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Needed Changes In NRMP, The National Resident Match Program

Radiology Residency Programs Every physician is well acquainted with the National Resident Match Program (NRMP), but the rest of the public is probably not aware of how the NRMP works. Simply put the Match, as it is called for short, takes the graduating group of medical students and places them into residency positions across the United States using a computer algorithm that is supposed to eliminate discrimination and promote fairness, it does neither. Here is how the Match works.

In the third year of medical school, every student who plans to become a licensed physician enters the Match. This means that they pay a fee to the NRMP to join a database of all of the graduating medical students who want to become residents so that they can then become fully licensed doctors. The general steps in medical training are college - medical school - resident - physician. The Match began in 1952 and was designed to simplify the complex process of obtaining a residency position as well as to level the playing field and give everyone an equal opportunity by preventing nepotism, backroom deals, and favoritism. The concept is simple:

1. Sign-up for the NRMP

2. Apply to residency programs you want to go to

3. Go to interviews that are offered to get to know the program and vice versa

4. Rank the places you want to go in order from most desirable to least desirable

5. The programs rank their applicants from most desirable to least desirable

5. A computer algorithm is applied to maximize the choices of residents with the choices of the training programs

Each student ranks the programs he/she would like to attend from most to least desirable. The programs also rank the students they would like to have from most to least desirable. The computer then makes matches (hence the name) between students and programs, trying to give the most desirable choice possible to both students and programs. In all, roughly 16, 000 residency spots are filled this way each year. Not every program participates, but the most do. The idea is to promote equality, but the result, as with most regulation, is to stifle creativity and remove the competitive aspects that usually promote innovation. Residents simply become a group because the Match minimizes differences between candidates. On the flip side, and more importantly, the Match allows the programs to engage in a sort of "price-fixing" whereby they obtain the very best residents possible with the fewest salary, work-hour, and benefit concessions.

Resident salaries have been artificially capped at roughly $46, 000 per year. No matter where you go in the country, whether the cost of living is low or high, the general number, give or take $3, 000 - $4, 000, is $46, 000 per year. That may seem reasonable until you realize that most medical graduates have over $139, 000 in debt according to the AAMC. After you take out living expenses, there is generally not enough left over to pay the $1800 per month in loan costs. The result is that most residents defer their loans for several years. While the loans are in deferment, interest is accruing on a portion of them and being capitalized to the principle at certain intervals. The result is that an initial $139, 000 in debt may rise to $200, 000 in debt simply because residents don't make enough to pay off their loans. The AMA website points to research demonstrating increased risk to patients due to resident debt. Why is that the case you ask? First, residents with high loan bills are more likely to moonlight to earn extra money. That means less sleep and more mistakes. Second, and probably more detrimental, increased debt makes residents more cynical and increases rates of depression. I can personally speak to this as my loan debt is the single biggest stressor in my life. Unhappy workers do not give their all on the job and there is an epidemic of unhappy residents right now.

The benefit of the NRMP, as one might expect, is especially generous for those programs that would normally attract the very best residents. Not all hospitals and training programs are equal, some are far better than others. Hospitals like Massachusetts General (MGH) and Johns Hopkins are considered the very best so they attract the very best residents even they don't pay them any more than if they were the very worst residents. Furthermore, they don't treat them any better either.

Another area in which the Match provides a disadvantage to residents is in work hours. It is well known that residents work long hours. Currently, the Resident Review Committee (RRC) has sent a limit of 80 hours per week that residents can work. If a program violates these rules by requiring their residents to work longer than 80 hours per week, they can be fined, put on probation, or forbidden from participating in the match. Despite this rule and the consequences for breaking it, many residents are still forced to work more than 80 hours a week. One can argue over the merits of long hours versus the merits of having well-rested doctors. The debate rages on as to how many hours are too many, what limitations on work hours mean for training, and so on and so forth.

In addition to the fatigue that is created simply by working 80 hours per week, residents are also attempting to lead normal lives outside of the hospital. This means raising families and taking care of the day to day bills, shopping, etc. that are part of normal life. The only difference is they have to do it in less time than the average person. This means two things happen. First, even if they only work 80 hours per week, it does not mean residents are spending the rest sleeping and recovering. They are spending it with family and friends. This means they are just as tired as if they had worked 100 hours in the hospital. The culture has changed and residents now put more focus on family and hobbies than in the past. Women no longer stay at home to raise the kids while the men toil away in the hospital being "super-doctors" (I doubt super-doctors ever existed, but that is what opponents of work hour restrictions would have us believe). Today, women are doctors too and men share in raising families, both out of choice. To expect either group to do differently is short-sighted, unfair, and bigoted.

Not only are residents spending their hours outside of the hospital differently, they are spending their time inside the hospital differently as well. Gone are the days when men worked and women took care of the home. In those days, women took care of the bills, repairs, and daily tasks of maintaining a household. Now, both partners work, meaning home "concerns" cannot be checked at the hospital door. Rather, residents must make calls regarding the phone bill or speak to the mechanic about the car. They have to arrange for repairs at home to be supervised while they are out or take time off of work to do so. The result is that they are distracted at work; not because they want to be, but because they have to be. If they are stuck their 80 hours per week they have no choice but to bring home to work. This means less focus on the task at hand, less attention to patients, and overall worse service as a result. Limiting working hours would mean the ability to concentrate on work while at work and still complete other errands after leaving the hospital.

I have participated in arguments and restricting work hours though the RRC and I feel very strongly about this. I think the RRC needs to limit hours for patient safety, resident happiness, and resident safety. However, the need for the RRC to be involved at all would be moot if we simply eliminated the NRMP and forced residency programs to compete for residents. Through competition would come ingenuity and customization. Residents would be able to negotiate deals that worked for them and provided the best balance possible.

