- Email: [email protected]
General surgery program directors’ perceptions of the match
ORIGINAL REPORT
General Surgery Program Directors’ Perceptions of the Match Kimberly D. Anderson, PhD,* and Donald M. Jacobs, MD† *Department of Surgery, Michigan State University, East Lansing, Michigan and †Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota PURPOSE: To identify expectations of general surgery program directors (PDs) for recruitment behavior, and to document the experiences, perceptions, and ethical dilemmas they experienced with the 1998 National Resident Matching Program (NRMP). METHODS: Two hundred sixty-five general surgery PDs were
asked to complete a 30-item written questionnaire. Questions inquired about PD perceptions of students’ interviewing practices, how communication with applicants is conducted and interpreted, and overall perceptions of the match. RESULTS: A total of 77.7% of PDs responded. A total of 44%
of PDs found nothing wrong with students interviewing in multiple specialties and conceded legitimate reasons for doing so; yet, 75% of PDs felt this practice negatively affected students’ rank order. A total of 46.6% of programs told students to keep in touch to be ranked; only 8.7% of PDs believed students’ stated interest, and 76.6% of PDs said these affirmations had no effect on students’ rank. A total of 36.5% of PDs felt students made informal commitments to them, and 90.4% felt students at least sometimes lied to them. A total of 51.7% of PDs felt the match was a reasonable process that needed no changes. CONCLUSIONS: As long as the stakes are high and there are no repercussions for unethical behaviors and practices during residency recruitment, gamesmanship will continue to be the accepted culture. (Curr Surg 57:460 – 465. © 2000 by the Association of Program Directors in Surgery.) KEY WORDS: ethics, graduate education, match, recruit-
ment
INTRODUCTION Curricular focus in medical schools, finance reform in graduate medical education, and a culture of gamesmanship have had a significant effect on both students and programs participating
Correspondence: Inquiries to Kimberly D. Anderson, PhD, Department of Surgery, Michigan State University, B-424 Clinical Center, East Lansing, MI 48824-1315; (517) 3536392; e-mail: [email protected]
460
in the National Resident Matching Program (NRMP). Consider these examples: Example 1: Matt attends a medical school whose mission is to graduate primary care physicians. He has always planned on going in to family practice. The clinical curriculum is front-loaded with the primary care clerkships. His final third-year required clerkship is surgery. He has a great time on the clerkship, earns honors for his performance, and is strongly encouraged by residents and faculty alike to consider this career option. He must start requesting letters of recommendation and applying to residencies, but is conflicted in terms of which specialty is a better fit for him. His interest in surgery is recent, and he is concerned about making a career decision based on an 8-week experience at 1 program. He has no time to do a general surgery elective at another program. He goes through the match applying to both Family Practice and General Surgery. He is forthright with programs about the reasons for applying to both programs. Example 2: Ann is a fourth-year student at a medical school whose mission is to place students in university residencies. She is a solid student with average board scores. Her advisor has told her that she should only apply to university general surgery programs. She gets a few interviews and, not surprisingly, does not match. She scrambles after the match and accepts a Family Practice position. Two months into the residency, she is miserable and realizes that she has made a huge career mistake. She obtains permission to interview once again for general surgery, this time expanding the breadth of programs to which she applies. She is told by numerous general surgery programs that they cannot consider her application because of funding issues. Because she accepted a first-year Family Practice position, her funding eligibility has been determined; full funding is guaranteed for the length of the training program—3 years. She is already using one of those funding years. If she were to match into a general surgery residency, the program would only receive full funding for 2 of her 5 years of training.
CURRENT SURGERY • © 2000 by the Association of Program Directors in Surgery Published by Elsevier Science Inc.
0149-7944/00/$20.00 PII S0149-7944(00)00309-3
Example 3: Eric is applying for a residency position in General Surgery. He has a Master’s Degree, 12 publications in peer-reviewed journals, honors in several required clerkships, Step 1 scores in the 70th percentile, and was a community and campus leader during his undergraduate years. Because of family issues, he must match in a specific geographic region. The general surgery program at his medical school has expressed a sincere interest in him. He likes the program and knows he could do well there, but is more interested in Program B, where there are several faculty who share his research interests. He interviews at Program B and is told by the Program Director that “there is no reason to look any further . . . people like you fit in well here. If you rank us number one there will be no surprises.” Eric ranks this program number one and does not match there. The above examples illustrate the dilemmas that regularly occur in the match process between students and programs. They occur because the system limits flexibility and because the stakes are high. The consequence of not matching or of matching poorly may be significant for students and programs alike. Recently, in response to medical student complaints about program directors (PDs) requesting prematch commitments as a condition of selection, the AMA Council on Medical Education investigated the issue. They concluded that “high turnover and ignorance of the rules” were the 2 primary reasons residency PDs frequently violated regulations governing the match.1 Match ethics was also questioned in several recent editorials discussing the pervasiveness of deception in the interviewing process.2– 4 Tara Young, in an editorial about the match process, stated that “honesty is never an issue—the emphasis is on avoiding failure and achieving success.” She further stated that in informal discussion with classmates, students believed that “their lies were beneficial and allowed them to appear more desirable to different programs. They argued that being completely honest would have hurt their chances.”2 The purpose of this study was to identify general surgery PDs’ perceptions of and experiences with the NRMP and to identify their expectations for recruitment behavior. To accomplish this, questions about 3 research areas were posed: What are PDs’ perceptions of students’ interviewing practices? How do programs communicate with and interpret communication from interviewed students? What are PDs’ overall perceptions of the match process?
