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Rule Breakers

IN THE MATCH, APPLICANTS AND PROGRAMS DON'T ALWAYS PLAY FAIR.

The New Physician September 2001
You’ve heard stories about him. You know, the Match cheater. He’s that student at the other school who made comments following his residency program interview. And those well-chosen words led to a side deal cementing him the prized residency program spot and saving him from the effort and anguish of the Match.


Of course, it’s always some other student—some mysterious unknown figure who broke the rules of the National Resident Matching Program (NRMP), the institution governing the Match. These stories have the ring of urban legend to them; they’re anecdotes future residents hear, immediately condemn and then secretly wonder if they could get away with it themselves. Well, for one fourth-year medical student, the temptation to make a special arrangement was just too great. And in the end, his actions almost cost him any chance of getting into the program he so desperately wanted.


You see, John Davis* felt he was in a precarious position. He was approaching his fourth year at a Midwest medical school and wanted to get into a highly competitive specialty program. To complicate matters, his pregnant wife was already a resident in the same program—a position she obtained through the military match. Davis felt there was no other place he could really go; he had to be in this program.


“I didn’t know what to do,” he says. “My adviser told me to just to go ahead and approach the program director to explain my situation, telling them that I needed to get into this program.”


Davis figured that because he was qualified and married to one of its residents, the program could give him some assurance that it would reserve a spot the following year, even though granting this request would be a violation of NRMP communication rules. Besides, if he were to get into trouble, he could use the tried-and-true naïve approach and just act as if he didn’t know any better.


So he approached the program’s director as planned. But Davis was not greeted with open arms. Instead, he received a lecture informing him that he would not be assured of a spot the following year. Furthermore, the director said Davis’ request might have cost him a spot.


Soon afterward, word spread among the program’s residents and the students who were attending the affiliated university—many of whom wanted to enter the residency program as well—that someone was trying to cheat, which would put their beloved program at risk of being admonished by the NRMP and the affiliated university. As Davis was already scheduled to do a rotation in the program and was visiting there regularly to see his wife, he frequently came in contact with people who greeted him with disdain.


“Word got out that I was an outsider trying to get in through the back door,” he says. “They sympathized with me, but they felt I might jeopardize their program. It was very awkward.” As if he were branded with a scarlet letter, Davis could feel—or at least imagine—the accusatory sideway glances from people he hoped would someday become his colleagues. It appeared his efforts had ruined that dream.


AN ATTEMPT TO END ABUSE


Of course, NRMP officials would like to think that this is what happens with most—if not all—of the future residents who attempt to cheat the system. However, with approximately 31,000 applicants maneuvering themselves to get into 23,000 first-year residency positions each year, it’s inevitable that someone will bend, if not outright break, the rules. And many of them will get away with it.


Ironically, the first Match was implemented in 1952 in order to end widespread abuse by both residency programs and students. Before the Match was founded, there was an abundance of residency positions and a lack of qualified applicants. As a result, programs tried to recruit students as early as their second year of medical school. Conversely, students regularly entered into agreements with programs and then reneged on the deals to accept better offers.


The NRMP, then known as the National Student Internship Program, tried to end this unethical behavior by enforcing a two-sided ranking system with a variety of rules seeking to ensure confidentiality, as well as ethical and professional conduct.


Under ideal circumstances, this is how the program should work: After exchanging information with residency programs and undergoing interviews, students submit a ranking of their top choices to the NRMP, while residency program directors submit a list of their top applicants. The NRMP configures the matches and announces them on a universally accepted day—currently the third Thursday in March, known as Match Day. Neither party makes any side deals or negotiates, but simply lists their favorites and lets the NRMP algorithm resolve any conflicts.


The system may sound nice, but many future residents have come to view it as a hindrance rather than as a benefit. Many believe the Match blocks their rights to openly compete for a program position and limits their abilities to negotiate contracts that would increase wages and provide better working conditions.


This displeasure with the Match is evident in a class-action antitrust lawsuit filed in May by three residents against the NRMP. The suit alleges that the NRMP, its sponsoring organizations and member hospitals have colluded to restrain competition in the Match process. While the lawsuit does not directly address the communication policy, the end result could be that what is currently construed as cheating would become the standard practice for students applying to residency programs. Dr. Paul Jung, the lead plaintiff who filed the lawsuit while he was a Robert Wood Johnson Clinical Scholar at Johns Hopkins University, says he is seeking a system that would permit applicants to consider multiple offers, negotiate with those programs, and then select the one that best fits their interests and needs.


