Match Point?
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《新英格兰医药杂志》
Last month, a federal district judge in Washington, D.C., dismissed the first antitrust lawsuit filed by medical residents. In an unusual twist, Congress retroactively granted residency programs and hospitals immunity from antitrust laws with a rare exemption previously granted primarily to major-league baseball players. The decision put the residency Match back into newspaper headlines and reignited a national debate over medical training. It was not the first time the Match faced controversy.
(Figure)
From the New York Times, October 22, 1951, and August 14, 2004.
Two years ago, we applied for residency as a couple during one of the most tumultuous Matches ever. A few weeks before we wrote our first essays, three residents filed the antitrust lawsuit. A few months later, the Accreditation Council for Graduate Medical Education (ACGME) announced new work-hour regulations that limited the resident workweek to 80 hours. As we crisscrossed the country, interviewing along with 24,000 other medical students, most of the residencies we visited were redesigning their programs to meet the new regulations. The details of our internship — our salary, schedules, and working conditions — were still in limbo when we held our breath, finalized our rank list, and launched into the Match.
Our Match seemed contentious, but it was nothing compared with the first. The Match was born out of a struggle between medical school faculty and students. In 1951, a group of influential medical leaders, including the director of the Association of American Medical Colleges and the president of Johns Hopkins, collaborated to fix a notoriously chaotic residency selection process by creating a centralized system to allocate positions. When they presented it, however, a fourth-year student found a flaw: if he (or any applicant) did not get his first choice, he would lose his second-choice spot to a less-qualified applicant who ranked the program first. When the student protested, the faculty stood firm.
Determined to apply in a fair system, W. Hardy Hendren and six of his classmates organized against the Match. "I borrowed $3,000 from my father to finance our effort," said Dr. Hendren, now chief of surgery emeritus at Children's Hospital in Boston. "We hired a secretary and a printing company and sent telegrams to class presidents across the country." Two weeks later, they held a meeting in New York with medical leaders and representatives from most of the nation's 72 medical schools, where they presented a revised algorithm for the Match. When medical leaders were reluctant to implement the revision, the group organized a national student vote and handed them an ultimatum: change the Match, or destroy it by losing the support of 95 percent of medical students. The revised Match took place a few months later, on March 15, 1952.
For more than half a century, the Match continued as an uncontested rite of passage, until May 2002, when three residents filed a lawsuit against 29 teaching hospitals and 7 professional associations, alleging that the system acts against students' interests. They argued that the Match artificially lowers salaries and lengthens work hours by assigning applicants to one program instead of allowing them to choose among competing hospitals.
The defendants countered that the Match allocates residency positions efficiently, without denying medical students negotiation rights. Although they acknowledged that students rarely ask for higher salaries during interviews, they argued that it was not expressly forbidden. They objected that the cost of litigation might bankrupt the medical system, and they filed a motion to dismiss the suit. They also hired lobbyists on Capitol Hill, including two former staff members from the office of Senator Edward Kennedy (D-Mass.).
As the courts reviewed the case, Senator Kennedy began shaping legislation to shield the Match from the suit. In March 2003, his office circulated a draft amendment to exempt the Match from antitrust laws. Senator Jeff Bingaman (D-N.M.) and others objected, and wrote a letter to Majority Leader Bill Frist (R-Tenn.) and Minority Leader Tom Daschle (D-S.D.), arguing that the proposal had "widespread implications" and should be decided by the legislative process, rather than being appended to a bill that would sidestep Senate committee hearings and public debate.1
In February 2004, the Federal District Court in Washington, D.C., ruled against the defendants' motion for dismissal, stating that there was an adequate basis to argue the existence of "a purported scheme of restraints that has the purpose and effect of fixing, artificially depressing, standardizing and stabilizing resident physician compensation."2
Two months later, Senators Kennedy and Judd Gregg (R-N.H.) quietly amended a pension bill with a broad antitrust exemption for the Match that was nearly identical to the draft that had been circulated one year earlier. The bill, which was quickly signed into law by President George W. Bush, stated that "it shall not be unlawful under the antitrust laws to sponsor, conduct, or participate in a graduate medical education residency program."3 Under the bill, Match participants cannot be accused of violating antitrust law in federal court. A second provision, however, stated that residency programs cannot collude to fix salaries or benefits.
