In1 .I. Rndiamn Oncology BioL Phys Vol. 22. pp. 114771154 Printed in the U.S.A. All rights reserved.
Copyright
0360-3016/92 $5.00 + .oO 8 1992 Pergamon Press Ltd.
??Technical Innovations and Notes
THE RESIDENCY
MATCH ALLEN
Department
S.
IN RADIATION LICHTER,
ONCOLOGY
M.D.
of Radiation Oncology, University of Michigan Medical Center, Rm. B2C490, Box 0010, 1500 E. Medical Center Drive, Ann Arbor, MI 48 109
Centralized matching of postgraduate training positions has been successfully implemented nationwide since 1951. Specialty and subspecialty matches have proliferated in the 1970’s and early 1980’s, and Radiation 0ncol)gy was the last residency program that did not have a centralized match arrangement. Responding to press&s from training program directors who were dissatisfied with the non-centralized matching of resident applicant , made especially acute by a rapid increase in the number of students interested in Radiation Oncology, the first ten b lized matching program for Radiation Oncology--the Radiation Oncology Matching Program (ROMP)-began in 1989. Two years of experience with the ROMP are summarized in this paper. Interest in training positions in diation Oncology remains high, with approximately 1.3 to 1.5 qualified applicants per each residency position. Th “k major problem with the current arrangement in ROMP is lack of full participation. In 1989, approximately 70% of first year positions were offered through ROMP, and in 1990 this was closer to 60%. While the majority of pl/ograms desire and participate in a centralized match, participation at less than an 85 to 90% level will likely duse the centralized match to disband. Reasons for and against a centralized matching process and a history of niatching programs in other specialties are discussed. Internship and residency, Medical education, Residency training in radiation oncology. INTRODUCTION
1.
2.
Ever since “straight” training in Therapeutic Radiology began in the 1960’s, directors of training programs and prospective resident applicants have had to interview and accept one another-in other words, match-as training partners for the 3 years of clinical residency training. Until relatively recently this matching of training programs with resident applicants was accomplished in an ad hoc fashion. While there was a loosely defined “gentleman’s agreement” not to offer training positions until late in November or early December, the application, interview, and acceptance process was driven almost entirely by the whims of each individual program. The non-system of residency matching worked reasonably well while there were relatively small numbers of candidates interested in the field of radiation oncology and while a substantial portion of residency slots remained unfilled. However, with the rapid increase in the number of prospective candidates interested in a career in Radiation Oncology, and with the filling of all residency slots which occurred in 1984 (Fig. l), discontent began to be voiced by the majority of training program directors concerning the ad hoc residency match arrangements. Program directors were searching for a system that:
Accepted
for publication
3 September
3. 4. 5.
Provided a uniform and rigidly observed date for extending residency offers; Offered freedom for candidates to interview as many programs as they desired up until the’offer date; Allowed freedom for programs to interview candidates right up to the offer date; Allowed candidates and programs to express their preferences fully and confidentially; amd Did not relinquish control of the selection process from the candidates or programs; that is, noI program would be required to accept a candidate that they did not wish to have in their program, and no candidate would be required to train at a program in which they did not wish to train.
In reflecting upon these stringent requirements and after 2 years of spirited discussion and debate, the Society of Chairman of Academic Radiation Oncology Programs (SCAROP) decided to sponsor a centralized residency match procedure for our field, similar if not identical to the matching programs that exist in every other PGY 1 and PGY 2 specialty field. This article will review the history of the centralized match process, discuss its application in other specialty fields, and review the experience in the Radiation Oncology Matching Program (ROMP) for 1989 and 1990.
199 1. 1147
1148
I. J. Radiation Oncology 0 Biology 0 Physics
Trends in Residency Training 1
*is Year
Fig. 1. Number of first year residents in training and percentage of first year positions filled for 1968 through 1988. (6)
HISTORY OF THE CENTRALIZED MATCH PROCESS
In the late 1940’s, competition between hospitals for internships became heightened as the number of approved internships exceeded the number of senior medical students by a factor of two (10). High-quality, prestigious programs with many more applicants than positions generally made their offers late in the students’ senior year of medical school, while programs with few applicants sought to recruit medical students early in the senior year. When students received internship offers, they had to carefully assess their chances and decide whether to take a sure offer from a lower quality institution or decline the offer but risk not receiving a later offer from a more prestigious institution. Program directors were equally perplexed. If a program filled its positions early on, it would not have room for a more desirable candidate who interviewed late in the process. On the other hand, if they left too many positions open for later in the year, they might not fill all of their available openings. A so-called “gentleman’s agreement” was tried from 1945-49 indicating a uniform date that hospitals could extend offers to students (11). This effort at adding decentralized structure to the match process was a failure. Finally, in October 1950, an organization called the National Interassociation Committee on Internship was formed and initiated a centralized matching system. As indicated by F. J. Mullin in the original description of the plan ( 17). “It (the plan) benefits applicants and hospitals by giving full recognition both to the student preference and to the hospital’s evaluation of its applicants. It prevents unfair pressure forcing students into early commitments, often to their detriment. Under the plan the student will not be required to make a decision on the basis of a telephone call or within a very limited period of time. . . . The matching plan does not remove the personal element from the selection procedure. The student may visit the hospitals to which he wishes to apply, talking to officials and
Volume 22, Number 5, 1992
others there. He makes individual applications to the hospitals of his choice just as at present. . . . Hospitals will be free to contact any eligible students and to request personal interviews or other procedures they deem desirable. Under this system, complete freedom of applying any criteria for selection is fully preserved for both the hospitals and the students.” The plan was immediately successful, with more than 95% of students obtaining their internship through the centralized match, the remaining few percent filling mostly non-match military slots (11). Most of us practicing radiation oncology today received our internship position through this program, which became known as the National Internship Matching Program (NIMP). Then, in the 1960’s, residencies began to proliferate and the number of unfilled but approved residency slots began to grow. The competition for first-year residencies (PGY 2 positions) began to accelerate, and the same problems that were seen in the late 1940’s with the internship began to appear in the 1960’s with the residency (11). A number of medical specialties introduced their own “gentleman’s agreement” for a uniform date of residency appointment. In the 1960’s, Psychiatry (2), Radiology (13), Orthopedic Surgery (5), Pediatrics (3), and Dermatology (16) tried their own centralized matching programs. The first four failed, generally because an insufficient number of programs participated. In 1968, the Millis report of the Citizens’ Commission on Graduate Medical Education appeared and recommended that the internship be abolished and be integrated with the first year of residency (10). The NIMP became the National Internship and Residency Matching Program (NIRMP) (7). The primary care specialties such as Family Practice, Pediatrics, Internal Medicine, and Obstetrics and Gynecology began to eliminate the traditional internship and integrate the PGY 1 year directly into residency. Finally, in 1978 in recognition that residencies were being offered to senior students in almost all specialties, the NIRMP changed its name to the National Resident Match Program (NRMP), which remains its appellation today (10). By the early 1980’s, the NRMP began to provide centralized matching services to specialties that still required a general PGY 1 year such as Diagnostic Radiology and Anesthesiology, a program called Advanced Positions for Students. Other specialties such as Neurosurgery, Ophthalmology, and Neurology formed their own independent centralized match systems based on NRMP guidelines. The algorithm used in centralized matching systems in the United States essentially matches each student to their highest ranking hospital that extends them a match offer ( 10). The algorithm first extends an offer from each program to each of its first choice applicants. The applicants tentatively accept the offer if it is from their highest ranked hospital. These applicants’ names are then removed from the lists of all programs that they have ranked lower down. Each program list is then examined to see how many offers
1149
Residency match in radiation oncology 0 A. S. LIGHTER
have been accepted and how many offers remain to be filled. Another round of offers is made and the process continues until the programs have filled their positions or have offered positions to all candidates on their rank order list without filling their positions. Applicants who tentatively accepted an offer from one institution may eventually reject that offer to move to an institution ranked higher on their list if that institution eventually offers them a position through subsequent rounds of the algorithm. This match is called a “stable match” in that when the matching process is over, each student finds any hospital that he or she would have preferred over the one they have matched to has already filled their quota of residents from students ranked higher on its list (20). No “gaming” the match list would have placed them at a more desirable institution. The NRMP has worked successfully for 30 years and is generally acknowledged to be “a vast improvement over the chaotic conditions that preceded it” (20). CENTRALIZED MATCHING IN OTHER SPECIALTY FIELDS Excluding Radiation Oncology, there are 18 fields which interview and recruit predominantly senior medical students into their training programs. Table 1 summarizes the centralized matching programs designed for graduating senior medical students. As can be seen, every specialty program currently uses a centralized matching system to distribute potential residency candidates into the various training programs. Levels of participation in centralized Table 1. Specialty matching programs primarily involving graduating seniors* %of programs Specialty
Match organization
No. of programs*
Anesthesiology Dermatology Emergency medicine Family practice Internal medicine Neurosurgery Neurology Ob-Gyn Ophthalmology Orthopedics Otolaryngology Pathology Pediatrics Physical medicine Psychiatry Radiology General surgery Urology
NRMP NRMP NRMP NRMP NRMP S.F.* S.F. NRMP SF. NRMP S.F. NRMP NRMP NRMP NRMP NMRP NRMP Ural**
157 100 80 383 842 94 119 282 138 164 106 217 226 70 205 209 286 128
in centralized match+ 100 84 100 97 97 100 99 92 99 88 100 75” 96 99 100 98 90 98
* Data from match statistics and AMA Residency Directory. ’ Numbers near 100% likely represent all non-military positions. * Match run by A. Colenbrander, M.D. in San Francisco. * Most programs participate, but approximately 75% of positions are offered through the match. ** Match run by Urology Society out of Houston, TX.
