I watched all the 6 videos in the Match playlist - for the second time :d. And I came across that the Gale-Shapley algorithm for stable matching won 2012 Nobel prize for Economics (e.g. Wikipedia Gale-Shapley algorithm). Very intriguing 😅
Nice series! I didn't match and I soaped into EM after originally applying to anesthesiology. This series really made me realize that I underapplied and obviously didn't play the game right. But, I did get multiple offers from multiple different specialties during the first round of soap, which was nice and I had the power to choose where I really wanted to be and ended up selecting a great EM program, so it all worked out!
These days the durations of residency are so long, while the residents and fellows are the main workhorse of hospitals, especially for public hospitals, but with such low salaries.
To address point 1; I think this would still occur in specialties which struggle to fill routinely. I don’t think the market would actually sort itself out for residency. There is a large asymmetry in terms of the places and programs which are highly desirable to applicants. There still needs to be a SOAP process at least to fill places that don’t fill. We actually need to fill slots efficiently in order to optimize the volume of the medical workforce being trained. I just cannot see an efficient allocation of students to spots if they all just did a mad dash on their own. I don’t see any serious problem with the Match, only benefits. The major issue is the monopsony power of the match as the sole buyer of resident labor artificially depresses resident wages. This can be solved by unionizing in individual programs. I’m not entirely convinced that all bad behavior would be unproblematic without a match either. We see anecdotes all the time of applicants getting screwed in shady prematch offers. There is legal recourse for this yes, but this is an additional set of stressors for vulnerable students to deal with when they’re already under duress. As to the question of whether residency selection is more chaotic with the match, I personally don’t think it is. A signaling system or strict application caps could solve the increased rate of applications amongst applicants. This really depends on whether you really believe that other labor markets are efficiently allocated; I don’t see good proof that attending job markets are well allocated. They don’t have nearly the same levels of centralization and rely on asymmetric information levels working through individual recruiting agents and agencies and one’s own personal search. None of these are more well allocated than a match! I would go ahead and argue that just because other labor markets don’t have a match does not mean they are well allocated either. You can get monopsony or oligopsony situations regardless of a match. If one health system is responsible for most of the hiring of new attendings in a region you don’t have a free market by any means. Also disagree on the resident salaries thing! It would not raise across the board, it would simply become asymmetric. Programs in rural areas would offer competitive salaries relative to places everyone is vying for. Urban popular programs would offer terrible salaries and people would still sign up. Same as how it works for attending salary markets. The only caveat here is that people aren’t adequately invested in improving resident wages because people have long viewed it as a temporary state before they enter a good life. This outlook is changing over time. And what you said about matched fellowships affecting the market in non matched fellowships is correct. It’s the same concept as to why the presence of some unions affects the broader labor market for people who aren’t in the union. Nonetheless, this was an elaborate video and I enjoyed watching it even if we have points of disagreement! Cheers
@ I think it’d be so cool to have Part 7 to this series to bring the USLME exams up to date, with some descriptions about the forces and process to turn STEP1 into Pass/Fail and possibly also will turn STEP3 into Pass/Fail as an one-day test instead of two.
Been watching these every day as soon as they come out. Incredibly well done! Hope you continue to make these kinds of videos. Such a great compliment to what you do in your blog
This was extremely informative and well presented. It gave a great history and presented the issues of the past and present system with clarity. Thank you!!
Thank you for a very informative series. It must have taken so much effort to find this information and assemble it so effectively. I hope that we can implement either ERAP or an interview match. I also hope that more programs will agree to a universal interview offer date
Thank you so much for making these videos. As a medical student it’s been very enlightening to learn some background on the Match. Your discussion of bargaining for salary in a world without the match raised a question for me. Given the supply/demand issue with residency selection in the status quo, why do you think resident salaries aren’t even lower than they currently are? Especially since it seems that in the current climate many graduates would be willing to work for less money in residency if it meant they got to pursue their specialty of choice.