The lawyers for the plaintiffs declared the amendment unconstitutional and "an egregious abuse of the legislative system." Shortly after it passed, however, the defendants filed a motion to dismiss the suit. Ultimately, the court ruled in their favor. On August 12, 2004, U.S. District Court Judge Paul Friedman wrote, "[The] plaintiffs understandably are frustrated. They won a significant victory in court. Congress now has snatched it away. . . . Absent a valid constitutional challenge to a law passed by Congress and signed by the President, however, the responsibility of the courts is to interpret and apply the statute, not to second guess."4
The plaintiffs have vowed to pursue legal action for better wages and working conditions for residents, suggesting that an appeal is likely. While the legal process continues to unfold, there is also new pressure from within. At the recent biannual meeting of the American Medical Association (AMA), the California Medical Association introduced a resolution to reform the Match. The resolution includes many of the provisions from the lawsuit. It mandates that the process be transparent, follow antitrust laws, recognize residents as labor, and bill programs instead of students for administrative costs. On June 15, 2004, the AMA House of Delegates voted to review the resolution before a national committee. If adopted as AMA policy, this resolution may spur broad reforms, since the AMA sits on the board of the National Resident Matching Program (NRMP).
Much of the debate hinges on whether a residency is a job or a continuation of medical education. Senior physicians argue that residency training provides invaluable educational opportunities — exposure to interesting cases, supervised clinical care, daily conferences — and contacts that are necessary for a lifetime of practice. The competition for spots in the leading residency programs remains stiff: in 2004, the internal medicine program at Brigham and Women's Hospital in Boston received approximately 2300 applications for 68 spots. Many senior physicians argue that abolishing the Match might backfire, driving down salaries in the most competitive programs. Whether the same is true for less prestigious programs is unclear, since residency positions outnumber the American medical school graduates available to fill them.
Many residents argue, however, that hospitals rely on house officers as cheap labor, expecting them to perform administrative tasks that are not educational. Residents routinely track down medical records, transport patients, coordinate inpatient studies, and schedule outpatient appointments. In 1999, the National Labor Relations Board agreed, declaring resident physicians employees instead of students. In its decision, the board compared house staff to apprentices or professionals who receive additional training while employed. This ruling allowed residents at private hospitals to organize labor unions and bargain collectively for the first time. Although the decision aroused fears about residents striking, few actually did.
The Match was not designed to maximize students' bargaining power, and that may ultimately be its greatest weakness. In the current system, students sign binding work agreements on entering the Match, and few feel comfortable negotiating before they secure a spot. Most residents rely on hospital administrators and regulatory bodies to represent them, but competing interests may compromise reform efforts. As hospitals respond to declining reimbursements by reducing staff and streamlining care, the administrative burden carried by residents often escalates unchecked, compromising the quality of education. In addition, many residents face financial hardship as they juggle low salaries and an average educational debt of $110,000. Although salaries increase after training, most physicians lose 7 to 14 years of earning potential after college, and residents' salaries are among the lowest in the health care industry.
Despite these flaws, the Match has survived for 50 years with few changes, and its strength still lies in its clear organization and ability to streamline a potentially chaotic system. The Match has been so successful that New York City used it as a model for assigning spots at public high schools this year, and 30 percent more students were assigned to their first-choice school as a result. The current residency-match algorithm favors students by moving down their rank lists first before considering programs' preferences. The Match also enables couples, such as ourselves, to apply to programs together, allowing us to give priority to personal relationships over a particular program. Finally, it offers students and program directors a set date when both parties will know their future.
The ACGME's work-hour regulations were the first national effort to standardize residents' working conditions, apart from the Match, and despite many shortcomings, they may now serve as a model for reform. If the Match is to remain shielded from antitrust legislation, many believe that hospitals, program administrators, and regulatory bodies must ensure that residents have a voice in controlling their salaries, their work hours, and most important, the quality of their education. By empowering residents to negotiate for better working conditions through collective bargaining, unions, and equal representation on all national boards, including the NRMP, we may free the Match to fulfill its original promise — pairing students with residency programs in a fair manner. We owe this much to future physicians and their patients.
Source Information
From Brigham and Women's Hospital, Boston.
References
150 Cong. Rec. S3991-92 (daily ed. Apr. 8, 2004) (statement of Sens. Bingaman, Feingold, Kohl, and Craig).
Jung v. Association of American Medical Colleges, 300F. Supp. 2d 119 (D.D.C. 2004).
Pension Funding Equity Act, H.R. 3108, Sec. 207, April 8, 2004.
