Out-of-Match Residency Offers: The Possible Extent and Implications of Prematching in Graduate Medical Education

Abstract

Background When the data from the National Resident Matching Program (NRMP) are used to analyze trends in medical students' career preferences, positions offered outside the match are omitted. The purpose of the study was to evaluate the extent and nature of out-of-match residency offers. Methods We obtained total resident complements and postgraduate year-1 positions offered in 7 specialties in 2007 and compared these with the 2007 NRMP match data. We compared the percentage of positions offered outside the match to “success” in matching United States medical doctors (USMDs) and to the availability of fellowship positions, using the Spearman rank order test (SROT). Results A total of 18 030 postgraduate year-1 positions were offered in 9 specialty areas. Of 15 205 positions offered in the match, 54% were taken by USMDs. The percentage of outside-the-match offers was found to vary by specialty, from 7% in obstetrics-gynecology to 23% in internal medicine, and was inversely correlated with the specialty's “success” in matching USMDs (SROT = −0.87). The 3 nonprocedural primary care specialties (internal medicine, family medicine, and pediatrics) accounted for 10 091 (46.2%) of the 21 845 total positions offered in the match, with 4401 (43.6%) offered almost entirely to non-USMDs. Another 2467 positions were offered outside the match, resulting in 6868 positions offered to non-USMDs (55% of all primary care positions). In internal medicine, the percentage of outside-the-match offers was significantly and inversely associated with the availability of intrainstitutional fellowship programs (P < .0001). Prematching of independent applicants was significantly higher in primary care than in procedural-lifestyle programs (P < .0001). Conclusion The NRMP's match data do not account for positions filled outside the match, a finding that appears to be significant. In 2007, 1 in 5 positions in primary care was offered outside the match.

Strategic complementarities and unraveling in matching markets

“…In the market for interns, some interns are allowed to take outside-the-match offers (for instance, osteopathic medical students and international medical graduates). Wetz et al (2010) find that 15 7% of the total number of postgraduate year-1 positions available in the three primary care and four procedural and/or lifestyle-oriented specialities studied, were offered outside the match. The authors conclude that about one in five positions in nonprocedural, primary care specialties were offered outside the match and, thus, the situation is similar to that which existed before 1952.…”

“…There is evidence that unraveling still exists in this market: Wetz et al (2010) study out-of-match residency offers during the year 2007. In the market for interns, some interns are allowed to take outside-the-match offers (for instance, osteopathic medical students and international medical graduates).…”

“…Ours is the first theoretical study that identifies strategic complementarities as the main force behind the unraveling of matching markets. One empirical investigation of the market for medical interns also attributes unraveling to strategic complementarities: Wetz et al (2010) write that early contracting is motivated by concerns over losing interns to other programs that operate outside of the centralized algorithm. Their explanation, based on agents' observed behavior in the market, is essentially what we have tried to capture formally in the present paper.…”

“…The best known episode of unraveling is the case of the market for hospital interns before 1945 (Roth 1984, 2002, Roth and Oliveira Sotomayor 1990. There is evidence that unraveling still exists in this market: Wetz et al (2010) study out-of-match residency offers during the year 2007. In the market for interns, some interns are allowed to take outside-the-match offers (for instance, osteopathic medical students and international medical graduates).…”

Rigidity of Transfers and Unraveling in Matching Markets

“…For example, the new arrivals may be unobserved agents, due to the imperfection of information in the first period. In student-job matching, the new arrivals can be new job openings on one side, 1 Wetz, Seelig, Khoueiry, and Weiserbs (2010) estimate that in 2007 one in five resident positions in primary care specialties was offered outside of the centralized National Resident Matching Program (NRMP); the data in Wetz, Seelig, Khoueiry, and Weiserbs (2010) suggests that unraveling still exists in the medical resident market, reminiscent of the situation before the introduction of NRMP.…”