Shhhhh!!! They’re gonna hear you! Actually, I’ve pondered the same question. The answer, I think, relates to the history of resident salaries. I thought about getting into this in the video but didn’t for brevity’s sake. Some older physicians get salty when you use the term “salary,” and many programs won’t even use this term on their website, preferring instead to call it a “stipend.” The issue here is that, in the old days, hospitals were explicit about how residents were NOT receiving wages for their labor. Instead, they were receiving some money to support them while they continued their education. The exact figure was determined based on the cost of living in the area, and was intended to support modest living expenses. From the beginning, there was a deliberate (and successful) attempt to divorce this figure from what a doctor - even an inexperienced one - might earn in the free market. Many deans, department chairs, etc. still cling to this idea - even though both the Supreme Court and the National Labor Relations Board have ruled that resident physicians are definitely workers, not students. Still, if hospitals decreased wages, it would fly in the face of this long-held belief. Instead, it’s easier to keep the old schedule and just provide a cost-of-living increase. Moreover, residents already provide a large and positive financial impact on their hospitals, so there’s no need to trim costs - and there’s risk in doing so. When all hospitals pay their residents essentially the same amount, everyone wins. But if you stand out from the pack by offering a lower salary, applicants will take that into consideration and it may hurt recruiting in a matched system.
Wondering about your thoughts about how doing away with the match would influence the costs which burden individuals going through the interview process. It seems in other job markets for highly educated applicants, employers are keen to remove fiscal barriers to getting applicants to interview. Do you think this would hold in the residency space or do you think nothing would change given your the discrepancy between open positions and applicants? Also, if there was no match do you think that would free people from the current “locked in” situation. Without the match do you think there might establish separate labor markets for interns, second years, third years, etc? Perhaps that might incentivize programs to do more to keep trainees once they have them?
This channel is an underrated gem, I really appreciate your work! I would love to reach out to you with my personal story as my wife and I are struggling with the match process...
Watching this series has been very interesting. The way it's worked in France for the last however many years is med students take a massive national synchronized exam and they get ranked on that exam from the number 1 best in the country to the very worst. There's a set amount of positions for each of the 44 specialties and each city based on perceived public health needs and then the students just pick in order of their rank. Let's say there's 26 plastic surgery spots across the country, you'd better be in the top 1000 students if you want to get a spot. Whereas there are 500 spots for psychiatry and it's not the most popular specialty so any student on the list from 1 to 9000 is guaranteed a spot. There is no other metric than that one (admittedly pretty huge) exam. There's not even an interview, to be fair here residents can rotate through all the hospitals in the region and change rotation every 6 months, so you're going to a region-specialty combo as opposed to a specific hospital. Ex : Anesthesia in Paris. The benefits I see vs "The Match" are numerous : Students don't have to force themselves to publish X amount of papers they don't actually care about. They don't have to pursue leadership roles solely to look good on a CV. They don't have to make up an inspiring story as to what motivated them to pick the specialty or program or to beg people to write them glowing recommendation letters. So it cuts down on a lot of lying or BS. They also don't have to apply to a million different places, which means they save on fees, stress and travel expenses. They can't be rejected by the specialty/city they end up getting, if the spot is still available by their turn, that's where they're going. It also pretty much eliminates any potential nepotism or bigotry since all the power is in the student and his exam result. Finally since the amount of spots available is decided by the state based on needs it helps with distribution of specialists, there are definitely going to be 3000+ family medicine residents simply because people who are low enough won't have many other positions left... Some drawbacks that are immediately obvious as well : Only academic performance (of a couple days mind you) matters, meaning someone who is a genuinely a great person, maybe tailor-made for a specific specialty, has an authentic beautiful story behind them but doesn't succeed on the test can kiss bye bye to becoming an opthalmologist...On the opposite end, someone who is a terrible person or terribly ill-suited for a specialty may just still get there simply because they're very good on tests. It also incentivizes spending as much time book learning as possible over making the most out of rotations. Some students even ghost their rotations to study instead.
