Cleaning up the scramble for medical residents with SOAP

Changes are coming in the scramble that follows the medical resident match run by the National Resident Matching Program (NRMP). A new, semi-centralized, partially computerized Supplemental Offer and Acceptance Program (SOAP) has been announced, for implementation in March 2010.

If I understand the proposal correctly, residency programs with unmatched positions will be able to submit preference lists of match participants who ended up unmatched, and these preferences will be used to make exploding offers, after which the preference lists and positions will be updated to take account of acceptances (e.g. candidates who accept a position will be removed from other program's preference lists), and new exploding offers will be issued. Unlike in the main match (which these days uses the Roth-Peranson algorithm, but which you can think of as a student-proposing deferred acceptance algorithm), applicants will not submit preference lists, but will accept or reject offers as they come in (i.e. they cannot defer acceptances by holding their best offer until they see if any better offers arrive later).

Part of the proposal is to integrate the scramble with the Electronic Residency Application Service (ERAS), which will make some kinds of automatic processing and regulation possible,while some of the proposed regulations may be more challenging to enforce. (Markets that use exploding offers at fixed times have often been subject to cheating of various sorts: here's a paper on the experience of the law clerk market. There are lots of differences in the market culture of doctors and lawyers that may result in different outcomes.)

Here are some of its proposed rules:

• Unmatched applicant and unfilled program information will be released simultaneously.

• There will be a “time out” period during which unmatched applicants can send applications but programs cannot make offers.

• Applicants and programs will be required to send and receive applications only through ERAS.

• NRMP-participating programs that fill positions during Match Week must do so only through the SOAP.

• New functionality will be added to the R3 System to allow programs to offer unfilled positions on the basis of preference lists submitted by the programs.

• Applicants must accept or reject their offer(s) within a specific timeframe; offers not accepted or rejected will expire.

• The R3 System will establish an electronic “handshake” when an applicant accepts a position.

• Positions will be deleted from the dynamic List of Unfilled Programs once an offer has been accepted.

• A program’s unfilled positions will be offered to applicants in order of preference until all positions are filled or the preference list has been exhausted; programs will be able to add applicants to the bottom of their preference lists throughout Match Week.

• The NRMP Match Participation Agreement will be expanded to include Match Week and SOAP, and sanctions will be imposed for improper behavior.
...
Eligible NRMP applicants:


• Must be able to enter GME on July 1 in the year of the Match

• Will be able to apply only to unfilled Match-participating programs during Match Week

􀀹 Access to the List of Unfilled Programs will be restricted by match status (preliminary or advanced)

􀀹 Must use ERAS and will be able to select only unfilled Match-participating programs

􀀹 Cannot use phone, fax, email, or other methods

􀀹 Cannot have another individual/entity contact programs on applicant’s behalf

􀀹 Will be able to accept positions only through SOAP during Match Week

• Can apply to non-Match-participating programs after Match Week

Ineligible NRMP applicants:

• Cannot participate in SOAP

􀀹 Cannot apply to Match-participating programs using ERAS, phone, fax, email, or other methods

􀀹 Cannot have another individual/entity contact Match-participating programs on applicant’s behalf

• Can apply to non-Match-participating programs during Match Week

􀀹 Can use ERAS to select non-Match-participating programs

􀀹 Can use phone, fax, email, or other methods

• Can apply to Match-participating programs after Match Week

Unfilled Programs:

• Must accept applications only through ERAS during Match Week

􀀹 Cannot use phone, fax, email, or personal contacts

• Must fill positions using SOAP during Match Week

􀀹 Cannot offer positions to ineligible applicants during Match Week

􀀹 Cannot make offers outside SOAP during Match Week

􀀹 Are not required to fill positions during Match Week

• Can add applicants to bottom of preference list

If an applicant rejects an offer or allows an offer to expire, no further offers will be made to that applicant by the same program.

Once an applicant accepts an offer, the applicant will not be able to send additional applications via ERAS.

Once a program has filled all of its positions through SOAP, applicants will be unable to send applications to that program via ERAS.

Offers extended by programs and accepted by applicants during the Match Week Supplemental Offer and Acceptance Program (SOAP) will create a binding commitment. Failure to honor that commitment or failure to adhere to SOAP policies will be a violation of the Match Participation Agreement.

2013 Results and Data Book from NRMP’s Main Residency Match

Here's the press release: 2013 Results and Data Book from NRMP’s Main Residency Match, and here's the data book for the 2013 Match

The data book also reports on the second year of the new SOAP scramble, but not in the same detail as last year's report. Last year I predicted that more of the visible action would move to the first round (reflecting more action before the beginning of the official scramble), but this year's data book doesn't give that information.

Here's the press release, though, which gives a good overview of the data, which seem to reflect a successful match year.

The National Resident Matching Program® (NRMP®) is pleased to announce the publication of its Results and Data 2013 Main Residency Match --- the most comprehensive Match data resource produced annually by the NRMP. The report provides statistics on the most successful Match in NRMP history, in which 28,130 of 29,171 available residency positions were filled.    

Included in the report are statistical tables and data graphs from the Main Residency Match and a state by state breakdown of each participating U.S. residency training program, with the number of positions offered and filled for each. This year, for the first time, the report includes results and charts from the Match Week Supplemental Offer and Acceptance Program® (SOAP®)-- the process used by NRMP for unfilled residency positions.

This year’s Results and Data Book is notable because the 2013 Match was the first to utilize NRMP’s All In Policy, which requires participating programs to register and attempt to fill all their positions through The Match.

NRMP Executive Director Mona M. Signer said, “Readers of the 2013 Results and Data Book will see the overwhelming success of the All In Policy. The 2013 Match produced the highest fill rate in NRMP history, and match rates rose for nearly every applicant group.”