METHODS The subjects for this study were general surgery PDs located in the United States and Puerto Rico (n ⫽ 265). Program directors were asked to complete a 30-item written questionnaire; 20 questions were close-ended, 6 questions were partially closeended to allow for comment, and 4 questions were open-ended (Table 1). Questions were related to program and PD demo-
graphics, PDs’ perceptions of students’ interviewing practices, communication with interviewed students, and the match process. A similar questionnaire was sent to senior students participating in the 1998 NRMP from the University of Kentucky, Michigan State University, and the University of Minnesota (n ⫽ 437).5 Seventy-two percent of students responded (n ⫽ 314). To illustrate diversity of perceptions, student responses are presented along with PDs’ responses for several of the more salient questions. Distribution procedures were identical for both the PD and the medical student surveys. Analyses were performed using the extended version of the Statistical Package for the Social Sciences (SPSS Windows, Release 6.1; SPSS, Chicago). Students t-test, chi-square, and descriptive statistics were performed. Responses to the open-ended items were content analyzed for dominant themes.
RESULTS A total of 206 PDs responded to the survey for a 77.7% response rate. Fifty-five percent of all PDs had been in their positions less than or equal to 10 years (mean ⫽ 8.28 years, SD ⫽ 6.95, range ⫽ ⬍1–30 years). The mean number of categorical positions offered per program was 4.15 (SD ⫽ 2.31, range ⫽ 0 –14). The mean number of applicants interviewed per program was 63.14 (SD ⫽ 36.88, range ⫽ 0 –300). A range starting with zero accounted for programs that did not interview applicants for reasons of being on probation, being terminated, or in the process of merging with another program. Thirty percent of the programs noted a decline in the number of applicants interviewed. The primary reasons cited for these decreases were program decision to limit the number of interviews (45.3%) and program perception that there were fewer numbers of qualified applicants (22.1%). Thirty-nine percent of programs matched only applicants whom they had highly ranked (e.g., top 20). Few programs (3.9%) exclusively matched applicants who rotated through their departments or were otherwise familiar to them before residency interviews. Multispecialty Interviewing The first research question addressed PDs’ perceptions of students’ interviewing practices. When characterizing their thoughts about students interviewing in more than one specialty, 44% of PDs found nothing wrong with this practice, 32.5% felt it was an inevitable byproduct of the match system, and 12.1% felt it was ethically wrong. The most common comment associated with this question was that this practice “indicated a lack of commitment to surgery.” Program directors who felt there were legitimate reasons for interviewing in more than 1 specialty cited the following reasons: undecided on field of interest (58.7%), couples match issues (53.4%), applicant wants to ensure match (39.3%), geographic constraints (32.0%), and academically weak (27.2%). Yet, when it came to rank-order decisions, 75.4% of PDs stated that students who interviewed in more than 1 specialty (even if they were forth-
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TABLE 1. Match Perceptions Instrument 1. How long have you been a program director (round to the closest year)? Mean ⫽ 8.28 total years 2. How many first year categorical positions does your program offer? Mean ⫽ 4.15 3. How many applicants did your program interview this year for these categorical positions? Mean ⫽ 63.14 b. In comparison to your recruiting efforts last year, does this number represent: 7.4% an increase in interviewed applicants 30.0% a decrease in interviewed applicants 62.6% about the same number of interviewed applicants c. If you had an increase or decrease in number of applicants that interviewed this year, what was the primary reason? Select the single best response. 45.3% program decision to limit number of interviews granted 7.0% program decision to increase number of interviews granted 22.1% fewer qualified applicants applying 11.6% greater number of qualified applicants applying 14% other 4. Which of the following best characterizes your thoughts about students interviewing in more than one specialty? Select all that apply. 12.1% I feel it is ethically wrong 32.5% I feel it is an inevitable byproduct of the match system 43.7% I don’t think there is anything wrong with it 11.7% other 5. If a student is forthright with you in telling you that he/she is interviewing in more than one specialty what effect does this have on his/her rank order? 28.1% significant negative effect 47.3% some negative effect 24.6% no effect 0% some positive effect 0% significant positive effect 6. What would you consider to be legitimate reason/s for interviewing in more than one specialty? Select all that apply. 11.2% no legitimate reason to interview in more than one specialty 53.4% couples match issues 58.7% applicant undecided on field of interest 39.3% applicant wants to insure that s/he matches 27.2% applicant is weak academically 32.0% applicant had to match in a specific geographic region 3.4% other 7. Do you offer contracts to first year categorical surgery applicants outside of the Match? 6.4% yes 93.6% no 8. Which applicants received follow-up communication from you/your program? 24.3% every applicant 45.0% select applicants 30.7% no applicants 9. What was your primary purpose in sending follow-up communication? Select the single best response. 46.5% to recruit them 41.7% as a courtesy 0.7% applicants expected it 11.1% other 10. Do you tell applicants to keep in touch with you/the program if they are interested in matching with your program? 26.0% always (100%) 20.6% frequently (50–99%) 20.6% sometimes (1–49%) 32.8% never (0%) 11. What percentage of applicant(s) contacted you/the program after their interviews to inform you that you were a “high” or Number 1 rank order choice? 1.5% 100% 18.7% 75–99% 27.1% 50–74% 23.2% 25–49% 28.1% 1–24% 1.5% 0% b. Generally speaking, how did you interpret this information? 8.7% I believed we were their Number 1 choice 60.0% I was skeptical 31.3% I didn’t believe them 462
