The National Resident Matching Program (NRMP) provides a system for the confidential ranking and subsequent matching preferences of both applicants and residency programs (the Match). The sole purpose of the NRMP is to allow both applicants and programs to make selection decisions on a uniform schedule and without pressure.1 Over the years, the Match process has developed many explicit and implicit rules. While both applicants and programs may try to influence decisions in their favor, any verbal or written contracts prior to the submission of rank order lists is a violation of NRMP rules.
The NRMP expects all participants to conduct their affairs related to the Match in an ethical and professionally responsible manner. Examples of violations of NRMP rules would include agreements made by participants before the Match, violations during Match week, and failure to honor results of the Match.
In 1992, the Association of Family Practice Residency Directors (AFPRD) presented guidelines for the ethical recruitment of family practice residents.2 These guidelines were developed in the early 1990s to address concerns that a decline in the number of applicants entering family practice residencies through the NRMP might escalate a possible recruitment war between family practice residency programs.3 The guidelines were created to help "maintain a positive recruitment environment," while recognizing that each program "has the right to present itself favorably and that each program has unique characteristics that may appeal to specific candidates."2 They promoted honesty, professional and legal standards, and provide a statement of responsibility for residency programs in family practice. Efforts to adopt these directives, however, were apparently halted as mandates may be in violation of antitrust legislation.
Research by Anderson and Jacobs4 indicates that applicants applying to many types of medical specialties perceive that residency programs engage in questionable ethical practices during the Match process. These practices may include making informal commitments, lying to applicants, and encouraging applicants to engage in unethical behavior. While 40% of the students felt the process was reasonable and needed no changes, more than half (52%) of respondents thought the process could be improved, 4% believed that it was unfair and needed a major overhaul, and 4% said it should be eliminated. Respondents also provided critical comments about the current process, such as "a process that rewards who you know and not what you know," "a tedious hoop for medical students to jump through," and "a matter of playing the game or running the risk of losing out completely." Furthermore, the respondents also indicated that the NRMP handbook rules that neither programs nor applicants "must ask the other to make a commitment as to how one will be ranked before the match" may be broken by both applicants and programs. These responses indicate that the process can promote unprofessional behavior and gamestership.
Based on a study by Carek et al,5 many of these rules are broken and the behavior of both applicants and program directors often does not meet expected ethical standards. While most program directors (98%) reported that at least some applicants contacted them following the formal interview to inform then that the program was a "high" first rank-order choice. In general, most program directors (84%) were either skeptical or did not believe such statements. Sixty percent of the program directors reported that applicants asked how the program was ranking them. The overwhelming majority of program directors (94%) stated that the Match process placed their program in the position of having to be dishonest with applicants to match their top choices. A similar number of program directors (91%) felt that they were lied to by applicants at least some of the time. Approximately half of the program directors (47%) felt that informal commitments had been made to them by applicants. More than 65% of programs failed to match an applicant who they felt made an informal commitment to their program. Furthermore, the results of this study indicated that many actions of program directors and applicants may not be consistent with the highest professional standards necessary to maintain a fair Match process. The program directors' recommendations included educating applicants and program directors in the process and ethics of the Match, allowing applicants and programs to provide honest feedback to each other, and enforcing the policies of the NRMP.
A similar study involving general surgery program directors6 found that 47% of program directors frequently or always told applicants to keep in touch if they were interested in matching at their program. However, when applicants contacted them after their interview to inform programs of their high rank order, 60% of program directors were skeptical and 31% did not believe their claims. More than two thirds (76.6%) of program directors stated that such overtures had no effect on the applicant's rank order. Similar to family practice program directors, 91% of general surgery program directors believed that they were at least occasionally lied to by applicants. More than half of these program directors (51.7%) stated the Match was a reasonable process that needed no changes. The authors encouraged chairpersons and program directors to develop an understanding of funding issues and to realistically counsel students about programs and about their chances of matching into surgery. They further encouraged program directors to communicate expectations in an honest manner with applicants.
Recently, urology residency program directors and applicants were surveyed to evaluate their behaviors and attitudes related to the residency matching program.7 Program directors and resident applicants were skeptical of each other: dishonesty was acknowledged by 31% of program directors and 44% of applicants; 82% of program directors thought applicants "lied" while 67% of applicants thought that programs lied. The authors of this study suggested that programs adopt policies to enhance fairness and also adopt a code of limited or no communication after interviews.
Unfortunately, current research addresses neither the advantages of the current system nor other issues that may influence resident recruitment and the Match. Although many disadvantages have been noted, the current system may still benefit the majority of participants. While the recruiting aspect of the current system may not appeal to all participants, the ability of the current centralized system to successfully place applicants into programs has not been studied.
Several factors place pressure on both applicants and programs. In some specialty fields, the limited number of positions creates competition among applicants. For other programs, declining numbers of applicants fosters competition among programs to recruit the best candidates. Additionally, reimbursement from state and federal agencies based on resident numbers may cause financial hardships for programs, and thus increase the competition for applicants. The use of sign-on bonuses, negative comments about other residencies, and recruitment of residents from other programs have also been cited as areas of concern.2 Other factors may serve as more appropriate recruitment tools. Having high-quality faculty, house staff, and residents with good attitudes, program location and size, community hospital affiliation, and salary are program characteristics that have been found to affect initial Match rates in family medicine residency programs.8,9 Therefore, the issues that actually influence resident recruitment and the Match are not fully delineated and the policies of the NRMP may have little effect upon them.
As previously noted, the purpose for the establishment of the Match process was 2-fold: (1) to provide a mechanism allowing applicants and program directors to consider all their options before making final commitments and (2) to establish a uniform date and time for the announcement of residency position appointments. In terms of the first objective, the impact of the actual interview and Match process on resident recruiting is not known and the ability to legislate and enforce professionalism among its members is a difficult task. Additionally, the legal system may not allow the enforcement of such guidelines.
However, we believe that the NRMP should actively enforce its policy regarding a uniform schedule. Agreements made by participants before the Match or failure to honor results of the Match potentially create educational service and financial hardships for programs. A system that reinforces this objective by exposing documented agreements by participants outside the match and applicants who fail to honor the results of the Match ("no show") would increase the credibility of the current system.
At best, the NRMP should educate participants about their policies and the ethical recruitment of residents. NRMP policies currently allow communication between applicant and programs, and do not prohibit either an applicant or program director from volunteering how each plans to rank the other. The NRMP reminds participants that statements should not be misinterpreted and that participants must understand that such statements are not binding and have no standing when final rank order lists are submitted. While the NRMP attempts to create a fair process, the Match and rank-order list is just a part of a larger recruiting system and many other factors are involved in the recruiting process (eg, program reputation, number of applicants, number of residency positions by specialty, location, and salaries). These factors would be better addressed by the sponsoring organizations of the NRMP, as they are outside the jurisdiction of the Match.
Carek PJ, Anderson KD. Residency Selection Process and the Match: Does Anyone Believe Anybody?. JAMA. 2001;285(21):2784-2785. doi:10.1001/jama.285.21.2784-JMS0606-5-1