Imagine for a moment that you have graduated at the top of your medical school class from a very prestigious school, like Harvard or Washington University. You are smart, talented, and the ideal candidate for any residency. Under the current NRMP, you rank the program and they rank you. No matter where you go, you are likely to work long hours for a salary of $45, 000, so you apply to only top programs and since you are so universally sought, you get into your first choice. They pay you $45, 000 and they get a super-smart resident who works 80 hours a week for $45, 000 per year. You cannot pay your loans and your debts slowly mount. Meanwhile, a mediocre student has applied to a somewhat less attractive residency program on the other side of town. Now, this student applied to the top schools as well, on the off chance that he might slip, but is now a mediocre resident at a mediocre program. He works 80+ hours per week for $45, 000 per year and cannot pay his loans so his debts are slowly mounting. You are basically the same.

Now imagine a different scenario. You are still the same super-resident as above, but this time there is no NRMP. Instead, you go on interviews and they offer you the job complete with salary, hours, vacation, and benefits. Now you are a great resident, so you can have your choice of top programs. You can go to MGH, Johns Hopkins, or any other outstanding institution in the country. For argument sake let's say you interview with MGH and Hopkins. MGH offers you 80 hours per week, 4 weeks of vacation, and $45, 000 per year. Hopkins, however, offers you 60 hours per week, 4 weeks of vacation, and $60, 000 per year. You really want to go to MGH, but the benefits at Hopkins are much better, so you negotiate. In the end MGH offers you $60, 000 per year, 80 hours per week, and 3 weeks of vacation. You feel this is a good compromise and go to MGH. In the mean time, the other guy applies to MGH as well and they tell him they will take him at 80 hours per week, 4 weeks of vacation, and $40, 000 per year. He also has an offer from the mediocre program for 80 hours per week, 4 weeks of vacation, and $45, 00 per year. He really needs more money to live on than $45, 000 and is not that interested in going to MGH so he tells the other program about the offer from MGH, they consider his qualifications and offer him $50, 000 instead of $45, 000 and he accepts. Now each person is happy and better off than if they had gone through the match. They end up in the same places, but were free to negotiate a deal that worked for them individually.

If programs were forced to compete with each other through things like salary and benefits, I think we would quickly witness two dramatic events. First, residents' salaries would increase and they would not be forced to accumulate increased debt because of loan deferment. This would free residents to choose specialties based upon interest and ability rather than upon salary alone. You may argue that salary would still play a role, and you would be right. However, most residents surveyed today state mounting loan debt as the reason for going after a higher salary and not simply the money alone. In other words, if they didn't have to make $1800 a month loan payments while trying to buy a house, raise a family, and enjoy life, they would feel free to make different decisions and to pursue their interests rather than the money. It would probably make for happier residents and happier physicians in the end.

You may argue that this would lead to severe inflation in salary, but you would be forgetting the other principles of free market economy as well as what is most important to residents. First, programs would not pay more than they were willing or capable to pay despite the merits of the resident. After all, no resident is so good as to command $100, 000 while another gets only $50, 000. In addition, even if resident salaries did increase, we could expect to see decreases elsewhere. Programs may choose to spend less on ancillary staff or pay the staff physicians less. After all, if they don't have the loan debt worry about, they may not quibble about the difference between $200, 000 and $210, 000. There are usually far more physicians in an institution than there are residents.

The second reason that salaries would not spiral out of control is because residents are interested in much more than just money. Many point to lifestyle as an important factor in their choice of specialty. By lifestyle they are referring not only to how they can live once they are licensed attendings, because they are free to set their own hours at that point, but more so to how they will live as residents. It is well known that specialties like radiology, dermatology, and ophthalmology require fewer, easier hours than specialties like surgery, internal medicine, and neurosurgery. Residents are often willing to trade money for time. Time is the most precious resource we have and few know that better than the residents who are forced to toil theirs away in the hospital. The face of medicine is changing and residents are no longer interested in investing all of their time into medicine at the expense of personal and family lives. More and more women are becoming doctors and more and more male physicians want to devote more time to family life. The result is that both men and women in medicine are interested in limiting work hours so that they can also raise families. Since most people start and family in their late 20's and early 30's, the very time residents are in training, it makes sense that they would like to work less than 80 hours per week. They are not lazy, they are simply trying to lead a fulfilling life. Why not let the individual define what is fulfilling for him or her, rather than mandating what everyone must do and demanding sacrifices that some may not want to make. You may argue that those people should not become doctors, but if that were the case, the physician shortage would be far worse than it already is. Change is here, but the bureaucracy of medicine is too cumbersome and too entrenched to deal with it. As in many situations, a free market would be much faster and better equipped to deal with these kinds of changes.

If the Match was eliminated, I can assure that programs would find creative solutions to work hour limitations, resident debt, and the myriad of other problems facing graduate medical training today. They would find the solutions because they would be forced to do so or perish; as is the case in any free market. If the NRMP were eliminated, we would see happier residents, fewer fatigue-related errors, and an increase in patient satisfaction. After all , wouldn't you rather be treated by a well-rested physician who is happier with his/her place of training and is free to focus on the task at hand rather than trying to fit in the activities of normal life while at the same time trying to take care of you. It certainly sounds like a better scenario to me.

By Logan Edmiston - I am 29 years old and recently graduated from Medical School. I have a B.S. biology and have spent significant time in the laboratory. I am deeply interested in medicine and in technology.