matching programs range from a low of 75% in Pathology up to nearly 100% in the majority of specialty fields. Many of these programs did not begin smoothly. Pediatrics, Orthopedic Surgery, and Radiology each folded one match program (11). Other programs began only after heated debate and considerable differences of opinion (2 1). The major reason cited for lack of success of failed matching programs concerned the lack of participation (9). When there are far more applicants than there are training positions, the temptation for an applicant to take a residency position offered outside the match is nearly overwhelming. Since non-match programs are not bound by a uniform acceptance date, such programs often preempt the match process by making offers days or weeks in advance of the match deadline. If sufficient numbers of applicants are removed from the match process due to this unfair competition, the specialty match inevitably collapses. This threatens to happen currently in Radiation Oncology. Nor are the centralized matches without’problems even to this day. Cries that other programs are cheating, candidates aren’t telling the truth, and that the match process is being subverted are still heard (4, 11, 18). In general however, the match process is considered to be successful in virtually all medical specialties. In the 1990 graduation questionnaire administered by the American Association of Medical Colleges (AAMC), ( 1) candidates were asked whether one or more programs had tried to get them to make a commitment before the announcement of the match. The result$ of the survey are presented in Table 2. Eleven thousand four hundred twenty-two students answered the questionnaire. Overall, 10.4% of students said that they were asked to make a commitment before the match. Since each program in-
Table 2. Percent of applicants who were asked to commit before the match* Specialty Anesthesiology Dermatology Emergency medicine Family practice Internal medicine Neurosurgery Neurology Ob-Gyn Ophthalmology Orthopedics Otolaryngology Pathology Pediatrics Physical medicine Psychiatry Radiology Genera1 surgery Urology All respondents ( 11,422) * Data from ref. 1.
Percent 17.8 9.8 7.7 6.6 6.9 4.8 12.4 Il.9 8.4 19.3 4.8 27.9 6.6 22.1 12.3 18.8 7.8 9.7 10.4
1150
I. J. Radiation Oncology 0 Biology 0 Physics
terviews a large number of students, the percent of programs that engage in this activity is likely a smaller percent. The percentages range from 4.8% in Otolaryngology and Neurosurgery up to 27.9% reported in Pathology. It is probably not a coincidence that Pathology, with its relatively low percentage of participation in the match has the highest levels of reported match violations, as programs offering match positions try to compete with institutions offering early acceptance outside the match. While there is no perfect match system, and while some program directors are blatantly dishonest, overall adherence to the match process appears to be quite high in most specialties. THE RADIATION ONCOLOGY MATCHING PROGRAM (ROMP) In 1989, the field of Radiation Oncology found itself the only field in medicine interviewing predominantly senior medical students for its postgraduate positions that did not have a centralized matching system in place. At the SCAROP meeting in May 1987 and again in 1988, lengthy discussions were held concerning the possibility of creating a centralized match system. Representatives from the NRMP were interviewed as well as Dr. August Colenbrander, an ophthalmologist from San Francisco who runs matching programs on behalf of the specialty societies for Ophthalmology, Neurosurgery, Neurology, Otolaryngology, and Plastic Surgery. Reasons proposed for having a match as discussed at those meetings are presented in Table 3. It was widely agreed that a centralized match guarantees a uniform date for acceptance. In a decentralized system, acceptances are sought whenever a program elects to make an offer. While a “gentleman’s agreement” had been in place, it clearly wasn’t working. In fact, in the history of interviewing and accepting candidates for internship or residency in any field over the past 50 years, no non-binding “gentleman’s agreement” has ever been successful in adding order to a decentralized match. A match was generally conceded to be fair to programs. Programs would be allowed to interview candidates at their own pace. In a non-centralized system, a common strategy used to outcompete other programs was to get the jump on the interview process and see candidates sooner. Programs who interviewed later in the Fall were clearly at a disadvantage, especially if they tried to adhere
Table
3. Reasons cited for using a central match in radiation
1. 2. 3. 4. 5. 6.
oncology
Establishes a uniform date for offers/acceptances Fair to programs Fair to applicants Process can be moved back in senior year calendar Data on applicant pool available Join other specialties
Volume 22, Number 5, 1992
to the “gentleman’s agreement.” The centralized match system was generally agreed to be fair to the candidates. Students who took their Radiation Oncology electives later in the year, or who had clerkship assignments that kept them from interviewing early in the process, would not be disadvantaged; any candidate could be interviewed up until the match deadline. Candidates were also confident that when they interviewed with a program there would still be uncommitted positions. In a decentralized system, applicants interviewing late in the year reported situations where offers had already been extended to a full quota of applicants, and the program was interviewing additional candidates only for “insurance” in case one or two applicants elected to go elsewhere. This obvious waste of candidates’ time and limited resources would be easily avoided with a centralized match. It was generally agreed that a centralized system would allow the match date to be moved later in the academic year. According to AAMC data (1) by the beginning of the fourth year of medical school only 66% of students have decided on their final specialty. The one-third of students who have not decided are almost excluded from considering Radiation Oncology as a specialty field since applications are usually due in September and offers begin to be extended in October and November. By moving the match date solidly into January or even early February, additional opportunities for undecided medical students to take electives in Radiation Oncology would be provided. It was also agreed that a centralized matching system would provide valuable data on the applicant pool available for Radiation Oncology. Although most program directors recognized that the applicant pool had “increased,” with no centralized system there were no solid data to indicate how many candidates were applying for each residency opening, nor how many were senior medical students, previous medical graduates, or foreign medical graduates. No trends in residency applications could be tracked from year to year in a decentralized system. Finally, the field of Radiation Oncology has fought for many years to be accepted as a specialty field that is on a peer level with all other specialties in medicine. The fact that we were the only specialty that did not use a centralized match system was regarded as one of the last vestiges that we were somehow “different” from other medical specialties. The first ROMP match took place on December 7, 1989. The results for this match are summarized in Table 4. Sixty of 83 approved training programs listed 120 positions of the approximately 150 first-year positions (80%). In the final match, 56 programs offered 113 positions with some programs having made previous commitments to candidates before the agreement to use a centralized match began, and other programs having been placed on probation by the Residency Review Committee (RRC). Overall, 103 positions were filled and 10 were left vacant. Forty-seven departments filled all their positions, and nine departments were left with vacancies. On average, it took
1151
Residency match in radiation oncology 0 A. S. LIGHTER Table 4. Results from the first ROMP (1989): programs
Table 6. Results from the second ROMP (1990): programs
In Directory: 60 programs with 120 positions Offered in Match: 56 programs with 113 positions Of 113 positions, 103 were filled (91%) 47/56 departments (84%) filled all positions 7/56 departments filled some positions 56 programs ranked 639 names = 11.4 names/program 325 offers were used to fill 103 positions = 3.16 offers/ acceptance