Results and Data 2013 Book Facts

Applicant Numbers (Comparisons to 2012) 

• 40,335 registrants (1,958 more)
• 34,355 active applicants (3,000 more)
• 17,487 U.S. allopathic medical school seniors (960 more)
• 2,677 osteopathic medical school students/graduates (317 more, highest ever)
• 5,095 U.S. citizen international medical school students/graduates (U.S. IMGs) (816 more)
• 7,568 non-U.S. citizen international medical school students/graduates (IMGs) (740 more)

Applicant Match Rates 

• 74.1 percent of all applicants were matched to PGY-1 positions
• 93.7 percent of U.S. allopathic seniors matched to PGY-1 positions; of those, 78.8 percent matched to one of their top three choices
• 53.1 percent of U.S. IMGs were matched to PGY-1 positions, up from 49.1 percent in 2012 and the highest Match rate for this applicant group since 2005
• 47.6 percent PGY-1 Match rate for IMGs, an increase of seven percentage points from 2012

Increased Positions/High Fill Rates
Available residency positions increased to 29,171, 2,399 (9 percent) more than in 2012, when 26,772 positions were offered. The increase is due primarily to implementation of the All In Policy, which resulted in some specialties offering significantly more positions in 2013. Internal Medicine offered 1,000 more positions, Family Medicine offered 297 more, and Pediatrics offered 141 more than the prior year.

The overall position fill rate increased 1.1 percentage points to 96.4 percent, the highest in NRMP history. In 2013, only 1,041 first-year and second-year positions were unfilled; of those, 939 were placed in SOAP, and all but 61 were filled.

Notable Specialties
Often Match results can be an indicator of competitiveness. This year, several specialties and specialty tracks had 100 percent fill rates: 

• Medicine Emergency Medicine
• Pediatrics Primary
• Pediatrics/Psychiatry/Child Psychiatry
• Physical Medicine and Rehabilitation – Post graduate year one (PGY-1)
• Plastic Surgery – Post graduate year two (PGY-2)
• Psychiatry Family Medicine
• Radiation Oncology (PGY-1)
• Thoracic Surgery

The following specialties filled more than 90 percent of positions with U.S. seniors: 

• Plastic Surgery: 95.7 percent
• Otolaryngology: 94.5 percent
• Neurological Surgery: 93.1 percent
• Orthopedic Surgery: 91.8 percent

Couples in the Match
In 2013, a record 1,870 applicants (935 couples) participated in the 2013 Match. They continued to enjoy great success with a match rate of 95.2 percent. Couples have been able to participate together in The Match since 1984. The two partners identify themselves as a couple to the NRMP and submit rank order lists of identical length. The algorithm treats their lists as a unit, matching the couple to the highest linked program choices where both partners match.

SOAP - Supplemental Offer and Acceptance Program
The NRMP launched the Match Week SOAP in 2012 to replace the "Scramble" and to streamline the process for unmatched applicants and the directors of unfilled programs. During SOAP, eligible applicants use ERAS® to apply to programs with unfilled positions and offers are extended to applicants based upon the number of unfilled positions remaining in the program.

U.S. seniors accepted the majority of positions (595 of 878) filled during SOAP. More than 13,808 applicants were SOAP-eligible, 261 more than in 2012. This year, 406 unfilled programs elected to participate in SOAP, offering 939 of the 1,041 positions not filled when the matching algorithm was processed.

A total of 1,327 offers were sent to applicants. By the conclusion of SOAP, 93.5 percent (878 of 939) of the positions had been filled.

How the Match Works
Conducted annually by the NRMP, The Match uses a computerized mathematical algorithm to align the preferences of applicants with the preferences of residency program directors in order to fill the training positions available at U.S. teaching hospitals. Research on the NRMP algorithm was a basis for Dr. Alvin Roth’s receipt of the 2012 Nobel Prize in Economics.

# # #
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 Main Residency Match, the NRMP conducts matches for more than 40 subspecialties. For more information, contact NRMP at 1-866-653-NRMP (6767) or visit http://www.nrmp.org. For interviews, please email cherbert@nrmp.org.

Read more: http://www.digitaljournal.com/pr/1278215#ixzz2V7ttPAqX

Medical residency scramble

Dr.  Naveed Saleh, writing in New Physician, describes some of the different prognoses suggested for the new resident scramble (SOAP) which will operate next year: Unscrambling the Match.

"Roth predicts that the rules of the SOAP will be subverted by both programs and applicants eager to match. "If it's really, really tempting for people on both sides to break the rules," says Roth, "often the rules get broken."
Roth suggests that instead of the SOAP, the NRMP and ERAS should institute a properly organized second match during Match Week.
Mona M. Signer, executive director of the NRMP, disagrees with Roth's prediction that decision-making during the SOAP will be strategic. Instead, she predicts that programs and applicants will continue to pursue their best opportunities. Additionally, as with the Match, should a program or applicant violate prescribed rules, sanctions would be imposed.

My previous posts on the residency scramble, and the proposed new rules are here.

The market for radiation oncologists

 Dr. Wes Talcott at Yale points me to some contemporary discussion of the labor force in radiation oncology.  As with a number of other medical specialties, there's a tension between the number of staff needed to prep a patient for treatment and the number of new board certified specialists needed to supervise such treatment. Residents fill the first kind of position, and time and training transforms them into the second.

The contemporary discussion seems to focus on proposals that individual residency programs should reduce the number of residency positions they need to fill, in a decentralized manner, either by offering fewer positions in the Match, or declining to fill positions that aren't filled in the main Match. There is a concern that a coordinated reduction in positions would invite antitrust scrutiny, although other specialties (such as gastroenterology*) have managed that.

Here's an article from the International Journal of Radiation Oncology*Biology*Physics:

Chicken Little or Goose-is-Cooked? The State of the US Radiation Oncology Workforce: Workforce Concerns in US Radiation Oncology by Chirag Shah, MD and Trevor J. Royce, MD, MS, MPH, Published:March 11, 2021 DOI: https://doi.org/10.1016/j.ijrobp.2020.11.056  

"oversupply worries have reached a fever pitch among trainees, with the job market being the primary concern and 52% perceiving an increasingly competitive market10; these concerns have manifested in a precipitous decline in student interest, with 14% of RO residency positions unmatched in the 2020 Match (compared with previous rates of near 0%) and worse numbers expected for the 2021 match."

