During medical school, I thought that our residency matching system is the best out there, come on, literally, the people who designed the matching algorithm won a whole Noble Prize for it. It is the utopian meritocracy we all fantasized about, all of which was delivered to us by our esteemed ACGME, the all-mighty all-knowing ACGME. To say the least, I was enamored and defended this entity vehemently against all critics. But nowadays, out of residency and as a fresh attending in the outside world, out of our protected cocoon in medical school and residency, something about this organization did not sit well for me and I had to dig deeper in and convince myself it is really the best out there… or isn’t it?
Join me down this rabbit hole
For people who don’t know how things work in medicine, students in medical school around their 2nd or 3rd year decide which specialty they want to match in to train to eventually practice independently afterward, that is when the matching system comes into play. “The match” is an algorithm that decides who goes to where and how, medical students after interviewing in multiple places, rank their choices according to their preference and the programs do the same for their applicants, all goes into the super-secret “match” algorithm, which spits out the results, that everyone is basically obligated to abide by.
Now on paper, all of this looks great! Right? Everybody wins, the students, the programs, and our all-mighty ACGME overlords. But sadly, like with everything, the devil is in the details and the best place to start deconstructing the downside of this approach more than this lawsuit that was filed against the ACGME in the early 2000s. So, let's dig deeper!
JUNG V ACGME
Paul Jung, MD, and 2 other physicians brought a class-action suit on behalf of all current and former medical residents against the ACGME and hospital organizations. Jung claimed that the organizational and institutional defendants, through the match, imposed anticompetitive restraints on residency placement and hiring that basically took the ability of residents to negotiate their employment contracts, resulting in fixed compensation packages across the board. Jung argued that defendants violated Section 1 of the Sherman Antitrust Act, which basically states that any contract that “unreasonably” restrain trade or commerce is declared to be illegal.
The components of the alleged antitrust conspiracy waged by Jung against the ACGME are three as detailed in the lawsuit:
1Forced participation of fourth-year medical students who want to enter residency in the NRMP, a system that allows no negotiation
2ACGME accreditation systems imposed on residency programs are restrictive and anticompetitive
3Defendants’ exchange of information on residency compensation has the effect of standardizing and stabilizing compensation and other terms of employment
Do you have a headache? Because I already do, just going through all this legal mumbo jumbo broke my brain, but let’s break it down, because this is insanely important to understand how those claims have altered the way we approach residency matching across the years in a tangible way.
- Medical students realistically have no choice
As we all know, under the current system structure, all medical students need to apply through the match to be placed in a residency program, some can opt-out if they were able to secure a pre-match contract, but these instances are rare and most are offered by lower-tier programs that are in need for medical residents and historically had unfavorable match rates.
Now once a student matches into a residency program, they are obligated by the ACGME/NRMP system to accept that position unless there are extraneous circumstances preventing that, and students who don’t accept that position get blacklisted, to say the least. As you can see, this current structure does not allow for much negotiation when it comes to hours, contracts, benefits, or wages, leaving students and future residents in a precarious position of no leverage whatsoever.
- Residency programs have no choice but to accept the Match imposed upon them
ACGME encourages and sometimes requires the program to participate in the Match to be accredited. This locks virtually all programs that are looking for quality residents into this dogma, without having any other choice in the matter, creating an anticompetitive environment with only one choice.
- MONEY AND INCENTIVES
The case alleges that multiple surveys are done by the American medical association (AMA) in residency programs allow for sharing information regarding salaries and hours between different hospitals, which leads to national standardization of salaries at artificially low wages and removing incentives that might attract better and brighter candidates to different hospitals.
Lock students (with huge school debts) into a Match system that enforces the match position result on you. While you chose your ranking list options, most residents end up ranking most programs they interviewed at, even if some were unfavorable, because the penalty of not matching at the end of the day is too much to bear, financially, professionally, and mentally.
Lock programs into the Match or else you will not get accredited by ACGME, making your program significantly less favorable in the eyes of most applicants, and also limiting your ability to incentivize other better talent to come and train there.
Develop a standard model for hospitals to abide by, with surveys shared amongst all players, eliminating the ability for residents to negotiate contracts due to the lack of competitive edge that they may leverage.
Surprise, surprise! ACGME won the lawsuit! but how?
The Jung lawsuit was filed in 2002 but dragged till 2004 in federal courts, where a new legislative action by congress changed the fate of the case.
AAMC lobbied hard along with the American Hospital Association to amend the Pension funding Equity Act to include a provision to confirm the antitrust status of graduate medical resident matching programs in Section 207, declaring the current Match and residency structure as an effective and pro-competitive process that has benefited residents for 50 years.
With the passage of that act along with new provisions placed by AAMC lobbyists, the fate of the Jung case was doomed and ACGME along with the other defendant organizations won.
A sneaky way to win a lawsuit if I may interject here, but who am I? a stranger on the internet, am I right?
Now at this point, you are saying, Come on man! The Match is great and solves a lot of problems related to residency placement, and I am not arguing it is not. It is truly a breakthrough approach to allocating a huge number of students across this vast country to pursue their passion. I am trying to show you the downside of this system and how it is shaping an anti-competitive structure that works against residents and smaller programs stifling innovation and possibly leading to higher degrees of burnout and dissatisfaction.