In Directory: 57 programs with 111 positions Offered in Match: 49 programs with 98 positions Of 98 positions, 92 were filled (94%) 43/49 departments (88%) filled all positions 3/49 departments (6%) filled some positions 49 programs ranked 5 14 names = 10.5/program 298 offers were used to fill 92 positions = 3.24/acceptance
3.16 offers to achieve an acceptance. The departments that filled all positions listed many more candidates per available position than did departments who were left with vacancies ( 14 listings vs. 7). This may have reflected the novelty of the match process for some programs and their failure to strategize appropriately for the highly competitive nature of the match. The 1989 match as viewed from the candidates’ position is summarized in Table 5. Overall, there were 255 candidates registered. One hundred sixty-two applicants submitted rank lists and 146 candidates were listed by programs, a ratio of 1.29 listed applicants per available position. A significant number of candidates withdrew to occupy the 30-35 residency slots that were offered outside the match. The ROMP results were virtually identical to the long history of the NRMP program in terms of students receiving their preferred institutional choices. In the ROMP, 53% of students received their first choice, 16% their second choice, 14% their third choice, 7% their fourth choice, and 14% their fifth or lower choice. In the NRMP, approximately 57% received their first choice, 16% their second, 10% their third, 6% their fourth, and 11% their fifth or lower choice ( 19). The 1990 ROMP match was held on January 7, 199 1. Data for this match are summarized in Table 6 from the programs’ point of view and in Table 7 from the applicants’ point of view. Participation in the second ROMP was less than that of the first because of some programs withdrawing and still others having no positions to offer due to difficulties with certification from the RRC. In all, 98 positions were offered and 92 were filled. Interest in the match remained high, with 295 candidates registering,
16 1 submitting rank lists, and 143 being ranked. Overall, there were 1.46 ranked applicants per open position. Data on applicant subgroups for the two matches are presented in Table 8. Overall, approximately 70% of ranked students are current United States senior medical students, 25% are earlier United States graduates, and approximately 2% are graduates of foreign medical schools. In 1989,79% of all matched candidates were U.S. seniors and 2 1% were earlier U.S. graduates; no foreign medical graduates matched in that year. In the 1990 match, 75% of those matching were U.S. seniors, 20% were earlier U.S. graduates, and 2% were foreign graduates. In comparison, in the overall 1990 NRMP, 8 1% of 16,000 matched candidates were current U.S. seniors, a figure not too dissimilar from our own match (2 1). Additional details of the 1990 match are presented in Figure 2. The 92 matched candidates listed a median of five programs on their rank list, and were listed by a median of four programs. Only 16% of these candidates ranked fewer than three programs and 34% ranked seven or more programs. These candidates were highly sought after by programs, and 43% of them appeared on the rank list of five or more programs. In contrast, the 49 applicants who had match lists but received no offers listed a median of two programs, and were ranked by a median of one program (Fig. 3). It is difficult to know whether these candidates were seriously interested in Radiation Oncology, accepted offers outside the match but put in a brief match list as a “flyer,” were geographically constrained to apply to only a single program or to nearby programs, or had other factors that truncated their’rank listings. A total of 53 candidates withdrew from the match. Of
Table 5. Results from the first ROMP (1989): applicants
Table 7. Results from the second ROMP (I 990): applicants
No. of registrants No. of rank lists No. of applicants listed by any program
255 (2.28/position 162 (1.43/position
offered) offered)
146 (1.29/position
offered)
No. of registrants No. of rank lists No. of applicants listed by any program
295 (3/position offered) 16 1 ( 1.64/position offered) 143 (1.46/position
Applicants applied to an average of 15.2 programs; interviewed at an average of 6.5 programs; ranked an average of 5.7 programs.
Applicants applied to an average of 12.9 programs; interviewed at an average of 5.5 programs; ranked an average of 4.1 programs.
103 matched applicants received their following choices:
92 matched applicants received the following choices:
offered)
1st
2nd
3rd
4th
5th
6th or greater
1st
2nd
3rd
4th
5th
6th or greater
53%
16%
14%
7%
3%
7%
64%
15%
5%
8%
3%
4%
1152
I. J. Radiation Oncology 0 Biology0 Physics
Volume
22, Number 5, 1992
Table 8. Demographics and results from the applicant pool 1989 Total listed* Current U.S. senior Earlier U.S. grad Foreign grad Total matched Current U.S. senior Earlier U.S. grad Foreign grad Chance of matching if: Rank list submitted Current U.S. senior Earlier U.S. grad Foreign grad
146 105 37 3 103 81 22 0
(72%) (25%) (2%) (79%) (21%) (0%)
103/162 (64%) 76% (81/107) 49% (22/25) 0% (O/9)
1991 143+ 99 (69%) 36 (25%) 3 (2%) 92 69 (75%) 18 (20%) 2 (2%) 92/16 1 (57%) 67% (69/103) 43% ( 18/42) 22% (2/9)
* Listed by one or more programs. + 4% of 1990 listed candidates had unknown status.
these, 37 were listed 93 times by 34 separate programs (Fig. 3). The large number of listings for these candidates and the significant amount of interviewing that these candidates were involved in indicates that these were candidates who likely withdrew from the match to accept offers in other programs. Following the release of match results, programs with open positions can elect to announce the availability of a vacancy through a phone recording maintained by the match office. This “hot line” may be accessed 24 hours a day. Interest in these few vacancies remains high and one program director has reported receiving 37 inquiries for a single opening within 4 weeks of the match closure (Asbell, S. Oral personal communication.). THE FUTURE OF THE ROMP The Radiation Oncology Matching Program has carried out its first two centralized match assignments smoothly and successfully. The major problem that exists with this
Number of Listings by Applicants or Programs - 92 matched Applicants in 1990 -
Listings Applicants
8
2
7
2
of Withdrawn Applicants or Who Had List but No Offers
W withdrawn but Ilstsd by... ??Applicants with no offars Mad.... ??Applicants with no otters ware Mad by...
0
20
10
30
Applicants
Fig. 3. Number of programs listing withdrawn applicants or applicants with no offers, and number of programs listed by applicants with no offers.
program is lack of participation. With only 60-65s of the applicant slots being arranged through the match, the program will surely disintegrate, as other specialty matches have shown us historically. There are a variety of reasons cited by institutions who have not participated in the match as to why a match is undesirable. These reasons are summarized in Table 9. The first and most widely cited reason is “The match is unnecessary because the system was working just fine before.” This is a perception that is not shared by most program directors in Radiation Oncology nor most program directors in other specialty fields. The pressure on students to make early and potentially premature decisions has been widely regarded as both enormous and deleterious. The pressure for programs to offer residencies to students earlier and earlier is an experience reported by every specialty field under a decentralized system. The fact that all Radiation Oncology programs filled all positions from 1984 through 1988 should be considered an historic step forward for a specialty field that barely filled 50% of its residency slots through 1982 (6). However, the intense competition for radiotherapy positions seems to argue for a more organized residency matching program. Some program directors state that they like to “hand pick” their applicants so specifically that an offer to canTable 9. Reasons cited not to use a central match in radiation oncolozv
by... A 10
Applicants
Fig. 2. Number of programs listed by applicants and number of programs listing each applicant for the 92 matched applicants in 1990 (10 applicants listed 5 programs; 11 applicants were listed by 5 different programs).
