One Day and One Dramatic Year in the Lives of Three New Doctors
By Brian Eule
St. Martin's Press Copyright © 2009 Brian Eule
All rights reserved.
For a few minutes, in the weeks before medical schools began the nerve-racking ceremonies of handing out envelopes, 15,008 graduating students from U.S. allopathic medical schools were jammed into a single room in the northwest quadrant of Washington, D.C. They did not appear in person, clutching résumés or transcripts. Their essays and letters of recommendation were nowhere in sight. They, and their list of preferences, arrived only as computerized data points. Everything that mattered had been reduced to a few numbers for this final step. That way, a simple desktop computer running MatchPro software could pair each applicant with the teaching hospital where he or she would spend the next three-to-seven years of training. Nothing about the computer, or the desk on which it sat, seemed special. The only indication of all the lives altering course at that very moment was the series of numbers briefly displayed on the computer's monitor.
The Match had numbers for everything. Medical students entered their eight-digit identification codes on the Match's Web-based "Registration, Rankings, and Results System." Historic institutions were coded with four digits. Harvard's Massachusetts General Hospital became 1261. Johns Hopkins, 1241. The Mayo Clinic in Minnesota, 1328. A series of three numbers indicated the specialty a new doctor would practice. A career in anesthesiology meant the numbers 040. General surgery was coded as 440. Dermatology, 080. Combined, strings of numbers formed the genomes of the thousands of residency programs with positions for the nation's newest doctors.
The computer worked efficiently. It made temporary matches based on the first student and hospital rank order lists it came across, then reassigned the candidates as it digested more lists, shifting future doctors like contestants in a high-speed game of musical chairs. By the time the music stopped, the computer program had married the majority of the country's newest doctors to the hospitals where they would first practice medicine. The actual matching took less than ten minutes. It was over before most people knew it began.
A few other computers ran similar operations for a small handful of medical specialties. It was the urology match that caused panic one year with an onslaught of undesirable results until the American Urological Association revealed that there had been a glitch in the computer system and its match would be run again. For the vast majority of students, though, it was the computer in the National Resident Matching Program's office that held their results in its digital pairings. The staff carefully checked the data several times, uploaded the results into a password-protected online system, and prepared reports. But it would be days before the students would learn the results.
First came the Monday before Match Day — the day students dubbed "Black Monday." Applicants raced to Internet connections and logged into the online system to learn whether or not they matched. No other details were given. On average, the computer only spit out 6 or 7 percent of the country's allopathic medical school seniors — the students who would be awarded the M.D. degree — without a position. Often they had applied in a competitive field and not ranked enough hospitals. The numbers weren't always as favorable for the thousands of independent applicants — a group that included graduates of foreign medical schools and osteopathic schools. The wrong news on Black Monday meant moving on to the Scramble — a frantic two-day process in which unmatched students, with the help of their deans, telephoned programs with unfilled positions and tried to sell themselves. But for the majority, seeing the words "Congratulations, you have matched!" meant a quick sigh of relief, then waiting three more days for a ritual that had grown more intense and anticipated than graduation itself.
On the third Thursday in March, medical schools across the country held gatherings to unveil the computer's results. Some schools waited for the designated hour, then unleashed the students to retrieve the envelopes with their results and braced for a stampede. Others, including Vanderbilt University, called students at random to the front of a lecture hall. On the way, each student dropped a dollar bill into a fishbowl as compensation for the suffering that the last person was to endure while waiting. One by one, they received and opened their envelopes, leaned into a microphone, and announced the result to classmates, family, and anybody watching on Vanderbilt's live Webcast.
Students could skip the ceremonies and wait to view results online later in the day, but it was a harrowing process no matter how the medical school or student treated the day. Some students misunderstood the way the computer worked and wondered if they could game the system by altering their rank lists. Others finished interviews with winks from program directors or post-interview phone calls, like high school basketball stars recruited by overzealous college coaches, and were stunned if they did not match with a particular hospital. The not-for-profit National Resident Matching Program, which, as it described itself on its Web site, provided "an impartial venue for matching applicants' and programs' preferences for each other consistently," could show the Match as a success for the masses, with more than 80 percent of the candidates ending up at one of their top three choices. Yet for the individual applicant, suddenly embarking on a new career at a different, less appealing institution than hoped for could be hard to cope with; leaving students sometimes wondering about the origins of this unusual process.
