Make Me A Match

Where did you match?” echoed through the halls of many a medical center last June, as prospective rheumatology fellows found out where they were going for their subspecialty training. Ever since the ACR adopted the match, a computer-based system of pairing fellowship applicants with training programs according to the preferences of both, “Match Day” has been a heavily anticipated day for applicants and program directors alike. Before this system was in place, training applicants received fellowship offers over a non-uniform timetable. As a result, they often felt pressured to accept training positions before knowing the range of opportunities that might be available to them.

Professionalizing a Chaotic Process

According to Walter G. Barr, MD, professor of medicine at Northwestern University Feinberg School of Medicine in Chicago, director of the rheumatology training program there, and chairperson for ACR’s Committee on Training and Workforce Issues, the match was adopted to provide an orderly and fair selection process. “The match has professionalized a chaotic and unregulated selection process that for too many years did not serve the best interests of applicants or the training programs,” he says.

The match has been in operation for two years, and so far the results have been encouraging. “I was definitely glad rheumatology had one application, one deadline,” says Peggy Wu, a first-year rheumatology fellow at Northwestern Medical Center. “Because I only had one deadline, I was able to visit and interview at every program [I was interested in] without the pressure of having to make a decision until later. … [I had] time to even revisit some programs to make an informed decision. And I ended up where I wanted to be.”

Program directors concur that the experience to date with the match has been excellent. According to Michael H. Pillinger, MD, associate professor of medicine and pharmacology at the NYU School of Medicine, director of the rheumatology fellows’ training program there, and chairperson for the ACR’s Training Resources Subcommittee, the technical aspects of the matching process went smoothly. “Ninety-four programs participated in the 2006 match, compared to 88 in 2005. Ninety-six percent of the fellowship positions were filled in the match, and the few programs that had unfilled positions after the match successfully filled their training programs with well-qualified candidates.”

David Daikh, MD, PhD, assistant professor of medicine at the University of California, San Francisco Medical School, director of the rheumatology training program there, and chairperson-elect for ACR’s Committee on Training and Workforce Issues, agrees. “Participants are following the procedures and rules appropriately,” he says. “The match is a real step forward for rheumatology.”

A Multitude of Applications and Timelines

Before the match was instituted, the process was more involved and time-consuming for residents and program directors alike. “The old ‘system’ amounted to every program having its own rules/applications and interview schedule,” explains Carlos Lozada, MD, associate professor of medicine at the University of Miami Miller School of Medicine, director of the rheumatology fellows’ training program there, and chair of the Electronic Residency Application Service/Match Task Force.

Individual applications were completed 18 months to two years in advance of the start date. Each program had its own requirements and deadline. Program directors then sorted the applications and selected applicants for interview. Applicants went on interviews, often interviewing with one program months before another. Program directors then began making offers to selected candidates. Frequently, an applicant was asked to make a decision about an offer before knowing if he or she would receive other offers.

According to Dennis W. Boulware, MD, senior associate dean for academic affairs at the University of Alabama Health System and past president of the Association of Subspecialty Professors, “It was not uncommon to be given an offer and have to make a decision within a day—or even an hour.”

Program directors found it disadvantageous to allow an applicant significant time to think over an offer. If the applicant rejected it, their next choice for the position may have already accepted an offer elsewhere. As a result, some program directors began to offer training positions to applicants earlier and earlier in the process.

In reviewing these scenarios, the Committee on Training and Workforce Issues, whose responsibilities include overseeing the application and acceptance of fellows into rheumatology training programs, identified many areas of concern in the pre-match system:

1. Each program had its own paper application.
2. Each program had its own timetable for receiving applications and conducting interviews.
3. The application process started early in the second year of medical residency. This factor may have limited the number of internal medicine residents who would apply for rheumatology fellowships because of lack of contact or experience with this subspecialty.
4. Applicants felt pressured to accept positions before receiving all potential offers, causing anxiety and limiting their ability to obtain their first choice.
5. Program directors felt pressured to offer positions to multiple applicants simultaneously, as it was unclear who had already accepted a training spot. Occasionally, this led to the worst-case scenario of having to rescind an offer if too many applicants accepted.
6. The variable timetable of this process made it difficult for applicants to examine different regions of the county for their subspecialty training. Residents tended to stay “close to home,” and were less likely to seek out a more varied experience at a distant hospital.

Universal Electronic Application

In recognition of these problems, the ACR adopted the match, and also the Electronic Residency Application Service (ERAS) universal application. Since the commencement of these programs, potential rheumatology fellows begin the application process by utilizing ERAS. This service supplies a universal online application and allows applicants to virtually attach transcripts, letters of recommendation, tests scores, and other credentials.

After preparing the application, the potential fellow electronically selects training programs to which to application is to be sent. The application is then sent to the program directors of the selected sites, who may then download the application for review. Program directors select applicants for interview based on this application. Interviews are conducted over a fairly uniform timetable for all participating programs. While completing interviews, applicants and training programs register for the match.

The match itself is conducted by the National Resident Matching Program (NRMP), a private, not-for-profit organization. This corporation was chosen because of its vast experience with the residency match. NRMP uses a computer-generated algorithm to pair applicants with training programs in a way that favors the highest choice of the applicant. Applicants and program directors each create what is commonly known as a “rank order list.” For the applicant, it consists of a prioritized list of training programs; for the program directors, a similarly stratified list of previously interviewed applicants. Both lists are submitted online to the NRMP, which impartially conducts the actual matching process.

The results are released for training programs and applicants on a predetermined date (at which point both parties usually let out a collective sigh of relief). It is possible that a training position may go unfilled—even in the face of a surplus of applicants. In this situation the unmatched applicants have the option of calling program directors of the unfilled training programs to directly ascertain a spot. This process is not-so-fondly referred to as “scrambling.”

A Level Playing Field

The matching process is straightforward enough, but there is a caveat. The integrity of the match rests upon both parties adherence to the “cardinal rule” of the NRMP. That is, there are no behind-the-scenes handshakes, winks, or other preconfigured agreements between applicants and program directors to rank each other first.

However, according to Alvin Roth, PhD, the George Gund professor of economics and business administration in the department of economics at Harvard University, who extensively researched the gastroenterology fellows’ match, so long as the rules are endorsed by the overseeing organization, potential fellows are likely to go through with the match even if offered outside agreements. This in turn gives confidence to the subspecialty community that positions will be offered and filled through the match.

The Committee on Training and Workforce Issues hopes that the adoption of the match will result in an even larger pool of well-qualified applicants for rheumatology training positions, and the continual advancement of training programs. According to Dr. Barr, “The match levels the playing field for programs as they compete for the best applicants. Undoubtedly the increased competition will lead to improvement in our training programs. Most importantly, the residents who choose rheumatology are assured of the best opportunity to match their career goals with the most suitable program.”

Dr. Landis is a rheumatologist and freelance writer.