1. No need to change-old system working fine 2. Residents should be “hand picked” 3. Senior medical students are the minority of resident applicants 4. Everyone cheats in a centralized system 5. A centralized system is too much work for programs 6. My program received more acceptances with the old match process 7. Only a few unique applicants want my program 8. I compete geographically
Residency match in radiation oncology 0 A. S. LIGHTER
didate “B” might hinge entirely around whether candidate “A” accepts or rejects their offer. With a centralized match process, this customized tailoring of residency acceptance cannot be accommodated. One can only rank the best applicants in the order that one appraises their merit. Most medical educators concede that the interview (15) and letters of recommendation (8) are relatively inexact measures of future residency performance. All of us have had experience with the “can’t miss” resident who turns out to be a poor performer, and the “average” candidate who blossoms into an outstanding performer. It is unlikely that “hand picking” one’s resident class will produce a superior outcome than selecting them through a carefully contemplated and well ordered rank list. Other programs have voiced their reluctance to join the match, stating that they believed our specialty to be unique in that we interview and select predominantly from previous medical graduates rather than from senior medical students. The data from the match do not show this to be the case. Between 70 and 75% of residents obtaining slots through the ROMP are senior medical students, which compares favorably to the 8 1% of candidates matching in all positions in the NRMP. The fact is that our specialty is not substantially different than other fields in terms of our candidate pool. Many programs say that they will not join the match because “Everyone cheats in the match anyway.” This is somewhat like the complaint that Congress is rotten but my Congressman is honest. All programs admit that if they were in the match, they would behave honorably, but its the other guy who is cheating. In fact, there is probably some dishonesty in every system. As presented earlier in Table 2, the amount of cheating that is reported by students is relatively low, especially in matches with full participation. While it is true that in a decentralized match process there is no cheating-one cannot break the rules if there are no rules to break-to avoid a centralized match because of fears of rampant cheating does not seem to have a foundation in fact. Some programs have expressed that the interview and selection process under a centralized match system is too much work compared to a decentralized system. It is likely true that a centralized match involves more effort from programs. In a decentralized system, one can accept candidates with a “rolling” acceptance plan. If one sees excellent candidates in the first few interviews sessions, one may immediately offer these candidates positions, fill the program, and cancel out all the other students. While this type of activity and attitude might be beneficial to individual programs, this behavior does not translate well to an entire field. With early acceptance by one program, other programs are encouraged to accept their candidates even earlier, which can lead, as it has in other fields, to eventually accepting residents in the third or even second year of medical school (4). In a procedure as important to our field as the selection of its future practitioners, some extra time an effort to interview candidates fairly and ac-
1153
cept them into our field in an equitable fashion is likely to be time well spent. Some programs state that they always secured acceptances from everyone they wanted with a decentralized system, but found that they were getting rejections inside the match system. Therefore, there must be something wrong with the centralized match since nothing could be wrong with their training program or their interview process. It is likely that a program that is having a difficult time recruiting candidates inside the mafich should first look to their own program for possible answers. In fact, it is possible to interview applicants who turn down positions in the match, find out their perceptions of the program, and use that feedback to improve the residency interview process in subsequent years ( 14). The program rather than the process is usually to blame for an unsuccessful match experience. It is also important to employ an appropriate strategy for operating in a centralized system. Competition for the very best candidates remains keen, and a centralized match levels the playing field so that all candidates can interview at as many programs as they desire. Candidates are under no p&sure to accept one program over another as they are in a decentralized system. Thus, each program should striveito present itself in the best light possible, and each program should interview and rank a sufficient number of candidates to allow for competition with peer institutions. Some programs state that their residency is so unique and unusual that only a few select candiddtes would want their program anyway. To enter the match would be pointless since it is only a “very special” applicant who would even be interested in training in thdr environment. No doubt there are variations in the qu&lity of resident training from institution to institution, as anyone who reviews programs for the RRC can attest. But, the RRC essential guidelines mandate a great deal of basic residency training today, and no program can stray terribly far from the guidelines and still maintain residency approval. The number of programs that offer a dedicated research experience has also begun to increase over the past few years, and it is likely a misperception that there are one or two programs in the field that only interview and select from a tiny subset of the applicant pool. Finally, there is the geographic argument. This is an especially frequent argument from training programs in New York City. The argument goes that the handful of New York City training programs only compete against each other for applicants, and for some reason if all the New York programs were in the match,, they could no longer successfully compete with each other for this pool of candidates. The fact is that if all the $chools in a particular geographic area were in the match and competed for a select pool of candidates who wished to stay in that geographic area, a centralized system would probably match candidates to training programs as efficiently or more efficiently than an ad hoc system would. Several small fellowship programs with only 10 to 20 applicants
1154
I.
J. Radiation Oncology 0 Biology0 Physics
in the entire match process have held successful centralized matches for a number of years. This is probably the size of the residency pool in the metropolitan New York area. SUMMARY
The Radiation Oncology Matching Program provides an orderly, structural framework for the matching of resident applicants to training programs. Arguments against
Volume 22, Number 5, 1992
a centralized match, fairly conducted and administered, stand up poorly to careful scrutiny. However, with only 60-65% of programs participating, the match will certainly cease to function. The training program directors will vote again in 1991 as to whether to continue or abandon the process. By most accounts, a successful match requires approximately 90% participation. If that level of involvement can be achieved, it is likely that the ROMP will successfully join the other specialty matches. Without that level of support, there is little point in continuing.
REFERENCES 1. American Association of Medical Colleges: Experiences of 1990graduates in obtaining a residency. 1990 AAMC grad-
uation auestionnaire summarv results. Washington. D.C. 2. Barchilon, J.; Darley, W. National psychiatri; re$idency matching program. J. Med. Educ. 41: 884-888; 1966. 3. Calcagno, P. L. National pediatric residency matching program. Amer. J. Dis. Child. 116: 534-536; 1968.
4. Cockerell, C.; Dixon, S. L. Are the matching programs for 5. 6.
7. 8. 9.
10. 11.
training in dermatology and pathology operating fairly and without bias? Amer. J. Dermatol. 5: 193-195; 1983. Coleman, S. S.; Darley, W. Matching plan for orthopaedic surgery. Clin. Orthoped. Related Res. 75: 117- 124; 197 1. Cox, J. D.; Flynn, D. R.; Pittman, D. A.; Del Regato, J. A. Postgraduate training in radiation oncology in the United States, 1986. Int. J. Radiat. Oncol. Biol. Phys. 13: 13831388; 1987. Editorial: NIMP to NIRMP. New. Engl. J. Med. 278: 907908; 1968. Friedman, R. B. Fantasy land. New Engl. J. Med. 308: 65 l653; 1983. Graettinger, J. S. Graduate medical education viewed from the national intern and resident matching program. J. Med. Educ. 51: 703-715; 1976. Graettinger, J. S. The matching program. New Engl. J. Med. 304: 1163-l 165; 1981. Graettinger, J. S. The residency matching program. Arch. Otolaryngol. 104: 6615-619; 1978.
12. Golden, W. E. Match march. J. Amer. Med. Assoc. 243: 1047-1048; 1980. 13. Hall, F. M. Resident matching program in radiology. Am. J. Roentgenol. 137: 631-632; 1981. 14. Julian, R. M.; Bornsztein, B. Use of resident applicant feedback to improve a residency program’s matching of highly ranked applicants. J. Med. Educ. 63: 650-652; 1988. 15. Komives, E.; Weiss, S. T.; Rosa, R. M. The applicant interview as a predictor of resident performance. J. Med. Educ. 59: 425-426; 1984. 16. Malkinson, F. D. National residency matching program for dermatology. An evaluation. Arch. Den-n. 99: 350-353; 1969. 17. Mullin, F. J.; Stalnaker, J. M. The matching plan for internship appointment. J. Med. Educ. 26: 341-346; 1952. 18. Myers, J. M. Gentlemen’s agreements and the national residency matching program. J. Clin. Psych. 39: 689; 1978. 19. National resident matching program. Evanston, IL: NRMP Data; April, 1990. 20. Roth, A. E. New physicians: a natural experiment in market organization. Science 250: 1524- 1528; 1990. 21. Tucker, J.; Cantrell, R.; Smith, R.; Jafek, B.; Shumrick, D.; Cummings, C.; Parkin, J. Resolved: all otolaryngology programs should participate in the residency matching program. Arch. Otolaryngol. 104: 627-635; 1978.