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Here's a reply, suggesting that the current situation presents an opportunity for the RO profession to remake itself in various ways:

When in a Hole, Stop Digging: In Reply, Workforce Concerns in US Radiation Oncology  Louis Potters, MD, FASTRO, FACR,  Published:March 11, 2021, International Journal of Radiation Oncology*Biology*Physics, DOI: https://doi.org/10.1016/j.ijrobp.2020.12.024

#####################

A different kind of reply is that fewer U.S. medical graduates are applying for RO residency positions in the Match:

No Longer a Match: Trends in Radiation Oncology National Resident Matching Program (NRMP) Data from 2010-2020 and Comparison Across Specialties  by Chelain R.GoodmanM.D., Ph.D.aAustinSimM.D., J.D.hElizabeth B.JeansM.Ed, M.D.dJustin D.AndersonM.D.bSarahDooleyM.D.cAnkitAgarwalM.D., M.B.A.gKarenTyeM.D., M.S.eAshleyAlbertM.D.fErin F.GillespieM.D.iRahul D.TendulkarM.D.kClifton D.FullerM.D., Ph.D.aBrian D.KavanaghM.D.jShauna R.CampbellD.O. Available online 11 March 2021,In Press, Journal Pre-proof International Journal of Radiation Oncology*Biology*Physics https://doi.org/10.1016/j.ijrobp.2021.03.006

"In the 2020 NRMP, 122 US MD senior graduates preferentially ranked radiation oncology, a significant decrease from 2010-2019 (Median [Interquartile Range],187 [170-192], p<0.001). Across all specialties, radiation oncology experienced the greatest declines in the 2020 NRMP cycle relative to 2010-2019 in both the number of ERAS applicants from the US and Canada (-31%) as well as the percentage of positions filled by US MD or DO senior graduates (-28%). Of 189 available positions, 65% (n=122) were filled by US MD senior graduates who preferentially ranked radiation oncology as their top choice of specialty, a significant decrease from 2010-2019 (Median=92% [IQR, 88-94%], p=0.002). The percentage of radiation oncology programs and positions unfilled prior to the SOAP was significantly increased in 2020 compared to 2010-2019 (Programs: 29% versus 8% [5-8%], p<0.001; Positions: 19% versus 4% [2-4%], p<0.001). Despite >99% (n=127 of 128) of US senior applicants successfully matching in the 2020 NRMP, 16 of 24 remaining unfilled positions were filled via the SOAP. Radiation oncology was the top utilizer of the 2020 SOAP, filling 15% of total positions versus a median of 0.9% [0.3-2.3%] across all specialties (p<0.001).

Conclusions

Supply of radiation oncology residency positions now far exceeds demand by graduating US medical students. Efforts to nullify a market correction revealed by medical student behavior via continued reliance on the SOAP to fill historical levels of training positions may not be in the best of interest of trainees, individual programs, or the specialty as a whole."

##################

*The reduction in gastroenterology residency positions was combined with an increase of a year in required training, and this combination contributed to the unraveling of the gastro Match, which has since been restored. See the background discussion in

McKinney, C. Nicholas, Niederle, Muriel and Alvin E. Roth, "The collapse of a medical labor clearinghouse (and why such failures are rare)," American Economic Review, 95, 3, June, 2005, 878-889.

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

Update: here's a discussion of the RadOnc situation by the Rad Onc Virtual Visiting Professor Network

First year of the new medical residency scramble, SOAP

I've written before about the new Supplemental Offer and Acceptance Program (SOAP), and the National Resident Matching Program has now released a report on its first year of operation.

There were 1,100 unfilled first year positions at the end of the main match, and 815 unmatched seniors graduating from U.S. medical schools (and many more unmatched applicants when foreign medical schools are included). Most of the unmatched positions were in family medicine and in "preliminary" rotations in surgery and internal medicine.

After the first day of the SOAP exploding offer process (i.e. after two rounds of exploding offers), only 267 positions remained, and 98 of these remained unfilled. So, most of the action happened the first day.

Medical schools complained that students were asked to "commit" to programs prior to receiving an offer, and thought that rounds should be longer. Residency programs thought rounds should be shorter.

In line with the criticisms of the design offered earlier (see here), I anticipate that next year more students will be asked to "commit" before receiving an offer (even though it's against the rules), and that even more of the action will be concentrated in the first day and the first round, with more of the market shifting out of the formal scramble, either officially or de facto, through the offline "commitment" process....

As I was quoted saying last year (see here), "If it's really, really tempting for people on both sides to break the rules," says Roth, "often the rules get broken."


HT: Nikhil Agarwal

Comment on the proposed NRMP scramble following the resident match

The NRMP website asked for comments on the NRMP's new plan for organizing the post-match scramble, and some of my young colleagues and I were moved to send one in:

Comment on the NRMP’s “Supplemental Offer and Acceptance Program” Proposed to Replace the Post-Match Scramble by Peter A. Coles, Clayton R. Featherstone, John William Hatfield, Fuhito Kojima, Scott Duke Kominers, Muriel Niederle, Parag A. Pathak, and Alvin E. Roth.

Executive Summary: "Historical precedent and economic principles suggest that the Supplemental Offer and Acceptance Program (SOAP) proposed for the NRMP Scramble will lead to unsatisfactory outcomes by forcing participants to make unnecessarily difficult decisions and giving them strong incentives to break the rules laid out in the SOAP proposal. We suggest, as an alternative Scramble mechanism, that the NRMP run a “Second Match” for the Scramble participants using rules similar to those of the Main Match."


Here's my previous post: Cleaning up the scramble for medical residents with SOAP

Match Day for new doctors

Today is Match Day, when graduating medical students find out where they will do their residency.

MAR18

Match Day!

Applicants: Medical school Match Day ceremonies at 12:00 p.m. ET. Learn where you matched in the R3 system and by email at 1:00 p.m. ET.

Programs: Match Results by Ranked Applicant and SOAP Results by Preferred Applicant reports available at 2:00 p.m. ET.

Advance Data Tables available on www.nrmp.org at 1:00 p.m. ET.

Here's an earlier WSJ story by a graduating doctor:
Match Day, the NFL Draft of Medicine
On March 18, thousands of budding doctors find out where they’ll be serving their residencies.
"As you can imagine, it is a day of high anxiety, celebration and disappointment. My classmates and I have spent the past year choosing specialties, filling out applications and interviewing with residency programs. This process has taken us to cities, hospitals and universities around the country. After years of study, we’re about to become physicians. Both our professional and personal lives hinge on the results of this algorithm.