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TABLE 1. (continued)
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
c. How much did this information from applicants influence your rank order decision? 2.0% significantly 21.4% somewhat 76.6% did not effect our rank order decision How frequently were you asked by applicants how you were ranking them? 5% always (100%) 6.9% frequently (50–99%) 42.6% sometimes (1–49%) 50.0% never (0%) If an applicant you were likely to rank highly asked you how they were being ranked, how did you respond? 15.6% honestly - “we will rank you at the top of our list” 49.7% gave a vague but positive response 0% lied 34.7% responded that you weren’t allowed to tell them If an applicant you were likely to rank low on your list asked you how they were being ranked, how did you respond? 11.7% honestly - “you will not be one of our top candidates” 12.7% gave a vague but positive response 31.0% gave a vague but negative response 0% lied 44.7% responded that you weren’t allowed to tell them If you were less than candid with an applicant, which of the following best characterizes your thoughts? Select all that apply. 5.8% I felt ethically torn about being dishonest 7.3% I felt badly but it is how the game is played 9.2% I did not feel badly 4.9% other 61.2% not applicable Did you inform any applicant that they were your Number 1 rank order choice? 8.4% yes 91.6% no b. Did you inform more applicants than your approved number of categorical positions that they were your Number 1 rank order choice? 1.1% yes 98.9% no What percentage of your matched categorical applicants had rotated through your department or were otherwise familiar to you prior to residency interviews? 3.9% 100% 3.4% 75–99% 12.7% 50–74% 18.1% 25–49% 34.3% 1–24% 27.5% 0% Do you feel the Match process placed you/your program in the position of having to be dishonest with applicants in order to Match your top choices? 4.9% yes 95.1% no What percentage of your matched applicants had been ranked “highly” by your program (i.e. upper 20%)? 38.8% 100% 17.4% 75–99% 17.9% 50–74% 12.4% 25–49% 9.0% 1–24% 4.5% 0% Do you feel you were “lied” to by applicants? 3.5% always (100%) 23.1% frequently (50–99%) 63.8% sometimes (1–49%) 9.5% never (0%) Do you feel that “informal” commitments were made to you by applicants? 36.5% yes 63.5% no (continued on next page)
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TABLE 1. (continued) b. If yes, what was said or written to make you believe an applicant had made a commitment to you? Select all that apply. 31.6% verbal assurances by applicant 26.2% written assurances by applicant 1.5% other (please briefly describe) c. Did you fail to match any applicant/s who you felt had made an “informal” commitment to you? 51.8% yes 48.2% no 22. What is your overall feeling about the Match process? 51.7% it is a reasonable process and needs no changes 43.8% it could be improved 3.5% it is unfair and needs a major overhaul 1.0% it should be eliminated 23. Specific recommendations for change?
right about their reasons for doing so) were at least somewhat negatively effected in the rank order because of this behavior. Communication The second research question asked about communication practices— how programs communicated with students and how communication from students was interpreted by programs. When asked which applicants received follow-up communication from their programs, 45% of programs followed-up with select applicants and 24.3% followed up with every applicant. The primary purpose of this communication was to recruit them (46.5%) and as a courtesy (41.7%). Students responded similarly; 54.8% sent follow-up communication to select programs, and 39.1% sent such communication to every program. The primary purpose in their follow-up was to help programs remember them (46.3%) and as a courtesy (42.5%). Forty-seven percent of programs said that they frequently or always told applicants to keep in touch if they were interested in
matching there. Fifty-seven percent of students said that they were frequently or always told to keep in touch if they wanted to match at a particular program. Program directors stated that nearly half (47.3%) of applicants contacted them after their interviews to inform them that they were a “high” or “number 1” rank order, but 60% of PDs stated that they viewed this information with skepticism, and 31.3% did not believe it at all (Table 2). Factors Influencing Rank Order When asked how confirmatory rank-order statements from applicants influenced their rank order, 76.6% of PDs said it had no effect. A small percentage of students (12%) said they were contacted by programs to inform them they were a top rankorder choice; however, only 42% of them believed the programs. At least 35% of the students contacted by programs stated that this affirmation affected their rank order (Table 1). In response to questions about the communication process, 1 PD wrote: “My major gripe is unsolicited, untruthful verbal
TABLE 2. Communication Between Programs and Interviewed Students Did you tell applicants to keep in touch if you wanted to match?/ Did programs tell you to keep in touch if you wanted to match? Always/frequently Sometimes Never How did you interpret letters of interest from students/programs? Believed Didn’t believe Influence of letters claiming interest on rank order? Significant positive effect Some positive effect No effect Do you feel an informal commitment was made to you? Yes No Do you feel you were lied to? Always/frequently Sometimes Never 464