After twenty years of exams and classrooms, the fourth-year medical students were just a few months shy of commencement ceremonies in which they would suddenly be pronounced doctors. Years of bending over Robbins's Pathology and Netter's Anatomy textbooks, inhaling formaldehyde seeping from dissected cadavers, and writing ever-growing tuition checks gave way to jobs and legitimacy. But while deans and diplomas could transform students into physicians, a new doctor lacked sufficient experience. As a result, since the early 1920s, a postgraduate year of intense on-the-job training had been standard practice. For physicians who wanted to specialize, that training formalized into from three to seven years, depending on a doctor's desired specialty. This extended training period was called residency. The first year was internship.
When internship and residency were first developed, the young doctor lived at the hospital, hence the term resident, and expectations of a life devoted solely to work were hinted at, with some hospitals forbidding marriage. Interns were allowed to practice medicine under a hospital's license. They weren't paid much, if anything, were sleep deprived, and had few days off. Though most interns no longer live at the hospital, the practice continues today. The weak are toughened, hospitals get the help they need at a cheap price, and new doctors are initiated into the world of medicine with the experience and patient care time they require.
But soon after the development of the internship, fierce competition for the best graduating medical students led to problems. With more positions than candidates, some hospitals raced to offer internships before their competitors. At first, they contacted fourth-year medical students, but soon reached out to third-years, more than a year in advance of the job. By the 1940s, some students reported receiving offers in their second year of medical school, despite the fact that hospitals could only guess, at such an early point, who would turn out to be the best doctors.
To stop this trend and the disruption it caused, the Association of American Medical Colleges agreed that schools would not release transcripts and recommendations until after a student's third year of medical school. While this tactic worked in pushing back the date of the offers, it led to another problem. Now hospitals limited the time a student had to respond to an offer, hoping to avoid being left with a shortage of doctors should a candidate take too long to reply with a rejection. Students were given ten days to respond. They complained of pressure and often accepted the first position to come along, only to regret the decision or consider rescinding it if a better offer arrived. By then, a hospital might have lost out on its second, third, or fourth choice. The following year, students were given only seven days to respond. The year after, it was three. One year later, students had twelve hours.
Again, the association worked on a solution, this time convening a committee to work on a centralized clearinghouse as the final step in the selection process. Students would still apply to and interview at hospitals. But by submitting an ordered list ranking their choices at the conclusion of the interview season, they were not pressured or rushed into accepting an offer. And hospitals, with their own ordered lists of applicants who had interviewed, had no need to fear the repercussions of a student's rejection. After a trial run during the 1950–51 school year, and altering of the algorithm when a group of students pointed out that it could penalize those who listed unrealistic first choices, the process was agreed upon and implemented the following year. The Match, as it was called, proved a popular solution and more than fifty years later was still in effect. Though like a living organism, it had changed over the years.
If you wanted to put a face on this faceless machine, it would have a thick black beard, beginning to go gray. It would have a receding hairline. It would wear glasses, squint when smiling, and present a big forehead adding to its contemplative appearance. It would look, in this case, much like an economist at Harvard University named Alvin Roth.
For his fiftieth birthday, colleagues crowned Roth with a hat that read, "Mr. Matching." He fit the stereotypical image of a professor, pacing the classroom when he spoke to a group, his conversations and lectures rich with hypotheticals and examples of conundrums. By the time I grew interested in the Match, Roth's algorithms assigned children to schools in Boston, placed teenagers at New York City public high schools, selected compatible kidneys and patients for transplants in a process known as paired donations, and since 1998, ran on the National Resident Matching Program's computer. Despite this, Roth remained unrecognizable to most physicians. He rarely even mentioned his work on personal checkups or encounters with doctors. It was the medical students' scores, interview skills, and rank order lists that led to their jobs, he told people, not his algorithm. The way he viewed it, he had simply been a consultant hired to fix a marketplace that had grown controversial again.