I watched all the 6 videos in the Match playlist - for the second time :d. And I came across that the Gale-Shapley algorithm for stable matching won 2012 Nobel prize for Economics (e.g. Wikipedia Gale-Shapley algorithm). Very intriguing 😅
Nice series! I didn't match and I soaped into EM after originally applying to anesthesiology. This series really made me realize that I underapplied and obviously didn't play the game right. But, I did get multiple offers from multiple different specialties during the first round of soap, which was nice and I had the power to choose where I really wanted to be and ended up selecting a great EM program, so it all worked out!
These days the durations of residency are so long, while the residents and fellows are the main workhorse of hospitals, especially for public hospitals, but with such low salaries.
To address point 1; I think this would still occur in specialties which struggle to fill routinely.
I don’t think the market would actually sort itself out for residency. There is a large asymmetry in terms of the places and programs which are highly desirable to applicants.
There still needs to be a SOAP process at least to fill places that don’t fill. We actually need to fill slots efficiently in order to optimize the volume of the medical workforce being trained.
I just cannot see an efficient allocation of students to spots if they all just did a mad dash on their own.
I don’t see any serious problem with the Match, only benefits. The major issue is the monopsony power of the match as the sole buyer of resident labor artificially depresses resident wages. This can be solved by unionizing in individual programs.
I’m not entirely convinced that all bad behavior would be unproblematic without a match either. We see anecdotes all the time of applicants getting screwed in shady prematch offers. There is legal recourse for this yes, but this is an additional set of stressors for vulnerable students to deal with when they’re already under duress.
As to the question of whether residency selection is more chaotic with the match, I personally don’t think it is. A signaling system or strict application caps could solve the increased rate of applications amongst applicants. This really depends on whether you really believe that other labor markets are efficiently allocated; I don’t see good proof that attending job markets are well allocated. They don’t have nearly the same levels of centralization and rely on asymmetric information levels working through individual recruiting agents and agencies and one’s own personal search. None of these are more well allocated than a match! I would go ahead and argue that just because other labor markets don’t have a match does not mean they are well allocated either.
You can get monopsony or oligopsony situations regardless of a match. If one health system is responsible for most of the hiring of new attendings in a region you don’t have a free market by any means.
Also disagree on the resident salaries thing! It would not raise across the board, it would simply become asymmetric. Programs in rural areas would offer competitive salaries relative to places everyone is vying for. Urban popular programs would offer terrible salaries and people would still sign up.
Same as how it works for attending salary markets.
The only caveat here is that people aren’t adequately invested in improving resident wages because people have long viewed it as a temporary state before they enter a good life. This outlook is changing over time.
And what you said about matched fellowships affecting the market in non matched fellowships is correct. It’s the same concept as to why the presence of some unions affects the broader labor market for people who aren’t in the union.
Nonetheless, this was an elaborate video and I enjoyed watching it even if we have points of disagreement! Cheers
Hi Dr. Carmody: would you know the force and process that lead to the change of STEP1 to pass or fail?
Oh, I know quite a bit about it. What in particular did you want to know?
@ I think it’d be so cool to have Part 7 to this series to bring the USLME exams up to date, with some descriptions about the forces and process to turn STEP1 into Pass/Fail and possibly also will turn STEP3 into Pass/Fail as an one-day test instead of two.
Been watching these every day as soon as they come out. Incredibly well done! Hope you continue to make these kinds of videos. Such a great compliment to what you do in your blog
This was extremely informative and well presented. It gave a great history and presented the issues of the past and present system with clarity. Thank you!!
Thank you. I appreciate you taking the time to watch and think about these things.
Thank you for a very informative series. It must have taken so much effort to find this information and assemble it so effectively. I hope that we can implement either ERAP or an interview match. I also hope that more programs will agree to a universal interview offer date
Thank you so much for making these videos. As a medical student it’s been very enlightening to learn some background on the Match.
Your discussion of bargaining for salary in a world without the match raised a question for me. Given the supply/demand issue with residency selection in the status quo, why do you think resident salaries aren’t even lower than they currently are? Especially since it seems that in the current climate many graduates would be willing to work for less money in residency if it meant they got to pursue their specialty of choice.
Shhhhh!!! They’re gonna hear you!
Actually, I’ve pondered the same question. The answer, I think, relates to the history of resident salaries. I thought about getting into this in the video but didn’t for brevity’s sake.