“Let’s step back for a moment and look at what the matching program really does and what may happen if the Match is removed,” Jung previously told The New Physician; he is no longer accepting media calls regarding the lawsuit. “Students currently apply to multiple residency programs, have letters of recommendation forwarded to these programs, interview at several programs, and then decide how to rank programs on their preference list. All of those steps are consistent with a free market and would be the same if the matching program were dissolved.… But then instead of receiving multiple offers from residency programs and being able to choose one…we are assigned a position and are obligated to take it. What chaos would result if we received multiple offers…?”


UNDERSTANDING THE RULES


Many Match participants say the process is already chaotic, especially with the frequent misunderstandings or misinterpretations of the NRMP communication policy. According to the NRMP Web site, the policy on “Persuasion and Commitments” states: “The sole purpose of the Matching Program is to allow both applicants and programs to make selections on a uniform schedule and without pressure. Both applicants and programs may try to influence decisions in their favor, but any verbal or written contracts prior to the submission of Rank Order Lists is a violation of the Match. The final preferences of program directors and applicants, as reflected on the submitted Rank Order Lists, will determine the offering of positions and the placements of applicants.”


So what does that mean exactly? Well, mostly, it means students and programs can offer any information they want in order to persuade the other party to rank them highly in the Match. But neither party can ask for or offer a guarantee that they will be matched. “They are allowed to express the interest, but they are not allowed to ask the other party about their [interest],” NRMP director Liz Lostumbo says.


Despite these vague policies, however, Lostumbo says she believes that less than 1 percent of applicants and programs engage in unethical communication. However, others, like the University of Pittsburgh Medical Center’s pathology residency program director Dr. Jeffrey Kant, believe that rule breaking occurs more often than most people would like to think. And Kant, who has written several journal articles about the Match, warns that the problem is even greater among residency programs than among applicants.


“I think students are very good compared to program directors,” he says. Many program directors violate the NRMP communication policy because they feel the need to break the rules in order to compete for the top applicants, he says. Kant adds that program directors, unlike students, subtly violate the rules without ever announcing their intentions. “Students can propose it by saying, ‘Can you take someone out of the Match?’ Meanwhile, program directors propose it more subtly, by saying things like, ‘We really like you, and we want you in the program. Can you tell us in a week or a week and a half?’ Plus they’ll add something like, ‘Oh by the way, since you are not taking this offer, we assume you are not interested.’ Without directly soliciting, they’ve put a deadline on the student to pressure them.”


With these comments, Kant says, a program can place enormous stress on a student. “It’s very difficult [for an applicant] to turn down a program. The people who are good, but not absolutely outstanding, are put in the worst spot if they want to go to the best training possible,” he says.


With all of these attempts to influence the Match process, many students develop a high level of mistrust for the programs. This can often lead applicants to overstate their interest in programs, says Kimberly Anderson, Ph.D., a professor of surgery at the University of Texas Health Science Center at Houston. “The biggest issue is that there is a power differential between programs and students,” she says. “Students have accrued incredible debt loans and feel torn between ‘playing the game’ or laying out all of their cards and risking the chance of not matching into their field of choice.”


In “Is Match Ethics an Oxymoron?” an article published in the March 1999 issue of the American Journal of Surgery, Anderson and her co-authors detail just how frequently Match participants play this game. A survey of more than 300 post-Match seniors from the University of Kentucky, University of Minnesota and Michigan State University medical schools found that 57 percent of the students were asked by programs to “keep in touch” after their interviews. And 39 percent had follow-up communication with programs. More than 40 percent of those students said they stayed in contact with programs to remind them of their interest, regardless of their actual level of interest.


Meanwhile, 13 percent of the students said programs contacted them after their interviews to tell them they were a No. 1 rank order choice. And 58 percent of these applicants said they were skeptical of what the programs told them. One surveyed student told the authors, “I was flattered by the information but did not count on it. It was sort of a ‘feel good’ which lasted a moment…I didn’t assume anything.” Apparently this student wasn’t alone. Only 35 percent of students said their rank order decision was positively influenced by a program’s comment of a high ranking.