The Match was introduced in 1952 to address many of the uncertainties of residency applications. Before, medical students had to seek residency spots by themselves. But this decentralized system was rife with coercion, favoritism and deceit. Residency programs would demand medical students accept offers before applicants could consider other options. Students and programs betrayed one another by reneging on commitments.

The Match provides structure to the process. Students apply for residency positions through a common application. Strict policies govern communication between programs and applicants, with public reporting of violations. Applicants and programs submit ranking preferences into a centralized system. The Match algorithm couples these rankings and establishes binding contracts for residency positions.

Last year saw record numbers, when nearly 35,000 applicants submitted ranking preferences for roughly 30,000 residency slots. Medical schools host ceremonies to celebrate the event. Researchers Alvin Roth and Lloyd Shapley even won the 2012 Nobel Prize in Economics for their work related to the Match."
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Here's the NRMP page on why it takes 23 days from the time preferences are submitted to announce the match results

What Happens Between Rank Order List Deadline And Match Day?

Between the Rank Order List Certification Deadline and Match Day, the NRMP conducts a rigorous review of Match data, including:

• Assessing and confirming the integrity of the data
• Conducting a final verification of applicants’ credentials
• Withdrawing applicants who are ineligible for the Match
• Transferring the data from the R3 system to the matching algorithm module, rechecking the data, processing the algorithm, and transferring data back into the R3 system
• Verifying the results of a Match and transferring the data into the NRMP databases
• Verifying applicants’ credentials for Main Residency Match SOAP participation
• Preparing 50,000 individual Match Week reports for Main Residency Match applicants, program directors, and medical schools

These steps, all completed in a few weeks, ensure the accuracy of Match results.

Here's a story on the SOAP scramble for unmatched students:https://www.statnews.com/2016/03/17/medical-students-match-day/ 

Today is match day (for medical residents)

Here's the press release: U.S. Medical Students Learn 2014 National Resident Matching Program (NRMP) Main Residency Match Day Results in Ceremonies Today

"In the 2014 NRMP Main Residency Match results released today, more than 16,000 U.S. medical school seniors are among the 25,687 applicants who successfully matched to first-year residency positions. Students receive Match results today at their medical school Match Day ceremonies.

Washington, D.C. (PRWEB) March 20, 2014

Embargoed for release until 1:00 PM EDT, March 21, 2014

The National Resident Matching Program®(NRMP®) 2014 Main Residency Match® results released today show that 16,399 U.S. allopathic medical school seniors have matched to first-year residency positions. U.S. seniors around the country will celebrate these results at Match Day ceremonies being held today. Match Day is an annual rite of passage for U.S. medical school students and other applicants, a day when they learn at which U.S. residency programs they will train for the next three to seven years.

This year, the Match offered 29,761 first- and second-year positions, 500 more than in 2013 and an all-time high. More than half of the additional positions were in the primary care specialties of Internal Medicine and Family Medicine. According to NRMP Executive Director Mona M. Signer, the 2014 numbers continue a steady trend of position growth. In the past five years alone weve seen an increase of more than 4,000 positions, and more than half of those are in Internal Medicine and Family Medicine, Signer said.

Although the total number of registrants increased in 2014, the number of U.S. seniors declined. Eighty-nine fewer seniors registered for the Match and 113 fewer submitted rank order lists of programs. Thats a surprise, said Signer. She added, The good news is that the number of U.S. seniors choosing primary care continued to increase modestly, with 3,167 seniors matching in Internal Medicine and 1,398 in Family Medicine. An additional 1,818 seniors matched in Pediatrics, 19 fewer than last year.

Match Rates for Applicant Groups
This years Match included 40,394 registrants, 59 more than last year; however, 85 fewer applicants submitted rank order lists of programs. With more positions and fewer applicants competing for them, match rates rose for all key applicant groups. The overall match rate to first-year positions was 75 percent, the highest since 2006. The match rate for U.S. seniors was 94.4 percent, 0.7 percentage points higher than last year. Of the applicants who matched, 54 percent of U.S. seniors and almost 50 percent of all other applicants matched to their first choice for training.

Prior-year graduates of U.S. allopathic medical schools, students and graduates of osteopathic (D.O. degree) schools, and students and graduates of international medical schools represent the other key applicant groups who submitted rank order lists of programs:

    1,662 previous graduates of U.S. allopathic medical schools, an increase of 175 over last year; their match rate of 48.0 percent rose 7.2 percentage points
    2,738 osteopathic students/graduates, an increase of 61 over last year; their match rate of 77.7 percent was 2.9 percentage points higher than last year
    5,133 U.S. citizen students/graduates of international medical schools, 38 more than last year; their match rate of 53.0 percent was an increase of 0.2 percentage points
    7,334 non-U.S. citizen students/graduates of international medical schools, 234 fewer than last year; their match rate of 49.5 percent was an increase of 2.5 percentage points
Primary Care Specialty Trends and Position Fill Rates

With the total number of positions reaching an all-time high, increases were noted in the number of primary care programs and positions offered in the Match:

    Internal Medicine programs offered 6,524 positions, 247 more than in 2013; 99.1 percent of positions filled, and 48.5 percent filled with U.S. seniors
    Family Medicine programs offered 3,109 positions, 72 more than in 2013; 95.8 percent of positions filled, and 45 percent filled with U.S. seniors
    Pediatrics programs offered 2,640 positions, 24 more than last year; 99.5 percent of positions filled, and almost 70 percent filled with U.S. seniors
The most competitive specialties were Neurological Surgery, Orthopedic Surgery, Otolaryngology, Plastic Surgery, and Radiation-Oncology, specialties that offered at least 50 positions in the Match and filled at least 90 percent with U.S. seniors.

Applicants who did not match to a residency position participate in the NRMP Supplemental Offer and Acceptance Program (SOAP). During SOAP, the NRMP makes available the locations of unfilled positions so that unmatched applicants can apply for them using the AAMC Electronic Residency Application Service® (ERAS). This year, 1,075 of the 1,181 unfilled positions were offered during SOAP.

Couples in the Match

The NRMP allows any two applicants to participate in the Match as a couple. Participants who enter the Match as a couple agree to have their rank order lists of preferred residency programs linked to each other so they can try to match to a pair of programs that suits their needs. This year, 925 couples participated in the Match and 843 of them matched to their residency program preferences.

