physician Shortage

"Legislation introduced in Congress on Monday would expand the number of Medicare-sponsored training slots for new doctors by 15,000, a step that two medical-education groups said would go a long way toward easing a projected shortage of physicians.

"The bill, the Physician Shortage Reduction and Graduate Medical Education Accountability and Transparency Act (HR 6352), is sponsored by Rep. Aaron Schock, an Illinois Republican, and Rep. Allyson Schwartz, a Pennsylvania Democrat.

"Medical schools have been expanding their enrollments and new schools have been opening up as concerns have grown about a shortage that could reach more than 90,000 physicians by 2020, according to the Association of American Medical Colleges.

"Those worries have intensified with passage of the Affordable Care Act, which will greatly increase the number of people seeking medical care by providing insurance coverage to 32 million more people.

"But while more students are making their way through the medical-school pipeline, they're likely to run into bottlenecks because of a cap on the number of Medicare-supported residency training slots that Congress imposed in 1997."

The market for medical referrals

The medical profession finds (explicit) advertising repugnant, but specialists depend upon referrals, so there's a marketing industry at work: The Surprising Secret Behind Doctor Referrals

"Most patients assume that if they've got an ailment their family doctor can't fix, they'll be referred to a specialist who's, well, special for reasons they expect: ... So it may come as a surprise that the nattily dressed guy or gal sitting two chairs down in the waiting room, the one who brought that jumbo tin of caramel popcorn for the front-desk staff, may play a role in determining the next surgeon they see.


"With specialists' operating margins having fallen in the past decade and health care reforms putting increasing pressure on their bottom line, more are turning to this burgeoning group of marketing pros to open new-patient pipelines. For anywhere from $3,000 to $10,000 a month, these so-called referral-development consultants will provide marketing plans and dispatch a "physician liaison" to pound the pavement and praise the doctors' prowess. The pitches can focus as much on waiting-room decor as on clinical credentials, but in the end, marketers say, they're sparing doctors the roadside-billboard approach to bringing in patients, and reshaping a long-ignored, but important component of doctoring. "I tell doctors how to sell their business without looking needy, cheesy, greedy or sleazy," says Stewart Gandolf, founding partner of Healthcare Success Strategies, a Southern California medical marketing firm, which says it helped double referrals for one Midwest ophthalmologist in a six-month period.

"But while no one can fault a doctor for trying to drum up business in tough times, critics say that medicine and marketing can make for strange bedfellows. To be sure, accepting payment for a referral is illegal and patient advocates say that no doctor will intentionally make a bad referral....[But] a steady stream of thank-you gifts might keep a specialist top-of-mind. (Even years later, the Mobile, Ala., dental community still raves about one oral surgeon's gift basket: ribs and bottles of Jack Daniels.)

...

"The American Medical Association's Code of Medical Ethics requires doctors to provide patients with "relevant information" about potential procedures, but has no guidelines on what to tell them about the specialist to whom they're being sent. "It goes against the basic trust that is the centerpiece of the physician patient relationship," says Peter Clark, director of the Institute of Catholic Bioethics 

...

"If doctors are just getting in on the referral game, hospitals have been at it for some time -- and on a larger scale. Whereas patients see a hospital only as a place for serious tests and procedures, administrators see a hospital also as a collection of business areas (radiology, ORs, cancer centers) with specific revenue targets -- goals most readily reached when providers send along more patients. When hospitals buy physician practices and become their bosses, federal law prevents them from tying doctors' compensation to in-house referrals. But they are allowed to incentivize them by offering bonuses based on the overall performance of the hospital. "Go into a hospital board room, and 99 percent of the time they're talking about referrals and physician relations," says Timothy Crowley, a former managing director at Leerink Swann, a health care investment bank.

