Is the Match System Worth Keeping?

In this video, Jeremy Faust, MD, editor-in-chief of MedPage Today, sits down with Bryan Carmody, MD, of Children's Hospital of the King's Daughters in Norfolk, Virginia, to discuss the 2023 Match Day data. Carmody breaks down the distribution of open Supplemental Offer and Acceptance Program (SOAP) positions this year, explains how residents can be trapped in their programs, and proposes potential reforms for the medical training system.

The following is a transcript of their remarks:

Faust: Hello, it's Jeremy Faust with MedPage Today. Today, we're going to be joined by Dr. Bryan Carmody.

Dr. Carmody is a pediatric nephrologist and an associate professor at the East Virginia Medical School, and he's also a complete expert on all things data related to the National Residency Matching Program that takes graduating medical students and helps them match into the residency programs where they will complete their training.

Dr. Bryan Carmody, thank you so much for joining us here on MedPage Today.

Carmody: It's a pleasure to be here.

Faust: So overall, how did the Match go this year? You're an expert on this. You've been watching this for years. How did the Match go for this year's class of incoming residents?

Carmody: Well, I guess that depends where you stand. The overall match rate, if you take all comers, was actually the highest that it's been in the modern era: 81% of all applicants who submitted a rank order list ended up matching to a position for PGY1 [postgraduate year 1]. So from that standpoint, it was the most successful Match we've seen for a while. But individual applicants may see it as a win or a loss depending on their own circumstances.

Faust: Now, as a person in emergency medicine, there are a lot of red flags about the open spots that were available on Monday. I'm not sure how many were filled by Friday; I hear a lot of them were. But can you tell us what are some other fields that had some difficulties this year?

I'm particularly interested in whether ob/gyn had a different feel or landscape, this being the first match in the post-Roe and Dobbs era.

Carmody: Those are good questions.

In terms of other trouble spots, you're right, the big story has been the number of unfilled emergency medicine positions, which historically is very unusual. I mean, we had more unfilled positions after the Match this year than there have been in the past 15 years combined.

The number of unfilled positions in pediatrics was up a little bit, and so one prediction I have for next year's Match is that we'll see the number of categorical pediatric positions that are unfilled [increase] -- we'll have over 200 next year. Because the same trend that's been occurring in emergency medicine where the number of applicants is in decline as programs continue to expand is happening in pediatrics too. Unless programs alter their recruitment strategies, I think some programs are going to go home unhappy next year.

The surgical specialties remained very competitive. Every single position filled in orthopedic surgery and thoracic surgery and plastic surgery. I think the surprising competitive field this year was radiology, which is often a competitive field, but this year every single radiology position got filled in the Match, which is really remarkable. So I think that some of the applicants who in previous years might have steered themselves toward emergency medicine instead found that and targeted radiology as their specialty of choice.

For primary care statistics, there's a continuing lack of popularity in primary care for many U.S. MD and DO students. If you look at family medicine, about 12% of positions were available in the SOAP. And the U.S. MD and DO seniors only filled about 60% or less of the available positions. There's not even close to enough interest from graduating U.S. medical students to fill those positions in that specialty.

Faust: Tell us what happens with SOAP. SOAP is actually a relatively newer intervention, it's several years now. What happens in SOAP? Is it that an emergency medicine applicant just didn't get enough interviews and they didn't match and they can go to other programs? Or is it like, "Oh, you know what, I wanted to be a plastic surgeon, but I didn't match. Boy, EM is kind of cool because you can do plastic surgery right there in the ER." Is it really a matter of people staying within their field and looking elsewhere? Or is it field switching at the last second?

Carmody: There's some of both. If you look at the landscape of positions that are unfilled, there are some categorical positions that are available, so some positions that people can enter. At the end of that training, they're eligible for board certification in that specialty. So, we had 500 and some family medicine positions, 554 emergency medicine positions, some internal medicine positions, and then a smattering of categorical positions that came up in other specialties, but usually not many.

Like I said, some specialties had no positions available in the SOAP. Others had very few -- pathology this year had only six positions that went unfilled in the Match, which is a low number for that field. There were four positions, I think, in obstetrics and gynecology that were available. So if you're someone who didn't match in one of those specialties, there's really not many positions that may be in line with your career goals available for you in the SOAP.

What there are a lot of, though, are preliminary PGY1-only positions in medicine or surgery or some transitional year positions available. Whether applicants want to target those really is a matter of judgment about the strength of their own application and whether doing that will put them on the track to achieve their career goals or not. That's really a circumstance-specific kind of question.

Faust: What happens to people who match into a 1 year program these days? Back in the day it was pretty common that you matched into a first year internship and then you either stuck around or went somewhere else for your residency.