Match Day Ceremonies

Match Day ceremonies begin at 12:00 p.m. EDT on Friday, March 21, at U.S medical schools. Contact your local medical school for details and photographs or videos from their Match Day ceremonies.

The NRMP Match
The Match uses a computerized mathematical algorithm to align the preferences of applicants with the preferences of residency program directors in order to fill training positions available at U.S. teaching hospitals. Research on the NRMP algorithm was a basis for awarding The Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel in 2012."

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."

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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.

Domestic and foreign medical residents in the U.S.

 From the Health Affairs blog:

Graduate Medical Education Positions And Physician Supply Continue To Increase: Implications Of The 2021 Residency Match  by Edward S. Salsberg Candice Chen

"With the merger of the Accreditation Commission for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA) accreditation system between 2015 and 2020, the “NRMP Main Match” now covers an estimated 96 percent of the physicians entering GME in the US. This post looks at some of the major takeaways from the 2021 NRMP Match including the implications for the physician workforce.

"Serious concerns have been expressed that there are too few residency training positions in the US and that this is contributing to a gap between the number of medical school graduates and the number of training slots, often referred to as the “GME squeeze,” and that this shortage of residency positions is also contributing to a potential future physician shortage. In 2020, the Association of American Medical Colleges (AAMC) released their annual report projecting primary and non-primary care physician shortages between 55,100 and 141,900 physicians over the next decade.

...

"In this piece, we focus on the 35,194 first-year positions offered in the 2021 Match, and the 26,967 US MD and DO seniors actively participating in the Match for a first-year position.  

...

"Key Takeaways

"The Number Of Entry GME Positions Continues To Grow 

"There were 35,194 first-year positions offered in the 2021 Main Residency Match representing an increase of 2.7 percent from 2020. Comparing the combined number of ACGME- and AOA-accredited first-year positions in 2013 with the 2021 data indicates a 24.5 percent increase in positions over the eight years for an annual increase of 2.8 percent (exhibit 1). The net increase of 6,930 first-year positions over such a short period will be surprising to many given the absence of a major new federal funding initiative or change in GME policy.

...

"There Are No Signs Of A Major GME Squeeze For US MD And DO Seniors

"The number of new first-year GME positions is growing more rapidly than the annual number of graduating US medical school seniors. As noted above, the number of first-year positions grew by 6,930 positions at a 2.8 percent annual rate between 2013 and 2021.

...

"International Medical Graduates Continue To Be A Major Source Of Residents And Physicians For America 

In 2021, there were 13,238 active IMG applicants in the NRMP Match of which 7,508 IMGs were matched to first-year positions (excluding SOAP). Overall, IMGs represented 22.5 percent of all applicants who matched to first-year positions. IMGs include two very different cohorts: US IMGs, US citizens who have gone to medical school outside of the US, mostly at for-profit schools in the Caribbean; and non-US citizens who attended medical school in a foreign country, usually their home country.

...

"The numbers of both types of IMGs matched in the Main Match has been increasing slowly (exhibit 2), with 4,356 non-US IMGs and 3,152 US IMGs matching to first-year positions in 2021 (excluding SOAP). Interestingly, while the number matched went up 22.5 percent for non-US IMGs and 17.1 percent for US IMGs between 2013 and 2021, the number of active applicants was more consistent, rising only 5.0 percent and 3.9 percent over the same time period for each group."

Repugnant transactions in Saudi Arabia

I call a transaction 'repugnant' if some people want to engage in it, but others don't want them to. In Saudi Arabia these often involve religious views.
The NY Times report that the Turkish soap opera Noor is very popular among Saudi women, but not among clerics: Arab TV Tests Societies’ Limits With Depictions of Sex and Equality .
"That divided response was apparent this month when Sheik Luhaidan, the Saudi cleric, made his comment about killing the owners of satellite TV stations that broadcast indecent material.
His comments were quickly rebroadcast, and an uproar ensued. Critics across the ideological spectrum, including some hard-line Saudis, berated him as having crossed the line. Some of the television networks Sheik Luhaidan appeared to be referring to are owned, after all, by members of the Saudi royal family.
Sheik Luhaidan, who is chief justice of Saudi Arabia’s highest legal authority, the Supreme Judicial Council, is said to have been surprised by all the controversy.
A few days later, apparently under pressure from senior figures in the Saudi government, he appeared on state television to explain. He said he had not meant to encourage or condone the murder of station owners. Assuming other penalties do not deter them, he said, the owners should first be brought to trial and sentenced to death — and then they could be executed."

For some other, related examples, see
Saudi Arabia bans sale of dogs, cats in capital, and
Saudi Arabia bans all things red ahead of Valentine's Day.

However, as elsewhere, what transactions are repugnant can change over time, in both directions, and things formerly repugnant can become less so:
Saudi Women Can Now Stay in Hotels Alone

OB-GYN doctors will use a new application system to apply to residency programs (but will continue to go through the NRMP resident match)

 Before new doctors can participate in the resident match (by engaging with the NRMP), they first have to apply to residency programs, and arrange interviews.  This process has been experiencing congestion, and the specialty of Obstetrics and Gynecology has now decided to switch application services. 

However, participation in the NRMP will not change: the Association of Professors of Gynecology and Obstetrics (APGO) FAQ states "Obstetrics and gynecology applicants will use the National Residency Match Program (NRMP) for the Match. This new application does not change how the applicant or programs interact with the NRMP Match system."

Medpage Today has the story:

Ob/Gyn Switching to Independent System for Residency Applications— This is the last year ob/gyn will use ERAS, despite helping to pilot the program  by Rachael Robertson, Enterprise & Investigative Writer, MedPage Today August 25, 2023

"Beginning next year, ob/gyn programs will start using an independent system for processing residency applications, rather than the Electronic Residency Application Service (ERAS).

"The joint decision to switch to the new system was made by the American College of Obstetricians and Gynecologists (ACOG), the Association of Professors of Gynecology and Obstetrics (APGO), and the Council on Resident Education in Obstetrics and Gynecology (CREOG). The new system will be managed by Liaison International, which uses "Centralized Application Service (CAS) technology," according to the company's website.