Programs
Students
46.6% 20.6% 32.8%
56.9% 23.1% 19.9%
8.7% 31.3%
41.7% 00.0%
2.0% 21.4% 76.6%
9.3% 46.5% 44.2%
36.5% 63.5%
42.9% 57.1%
26.6% 63.8% 9.5%
7.5% 25.6% 66.9%
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and/or written offerings by the candidates assuring me that our program is regarded “highly” or “at the top of the list.” This dishonesty is degrading to the applicants, programs and process. It has been rampant throughout my 30-year experience and I don’t know how to police or stop it.” Impressions The final research question asked about perceptions of the match process. Thirty-seven percent of PDs felt informal commitments had been made to them in the form of verbal and written assurances. Ninety-one percent of PDs felt they were at least occasionally lied to by applicants, and 33% of students felt they had been lied to by programs (Table 1). When asked their overall feelings about the match process, over half of the PDs (51.7%) felt it was a reasonable process that needed no changes; only 39.6% of students felt similarly. One program director commented: “Everyone tries to improve the odds for themselves—it’s human nature. Thus far I think it is a fair system and the best we have. However, the scramble for preliminary spots or unmatched spots is a vicious event where wholesale lying takes place.”
DISCUSSION If used according to design, “the NRMP makes the selection process advantageous to both programs and applicants by allowing decisions about preferences to be made in private and without pressure.”6 However, in the current environment, there is little room for error in decision making on the part of programs and students, thus, increasing both the pressure for successful recruitment and reports of unethical behavior during the process. At the root of this ethical quagmire is the evolving graduate medical education landscape. In increasing numbers of medical schools, the focus on primary care has been realized through curricular changes that have negatively impacted the desirability of specialties.7 Frontloaded primary care clerkships and decreases in the amount of time students spend on the surgical specialties in their third and fourth years have limited students’ exposure to specialty fields before making career choices.8 Students are understandably wary of pursuing careers in specialty fields with such limited background and information. Yet when students are forthright about their career indecision and their reasons for interviewing in more than 1 specialty, this study supports Dr. Young’s claim2 that students are penalized for their honesty. Commitment to a specialty and course of study clearly strengthens an applicant’s appeal, but when students’ experiences are defined by factors outside of their control should they be penalized? Restrictions on federal funding for graduate medical education have placed greater pressures on students to match—not only must medical students match successfully as seniors, but they must be wary of changing specialties to avoid loss of funding for their training.9 Chairpersons and PDs need to understand funding issues and must realistically counsel students about programs and their chances of matching into surgery. Students who are at risk for not matching because of career
indecision should perhaps be encouraged to apply for preliminary surgery positions and not categorical positions that will limit their future training options. If completing an “audition elective” with a program has no bearing on a student’s chances of matching there, a student should be informed of this at the time they sign up for the experience. If communicating with programs after the interview not only has no bearing on students’ rank order but is routinely disbelieved, students should not be told to keep in touch. This discrepancy between stated expectations and the reality of their interpretation sets a stage characterized by mutual distrust. However, as long as the stakes are high and there are no repercussions for unethical behaviors and practices during residency recruitment, gamesmanship will continue to be the accepted culture. We perpetuate many of the problems in the match through our behavior. What are PDs’ perceptions of the match? Many are confused about how the match actually works. They feel it is too expensive and time consuming for the applicants and the programs. Suggestions to improve the process included “stiff penalties for students and their schools when students do not honor their match obligations,” “formal mechanisms to report program directors and/or programs who act unethically,” and “exposure and ceremonial execution of offenders— both students and program directors—no punishment means people ignore the rules.” As one PD summarized: “The Match is not the problem; people who lie are the problem.” The practices and perceptions of unethical behavior in the match will continue until PDs decide to accept the challenge and set the behavioral standard.
REFERENCES 1. Greene J. AMA to monitor residency match violations. Am
Med News 2000;43:1.3. 2. Young T. Teaching medical students to lie. The disturbing
contradictions: medical ideals and the resident-selection process. Can Med Assoc J 1997;156:219 –222. 3. Healy M. Lies students tell. Can Med Assoc J 1997;156:1266. 4. Taylor B. Lies students tell. Can Med Assoc J 1997;156:
1265–1266. 5. Anderson K, Jacobs DM, Blue AV. Is match ethics an oxy-
moron? Am J Surg 1999;177:237–239. 6. National Resident Matching Program Handbook for Institu-
tions and Program Directors, 1998 Match. Washington, DC. 1988. 7. Council on Graduate Medical Education. First Report of the
Council (Volume 1). Washington, DC: Government Printing Office, 1988. 8. Polk H. The declining interest in surgical careers, the pri-
mary care mirage, and concerns about contemporary undergraduate surgical education. Am J Surg 1999;178:177–179. 9. 63 Federal Register 26330 (1998).