As a young assistant professor of economics at the University of Illinois in the early 1980s, Roth had called up the school's medical librarian and asked for any articles on the Match. He was full of curiosity. The unique process had handled the labor market for doctors for thirty years, and Roth wanted to see what made it work. By an economist's terms, he decided, the Match's success had to do with stability: there was no hospital and candidate not already matched to each other in which both parties wished they were. That seemed important — if the Match had been unstable, Roth figured, it would have led hospitals and candidates to circumvent the system.
The algorithm functioned somewhat like a common mathematical equation taught in schools known as the stable marriage algorithm. When Roth first studied the Match, its algorithm started with the hospitals' rank lists or, as some described it, with the hospitals proposing to the students. The students matched with their top choices among the offers they received. Roth wrote several papers on the process and in 1990 coauthored an academic book called Two-Sided Matching: A Study in Game-Theoretic Modeling and Analysis. By 1995, the National Resident Matching Program called him for help.
It seemed the Match had come under some scrutiny. In an article for Academic Medicine, a Philadelphia medical professor accused the National Resident Matching Program of not clearly portraying the algorithm as favoring the hospitals. He also wondered whether, under the current system, students had incentives to misrepresent their preferences on their rank list to improve their chances. Students wondered whether they were at a disadvantage because they were not the ones proposing in the algorithm. The Health Research Group — a division of a consumer advocacy group formed by Ralph Nader — and the American Medical Student Association prepared a report on the alleged hospital bias in the Match, and sent a letter of concern to the Association of American Medical Colleges requesting that the algorithm be switched from hospital-optimal to student-optimal.
If people were concerned about the Match, they might stop using it. And if some stopped, the system would break down for the rest. So the National Resident Matching Program hired Roth to study the existing algorithm and create one in which the students proposed. Complicating the situation were all the variations the Match now took into account. Some students needed to submit two separate lists — one for an intern year and one for the remaining years of residency — if their residency program didn't include the internship as part of its training. Other students applied to the Match as a couple, linking their lists together.
The National Resident Matching Program gave Roth and a fellow consultant, Elliott Peranson, five years of Match data. Roth experimented with alterations to the algorithm like a kid playing with a chemistry set, testing to see how different actions caused new reactions. He changed the algorithm and sent it off to Peranson to plug in, then watched as some of the candidates — their names and identifying information blocked out — paired with different hospitals than they had in the real Match.
Roth got a kick out of what he was doing, but he denied that he was playing with lives. He was just exploring possibilities, moving numbers around, and altering the order of the operation. On occasion, he got visits from an officer of the American Medical Student Association, or a hospital's program director, and Roth suspected they were feeling him out to see if he was in the pocket of the other guys. "Look, I'm an economist," he told them. To prove it, he launched into long orations about the intricacies of the algorithms. Visitors might walk away baffled but oddly satisfied.
Ultimately, Roth found that for either algorithm — the existing one or his new one — applicants and residency programs would have the best results if they played by the rules and arranged their lists simply by preference rather than shorten lists or change their first choices. He also discovered that the new algorithm, in which students proposed, helped a very small number of additional applicants — about one in a thousand — earn spots at institutions higher on their lists. Still, the National Resident Matching Program adopted Roth's new algorithm, and it was in the computer by 1998. The controversy over, things seemed calm for a few years.
But there was another concern that had never been addressed. The Match, some students complained, left candidates with no power to negotiate. Although students applied to hospitals and went on interviews, much like candidates in any job market, the Match meant the graduating students most in demand did not have multiple offers to use to negotiate salary and employment conditions. The free market was eliminated. Students signed binding agreements on entering the Match, and thus candidates had little choice but to accept the conditions of the hospitals with which they matched. On average, the $43,000 annual salary for a doctor just out of medical school was less than half that of a recent law school graduate at some large private firms and translated into a wage of approximately ten dollars an hour. After taking on hundreds of thousands of dollars in medical school loans, these young doctors needed all the money they could get. (Continues...)
Excerpted from Match Day by Brian Eule. Copyright © 2009 Brian Eule. Excerpted by permission of St. Martin's Press.
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