"Indeed, at a recent Hospital and Physician Relations Summit in Scottsdale, Ariz., hospital administrators and doctors gathered for three days to collectively fret about everything from "physician alignment" to "referral leakage." In one session, a Pennsylvania hospital official identifies one type of leak -- proactive patients doing their own doctor research -- as a growing challenge. Not that patients can't be corralled. Many hospitals now employ staffers called "navigators," who help recovering patients with paperwork and follow-up appointments. Part of their job, though, is insuring that the patients' next specialist has the same hospital logo on his or her lab coat.

Yuichiro Kamada defends his Ph.D. dissertation

Defense 2 (Offense 0)

Yuichiro (in suit:), with Tomasz Strzalecki and Al Roth (and Drew Fudenberg and Attila Ambrus via skype)

Yuichiro with the full defense team

Yuichiro had to choose three out of his many papers for his dissertation, which he called "Essays on Revision Games." Those papers all concern the difficult problem of analyzing incentives in non-stationary environments.

Multi-Agent Search with Deadline (joint with Nozomu Muto), December 31, 2011.(An earlier version of this paper referred to in the new version is here)

Revision Games (joint with Michihiro Kandori), December 31, 2011

Asynchronicity and Coordination in Common and Opposing Interest Games (joint with Riccardo Calcagno, Stefano Lovo, and Takuo Sugaya), March 2012, Revise and Resubmit, Theoretical Economics. (This paper is a result of a merger between two independent papers: Preopening and Equilibrium Selection by Calcagno and Lovo, and Asynchronous Revision Games with Deadline: Unique Equilibrium in Coordination Games by Kamada and Sugaya)

I earlier blogged about another of his papers, on the design of the market for new Japanese doctors:

Matching Japanese Doctors: problems with the current mechanisms, and suggestions for improvement by Yuichiro Kamada and Fuhito Kojima

Yuichiro is one of the group of job market candidates I blogged about here: Five Harvard candidates for the Economics job market this year (2011-12)

 He will be going next year to a postdoc at Yale, after which he'll take up a position at Berkeley-Haas.

Two more defenses are coming up this week.

 Welcome to the club, Yuichiro.

Medical (and pre-medical) culture: cheating on tests

While some of the very best motivated and most talented students find their way into medicine, it is also a large, well-compensated profession fed by a stream of undergraduate "pre-med" majors who grow up in a culture of exam-taking. It shouldn't be surprising if this carries over into their post-graduate years (in fact I can't even tell if this CNN headline is meant to be ironic): Exclusive: Doctors cheated on exams

"For years, doctors around the country taking an exam to become board certified in radiology have cheated by memorizing test questions, creating sophisticated banks of what are known as "recalls," a CNN investigation has found."

The job market in gastrointestinal endoscopy

After completing a 3 year subspecialty match in gastroenterology, doctors wishing to specialize further can do a fellowship in advanced endoscopy. The American Society for Gastrointestinal Endoscopy is trying to organize that job market, and, at least for this year, they are doing something quite different from a standard medical match. Aside from a system of prescribed dates (First date to offer an interview: 4/1/2011; First date to offer a position 7/15/2011: Fellowship start date: 7/1/2012), the process is described to applicants (in a letter) as follows:

******
"At 12pm EDT on July 15th, all program directors will send out an email to their top
choice. The fellow will then have 1 hour to decide if they wish to take that position or
wait for other offers. Please send a return email confirming that you got the offer.
You may respond at any time during that hour, ideally as soon as you make your
decision. If you do not respond within that hour, the program director may move on to
their second choice, so please respond within the hour.


"One of 2 things will then happen once you respond:


1. If you have chosen the offer, and send an affirmative email, the program
director will then send an email ASAP to all of its other applicants to
alert them that the spot has been filled, so that other applicants will be
aware that that position at that particular institution is no longer
available.


2. If you chose to reject the offer, please alert the program director via email
ASAP, so that the program director can then make an offer to the next
applicant on the list.