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General Surgery Program Directors’ Perceptions of the Match Kimberly D. Anderson, PhD,* and Donald M. Jacobs, MD† *Department of Surgery, Michigan State University, East Lansing, Michigan and †Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota PURPOSE: To identify expectations of general surgery program directors (PDs) for recruitment behavior, and to document the experiences, perceptions, and ethical dilemmas they experienced with the 1998 National Resident Matching Program (NRMP). METHODS: Two hundred sixty-five general surgery PDs were
asked to complete a 30-item written questionnaire. Questions inquired about PD perceptions of students’ interviewing practices, how communication with applicants is conducted and interpreted, and overall perceptions of the match. RESULTS: A total of 77.7% of PDs responded. A total of 44%
of PDs found nothing wrong with students interviewing in multiple specialties and conceded legitimate reasons for doing so; yet, 75% of PDs felt this practice negatively affected students’ rank order. A total of 46.6% of programs told students to keep in touch to be ranked; only 8.7% of PDs believed students’ stated interest, and 76.6% of PDs said these affirmations had no effect on students’ rank. A total of 36.5% of PDs felt students made informal commitments to them, and 90.4% felt students at least sometimes lied to them. A total of 51.7% of PDs felt the match was a reasonable process that needed no changes. CONCLUSIONS: As long as the stakes are high and there are no repercussions for unethical behaviors and practices during residency recruitment, gamesmanship will continue to be the accepted culture. (Curr Surg 57:460 – 465. © 2000 by the Association of Program Directors in Surgery.) KEY WORDS: ethics, graduate education, match, recruit-
ment
INTRODUCTION Curricular focus in medical schools, finance reform in graduate medical education, and a culture of gamesmanship have had a significant effect on both students and programs participating
Correspondence: Inquiries to Kimberly D. Anderson, PhD, Department of Surgery, Michigan State University, B-424 Clinical Center, East Lansing, MI 48824-1315; (517) 3536392; e-mail: [email protected]
460
in the National Resident Matching Program (NRMP). Consider these examples: Example 1: Matt attends a medical school whose mission is to graduate primary care physicians. He has always planned on going in to family practice. The clinical curriculum is front-loaded with the primary care clerkships. His final third-year required clerkship is surgery. He has a great time on the clerkship, earns honors for his performance, and is strongly encouraged by residents and faculty alike to consider this career option. He must start requesting letters of recommendation and applying to residencies, but is conflicted in terms of which specialty is a better fit for him. His interest in surgery is recent, and he is concerned about making a career decision based on an 8-week experience at 1 program. He has no time to do a general surgery elective at another program. He goes through the match applying to both Family Practice and General Surgery. He is forthright with programs about the reasons for applying to both programs. Example 2: Ann is a fourth-year student at a medical school whose mission is to place students in university residencies. She is a solid student with average board scores. Her advisor has told her that she should only apply to university general surgery programs. She gets a few interviews and, not surprisingly, does not match. She scrambles after the match and accepts a Family Practice position. Two months into the residency, she is miserable and realizes that she has made a huge career mistake. She obtains permission to interview once again for general surgery, this time expanding the breadth of programs to which she applies. She is told by numerous general surgery programs that they cannot consider her application because of funding issues. Because she accepted a first-year Family Practice position, her funding eligibility has been determined; full funding is guaranteed for the length of the training program—3 years. She is already using one of those funding years. If she were to match into a general surgery residency, the program would only receive full funding for 2 of her 5 years of training.
CURRENT SURGERY • © 2000 by the Association of Program Directors in Surgery Published by Elsevier Science Inc.
0149-7944/00/$20.00 PII S0149-7944(00)00309-3
Example 3: Eric is applying for a residency position in General Surgery. He has a Master’s Degree, 12 publications in peer-reviewed journals, honors in several required clerkships, Step 1 scores in the 70th percentile, and was a community and campus leader during his undergraduate years. Because of family issues, he must match in a specific geographic region. The general surgery program at his medical school has expressed a sincere interest in him. He likes the program and knows he could do well there, but is more interested in Program B, where there are several faculty who share his research interests. He interviews at Program B and is told by the Program Director that “there is no reason to look any further . . . people like you fit in well here. If you rank us number one there will be no surprises.” Eric ranks this program number one and does not match there. The above examples illustrate the dilemmas that regularly occur in the match process between students and programs. They occur because the system limits flexibility and because the stakes are high. The consequence of not matching or of matching poorly may be significant for students and programs alike. Recently, in response to medical student complaints about program directors (PDs) requesting prematch commitments as a condition of selection, the AMA Council on Medical Education investigated the issue. They concluded that “high turnover and ignorance of the rules” were the 2 primary reasons residency PDs frequently violated regulations governing the match.1 Match ethics was also questioned in several recent editorials discussing the pervasiveness of deception in the interviewing process.2– 4 Tara Young, in an editorial about the match process, stated that “honesty is never an issue—the emphasis is on avoiding failure and achieving success.” She further stated that in informal discussion with classmates, students believed that “their lies were beneficial and allowed them to appear more desirable to different programs. They argued that being completely honest would have hurt their chances.”2 The purpose of this study was to identify general surgery PDs’ perceptions of and experiences with the NRMP and to identify their expectations for recruitment behavior. To accomplish this, questions about 3 research areas were posed: What are PDs’ perceptions of students’ interviewing practices? How do programs communicate with and interpret communication from interviewed students? What are PDs’ overall perceptions of the match process?