...

"A joint statement on the APGO website opens in a new tab or window

said that the new system "will be user friendly and efficient, less expensive for applicants, and will directly decrease the burdens faced by program directors, program managers, and applicants alike," and "will incorporate the entirety of interview season functions, from application submission, review, interview offers and interviews, to rank list submission."

ACOG explained that the decision to pull the ERAS stemmed from the Right Resident, Right Program, Ready Day One initiativeopens in a new tab or window, noting that the new system is mobile-friendly and "will include immediate fee reduction," as detailed on their FAQ pageopens in a new tab or window.

In response, the Association of American Medical Colleges (AAMC), which runs ERAS, issued a statementopens in a new tab or window attributed to President and CEO David J. Skorton, MD, and Alison J. Whelan, MD, the chief academic officer, saying they were "surprised and dismayed" by the decision. 

...

"Bryan Carmody, MD, of Eastern Virginia Medical School in Norfolk, shared information  opens in a new tab or window

about the change on social media, writing on his blogopens in a new tab or window that ob/gyn program directors helped to pilot ERAS when it was first rolled out in the mid-90s.

Carmody told MedPage Today that he anticipates the biggest downsides will fall on applicants, such as those who want to apply to another specialty in addition to ob/gyn.

"Those applicants will have to use one system to apply to ob/gyn and another to their other specialty," he explained. "The same thing applies to applicants who fail to match. They'll have to use ERAS to apply to another specialty during SOAP [Supplemental Offer and Acceptance Program] since few, if any, ob/gyn positions are typically available."

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

OB-GYN will continue to employ signaling  (very loosely modeled on the signaling used in the Econ PhD job market, but asking applicants to submit 3 "gold" signals and 15 "silver" signals): 

Program Signaling for OBGYN Residency Application Background and FAQs

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

Earlier:

Friday, April 21, 2023

Transition from medical school to residency: defending the parts that work well (namely the NRMP Resident Match)

More on plasma, payments, and convalescent plasma

Peter Jaworski gives some more reasons that countries should legalize compensation to plasma donors, rather than buying their plasma products from the U.S.

In Reason:
Americans Get Paid To Donate Plasma. Everyone Else Should Too
Our secret weapon against COVID-19 could be cold, hard cash.  7.2.2020

"American dominance in the plasma market is explained by one simple fact: In America, it is legal and commonplace to pay people to give plasma. Millions of Americans regularly give plasma in exchange for $30 to $50 per donation. The average American donor gives 21.4 times per year, with a per capita collection volume of 113 liters of plasma per 1,000 people. If you add plasma obtained from Germany, Austria, Hungary, and Czechia—the other places where a form of compensation (typically capped at 25 euros, intended only to cover expenses) is offered—paid plasma accounts for a staggering 89 percent of all the plasma used to make plasma therapies for the whole world. Just five countries account for nine-tenths of the world's plasma.
...
"Donor recruitment and retention, staffing, plus marketing costs, combine to make the collection of unpaid plasma two to four times more expensive than just giving money to the donors.
...
"[bans on payment were partly] motivated by the concern that payment attracted people from lower socioeconomic rungs of the economic ladder who are more likely to be carriers of HIV, hepatitis C, and other transfusion-transmissible infections.

"But those concerns no longer apply, partly due to significant improvements in testing technology since the 1970s when the WHO first recommended not paying blood and plasma donors. This improvement in testing happens to form the backbone of arguments among advocates of eliminating restrictions on blood and plasma donation by gay men, which currently require three months of celibacy per the Food and Drug Administration's revised guidance issued this April. But improvements in testing alone are not the reason why plasma for plasma therapies should be considered categorically different from blood and plasma used for transfusions; it is manufacturers' ability to use virus removal and inactivation techniques that marks the stark difference.

"In the 1980s, we discovered that heat treatment was effective against HIV. Much like how washing your hands with soap destroys the coronavirus, use of solvents and detergents are effective against lipid-enveloped viruses, including hepatitis C and HIV. Nanofiltration ensures that only molecules of a certain size—the proteins we want—get through, preventing larger molecules from passing into the plasma pool. Most American paid plasma collection centers are also International Quality Plasma Program (IQPP) certified. This voluntary standard, issued by the Plasma Protein Therapeutics Association, involves additional safety steps including the requirement that any donor's first donation be placed on hold, only to be released with the second donation from the same donor. This holding step gives us an opportunity to test the same plasma twice, avoiding the rare possibility of a virus being within the window period where it cannot be detected. This hold means that if you give plasma once and don't go back, your plasma will be discarded."
**********

With convalescent plasma donation,  the safety check involved in sequestering the first donation until the second one is also tested for infection is not the only set of tests.  For each donation there is also a measurement of how much Covid-19 antibody (IgG) is present, and if it is enough to be therapeutic. So, for example, after each donation I have to wait for those results to find out if I'll be invited to donate again. (So far, at each visit I give a bit over 800ml of plasma, and that donation is divided into four units of 200ml. My understanding is that my units have so far all been administered to hospitalized Covid-19 patients in Fresno and San Jose.)

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.

Match Day today for new doctors

Good luck to all those matching today!

Here's the Wall Street Journal's anticipatory story: New Doctors Eagerly Await 'Match Day'

"The National Resident Matching Program, the nonprofit group that pairs applicants with openings, expects this year's match to be the largest ever, surpassing last year when 31,355 U.S. and foreign applicants vied for 24,035 first-year residency openings."

Here's the NRMP's press release:

The National Resident Matching Program® (NRMP®) will announce the 2013 medical residency Match results for more than 17,000 United States allopathic medical school seniors and more than 16,000 other applicants on Friday, March 15, 2013 at 1:00 p.m. EDT. Match Day, an annual rite of passage, is when medical school students learn where they will live and train for the next three to seven years at their medical residency programs.

“It’s a wonderful and exciting day,” said Mona M. Signer, executive director of the NRMP. She added, “We are honored to play a small role each year in moving forward the careers of young physicians.”

U. S. senior medical students typically begin the residency application process at the beginning of their final year in medical school. After they apply to programs, programs review applications and invite selected candidates for interviews, which are held in the fall and early winter. Once the interview period is over, both parties create rank-order lists. Programs rank applicants in order of preference, and applicants compile their lists based on their preferred medical specialty and the location of the training programs.