Perhaps this skepticism is promoted by the frequency of presumed verbal commitments; 43 percent of the surveyed students felt they received an informal commitment from a residency program. However, the NRMP warns that some students may be misconstruing comments to be commitments. On its Web site, the NRMP advises participants that: “Program directors and applicants frequently engage in the practice of sending letters following the applicant’s interview with the program. These letters often contain statements that can be misinterpreted by either party. Match participants must understand that such letters are not binding and have no standing when final rank order lists are submitted.”


Lostumbo says some students may feel cheated because of this misperception. “What people think is said or is not said is often just the result of a misunderstanding,” she says.


MATCH OUTDATED?


Anderson and her co-authors blame the widespread violations on the Match not keeping pace with a changing medical education environment. When the Match was founded, only 6,000 U.S. medical school seniors had to be matched into the 10,500 intern positions. With so many positions available, students had no reason to feel pressured to enter a top program early because a position would likely be available at another high-ranking program. With only 0.74 positions available for each applicant now, students are placed in a highly competitive environment and are easily distressed by the possibility they might be completely left out in the cold, the authors say.


In the meantime, budget-conscious hospitals are relying more and more on residency programs to provide work staff. Hiring competent residents has become a crucial part of their business; hence, recruiting has become highly competitive among programs.


And of course, all of these issues are further compounded by a lack of enforcement of NRMP communication rules—something Lostumbo says the NRMP is hoping to improve on by instituting more severe penalties for violations. Beginning next year, applicants who break the rules face a three-year ban from participating in the Match. In addition, the NRMP will report the incident to the student’s school and ask that the violation be included in the applicant’s permanent record. For programs, the penalties are equally stiff. The NRMP intends to report violating residency programs to the Accreditation Council for Graduate Medical Education and to the American Board of Medical Specialties. The NRMP will also “flag” a program to alert interested students of its past unethical conduct. Lostumbo says the mechanism for notifying students is still being developed.


Before this policy, the NRMP had no means to truly discipline violators of its communication policy. For programs breaking the rules, it could only inform the affiliated hospital or university administration, while students would be punished only at the discretion of their school’s dean.


“While the problem is not big, we are working to make sure everybody is playing under the same rules so that it is fair to everyone participating,” Lostumbo says.


Unfortunately, the more severe penalties may be rendered ineffective without greater reporting of violations. Lostumbo says applicants seldom report programs for trying to influence their rankings because they are wary of future repercussions. “It’s extremely rare that it is reported…. It is my impression that it is more frequent among programs, but we don’t know, ” she says.


So what does all this mean? Well, as Anderson and her colleagues discovered, to many students, it means don’t believe anything you hear and say whatever you need to in order to obtain a high ranking, even if you have only minimal interest in the program. And according to the 1999 article, this approach can do more harm than just rule breaking. “Such actions by both parties ultimately work against the Match process and may ultimately work to the detriment of both students and residency programs,” Anderson and her co-authors write.


SWEATING IT OUT


That was almost the case for Davis. So worried about the appearance of impropriety, the program director told the fourth-year medical student his query might cost him any opportunity to enter the program. Fortunately for Davis, though, his college adviser stepped in on his behalf. After some explanation and asserting Davis’ ignorance of the rules, the adviser had convinced the program director to soften his stance and to consider accepting him into the program through the Match. Davis’ chances were further buoyed when the program director stepped down from the post, and the replacement was unfamiliar and seemingly unconcerned with Davis’ breach of NRMP rules.


So on Match Day, Davis sweated it out, wondering if he would end up in the only program he had any desire to join and thinking about what he would do if he were forced to accept a residency away from his wife and newborn child.


When word finally came, however, all of those questions became inconsequential. Davis had been accepted. “It was elation,” he says. “I was happier than the day I had gotten into medical school…. I guess I was lucky there was a change of directors and some time had passed. In retrospect, I guess it wasn’t too wise to go in there as an outsider and announce my plan—that I intended to have one of these spots.”


Besides the relief of being located with his family, Davis says he has also been warmly received into the program, which is a stark contrast to how he felt during earlier visits. “It’s been a lot different tone,” he says. “Before they were saying ‘maybe’ or ‘we’ll see.’ Now, they are telling me that I was a top choice all along, and they were afraid I wasn’t going to match them. I guess they were just really, really following the rules.”


Ironically, Davis now finds it comforting that his residency program abided by the rules and behaved in such a straightforward manner. “In some ways, I have more respect for my program because I know they do everything upfront,” he says. “It makes me confident that there is nothing secretive going on.”


How many students and programs live up to that standard remains an unanswered question.
Scott T. Shepherd is an associate editor with The New Physician.