METHODS The subjects for this study were general surgery PDs located in the United States and Puerto Rico (n ⫽ 265). Program directors were asked to complete a 30-item written questionnaire; 20 questions were close-ended, 6 questions were partially closeended to allow for comment, and 4 questions were open-ended (Table 1). Questions were related to program and PD demo-
graphics, PDs’ perceptions of students’ interviewing practices, communication with interviewed students, and the match process. A similar questionnaire was sent to senior students participating in the 1998 NRMP from the University of Kentucky, Michigan State University, and the University of Minnesota (n ⫽ 437).5 Seventy-two percent of students responded (n ⫽ 314). To illustrate diversity of perceptions, student responses are presented along with PDs’ responses for several of the more salient questions. Distribution procedures were identical for both the PD and the medical student surveys. Analyses were performed using the extended version of the Statistical Package for the Social Sciences (SPSS Windows, Release 6.1; SPSS, Chicago). Students t-test, chi-square, and descriptive statistics were performed. Responses to the open-ended items were content analyzed for dominant themes.
RESULTS A total of 206 PDs responded to the survey for a 77.7% response rate. Fifty-five percent of all PDs had been in their positions less than or equal to 10 years (mean ⫽ 8.28 years, SD ⫽ 6.95, range ⫽ ⬍1–30 years). The mean number of categorical positions offered per program was 4.15 (SD ⫽ 2.31, range ⫽ 0 –14). The mean number of applicants interviewed per program was 63.14 (SD ⫽ 36.88, range ⫽ 0 –300). A range starting with zero accounted for programs that did not interview applicants for reasons of being on probation, being terminated, or in the process of merging with another program. Thirty percent of the programs noted a decline in the number of applicants interviewed. The primary reasons cited for these decreases were program decision to limit the number of interviews (45.3%) and program perception that there were fewer numbers of qualified applicants (22.1%). Thirty-nine percent of programs matched only applicants whom they had highly ranked (e.g., top 20). Few programs (3.9%) exclusively matched applicants who rotated through their departments or were otherwise familiar to them before residency interviews. Multispecialty Interviewing The first research question addressed PDs’ perceptions of students’ interviewing practices. When characterizing their thoughts about students interviewing in more than one specialty, 44% of PDs found nothing wrong with this practice, 32.5% felt it was an inevitable byproduct of the match system, and 12.1% felt it was ethically wrong. The most common comment associated with this question was that this practice “indicated a lack of commitment to surgery.” Program directors who felt there were legitimate reasons for interviewing in more than 1 specialty cited the following reasons: undecided on field of interest (58.7%), couples match issues (53.4%), applicant wants to ensure match (39.3%), geographic constraints (32.0%), and academically weak (27.2%). Yet, when it came to rank-order decisions, 75.4% of PDs stated that students who interviewed in more than 1 specialty (even if they were forth-
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TABLE 1. Match Perceptions Instrument 1. How long have you been a program director (round to the closest year)? Mean ⫽ 8.28 total years 2. How many first year categorical positions does your program offer? Mean ⫽ 4.15 3. How many applicants did your program interview this year for these categorical positions? Mean ⫽ 63.14 b. In comparison to your recruiting efforts last year, does this number represent: 7.4% an increase in interviewed applicants 30.0% a decrease in interviewed applicants 62.6% about the same number of interviewed applicants c. If you had an increase or decrease in number of applicants that interviewed this year, what was the primary reason? Select the single best response. 45.3% program decision to limit number of interviews granted 7.0% program decision to increase number of interviews granted 22.1% fewer qualified applicants applying 11.6% greater number of qualified applicants applying 14% other 4. Which of the following best characterizes your thoughts about students interviewing in more than one specialty? Select all that apply. 12.1% I feel it is ethically wrong 32.5% I feel it is an inevitable byproduct of the match system 43.7% I don’t think there is anything wrong with it 11.7% other 5. If a student is forthright with you in telling you that he/she is interviewing in more than one specialty what effect does this have on his/her rank order? 28.1% significant negative effect 47.3% some negative effect 24.6% no effect 0% some positive effect 0% significant positive effect 6. What would you consider to be legitimate reason/s for interviewing in more than one specialty? Select all that apply. 11.2% no legitimate reason to interview in more than one specialty 53.4% couples match issues 58.7% applicant undecided on field of interest 39.3% applicant wants to insure that s/he matches 27.2% applicant is weak academically 32.0% applicant had to match in a specific geographic region 3.4% other 7. Do you offer contracts to first year categorical surgery applicants outside of the Match? 6.4% yes 93.6% no 8. Which applicants received follow-up communication from you/your program? 24.3% every applicant 45.0% select applicants 30.7% no applicants 9. What was your primary purpose in sending follow-up communication? Select the single best response. 46.5% to recruit them 41.7% as a courtesy 0.7% applicants expected it 11.1% other 10. Do you tell applicants to keep in touch with you/the program if they are interested in matching with your program? 26.0% always (100%) 20.6% frequently (50–99%) 20.6% sometimes (1–49%) 32.8% never (0%) 11. What percentage of applicant(s) contacted you/the program after their interviews to inform you that you were a “high” or Number 1 rank order choice? 1.5% 100% 18.7% 75–99% 27.1% 50–74% 23.2% 25–49% 28.1% 1–24% 1.5% 0% b. Generally speaking, how did you interpret this information? 8.7% I believed we were their Number 1 choice 60.0% I was skeptical 31.3% I didn’t believe them 462
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TABLE 1. (continued)
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