Copyright
0360-3016/92 $5.00 + .oO 8 1992 Pergamon Press Ltd.
??Technical Innovations and Notes
THE RESIDENCY
MATCH ALLEN
Department
S.
IN RADIATION LICHTER,
ONCOLOGY
M.D.
of Radiation Oncology, University of Michigan Medical Center, Rm. B2C490, Box 0010, 1500 E. Medical Center Drive, Ann Arbor, MI 48 109
Centralized matching of postgraduate training positions has been successfully implemented nationwide since 1951. Specialty and subspecialty matches have proliferated in the 1970’s and early 1980’s, and Radiation 0ncol)gy was the last residency program that did not have a centralized match arrangement. Responding to press&s from training program directors who were dissatisfied with the non-centralized matching of resident applicant , made especially acute by a rapid increase in the number of students interested in Radiation Oncology, the first ten b lized matching program for Radiation Oncology--the Radiation Oncology Matching Program (ROMP)-began in 1989. Two years of experience with the ROMP are summarized in this paper. Interest in training positions in diation Oncology remains high, with approximately 1.3 to 1.5 qualified applicants per each residency position. Th “k major problem with the current arrangement in ROMP is lack of full participation. In 1989, approximately 70% of first year positions were offered through ROMP, and in 1990 this was closer to 60%. While the majority of pl/ograms desire and participate in a centralized match, participation at less than an 85 to 90% level will likely duse the centralized match to disband. Reasons for and against a centralized matching process and a history of niatching programs in other specialties are discussed. Internship and residency, Medical education, Residency training in radiation oncology. INTRODUCTION
1.
2.
Ever since “straight” training in Therapeutic Radiology began in the 1960’s, directors of training programs and prospective resident applicants have had to interview and accept one another-in other words, match-as training partners for the 3 years of clinical residency training. Until relatively recently this matching of training programs with resident applicants was accomplished in an ad hoc fashion. While there was a loosely defined “gentleman’s agreement” not to offer training positions until late in November or early December, the application, interview, and acceptance process was driven almost entirely by the whims of each individual program. The non-system of residency matching worked reasonably well while there were relatively small numbers of candidates interested in the field of radiation oncology and while a substantial portion of residency slots remained unfilled. However, with the rapid increase in the number of prospective candidates interested in a career in Radiation Oncology, and with the filling of all residency slots which occurred in 1984 (Fig. l), discontent began to be voiced by the majority of training program directors concerning the ad hoc residency match arrangements. Program directors were searching for a system that:
Accepted
for publication
3 September
3. 4. 5.
Provided a uniform and rigidly observed date for extending residency offers; Offered freedom for candidates to interview as many programs as they desired up until the’offer date; Allowed freedom for programs to interview candidates right up to the offer date; Allowed candidates and programs to express their preferences fully and confidentially; amd Did not relinquish control of the selection process from the candidates or programs; that is, noI program would be required to accept a candidate that they did not wish to have in their program, and no candidate would be required to train at a program in which they did not wish to train.
In reflecting upon these stringent requirements and after 2 years of spirited discussion and debate, the Society of Chairman of Academic Radiation Oncology Programs (SCAROP) decided to sponsor a centralized residency match procedure for our field, similar if not identical to the matching programs that exist in every other PGY 1 and PGY 2 specialty field. This article will review the history of the centralized match process, discuss its application in other specialty fields, and review the experience in the Radiation Oncology Matching Program (ROMP) for 1989 and 1990.
199 1. 1147
1148
I. J. Radiation Oncology 0 Biology 0 Physics
Trends in Residency Training 1
*is Year
Fig. 1. Number of first year residents in training and percentage of first year positions filled for 1968 through 1988. (6)
HISTORY OF THE CENTRALIZED MATCH PROCESS
In the late 1940’s, competition between hospitals for internships became heightened as the number of approved internships exceeded the number of senior medical students by a factor of two (10). High-quality, prestigious programs with many more applicants than positions generally made their offers late in the students’ senior year of medical school, while programs with few applicants sought to recruit medical students early in the senior year. When students received internship offers, they had to carefully assess their chances and decide whether to take a sure offer from a lower quality institution or decline the offer but risk not receiving a later offer from a more prestigious institution. Program directors were equally perplexed. If a program filled its positions early on, it would not have room for a more desirable candidate who interviewed late in the process. On the other hand, if they left too many positions open for later in the year, they might not fill all of their available openings. A so-called “gentleman’s agreement” was tried from 1945-49 indicating a uniform date that hospitals could extend offers to students (11). This effort at adding decentralized structure to the match process was a failure. Finally, in October 1950, an organization called the National Interassociation Committee on Internship was formed and initiated a centralized matching system. As indicated by F. J. Mullin in the original description of the plan ( 17). “It (the plan) benefits applicants and hospitals by giving full recognition both to the student preference and to the hospital’s evaluation of its applicants. It prevents unfair pressure forcing students into early commitments, often to their detriment. Under the plan the student will not be required to make a decision on the basis of a telephone call or within a very limited period of time. . . . The matching plan does not remove the personal element from the selection procedure. The student may visit the hospitals to which he wishes to apply, talking to officials and
Volume 22, Number 5, 1992
others there. He makes individual applications to the hospitals of his choice just as at present. . . . Hospitals will be free to contact any eligible students and to request personal interviews or other procedures they deem desirable. Under this system, complete freedom of applying any criteria for selection is fully preserved for both the hospitals and the students.” The plan was immediately successful, with more than 95% of students obtaining their internship through the centralized match, the remaining few percent filling mostly non-match military slots (11). Most of us practicing radiation oncology today received our internship position through this program, which became known as the National Internship Matching Program (NIMP). Then, in the 1960’s, residencies began to proliferate and the number of unfilled but approved residency slots began to grow. The competition for first-year residencies (PGY 2 positions) began to accelerate, and the same problems that were seen in the late 1940’s with the internship began to appear in the 1960’s with the residency (11). A number of medical specialties introduced their own “gentleman’s agreement” for a uniform date of residency appointment. In the 1960’s, Psychiatry (2), Radiology (13), Orthopedic Surgery (5), Pediatrics (3), and Dermatology (16) tried their own centralized matching programs. The first four failed, generally because an insufficient number of programs participated. In 1968, the Millis report of the Citizens’ Commission on Graduate Medical Education appeared and recommended that the internship be abolished and be integrated with the first year of residency (10). The NIMP became the National Internship and Residency Matching Program (NIRMP) (7). The primary care specialties such as Family Practice, Pediatrics, Internal Medicine, and Obstetrics and Gynecology began to eliminate the traditional internship and integrate the PGY 1 year directly into residency. Finally, in 1978 in recognition that residencies were being offered to senior students in almost all specialties, the NIRMP changed its name to the National Resident Match Program (NRMP), which remains its appellation today (10). By the early 1980’s, the NRMP began to provide centralized matching services to specialties that still required a general PGY 1 year such as Diagnostic Radiology and Anesthesiology, a program called Advanced Positions for Students. Other specialties such as Neurosurgery, Ophthalmology, and Neurology formed their own independent centralized match systems based on NRMP guidelines. The algorithm used in centralized matching systems in the United States essentially matches each student to their highest ranking hospital that extends them a match offer ( 10). The algorithm first extends an offer from each program to each of its first choice applicants. The applicants tentatively accept the offer if it is from their highest ranked hospital. These applicants’ names are then removed from the lists of all programs that they have ranked lower down. Each program list is then examined to see how many offers
1149
Residency match in radiation oncology 0 A. S. LIGHTER
have been accepted and how many offers remain to be filled. Another round of offers is made and the process continues until the programs have filled their positions or have offered positions to all candidates on their rank order list without filling their positions. Applicants who tentatively accepted an offer from one institution may eventually reject that offer to move to an institution ranked higher on their list if that institution eventually offers them a position through subsequent rounds of the algorithm. This match is called a “stable match” in that when the matching process is over, each student finds any hospital that he or she would have preferred over the one they have matched to has already filled their quota of residents from students ranked higher on its list (20). No “gaming” the match list would have placed them at a more desirable institution. The NRMP has worked successfully for 30 years and is generally acknowledged to be “a vast improvement over the chaotic conditions that preceded it” (20). CENTRALIZED MATCHING IN OTHER SPECIALTY FIELDS Excluding Radiation Oncology, there are 18 fields which interview and recruit predominantly senior medical students into their training programs. Table 1 summarizes the centralized matching programs designed for graduating senior medical students. As can be seen, every specialty program currently uses a centralized matching system to distribute potential residency candidates into the various training programs. Levels of participation in centralized Table 1. Specialty matching programs primarily involving graduating seniors* %of programs Specialty
Match organization
No. of programs*
Anesthesiology Dermatology Emergency medicine Family practice Internal medicine Neurosurgery Neurology Ob-Gyn Ophthalmology Orthopedics Otolaryngology Pathology Pediatrics Physical medicine Psychiatry Radiology General surgery Urology
NRMP NRMP NRMP NRMP NRMP S.F.* S.F. NRMP SF. NRMP S.F. NRMP NRMP NRMP NRMP NMRP NRMP Ural**
157 100 80 383 842 94 119 282 138 164 106 217 226 70 205 209 286 128
in centralized match+ 100 84 100 97 97 100 99 92 99 88 100 75” 96 99 100 98 90 98
* Data from match statistics and AMA Residency Directory. ’ Numbers near 100% likely represent all non-military positions. * Match run by A. Colenbrander, M.D. in San Francisco. * Most programs participate, but approximately 75% of positions are offered through the match. ** Match run by Urology Society out of Houston, TX.
