A Job or More School? Young Doctors Take On 'The Match'
Date 04/16/2004 12:26:00 pm | Topic: Special Articles
| By ALEXI WRIGHT and INGRID KATZ, NYTIMES.COM
Last month, 25,000 medical students held their breath and peeled open white envelopes to learn where they would spend the next three to seven years of their lives.
For more than half a century, the match, as the process of pairing graduating medical students with residency programs is called, has been a rite of passage. A computer does the matching. The results, announced at noon Eastern time on the third Thursday in March, control where the best and the worst doctors are headed and shape health care for millions of Americans.
Recently, however, the match has come under increasing scrutiny, with some residents' arguing that the process shortchanges the students.
In February, a federal court denied a motion to dismiss a class action suit contending that the match violates antitrust laws by denying students opportunities to negotiate the terms of employment.
Medical residency occupies a singular space between education and employment. After four years of medical school, the graduates are technically physicians, but they are not yet certified to practice medicine. Instead, they work under trainees' licenses, supervised by the hospitals that employ them.
"I see residency as a continuation of my training," said April Armstrong, a Harvard medical student who this year applied for a residency in dermatology. "But for a lot of us, it's also the first time we have a real job."
Residents are required to work longer hours than staff physicians, and they are paid far less.
Salaries for the first year of residency, called internship, match the median incomes for their geographic regions. Nationally, the average intern earns $39,800 a year, or $10 an hour for an 80-hour workweek. In comparison, the median starting salaries of staff physicians vary from $120,000 a year for pediatricians to $380,000 a year for neurosurgeons.
"Residents have always been a source of cheap labor," said Dr. Kenneth M. Ludmerer, a professor of history and medicine at Washington University in St. Louis and the author of "Time to Heal," a history of American graduate medical education.
"Since the beginning, a fundamental tension has existed between education and service," Dr. Ludmerer said.
In the suit, filed in 2002 by three former residents, the plaintiffs say graduating medical students should be able to negotiate wages and work hours. The medical associations and hospitals named as defendants in the suit contend that the match system compensates residents fairly.
The Federal District Court in Washington ruled on Feb. 11 that the residents who sued had an adequate basis to argue the existence of "a purported scheme of restraints that has the purpose and effect of fixing, artificially depressing, standardizing and stabilizing resident physician compensation."
Graduates of medical schools now sign binding work agreements with residency programs the minute they file their applications, before most hospitals have announced the wages. A new policy, to take effect next year, will require that residents be shown copies of their contracts before committing to programs.
The concern over salaries is heightened by the fact that medical students often carry enormous debts. In 2003, the average debt of a medical student was nearly $110,000, double the figure in 1993.
A typical monthly loan payment can be a quarter of a resident's salary. As a result, many residents defer their loans, choosing to pay them off after residency. But interest continues to accrue, and many residents require 30 years to pay off the full amount.
Increasingly, students take income into account in choosing medical specialties, studies indicate.
Critics of the match system also argue that it takes advantage of residents by making them perform a significant share of the menial labor in hospitals, including drawing blood, moving patients and carrying out administrative work.
Still, many residents and doctors say the match improves on the haphazard process that preceded it.
Before 1952, when the match started, students applied to residencies individually. Each program reviewed applicants' grades, class standing and recommendations. Some also required oral and written examinations that lasted two days.
"In the era before the match, residencies responded at different times," Dr. Ludmerer said. "There was enormous pressure to decide at the moment. The process forced students to make rash decisions."
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He added, "The match brings equity, fairness and sanity."
Experts have compared the match to college fraternity or sorority rush. Each year from September to March, senior medical students and residency programs court each another in a long and subjective process. After months of interviewing, the students rank their choices in order — and so do the programs.
Each field has tiers of prestige. The top-ranked academic teaching hospitals — Harvard, Johns Hopkins, the University of Pennsylvania, Columbia, Yale, Washington University, Stanford and the University of California at San Francisco, among others — are the most competitive.
Residency selections shape future job opportunities, and headhunters recruit heavily at top programs.
At the end of February, the rankings compiled by the two sides are submitted to the National Resident Matching Program, which oversees the match. Then students and program directors sit and wait while a computer matches the applicants with the programs.
On match day, medical students across the country gather. According to tradition, students are handed sealed white envelopes with their results. At Harvard, students line up in front of the registrar's desk to receive their envelopes. At Penn, students' names are picked at random from a hat and, one by one, they march across a stage to receive their envelopes. At other institutions, the results are read aloud.
According to the national matching program, 80 percent of medical graduates match at one of their top three choices. Each year, however, an average of eight or nine medical students in each school do not match anywhere. Those students are notified on the Monday before the match, a day called Black Monday.
In a process referred to as "the scramble," unmatched applicants frantically fax, call and e-mail unfilled programs trying to secure positions. Many switch specialties.
Although it is easier to get into residency than medical school — residency positions outnumber the American medical graduates to fill them — applying for residency is one of a medical student's most stressful periods.
"Anyone in medical school is used to being No. 1," Dr. Nancy E. Oriol, associate dean of student affairs at Harvard, said. "Students take this as seriously as getting married, and a second choice can feel like a failure."
Since its creation in the 1870's, the first year in residency has been a marriage of convenience. Medical schools realized that four years of school was not enough to prepare doctors to practice but that the schools lacked resources to extend training.
Hospitals, eager to meet the demands of providing care for growing numbers of patients, created one- to two-year internships.
In the early years, interns did not receive salaries. They lived in the hospitals, were on call every other night and were prohibited to marry. After World War II, interns began to be compensated.
Last month, Daniel Garza, a fourth-year student at Harvard, lined up with his classmates to learn his fate.
Born in a predominantly working-class immigrant neighborhood of Los Angeles, Mr. Garza was, he says, "lucky to be one of the few who not only graduated from high school, but went on to college."
He peeled open his envelope with trepidation. But he need not have worried: he had been chosen by Harbor-UCLA Medical Center for its residency program in radiology, one of the most competitive fields.
Ms. Armstrong, too, was jubilant. She and her husband, also a medical student, had spent three months and $10,000 flying around the country to interview at 43 programs, and they hoped to find placements together.
But dermatology, her specialty, is a hard field to enter.
"Forty percent of applicants do not match," Ms. Armstrong said.
Shortly after noon, however, she breathed a sigh of relief.
She received her first choice, a residency at a Harvard-affiliated program, and so had her husband.
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