In the November 10 issue, Davin Quinn wrote about the National Residency
Matching Programs reasons for keeping the Match in place. While he correctly
summarized some of the arguments on the webpage (savethematch.org),
the issues surrounding the lawsuit against the Match go beyond simply doing
away with a dated system. The motive for filing the lawsuit is easy to
understand. It is money, or more specifically, the lack of it. Residents
earn low incomes and usually have huge financial burdens in the form of
medical school loans. But new interns are not at all like the Joads of Mr.
Quinn's literary reference (who traveled to California, not Oklahoma,
following promises of good wages).
Medical student know what they are getting into when they apply, and if
they do not, they learn rather quickly. Low residency salaries and big
educational loans are practically part of the curriculum. While we all
worry about that segment of our training and how we will manage, I am not
convinced that getting rid of the Match will solve our problems.
According to a study published in JAMA by economists Muriel Niederle
and Alvin Roth (JAMA 2003; 290:1153-1154), fellowship salaries
are unrelated to the presence of a match program. They suggest that
eliminating the match for residencies will not necessarily increase
resident salaries. Critics of this study maintain that the fellowship
market cannot be compared to the residency market. Niederlie and Roth
argue that comparisons of both fellowship and residency programs
before and after adoption of a match program, as well as similar
studies in the British medical market indicate that instituting a
match actually benefits residents and fellows. They conclude that
there is no evidence to support the claim that the match keeps
salaries low. (On the other hand, the AMA is listed as a defendant in
this case, so it's not surprising they would print this.
Coincidentally, Dr. Roth is the author of the algorithm used to
match students with residencies).
If you believe that getting rid of the Match will raise salaries
regardless of what these economists claim, there are implications for
the hospitals that might make the situation unpleasant for both future
residents and patients. An increase in salaries would place financial
burdens on hospitals already in fiscal trouble. Some might decide to
decrease the number of residents they take, or even get rid of their
programs altogether. While the reduction in the number of residency
spots might be good for the compensation of those who are still left
standing, the ultimate result would be fewer physicians trained and
decreased access to care.
While residency reform is clearly desired, a lawsuit is a bad way
to go about it. Besides the AMA, the defendants include the AAMC,
NRMP and the American Hospital Association as well as numerous
institutions, including BIDMC, Boston Medical Center and MGH. The
plaintiffs are not only seeking an injunction on the match program,
but monetary damages as well. All residents enrolled in
ACGME-accredited residency programs and subspecialty fellowships
since 1998 (~200,000 people) would be eligible to participate. In
return for a small reimbursement to the residents, a victory or
other settlement could do significant harm to the medical system,
especially when lawyers take 1/3 in fees.
The new 80-hour work week might be the first step in the direction
towards a residency reform that includes better pay. While it might
take longer to accomplish using administrative associations, a
solution worked out by physicians instead of lawyers and judges
sounds more beneficial in the long run. Until then, we might just
have to take Dean Cox's advice and "suck it up."