c. How much did this information from applicants influence your rank order decision? 2.0% significantly 21.4% somewhat 76.6% did not effect our rank order decision How frequently were you asked by applicants how you were ranking them? 5% always (100%) 6.9% frequently (50–99%) 42.6% sometimes (1–49%) 50.0% never (0%) If an applicant you were likely to rank highly asked you how they were being ranked, how did you respond? 15.6% honestly - “we will rank you at the top of our list” 49.7% gave a vague but positive response 0% lied 34.7% responded that you weren’t allowed to tell them If an applicant you were likely to rank low on your list asked you how they were being ranked, how did you respond? 11.7% honestly - “you will not be one of our top candidates” 12.7% gave a vague but positive response 31.0% gave a vague but negative response 0% lied 44.7% responded that you weren’t allowed to tell them If you were less than candid with an applicant, which of the following best characterizes your thoughts? Select all that apply. 5.8% I felt ethically torn about being dishonest 7.3% I felt badly but it is how the game is played 9.2% I did not feel badly 4.9% other 61.2% not applicable Did you inform any applicant that they were your Number 1 rank order choice? 8.4% yes 91.6% no b. Did you inform more applicants than your approved number of categorical positions that they were your Number 1 rank order choice? 1.1% yes 98.9% no What percentage of your matched categorical applicants had rotated through your department or were otherwise familiar to you prior to residency interviews? 3.9% 100% 3.4% 75–99% 12.7% 50–74% 18.1% 25–49% 34.3% 1–24% 27.5% 0% Do you feel the Match process placed you/your program in the position of having to be dishonest with applicants in order to Match your top choices? 4.9% yes 95.1% no What percentage of your matched applicants had been ranked “highly” by your program (i.e. upper 20%)? 38.8% 100% 17.4% 75–99% 17.9% 50–74% 12.4% 25–49% 9.0% 1–24% 4.5% 0% Do you feel you were “lied” to by applicants? 3.5% always (100%) 23.1% frequently (50–99%) 63.8% sometimes (1–49%) 9.5% never (0%) Do you feel that “informal” commitments were made to you by applicants? 36.5% yes 63.5% no (continued on next page)
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TABLE 1. (continued) b. If yes, what was said or written to make you believe an applicant had made a commitment to you? Select all that apply. 31.6% verbal assurances by applicant 26.2% written assurances by applicant 1.5% other (please briefly describe) c. Did you fail to match any applicant/s who you felt had made an “informal” commitment to you? 51.8% yes 48.2% no 22. What is your overall feeling about the Match process? 51.7% it is a reasonable process and needs no changes 43.8% it could be improved 3.5% it is unfair and needs a major overhaul 1.0% it should be eliminated 23. Specific recommendations for change?
right about their reasons for doing so) were at least somewhat negatively effected in the rank order because of this behavior. Communication The second research question asked about communication practices— how programs communicated with students and how communication from students was interpreted by programs. When asked which applicants received follow-up communication from their programs, 45% of programs followed-up with select applicants and 24.3% followed up with every applicant. The primary purpose of this communication was to recruit them (46.5%) and as a courtesy (41.7%). Students responded similarly; 54.8% sent follow-up communication to select programs, and 39.1% sent such communication to every program. The primary purpose in their follow-up was to help programs remember them (46.3%) and as a courtesy (42.5%). Forty-seven percent of programs said that they frequently or always told applicants to keep in touch if they were interested in
matching there. Fifty-seven percent of students said that they were frequently or always told to keep in touch if they wanted to match at a particular program. Program directors stated that nearly half (47.3%) of applicants contacted them after their interviews to inform them that they were a “high” or “number 1” rank order, but 60% of PDs stated that they viewed this information with skepticism, and 31.3% did not believe it at all (Table 2). Factors Influencing Rank Order When asked how confirmatory rank-order statements from applicants influenced their rank order, 76.6% of PDs said it had no effect. A small percentage of students (12%) said they were contacted by programs to inform them they were a top rankorder choice; however, only 42% of them believed the programs. At least 35% of the students contacted by programs stated that this affirmation affected their rank order (Table 1). In response to questions about the communication process, 1 PD wrote: “My major gripe is unsolicited, untruthful verbal
TABLE 2. Communication Between Programs and Interviewed Students Did you tell applicants to keep in touch if you wanted to match?/ Did programs tell you to keep in touch if you wanted to match? Always/frequently Sometimes Never How did you interpret letters of interest from students/programs? Believed Didn’t believe Influence of letters claiming interest on rank order? Significant positive effect Some positive effect No effect Do you feel an informal commitment was made to you? Yes No Do you feel you were lied to? Always/frequently Sometimes Never 464
Programs
Students
46.6% 20.6% 32.8%
56.9% 23.1% 19.9%
8.7% 31.3%
41.7% 00.0%
2.0% 21.4% 76.6%
9.3% 46.5% 44.2%
36.5% 63.5%
42.9% 57.1%
26.6% 63.8% 9.5%
7.5% 25.6% 66.9%
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and/or written offerings by the candidates assuring me that our program is regarded “highly” or “at the top of the list.” This dishonesty is degrading to the applicants, programs and process. It has been rampant throughout my 30-year experience and I don’t know how to police or stop it.” Impressions The final research question asked about perceptions of the match process. Thirty-seven percent of PDs felt informal commitments had been made to them in the form of verbal and written assurances. Ninety-one percent of PDs felt they were at least occasionally lied to by applicants, and 33% of students felt they had been lied to by programs (Table 1). When asked their overall feelings about the match process, over half of the PDs (51.7%) felt it was a reasonable process that needed no changes; only 39.6% of students felt similarly. One program director commented: “Everyone tries to improve the odds for themselves—it’s human nature. Thus far I think it is a fair system and the best we have. However, the scramble for preliminary spots or unmatched spots is a vicious event where wholesale lying takes place.”