"If after the 15th (and the weekend of the 16th-17th) you do not have a position, please
go to the ASGE AEF website, and a list of programs with open positions will be
posted so that you may contact any of them if you like.


"I know that this non-electronic “match” is not ideal, but until we adopt an electronic
match (hopefully next year) we hope this format works without too many glitches."
******


Note that this is a system of "exploding offers", so one can expect some communication between participants before the appointed hour... (See also the discussion of similar problems I anticipate in the proposed new rules for the residency scramble (SOAP)).

Gastroenterology fellowships enjoy a successful match, so it seems reasonable to speculate that the fellowship in advanced endoscopy will turn to one after trying this.

The gastro fellowship match after five years

A recent article takes stock of the Gastroenterology fellowship match, five years after it was reinstated with some new design rules (about exploding offers):
The Match: Five Years Later, by Deborah D. Proctor et al., Gastroenterology 2011;140:15–18

Proctor et al. report considerable progress, although they continue to monitor violations of market policy. There seems to be a particular issue with respect to research positions.

"...the NRMP/SMS was uniquely set up for our many diverse program offerings. Four tracks were created—Clinical, Clinical Investigator Research, Basic Science Research, and Research—and a reversion process was implemented for the 4 tracks, such that unfilled slots from 1 track could revert to open slots in another track. The GI Match successfully reopened in January 2006 with a match day in June 2006 for fellowship positions starting in July 2007."
...
"However, we must recognize that not all programs are eager or willing to participate in the Match process."
...

"The number of fellowship applicants genuinely committed to an academic research career has been
slowly declining. Simultaneously, competition has stiffened for the grant dollars that pay for these research training positions, and the criteria to renew grant support has become more demanding.
Needless to say, the competition for these increasingly scarce, well-qualified, research-track applicants has become fierce, and the authors are aware of several examples during the last application cycle of candidates interested in research being offered fellowship positions outside the Match.

...
"Although the statistics continue to demonstrate that Match participation is robust, healthy, and gradually increasing, there is also a growing desire to close the loopholes in Match rules that allow a small minority of programs to take unfair advantage of applicants and colleagues."

***************
To summarize the overall encouraging statistics, in the (2006) Match for 2007 positions, 283 positions were offered and 585 applicants applied, of whom 276 were matched. In the Match for 2011 positions, 383 positions were offered to 642 applicants, of whom 362 were matched.

Here are some papers reporting various elements of the Gastroenterology market design.
The match offers programs the ability to have unfilled positions of one kind (e.g. research positions) revert to other kinds of positions via the Roth-Peranson algorithm (see
Roth, A. E. and Elliott Peranson, "The Redesign of the Matching Market for American Physicians: Some Engineering Aspects of Economic Design American Economic Review, 89, 4, September, 1999, 748-780.)

Unraveling of pathology fellowships

A forthcoming paper in the journal Human Pathology gives a detailed account of the unraveling of the market for Pathology subspecialty fellowships, including the now familiar path towards earlier offers more diffuse in time, and to the increased hiring of internal candidates. It's an unusually thorough report that details some of the special pathologies of the Pathology labor market, and also compares it to the experience of other subspecialties such as Gastroenterology.

"Unlike the application process for first-year Pathology Residency, which is run through the National Resident MatchingProgram, applications for Subspecialty Pathology Fellowships are not coordinated by any consistent schedule. Competition for Subspecialty Pathology Fellowships has consistently resulted in undesirable drift of the fellowship application process to dates that are unacceptably early for many fellowship applicants. Responding to widespread dissatisfaction voiced by national pathology resident organizations, in 2007, the Association of Pathology Chairs began evaluation and potential intervention in the fellowship application process. Three years of intermittently intense discussion, surveys, and market analysis, have led the Council of the Association of Pathology Chairs to recommend implementation of a Pathology Subspecialty Fellowship Matching program starting in the 2011 to 2012 recruiting year, for those Applicants matriculating in fellowship programs July 2013. We report on the data that informed this decision and discuss the pros and cons that are so keenly felt by the stakeholders in this as-yet-incomplete reform process."

