The Residency Match: Escaping the Prisoner's Dilemma

Abstract

In December 2020, the Association of American Medical Colleges sent an unprecedented letter to program directors, student affairs officers, designated institutional officials, and medical students describing residency interview hoarding and maldistribution. The letter highlighted that students in the highest tiers of medical school were receiving a disproportionate number of interview invitations, leaving fewer opportunities for other students. 1 The COVID-19 pandemic exposed fault lines across society between the haves and have nots, 2 and medical education was no exception. Behaviors such as hoarding (eg, hand sanitizer, interviews) can be predicted by inherent inequities in systems like the residency Match within which people act in their own self-interest.The term ''match'' denotes both the process of connecting 2 things and a contest in which people or teams compete against one another. Current participants in the residency Match spend ever-increasing amounts of time, energy, and money for diminishing returns, often displaying behaviors rooted in fear and half-truths. 3 Despite multiple calls for reform, the problem continues to worsen. 4,5 Most proposed solutions do not fully address the underlying motivators and at best offer limited improvements. 6,7 Building on the recent discourse in the medical literature, 5,[8][9][10][11][12] we use the concept of the ''prisoner's dilemma'' to explore drivers of student, program, and institutional behaviors. Although others have used this framing in the past, we delve further into underlying motivations behind the actions we see in the Match and suggest a different path forward. We challenge academic medicine to devalue normative comparison in favor of high-level reproducible competence as the criterion for medical school graduation and residency selection.

The education passport: connecting programmatic assessment across learning and practice

“…16 Hiding weaknesses and competing to gain the "best" residency positions are the dominant motivations within medical school, and only cursory summations of performance are communicated to the next level of training. 17 The same tensions continue throughout residency and fellowship, and the problem deepens. In practice, the business of medicine demands the best clinical outcomes, the highest volume, the fastest throughput, the greatest patient satisfaction, the largest knowledge base, and the most innovative discoveries.…”

An Outcomes-Oriented Approach to Residency Selection: Implementing Novel Processes to Align Residency Programs and Applicants

“…Many applicants will subsequently feel pressure to signal “big name” or “dream” programs, rather than those that are better aligned with their values and priorities, to have any chance of obtaining an interview at those programs. 3,9 And without transparency from programs, it will be difficult for applicants to get reliable information to inform their signaling practices.…”

“…It is nearly impossible to ask students to apply to fewer programs in the current climate, when they know very little about the programs to which they are applying. 9 And while programs may be able to provide additional information about their general aims or training philosophy, primary training environment, patient population served, and other core details, this information is often insufficient for applicants to firmly identify if their values and priorities align with those of the program. The goal of residency selection should be to achieve a mutual "match" so the applicant can thrive as a resident and the program can achieve its training outcomes.…”

“…First, there is a significant fear amongst students of not matching, which drives this phenomenon of overapplication. 3,8,9 Capping applications, implementing an early Match, or adopting a preference signaling process will not sufficiently address this deeply rooted fear. These proposed logistical interventions will be unpalatable to applicants in the absence of solutions to also address the broader issues with the selection process itself.…”

Designing the “match of the future”: challenges and proposed solutions in the interview and match phase of the UME–GME transition

“…Establishing consensus and coordination from a large number of training programs and other stakeholders may be one of the greatest obstacles to implementing major modifications to the match process [63]. Importantly, stakeholders including students, residency programs, medical schools may have to shift from a "prisoner's dilemma" or "arms race" mindset in which behaviors that appear to be selfserving result in globally less optimal outcomes [68,83]. Additionally, changes will require cooperation from organizations such as the NRMP and AAMC/ERAS that could financially benefit from the fees generated by an increasing number of applications [21].…”