The NRMP matching algorithm pairs the preferences of applicants with the preferences of residency programs, producing a “best result” in order to fill the available training positions at U.S. teaching hospitals. Research about the NRMP algorithm was a basis of Dr. Alvin Roth’s receipt of the 2012 Nobel Prize in Economics.

Students and graduates of international medical schools, osteopathic (D.O. degree) schools, and Canadian candidates also participate in the Match. Last year more than 38, 377 applicants vied for positions, and the NRMP reported a 95% successful NRMP Match result for U. S. seniors.

For more information on this year’s Match results, please visit http://www.nrmp.org after 1:00 p.m. EDT on Friday, March 15, or contact your local medical school for details on their Match Day ceremonies.

Here's the schedule:

March 15, 2013	Match Day! Match results for applicants are posted to Web site at 1:00 p.m. eastern time. Supplemental Offer and Acceptance Program (SOAP) concludes at 5:00 p.m. eastern time.
March 16, 2013	Hospitals begin sending letters of appointment to matched applicants after this date.

NRMP Position Statement On The (In)Feasibility Of An Early Match

 There has been some suggestion that dividing the resident match into early and late matches might be a way to address the congestion in applications and interviews that has bedeviled the transition from medical school to residency in recent years.  The NRMP now has a statement pointing out that there are serious problems with that idea.

NRMP Position Statement On The Feasibility Of An Early Match

"For the past eighteen months the National Resident Matching Program® (NRMP®) has been working closely with other national medical education organizations to examine the current state of the transition to residency. Conversations have focused on mitigating burdens for both applicants and programs in the selection and recruitment process and addressing uncertainty in the future of the interview cycle.

...

"Among the proposed solutions to current challenges in the transition to residency are calls for an early match. Specifically, NRMP has been asked to implement the Early Result and Acceptance Program (ERAP) pilot program proposed for Obstetrics and Gynecology, created through American Medical Association’s Reimagining Residency Grant, “Transforming the UME to GME Transition: Right Resident, Right Program, Ready Day One”. The stated goals of the ERAP pilot are to allow applicants to engage in strategic decision-making, reduce burden on programs while hypothesizing that the change will result in holistic review, and reduce necessary applications and interviews. ERAP calls for an early match to begin in September 2022 for the 2023 Match cycle. ERAP permits applicants to apply to a maximum of three programs in the early match with programs including up to 50% of their positions if they choose to participate. This statement outlines NRMP’s concerns about the structure of the ERAP pilot program, the lack of evidence supporting the proposed changes to the Match, the implications of an early match for the matching process, and preliminary findings of modeling an early match being conducted by experts in market design and the matching algorithm.

"The NRMP has reviewed the ERAP pilot program with consideration for whether changes to the matching process have the potential to inadvertently disadvantage Match participants. It is through that lens NRMP remains concerned with the following aspects of the ERAP pilot:

"Although voluntary, applicants may feel pressured to participate in an early match where up to half the available positions in a specialty may fill before the Main Residency Match® opens.

"There exists no mechanism for demonstrating how an early match will make visible less competitive applicants and those underrepresented in medicine, which is hypothesized in the project document.

"The proposed limit of three applications per applicant could force applicants to make compromises not present in the Match today. ...While the ERAP investigation team hypothesized that the application limit will increase holistic review by programs, there are no mandates to ensure that programs conduct holistic review nor are there restrictions on the number of applications programs may accept, interviews they may offer, or applicants they may rank. With no objective evidence to support the hypothesis, we cannot conclude that the proposed application limit would increase holistic review of applications.

"There exists no mechanism for safeguarding an applicant’s failure to match in the early match from programs as they enter the Main Residency Match, which could result in the applicant being viewed as less competitive.

"In addition to concerns about disadvantaging applicants, NRMP is mindful of possible behavior changes resulting from changes to the Match process that could affect Match outcomes for all Match participants.

• "The structure of an early match does not allow for mixed-specialty couples ranking or multispecialty individual ranking, which may cause applicants to reconsider their specialty choices, fundamentally changing their career path.
• "Programs may have insufficient information (e.g., clinical evaluations, MSPE, LORs) to evaluate applicants fully and fairly in the early match.
• Programs may see a surge in non-traditional applicants as the early match provides three opportunities to enter training through either the early match, the Main Residency Match, or SOAP®. This may result in an increased number of applications or applicants who may otherwise not select the specialty.
• Not matching in the early match is likely to increase the number of applications per individual in the Main Residency Match, as applicants enter a matching cycle with only half of the positions remaining available. This may increase stress, cost, and could adversely affect the wellness of applicants.

...

"it is important to first outline the core concepts of the match as a stable “market”. The Match was established in 1952, to solve a “congestion” problem in medical residencies involving applications, offers, and acceptances. In a May 2021 pre-submission working paper, Itai Ashlagi, Ph.D. and Alvin Roth, Ph.D. describe the consequences of congestion as “unraveling” where programs initially responded to congestion by making “exploding offers” that prevented applicants from considering many programs because they were pressed to accept an early offer, before knowing whether an offer from a more preferred program might be forthcoming if they waited. The authors note that NRMP’s matching process, in its current form, has four distinct properties that are relevant to managing the problems of congestion and unraveling and maintaining a stable matching market. Specifically, the NRMP matching process

"1. Is Uncongested: participants make all decisions (on Rank Order Lists) in advance, so there is no delay in processing offers, rejections, and acceptances, which is done by the computerized Roth-Peranson algorithm.

"2. Defers acceptances: preferences of applicants and programs are not finalized until all preferences have been considered, thereby producing stable matching: i.e., matching in which there are no “blocking pairs” of applicants and programs not matched to one another but who both would prefer to be.

"3. Promotes true preferences: it is safe for participants to state their true preferences when they submit their Rank Order Lists (ROLs).

"4. Establishes a “thick” market: most residency programs in most specialties participate in the NRMP Match, which also allows for multi-specialty applications and couple matching (including for mixed-specialty couples).

"The authors opine that an early match such as the proposed ERAP pilot followed by the Main Residency Match would not share three of the four important properties of the Match:

"1. An early match would dilute the thick market: not all positions would be available at the same time (and further, it would not allow applicants to express multi-specialty preferences, nor would it accommodate mixed-specialty couples).

