Fixing the “Match”: How to Play the Game

Abstract

Every year, more than 35 000 individuals compete for about 25 000 residency positions in the United States. Participants include medical students and individuals with prior graduate medical education. This process is managed by the National Resident Matching Program (NRMP), which promises “an impartial venue for matching applicants' preferences for residency positions with program directors' preferences for applicants.”1 This has not always been the case. When residencies were first introduced, around 1900, hospitals began competing with one another to secure the best residents as early as possible. By the 1940s, positions were being offered in the third-year of medical school. Students were making career decisions without adequate exposure to their options, and hospitals were making hiring decisions with little data. Medical schools attempted to prevent early offers by embargoing letters of reference. Hospitals responded by giving students shorter deadlines to accept offers. By 1949, exploding offers—valid for only 12 hours—were common. In 1952, a centralized clearing house for all residency offers, the NRMP, was created in an attempt to fix the market. The Match, as it came to be known, has evolved since then, although the underlying algorithm has remained basically unchanged.2 There has been much focus on the Match's effects on medical students' professional and ethical development,3,4 but an analysis of Match strategy has been overlooked in the medical literature. This article investigates several aspects of the Match: Is there an optimal Match strategy? How should students and programs create rank lists? Would ethically troubling behaviors occur if students and programs employed optimal strategies? Could a change in NRMP rules reduce problematic behaviors and help the Match function better?