That's from the abstract of

"Pathology subspecialty fellowship application reform 2007 to 2010" by James M. Crawford MD, PhD,  Robert D. Hoffman MD, PhD, W. Stephen Black-Schaffer MD, in Human Pathology (2010)

Hours per week worked by (young) surgeons

In Britain as in the United States, there is considerable debate about the hours worked by physicians and surgeons, and what these mean for patient safety. Convincing data are lacking, but the Royal College of Surgeons of England has just weighed in with a new report, saying that limiting the hours of surgeons endangers patients: Patients are being harmed by working time limits, finds new study


The report argues that frequent handoffs allow patient information to be lost, as doctors have less chance to observe changes in a patient's condition.


"Surgeons across the country say patients are much less safe in the NHS since the August introduction of European Working Time Regulation (EWTR) 48 hour working limits as continuity of care for patient collapses, this is the damning assessment of a survey of NHS surgeons. Services are only being held together by a ‘grey market’ of doctors willing to covertly breaking the legislation to maintain care for patients."

..."The College surveyed 900 surgeons - almost an eighth of the UK surgical workforce – with responses from more than 360 consultants and more than 500 trainees to see how surgical services were faring under the new working time restrictions. It found some alarming results:
...
"A third say handover arrangements are inadequate in their hospital and 23 per cent say they cannot stay involved in all stages of individual patients clinical care that require their expertise."
...
"Patients are being lost and at increased risk of dying as a direct result of so many shift changeovers and rotas which leave no time available to handover. Trainee surgeons across the country are staying on unpaid after the hours limit because they want to see through care for patients. They are also taking on additional paid locum work in the hope of gaining the training opportunities they cannot get in their formal working week. Meanwhile hospitals are relying on this goodwill because they know they couldn’t stay open without them. As a result there is an emerging grey market in hospital cover with doctors true working hours being kept off the books."


On the other side is the argument that sleepy doctors endanger patients. We don't let airline pilots work long hours, why should the doctors who staff emergency rooms and operating rooms be different? In the United States, the 1984 death of Libby Zion led to new legislation in her name to limit the working hours of medical residents: A Life-Changing Case for Doctors in Training

NRMP to implement "managed scramble"

After the medical match, some applicants and positions remain unmatched. Right now, that is handled through a fairly decentralized "scramble." (Fairly decentralized, but with some centralized distribution of the information about who is matched and unmatched. It is more centralized than the economics job market scramble, since the NRMP knows immediately who all the unmatched applicants and participants are). Giving the medical scramble some more structure is now under active consideration.

"The NRMP Board of Directors, meeting in Washington, DC on May 4, 2009, voted to proceed with implementation of a "managed" Scramble for the Main Residency Match. A joint NRMP-AAMC work group will continue to refine the plan, which will require programs to offer and applicants to accept unfilled positions through the NRMP R3 System during Match Week. A "managed" Scramble would be implemented no earlier than the 2011 Match, according to NRMP Executive Director Mona M. Signer. " (http://www.nrmp.org/ on 9/13/09)

Medical match policies (NRMP)

The NRMP has some new rules for 2009, which suggests that there have been some new problems (I haven't been involved for a while).

• "Applicants who obtain positions through the Matching Program are prohibited from discussing, interviewing for, or accepting a concurrent year position with another program before a waiver has been granted by the NRMP.
• The deadline for an applicant to request a waiver based on change of specialty is the January 15 prior to the start of training in the matched program.
• Programs shall use the Applicant Match History in the Match Site to determine the match status of any applicant considered for appointment to the program.
• Applicants must provide complete, timely, and accurate information to programs.
• Programs are prohibited from requiring applicants to reveal ranking preferences or the names or identities of programs to which they have or may apply.