matching programs range from a low of 75% in Pathology up to nearly 100% in the majority of specialty fields. Many of these programs did not begin smoothly. Pediatrics, Orthopedic Surgery, and Radiology each folded one match program (11). Other programs began only after heated debate and considerable differences of opinion (2 1). The major reason cited for lack of success of failed matching programs concerned the lack of participation (9). When there are far more applicants than there are training positions, the temptation for an applicant to take a residency position offered outside the match is nearly overwhelming. Since non-match programs are not bound by a uniform acceptance date, such programs often preempt the match process by making offers days or weeks in advance of the match deadline. If sufficient numbers of applicants are removed from the match process due to this unfair competition, the specialty match inevitably collapses. This threatens to happen currently in Radiation Oncology. Nor are the centralized matches without’problems even to this day. Cries that other programs are cheating, candidates aren’t telling the truth, and that the match process is being subverted are still heard (4, 11, 18). In general however, the match process is considered to be successful in virtually all medical specialties. In the 1990 graduation questionnaire administered by the American Association of Medical Colleges (AAMC), ( 1) candidates were asked whether one or more programs had tried to get them to make a commitment before the announcement of the match. The result$ of the survey are presented in Table 2. Eleven thousand four hundred twenty-two students answered the questionnaire. Overall, 10.4% of students said that they were asked to make a commitment before the match. Since each program in-
Table 2. Percent of applicants who were asked to commit before the match* Specialty Anesthesiology Dermatology Emergency medicine Family practice Internal medicine Neurosurgery Neurology Ob-Gyn Ophthalmology Orthopedics Otolaryngology Pathology Pediatrics Physical medicine Psychiatry Radiology Genera1 surgery Urology All respondents ( 11,422) * Data from ref. 1.
Percent 17.8 9.8 7.7 6.6 6.9 4.8 12.4 Il.9 8.4 19.3 4.8 27.9 6.6 22.1 12.3 18.8 7.8 9.7 10.4
1150
I. J. Radiation Oncology 0 Biology 0 Physics
terviews a large number of students, the percent of programs that engage in this activity is likely a smaller percent. The percentages range from 4.8% in Otolaryngology and Neurosurgery up to 27.9% reported in Pathology. It is probably not a coincidence that Pathology, with its relatively low percentage of participation in the match has the highest levels of reported match violations, as programs offering match positions try to compete with institutions offering early acceptance outside the match. While there is no perfect match system, and while some program directors are blatantly dishonest, overall adherence to the match process appears to be quite high in most specialties. THE RADIATION ONCOLOGY MATCHING PROGRAM (ROMP) In 1989, the field of Radiation Oncology found itself the only field in medicine interviewing predominantly senior medical students for its postgraduate positions that did not have a centralized matching system in place. At the SCAROP meeting in May 1987 and again in 1988, lengthy discussions were held concerning the possibility of creating a centralized match system. Representatives from the NRMP were interviewed as well as Dr. August Colenbrander, an ophthalmologist from San Francisco who runs matching programs on behalf of the specialty societies for Ophthalmology, Neurosurgery, Neurology, Otolaryngology, and Plastic Surgery. Reasons proposed for having a match as discussed at those meetings are presented in Table 3. It was widely agreed that a centralized match guarantees a uniform date for acceptance. In a decentralized system, acceptances are sought whenever a program elects to make an offer. While a “gentleman’s agreement” had been in place, it clearly wasn’t working. In fact, in the history of interviewing and accepting candidates for internship or residency in any field over the past 50 years, no non-binding “gentleman’s agreement” has ever been successful in adding order to a decentralized match. A match was generally conceded to be fair to programs. Programs would be allowed to interview candidates at their own pace. In a non-centralized system, a common strategy used to outcompete other programs was to get the jump on the interview process and see candidates sooner. Programs who interviewed later in the Fall were clearly at a disadvantage, especially if they tried to adhere
Table
3. Reasons cited for using a central match in radiation
1. 2. 3. 4. 5. 6.
oncology
Establishes a uniform date for offers/acceptances Fair to programs Fair to applicants Process can be moved back in senior year calendar Data on applicant pool available Join other specialties
Volume 22, Number 5, 1992
to the “gentleman’s agreement.” The centralized match system was generally agreed to be fair to the candidates. Students who took their Radiation Oncology electives later in the year, or who had clerkship assignments that kept them from interviewing early in the process, would not be disadvantaged; any candidate could be interviewed up until the match deadline. Candidates were also confident that when they interviewed with a program there would still be uncommitted positions. In a decentralized system, applicants interviewing late in the year reported situations where offers had already been extended to a full quota of applicants, and the program was interviewing additional candidates only for “insurance” in case one or two applicants elected to go elsewhere. This obvious waste of candidates’ time and limited resources would be easily avoided with a centralized match. It was generally agreed that a centralized system would allow the match date to be moved later in the academic year. According to AAMC data (1) by the beginning of the fourth year of medical school only 66% of students have decided on their final specialty. The one-third of students who have not decided are almost excluded from considering Radiation Oncology as a specialty field since applications are usually due in September and offers begin to be extended in October and November. By moving the match date solidly into January or even early February, additional opportunities for undecided medical students to take electives in Radiation Oncology would be provided. It was also agreed that a centralized matching system would provide valuable data on the applicant pool available for Radiation Oncology. Although most program directors recognized that the applicant pool had “increased,” with no centralized system there were no solid data to indicate how many candidates were applying for each residency opening, nor how many were senior medical students, previous medical graduates, or foreign medical graduates. No trends in residency applications could be tracked from year to year in a decentralized system. Finally, the field of Radiation Oncology has fought for many years to be accepted as a specialty field that is on a peer level with all other specialties in medicine. The fact that we were the only specialty that did not use a centralized match system was regarded as one of the last vestiges that we were somehow “different” from other medical specialties. The first ROMP match took place on December 7, 1989. The results for this match are summarized in Table 4. Sixty of 83 approved training programs listed 120 positions of the approximately 150 first-year positions (80%). In the final match, 56 programs offered 113 positions with some programs having made previous commitments to candidates before the agreement to use a centralized match began, and other programs having been placed on probation by the Residency Review Committee (RRC). Overall, 103 positions were filled and 10 were left vacant. Forty-seven departments filled all their positions, and nine departments were left with vacancies. On average, it took
1151
Residency match in radiation oncology 0 A. S. LIGHTER Table 4. Results from the first ROMP (1989): programs
Table 6. Results from the second ROMP (1990): programs
In Directory: 60 programs with 120 positions Offered in Match: 56 programs with 113 positions Of 113 positions, 103 were filled (91%) 47/56 departments (84%) filled all positions 7/56 departments filled some positions 56 programs ranked 639 names = 11.4 names/program 325 offers were used to fill 103 positions = 3.16 offers/ acceptance