DISCUSSION If used according to design, “the NRMP makes the selection process advantageous to both programs and applicants by allowing decisions about preferences to be made in private and without pressure.”6 However, in the current environment, there is little room for error in decision making on the part of programs and students, thus, increasing both the pressure for successful recruitment and reports of unethical behavior during the process. At the root of this ethical quagmire is the evolving graduate medical education landscape. In increasing numbers of medical schools, the focus on primary care has been realized through curricular changes that have negatively impacted the desirability of specialties.7 Frontloaded primary care clerkships and decreases in the amount of time students spend on the surgical specialties in their third and fourth years have limited students’ exposure to specialty fields before making career choices.8 Students are understandably wary of pursuing careers in specialty fields with such limited background and information. Yet when students are forthright about their career indecision and their reasons for interviewing in more than 1 specialty, this study supports Dr. Young’s claim2 that students are penalized for their honesty. Commitment to a specialty and course of study clearly strengthens an applicant’s appeal, but when students’ experiences are defined by factors outside of their control should they be penalized? Restrictions on federal funding for graduate medical education have placed greater pressures on students to match—not only must medical students match successfully as seniors, but they must be wary of changing specialties to avoid loss of funding for their training.9 Chairpersons and PDs need to understand funding issues and must realistically counsel students about programs and their chances of matching into surgery. Students who are at risk for not matching because of career
indecision should perhaps be encouraged to apply for preliminary surgery positions and not categorical positions that will limit their future training options. If completing an “audition elective” with a program has no bearing on a student’s chances of matching there, a student should be informed of this at the time they sign up for the experience. If communicating with programs after the interview not only has no bearing on students’ rank order but is routinely disbelieved, students should not be told to keep in touch. This discrepancy between stated expectations and the reality of their interpretation sets a stage characterized by mutual distrust. However, as long as the stakes are high and there are no repercussions for unethical behaviors and practices during residency recruitment, gamesmanship will continue to be the accepted culture. We perpetuate many of the problems in the match through our behavior. What are PDs’ perceptions of the match? Many are confused about how the match actually works. They feel it is too expensive and time consuming for the applicants and the programs. Suggestions to improve the process included “stiff penalties for students and their schools when students do not honor their match obligations,” “formal mechanisms to report program directors and/or programs who act unethically,” and “exposure and ceremonial execution of offenders— both students and program directors—no punishment means people ignore the rules.” As one PD summarized: “The Match is not the problem; people who lie are the problem.” The practices and perceptions of unethical behavior in the match will continue until PDs decide to accept the challenge and set the behavioral standard.
REFERENCES 1. Greene J. AMA to monitor residency match violations. Am
Med News 2000;43:1.3. 2. Young T. Teaching medical students to lie. The disturbing
contradictions: medical ideals and the resident-selection process. Can Med Assoc J 1997;156:219 –222. 3. Healy M. Lies students tell. Can Med Assoc J 1997;156:1266. 4. Taylor B. Lies students tell. Can Med Assoc J 1997;156:
1265–1266. 5. Anderson K, Jacobs DM, Blue AV. Is match ethics an oxy-
moron? Am J Surg 1999;177:237–239. 6. National Resident Matching Program Handbook for Institu-
tions and Program Directors, 1998 Match. Washington, DC. 1988. 7. Council on Graduate Medical Education. First Report of the
Council (Volume 1). Washington, DC: Government Printing Office, 1988. 8. Polk H. The declining interest in surgical careers, the pri-
mary care mirage, and concerns about contemporary undergraduate surgical education. Am J Surg 1999;178:177–179. 9. 63 Federal Register 26330 (1998).
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