Now of course, for the most part, it's all one thing. It's just "intern" is what we call a first year resident, but there still are these programs that take people for 1 year, these prelim years. What happens to those folks in the second year?

Carmody: Well, the ideal path is that you take that position, you get a good broad-based training, you get off on the right foot with your program faculty, and you get their endorsements to reapply again. Either you rematch into a categorical position in the following Match or you jump into an open PGY2 position in general surgery, let's say, if you did a prelim surgery year. That would be the ideal circumstance, but that's not the experience that all applicants have with this.

Some applicants do these preliminary years and they're unsuccessful in finding placement in subsequent cycles. And that can be a very difficult position to get out of, because among other things, when you take one of those positions, you start the clock on the amount of funding that CMS is willing to provide to train you. So the hospitals that train you begin to draw off the total amount of funding that's available to you, which extends only to the amount of time that it would take to get you to board eligibility.

So if you start at a prelim medicine position, for instance, you get 3 years of funding. If you decide after a year that you want to do something that has a longer residency, your residency would then be on the hook for that portion of salary.

Unfortunately, the kind of tracking that we do of applicants with the NRMP statistics doesn't really capture the outcomes of these people very well. So how many people end up in one situation or another, how many people is it a win for them to take one of these prelim positions is really an open question that's up for some debate.

From my standpoint, it's not a system that any of us would've designed. I mean, if you set out to train physicians in the most efficient or the educationally optimal way, this is not what you would come up with, having this discontinuity between your first year of training and any subsequent years.

It's a historical artifact from a time when an internship was required to get a license. For many physicians, all they did was an internship and then began practice as a general practitioner. But now, that applies to almost no one, and yet we still have a system where we have this discontinuity.

I think there's no point in it, to be honest. I recognize that there are certain applicants whose application doesn't get a lot of interest from programs, they do a PGY1 year, and that opens doors for them. So I understand that there are some people who benefit in this system and may like it for that reason.

But if the goal of residency training is educational, if we believe that the goal is to train people to become physicians as good as they can, I don't know how you could defend a system with that kind of built-in discontinuity.

Faust: Talk to me about the difference in experience, in the statistics that you're an expert in, with United States medical graduates and IMGs -- international medical graduates. It seems like there's obviously a really big difference in this. Are IMGs unfairly looked at, or does it make sense for some state university or some government-funded hospital to say, "Look, we just trained all these U.S. doctors on our own turf. Let's prioritize them"?

Carmody: You know, this is a conversation. It raises a lot of issues that can be controversial and that are difficult to discuss frankly.

It just simply is not going to be politically tenable to have a system where U.S. graduates are not getting matched in large numbers. I mean, that's just a matter of political reality.

If we have public investment in medical education, people going to state medical schools, and then a substantial portion of that class doesn't match, politicians will get involved and correct that.

As a matter of fact, without any kind of rule dictating that it has to be that way, most residency programs prefer U.S. medical graduates from MD and U.S. DO schools.

Faust: I think that the main algorithm is a very ethical system for the problem at hand, [which is] trying to match all these applicants to these hospitals with thousands of different variables. As you've said before, the applicant is sort of favored, we know that now with how the algorithm goes.

Do you think that there are other parts of the application process that are not so equitable or that could be done better? Whether it's interviews, or whether it's once people have done their interviews how the matching is going, and even the fact that the SOAP is a 1 week process as opposed to being done earlier?

Do you agree with me that the algorithm itself is good and that there are other parts of the system that could be improved, and what are those?

Carmody: I agree. I think that the problems that exist in residency selection -- and there are many -- they exist external to the matching process and the algorithm itself, which works as it's designed.

Certainly, there are some applicants who would do better if we didn't have a matching system. There are people who might be better able to compete by snatching up positions earlier. But for the average applicant, I think the Match is a good thing that benefits programs and applicants.

That said, there are a lot of problems in the system. From my standpoint, one of the biggest problems remains what I call "application fever," that applicants each year apply to more and more programs. What that does is -- number one, it takes money out of their pocket with no ultimate improvement in Match outcomes. But number two, it imposes this evaluative burden on programs that makes a pressure that's going to force programs to go to the most convenient screening metric.

So if you want your application to be reviewed on its individual merits, if you want a program to see you as an individual, you want to have a system of limited applications where the mere act of submitting an application is a credible sign that you're interested in this program. The program director doesn't have to wonder, "Oh, well, this is a person from the West Coast, they're never going to come to my East Coast program" or, "This applicant's too good for us. We don't need to waste time interviewing them." You could take all that gamesmanship out of it and let people look at you individually, if you are willing to sacrifice unlimited applications everywhere. So I think that's the optimal area for reform.

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