In Directory: 57 programs with 111 positions Offered in Match: 49 programs with 98 positions Of 98 positions, 92 were filled (94%) 43/49 departments (88%) filled all positions 3/49 departments (6%) filled some positions 49 programs ranked 5 14 names = 10.5/program 298 offers were used to fill 92 positions = 3.24/acceptance
3.16 offers to achieve an acceptance. The departments that filled all positions listed many more candidates per available position than did departments who were left with vacancies ( 14 listings vs. 7). This may have reflected the novelty of the match process for some programs and their failure to strategize appropriately for the highly competitive nature of the match. The 1989 match as viewed from the candidates’ position is summarized in Table 5. Overall, there were 255 candidates registered. One hundred sixty-two applicants submitted rank lists and 146 candidates were listed by programs, a ratio of 1.29 listed applicants per available position. A significant number of candidates withdrew to occupy the 30-35 residency slots that were offered outside the match. The ROMP results were virtually identical to the long history of the NRMP program in terms of students receiving their preferred institutional choices. In the ROMP, 53% of students received their first choice, 16% their second choice, 14% their third choice, 7% their fourth choice, and 14% their fifth or lower choice. In the NRMP, approximately 57% received their first choice, 16% their second, 10% their third, 6% their fourth, and 11% their fifth or lower choice ( 19). The 1990 ROMP match was held on January 7, 199 1. Data for this match are summarized in Table 6 from the programs’ point of view and in Table 7 from the applicants’ point of view. Participation in the second ROMP was less than that of the first because of some programs withdrawing and still others having no positions to offer due to difficulties with certification from the RRC. In all, 98 positions were offered and 92 were filled. Interest in the match remained high, with 295 candidates registering,
16 1 submitting rank lists, and 143 being ranked. Overall, there were 1.46 ranked applicants per open position. Data on applicant subgroups for the two matches are presented in Table 8. Overall, approximately 70% of ranked students are current United States senior medical students, 25% are earlier United States graduates, and approximately 2% are graduates of foreign medical schools. In 1989,79% of all matched candidates were U.S. seniors and 2 1% were earlier U.S. graduates; no foreign medical graduates matched in that year. In the 1990 match, 75% of those matching were U.S. seniors, 20% were earlier U.S. graduates, and 2% were foreign graduates. In comparison, in the overall 1990 NRMP, 8 1% of 16,000 matched candidates were current U.S. seniors, a figure not too dissimilar from our own match (2 1). Additional details of the 1990 match are presented in Figure 2. The 92 matched candidates listed a median of five programs on their rank list, and were listed by a median of four programs. Only 16% of these candidates ranked fewer than three programs and 34% ranked seven or more programs. These candidates were highly sought after by programs, and 43% of them appeared on the rank list of five or more programs. In contrast, the 49 applicants who had match lists but received no offers listed a median of two programs, and were ranked by a median of one program (Fig. 3). It is difficult to know whether these candidates were seriously interested in Radiation Oncology, accepted offers outside the match but put in a brief match list as a “flyer,” were geographically constrained to apply to only a single program or to nearby programs, or had other factors that truncated their’rank listings. A total of 53 candidates withdrew from the match. Of
Table 5. Results from the first ROMP (1989): applicants
Table 7. Results from the second ROMP (I 990): applicants
No. of registrants No. of rank lists No. of applicants listed by any program
255 (2.28/position 162 (1.43/position
offered) offered)
146 (1.29/position
offered)
No. of registrants No. of rank lists No. of applicants listed by any program
295 (3/position offered) 16 1 ( 1.64/position offered) 143 (1.46/position
Applicants applied to an average of 15.2 programs; interviewed at an average of 6.5 programs; ranked an average of 5.7 programs.
Applicants applied to an average of 12.9 programs; interviewed at an average of 5.5 programs; ranked an average of 4.1 programs.
103 matched applicants received their following choices:
92 matched applicants received the following choices:
offered)
1st
2nd
3rd
4th
5th
6th or greater
1st
2nd
3rd
4th
5th
6th or greater
53%
16%
14%
7%
3%
7%
64%
15%
5%
8%
3%
4%
1152
I. J. Radiation Oncology 0 Biology0 Physics
Volume
22, Number 5, 1992
Table 8. Demographics and results from the applicant pool 1989 Total listed* Current U.S. senior Earlier U.S. grad Foreign grad Total matched Current U.S. senior Earlier U.S. grad Foreign grad Chance of matching if: Rank list submitted Current U.S. senior Earlier U.S. grad Foreign grad
146 105 37 3 103 81 22 0
(72%) (25%) (2%) (79%) (21%) (0%)
103/162 (64%) 76% (81/107) 49% (22/25) 0% (O/9)
1991 143+ 99 (69%) 36 (25%) 3 (2%) 92 69 (75%) 18 (20%) 2 (2%) 92/16 1 (57%) 67% (69/103) 43% ( 18/42) 22% (2/9)
* Listed by one or more programs. + 4% of 1990 listed candidates had unknown status.
these, 37 were listed 93 times by 34 separate programs (Fig. 3). The large number of listings for these candidates and the significant amount of interviewing that these candidates were involved in indicates that these were candidates who likely withdrew from the match to accept offers in other programs. Following the release of match results, programs with open positions can elect to announce the availability of a vacancy through a phone recording maintained by the match office. This “hot line” may be accessed 24 hours a day. Interest in these few vacancies remains high and one program director has reported receiving 37 inquiries for a single opening within 4 weeks of the match closure (Asbell, S. Oral personal communication.). THE FUTURE OF THE ROMP The Radiation Oncology Matching Program has carried out its first two centralized match assignments smoothly and successfully. The major problem that exists with this
Number of Listings by Applicants or Programs - 92 matched Applicants in 1990 -
Listings Applicants
8
2
7
2
of Withdrawn Applicants or Who Had List but No Offers
W withdrawn but Ilstsd by... ??Applicants with no offars Mad.... ??Applicants with no otters ware Mad by...
0
20
10
30
Applicants
Fig. 3. Number of programs listing withdrawn applicants or applicants with no offers, and number of programs listed by applicants with no offers.
program is lack of participation. With only 60-65s of the applicant slots being arranged through the match, the program will surely disintegrate, as other specialty matches have shown us historically. There are a variety of reasons cited by institutions who have not participated in the match as to why a match is undesirable. These reasons are summarized in Table 9. The first and most widely cited reason is “The match is unnecessary because the system was working just fine before.” This is a perception that is not shared by most program directors in Radiation Oncology nor most program directors in other specialty fields. The pressure on students to make early and potentially premature decisions has been widely regarded as both enormous and deleterious. The pressure for programs to offer residencies to students earlier and earlier is an experience reported by every specialty field under a decentralized system. The fact that all Radiation Oncology programs filled all positions from 1984 through 1988 should be considered an historic step forward for a specialty field that barely filled 50% of its residency slots through 1982 (6). However, the intense competition for radiotherapy positions seems to argue for a more organized residency matching program. Some program directors state that they like to “hand pick” their applicants so specifically that an offer to canTable 9. Reasons cited not to use a central match in radiation oncolozv
by... A 10
Applicants
Fig. 2. Number of programs listed by applicants and number of programs listing each applicant for the 92 matched applicants in 1990 (10 applicants listed 5 programs; 11 applicants were listed by 5 different programs).