Some older physicians get salty when you use the term “salary,” and many programs won’t even use this term on their website, preferring instead to call it a “stipend.” The issue here is that, in the old days, hospitals were explicit about how residents were NOT receiving wages for their labor. Instead, they were receiving some money to support them while they continued their education. The exact figure was determined based on the cost of living in the area, and was intended to support modest living expenses. From the beginning, there was a deliberate (and successful) attempt to divorce this figure from what a doctor - even an inexperienced one - might earn in the free market.
Many deans, department chairs, etc. still cling to this idea - even though both the Supreme Court and the National Labor Relations Board have ruled that resident physicians are definitely workers, not students. Still, if hospitals decreased wages, it would fly in the face of this long-held belief. Instead, it’s easier to keep the old schedule and just provide a cost-of-living increase.
Moreover, residents already provide a large and positive financial impact on their hospitals, so there’s no need to trim costs - and there’s risk in doing so. When all hospitals pay their residents essentially the same amount, everyone wins. But if you stand out from the pack by offering a lower salary, applicants will take that into consideration and it may hurt recruiting in a matched system.
Wondering about your thoughts about how doing away with the match would influence the costs which burden individuals going through the interview process. It seems in other job markets for highly educated applicants, employers are keen to remove fiscal barriers to getting applicants to interview. Do you think this would hold in the residency space or do you think nothing would change given your the discrepancy between open positions and applicants?
Also, if there was no match do you think that would free people from the current “locked in” situation. Without the match do you think there might establish separate labor markets for interns, second years, third years, etc? Perhaps that might incentivize programs to do more to keep trainees once they have them?
This channel is an underrated gem, I really appreciate your work! I would love to reach out to you with my personal story as my wife and I are struggling with the match process...
Thank you for your kind words… and there’s a contact form on my site (thesheriffofsodium.com).
Watching this series has been very interesting. The way it's worked in France for the last however many years is med students take a massive national synchronized exam and they get ranked on that exam from the number 1 best in the country to the very worst. There's a set amount of positions for each of the 44 specialties and each city based on perceived public health needs and then the students just pick in order of their rank.
Let's say there's 26 plastic surgery spots across the country, you'd better be in the top 1000 students if you want to get a spot. Whereas there are 500 spots for psychiatry and it's not the most popular specialty so any student on the list from 1 to 9000 is guaranteed a spot. There is no other metric than that one (admittedly pretty huge) exam. There's not even an interview, to be fair here residents can rotate through all the hospitals in the region and change rotation every 6 months, so you're going to a region-specialty combo as opposed to a specific hospital. Ex : Anesthesia in Paris.
The benefits I see vs "The Match" are numerous : Students don't have to force themselves to publish X amount of papers they don't actually care about. They don't have to pursue leadership roles solely to look good on a CV. They don't have to make up an inspiring story as to what motivated them to pick the specialty or program or to beg people to write them glowing recommendation letters. So it cuts down on a lot of lying or BS.
They also don't have to apply to a million different places, which means they save on fees, stress and travel expenses. They can't be rejected by the specialty/city they end up getting, if the spot is still available by their turn, that's where they're going. It also pretty much eliminates any potential nepotism or bigotry since all the power is in the student and his exam result. Finally since the amount of spots available is decided by the state based on needs it helps with distribution of specialists, there are definitely going to be 3000+ family medicine residents simply because people who are low enough won't have many other positions left...
Some drawbacks that are immediately obvious as well : Only academic performance (of a couple days mind you) matters, meaning someone who is a genuinely a great person, maybe tailor-made for a specific specialty, has an authentic beautiful story behind them but doesn't succeed on the test can kiss bye bye to becoming an opthalmologist...On the opposite end, someone who is a terrible person or terribly ill-suited for a specialty may just still get there simply because they're very good on tests. It also incentivizes spending as much time book learning as possible over making the most out of rotations. Some students even ghost their rotations to study instead.
This is very interesting - I had no idea how things worked in France. Thank you for sharing (and watching).
I matched this year. Interesting to find out the how the match evolved and why it is here to to stay.