"2. early match would introduce complicated strategic decisions into the formulation of ROLs: it would no longer be safe for participants to submit ROLs straightforwardly corresponding to their preferences.

"3. An early match would not produce a stable matching: there would be mutually disappointed blocking pairs of mismatched applicants and programs. This would also make it less safe to report ROLs that straightforwardly corresponded to preferences."

Transition from medical school to residency: defending the parts that work well (namely the NRMP Resident Match)

This post is about a recently published paper concerning the design of the market for new doctors in the U.S.  But it will require some background for most readers of this blog.   The short summary is that the market is experiencing problems related to congestion, and one of the proposals to address these problems was deeply flawed, and would have reduced market thickness and caused substantial direct harm to participants if implemented, and created instabilities that would likely have caused indirect harms to the match process in subsequent years. But this needed to be explained in the medical community, since that proposal was being  very actively advocated.

For those of you already steeped in the background, you can go straight to the paper, here.

Itai Ashlagi, Ephy Love, Jason I. Reminick, Alvin E. Roth; Early vs Single Match in the Transition to Residency: Analysis Using NRMP Data From 2014 to 2021. J Grad Med Educ 1 April 2023; 15 (2): 219–227. doi: https://doi.org/10.4300/JGME-D-22-00177.1

If the title doesn't remind you of the vigorous advocacy for an early match for select positions, here is some of the relevant back story.

The market for new doctors--i.e. the transition from medical school to residency--is experiencing growing pains as the number of applications and interviews has grown, which imposes costs on both applicants and residency programs.  

Below is a schematic of that process, which begins with applicants submitting applications electronically, which makes it easy to submit many.  This is followed by residency programs inviting some of their applicants to interview. The movement to Zoom interviews has made it easier to have many interviews also (although interviews were multiplying even before they moved to Zoom).  

After interviews, programs and applicants participate in the famous centralized clearinghouse called The Match, run by the NRMP. Programs and applicants each submit rank order lists (ROLs) ranking those with whom they interviewed, and a deferred acceptance algorithm (the Roth-Peranson algorithm) produces a stable matching, which is publicly announced on Match Day. (Unmatched people and positions are invited into a now computer-mediated scramble, called SOAP, and these matches too are announced on Match  Day.)

The Match had its origins as a way to control the "unraveling" of the market into inefficient bilateral contracts, in which employment contracts were made long before employment would commence, via exploding offers that left most applicants with very little ability to compare options.  This kind of market failure afflicted not only the market for new physicians (residents), but also the market for later specialization (as fellows). Consequently, over the years, many specialties have turned to matching for their fellowship positions as well.

  The boxes in brown in the schematic are those that constitute "The Match:" the formulation and submission of the ROLs, and the processing of these into a stable matching of programs to residents.  Congestion is bedeviling the parts in blue.

The boxes colored brown are 'The Match' in which participants formulate and submit rank order lists (ROLs), after which a deferred acceptance algorithm produces a stable matching of applicants to programs, which is accepted by programs and applicants on Match Day. The boxes in blue, the applications and interviews that precede the Match, are presently suffering from some congestion.  Some specialties have been experimenting with signals (loosely modeled on those in the market for new Economics PhDs, but implemented differently by different medical specialties).

The proposal in question was to divide the match into two matches, run sequentially, with the first match only allowing half of the available positions to be filled.  The particular proposal was to do this first for the OB-GYN specialty, thus separating that from the other specialties in an early match, with only half of the OB-GYN positions available early.

This proposal came out of a study funded by the American Medical Association, and it was claimed, without any evidence being offered, that it would solve the current problems facing the transition to residency.  Our paper was written to provide some evidence of the likely effects, by simulating the proposed process using the preferences (ROLs) submitted in previous years.  

The results show that the proposal would largely harm OB-GYN applicants by giving them less preferred positions than they could get in a traditional single match, and that it would create instabilities that would encourage strategic behavior that would likely undermine the successful operation of the match in subsequent years.

Itai Ashlagi, Ephy Love, Jason I. Reminick, Alvin E. Roth; Early vs Single Match in the Transition to Residency: Analysis Using NRMP Data From 2014 to 2021. J Grad Med Educ 1 April 2023; 15 (2): 219–227. doi: https://doi.org/10.4300/JGME-D-22-00177.1

Abstract:

"Background--An Early Result Acceptance Program (ERAP) has been proposed for obstetrics and gynecology (OB/GYN) to address challenges in the transition to residency. However, there are no available data-driven analyses on the effects of ERAP on the residency transition.

"Objective--We used National Resident Matching Program (NRMP) data to simulate the outcomes of ERAP and compare those to what occurred in the Match historically.

"Methods--We simulated ERAP outcomes in OB/GYN, using the de-identified applicant and program rank order lists from 2014 to 2021, and compared them to the actual NRMP Match outcomes. We report outcomes and sensitivity analyses and consider likely behavioral adaptations.

"Results--Fourteen percent of applicants receive a less preferred match under ERAP, while only 8% of applicants receive a more preferred match. Less preferred matches disproportionately affect DOs and international medical graduates (IMGs) compared to US MD seniors. Forty-one percent of programs fill with more preferred sets of applicants, while 24% fill with less preferred sets of applicants. Twelve percent of applicants and 52% of programs are in mutually dissatisfied applicant-program pairs (a pair in which both prefer each other to the match each received). Seventy percent of applicants who receive less preferred matches are part of a mutually dissatisfied pair. In 75% of programs with more preferred outcomes, at least one assigned applicant is part of a mutually dissatisfied pair.

"Conclusions--In this simulation, ERAP fills most OB/GYN positions, but many applicants and programs receive less preferred matches, and disparities increase for DOs and IMGs. ERAP creates mutually dissatisfied applicant-program pairs and problems for mixed-specialty couples, which provides incentives for gamesmanship."

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

I'm hopeful this paper will effectively contribute to the ongoing discussion of how, and how not, to modify the design of the whole process of transition to residency with an aim to fixing the parts that need fixing, without damaging the parts that work well, i.e. while doing no harm. 

(Signaling will likely continue to play a role in this.)