1. No need to change-old system working fine 2. Residents should be “hand picked” 3. Senior medical students are the minority of resident applicants 4. Everyone cheats in a centralized system 5. A centralized system is too much work for programs 6. My program received more acceptances with the old match process 7. Only a few unique applicants want my program 8. I compete geographically
Residency match in radiation oncology 0 A. S. LIGHTER
didate “B” might hinge entirely around whether candidate “A” accepts or rejects their offer. With a centralized match process, this customized tailoring of residency acceptance cannot be accommodated. One can only rank the best applicants in the order that one appraises their merit. Most medical educators concede that the interview (15) and letters of recommendation (8) are relatively inexact measures of future residency performance. All of us have had experience with the “can’t miss” resident who turns out to be a poor performer, and the “average” candidate who blossoms into an outstanding performer. It is unlikely that “hand picking” one’s resident class will produce a superior outcome than selecting them through a carefully contemplated and well ordered rank list. Other programs have voiced their reluctance to join the match, stating that they believed our specialty to be unique in that we interview and select predominantly from previous medical graduates rather than from senior medical students. The data from the match do not show this to be the case. Between 70 and 75% of residents obtaining slots through the ROMP are senior medical students, which compares favorably to the 8 1% of candidates matching in all positions in the NRMP. The fact is that our specialty is not substantially different than other fields in terms of our candidate pool. Many programs say that they will not join the match because “Everyone cheats in the match anyway.” This is somewhat like the complaint that Congress is rotten but my Congressman is honest. All programs admit that if they were in the match, they would behave honorably, but its the other guy who is cheating. In fact, there is probably some dishonesty in every system. As presented earlier in Table 2, the amount of cheating that is reported by students is relatively low, especially in matches with full participation. While it is true that in a decentralized match process there is no cheating-one cannot break the rules if there are no rules to break-to avoid a centralized match because of fears of rampant cheating does not seem to have a foundation in fact. Some programs have expressed that the interview and selection process under a centralized match system is too much work compared to a decentralized system. It is likely true that a centralized match involves more effort from programs. In a decentralized system, one can accept candidates with a “rolling” acceptance plan. If one sees excellent candidates in the first few interviews sessions, one may immediately offer these candidates positions, fill the program, and cancel out all the other students. While this type of activity and attitude might be beneficial to individual programs, this behavior does not translate well to an entire field. With early acceptance by one program, other programs are encouraged to accept their candidates even earlier, which can lead, as it has in other fields, to eventually accepting residents in the third or even second year of medical school (4). In a procedure as important to our field as the selection of its future practitioners, some extra time an effort to interview candidates fairly and ac-
1153
cept them into our field in an equitable fashion is likely to be time well spent. Some programs state that they always secured acceptances from everyone they wanted with a decentralized system, but found that they were getting rejections inside the match system. Therefore, there must be something wrong with the centralized match since nothing could be wrong with their training program or their interview process. It is likely that a program that is having a difficult time recruiting candidates inside the mafich should first look to their own program for possible answers. In fact, it is possible to interview applicants who turn down positions in the match, find out their perceptions of the program, and use that feedback to improve the residency interview process in subsequent years ( 14). The program rather than the process is usually to blame for an unsuccessful match experience. It is also important to employ an appropriate strategy for operating in a centralized system. Competition for the very best candidates remains keen, and a centralized match levels the playing field so that all candidates can interview at as many programs as they desire. Candidates are under no p&sure to accept one program over another as they are in a decentralized system. Thus, each program should striveito present itself in the best light possible, and each program should interview and rank a sufficient number of candidates to allow for competition with peer institutions. Some programs state that their residency is so unique and unusual that only a few select candiddtes would want their program anyway. To enter the match would be pointless since it is only a “very special” applicant who would even be interested in training in thdr environment. No doubt there are variations in the qu&lity of resident training from institution to institution, as anyone who reviews programs for the RRC can attest. But, the RRC essential guidelines mandate a great deal of basic residency training today, and no program can stray terribly far from the guidelines and still maintain residency approval. The number of programs that offer a dedicated research experience has also begun to increase over the past few years, and it is likely a misperception that there are one or two programs in the field that only interview and select from a tiny subset of the applicant pool. Finally, there is the geographic argument. This is an especially frequent argument from training programs in New York City. The argument goes that the handful of New York City training programs only compete against each other for applicants, and for some reason if all the New York programs were in the match,, they could no longer successfully compete with each other for this pool of candidates. The fact is that if all the $chools in a particular geographic area were in the match and competed for a select pool of candidates who wished to stay in that geographic area, a centralized system would probably match candidates to training programs as efficiently or more efficiently than an ad hoc system would. Several small fellowship programs with only 10 to 20 applicants
1154
I.
J. Radiation Oncology 0 Biology0 Physics
in the entire match process have held successful centralized matches for a number of years. This is probably the size of the residency pool in the metropolitan New York area. SUMMARY
The Radiation Oncology Matching Program provides an orderly, structural framework for the matching of resident applicants to training programs. Arguments against
Volume 22, Number 5, 1992
a centralized match, fairly conducted and administered, stand up poorly to careful scrutiny. However, with only 60-65% of programs participating, the match will certainly cease to function. The training program directors will vote again in 1991 as to whether to continue or abandon the process. By most accounts, a successful match requires approximately 90% participation. If that level of involvement can be achieved, it is likely that the ROMP will successfully join the other specialty matches. Without that level of support, there is little point in continuing.
REFERENCES 1. American Association of Medical Colleges: Experiences of 1990graduates in obtaining a residency. 1990 AAMC grad-
uation auestionnaire summarv results. Washington. D.C. 2. Barchilon, J.; Darley, W. National psychiatri; re$idency matching program. J. Med. Educ. 41: 884-888; 1966. 3. Calcagno, P. L. National pediatric residency matching program. Amer. J. Dis. Child. 116: 534-536; 1968.
4. Cockerell, C.; Dixon, S. L. Are the matching programs for 5. 6.
7. 8. 9.
10. 11.
training in dermatology and pathology operating fairly and without bias? Amer. J. Dermatol. 5: 193-195; 1983. Coleman, S. S.; Darley, W. Matching plan for orthopaedic surgery. Clin. Orthoped. Related Res. 75: 117- 124; 197 1. Cox, J. D.; Flynn, D. R.; Pittman, D. A.; Del Regato, J. A. Postgraduate training in radiation oncology in the United States, 1986. Int. J. Radiat. Oncol. Biol. Phys. 13: 13831388; 1987. Editorial: NIMP to NIRMP. New. Engl. J. Med. 278: 907908; 1968. Friedman, R. B. Fantasy land. New Engl. J. Med. 308: 65 l653; 1983. Graettinger, J. S. Graduate medical education viewed from the national intern and resident matching program. J. Med. Educ. 51: 703-715; 1976. Graettinger, J. S. The matching program. New Engl. J. Med. 304: 1163-l 165; 1981. Graettinger, J. S. The residency matching program. Arch. Otolaryngol. 104: 6615-619; 1978.
12. Golden, W. E. Match march. J. Amer. Med. Assoc. 243: 1047-1048; 1980. 13. Hall, F. M. Resident matching program in radiology. Am. J. Roentgenol. 137: 631-632; 1981. 14. Julian, R. M.; Bornsztein, B. Use of resident applicant feedback to improve a residency program’s matching of highly ranked applicants. J. Med. Educ. 63: 650-652; 1988. 15. Komives, E.; Weiss, S. T.; Rosa, R. M. The applicant interview as a predictor of resident performance. J. Med. Educ. 59: 425-426; 1984. 16. Malkinson, F. D. National residency matching program for dermatology. An evaluation. Arch. Den-n. 99: 350-353; 1969. 17. Mullin, F. J.; Stalnaker, J. M. The matching plan for internship appointment. J. Med. Educ. 26: 341-346; 1952. 18. Myers, J. M. Gentlemen’s agreements and the national residency matching program. J. Clin. Psych. 39: 689; 1978. 19. National resident matching program. Evanston, IL: NRMP Data; April, 1990. 20. Roth, A. E. New physicians: a natural experiment in market organization. Science 250: 1524- 1528; 1990. 21. Tucker, J.; Cantrell, R.; Smith, R.; Jafek, B.; Shumrick, D.; Cummings, C.; Parkin, J. Resolved: all otolaryngology programs should participate in the residency matching program. Arch. Otolaryngol. 104: 627-635; 1978.