Jung v. Association of American Medical Colleges, No. CIV.A. 02-0873, 2004 WL 1803198 (D.D.C. Aug. 12, 2004).(Alexi A. Wright, M.D., an)
(Figure)
From the New York Times, October 22, 1951, and August 14, 2004.
Two years ago, we applied for residency as a couple during one of the most tumultuous Matches ever. A few weeks before we wrote our first essays, three residents filed the antitrust lawsuit. A few months later, the Accreditation Council for Graduate Medical Education (ACGME) announced new work-hour regulations that limited the resident workweek to 80 hours. As we crisscrossed the country, interviewing along with 24,000 other medical students, most of the residencies we visited were redesigning their programs to meet the new regulations. The details of our internship — our salary, schedules, and working conditions — were still in limbo when we held our breath, finalized our rank list, and launched into the Match.
Our Match seemed contentious, but it was nothing compared with the first. The Match was born out of a struggle between medical school faculty and students. In 1951, a group of influential medical leaders, including the director of the Association of American Medical Colleges and the president of Johns Hopkins, collaborated to fix a notoriously chaotic residency selection process by creating a centralized system to allocate positions. When they presented it, however, a fourth-year student found a flaw: if he (or any applicant) did not get his first choice, he would lose his second-choice spot to a less-qualified applicant who ranked the program first. When the student protested, the faculty stood firm.
Determined to apply in a fair system, W. Hardy Hendren and six of his classmates organized against the Match. "I borrowed $3,000 from my father to finance our effort," said Dr. Hendren, now chief of surgery emeritus at Children's Hospital in Boston. "We hired a secretary and a printing company and sent telegrams to class presidents across the country." Two weeks later, they held a meeting in New York with medical leaders and representatives from most of the nation's 72 medical schools, where they presented a revised algorithm for the Match. When medical leaders were reluctant to implement the revision, the group organized a national student vote and handed them an ultimatum: change the Match, or destroy it by losing the support of 95 percent of medical students. The revised Match took place a few months later, on March 15, 1952.
For more than half a century, the Match continued as an uncontested rite of passage, until May 2002, when three residents filed a lawsuit against 29 teaching hospitals and 7 professional associations, alleging that the system acts against students' interests. They argued that the Match artificially lowers salaries and lengthens work hours by assigning applicants to one program instead of allowing them to choose among competing hospitals.
The defendants countered that the Match allocates residency positions efficiently, without denying medical students negotiation rights. Although they acknowledged that students rarely ask for higher salaries during interviews, they argued that it was not expressly forbidden. They objected that the cost of litigation might bankrupt the medical system, and they filed a motion to dismiss the suit. They also hired lobbyists on Capitol Hill, including two former staff members from the office of Senator Edward Kennedy (D-Mass.).
As the courts reviewed the case, Senator Kennedy began shaping legislation to shield the Match from the suit. In March 2003, his office circulated a draft amendment to exempt the Match from antitrust laws. Senator Jeff Bingaman (D-N.M.) and others objected, and wrote a letter to Majority Leader Bill Frist (R-Tenn.) and Minority Leader Tom Daschle (D-S.D.), arguing that the proposal had "widespread implications" and should be decided by the legislative process, rather than being appended to a bill that would sidestep Senate committee hearings and public debate.1
In February 2004, the Federal District Court in Washington, D.C., ruled against the defendants' motion for dismissal, stating that there was an adequate basis to argue the existence of "a purported scheme of restraints that has the purpose and effect of fixing, artificially depressing, standardizing and stabilizing resident physician compensation."2
Two months later, Senators Kennedy and Judd Gregg (R-N.H.) quietly amended a pension bill with a broad antitrust exemption for the Match that was nearly identical to the draft that had been circulated one year earlier. The bill, which was quickly signed into law by President George W. Bush, stated that "it shall not be unlawful under the antitrust laws to sponsor, conduct, or participate in a graduate medical education residency program."3 Under the bill, Match participants cannot be accused of violating antitrust law in federal court. A second provision, however, stated that residency programs cannot collude to fix salaries or benefits.
The lawyers for the plaintiffs declared the amendment unconstitutional and "an egregious abuse of the legislative system." Shortly after it passed, however, the defendants filed a motion to dismiss the suit. Ultimately, the court ruled in their favor. On August 12, 2004, U.S. District Court Judge Paul Friedman wrote, "[The] plaintiffs understandably are frustrated. They won a significant victory in court. Congress now has snatched it away. . . . Absent a valid constitutional challenge to a law passed by Congress and signed by the President, however, the responsibility of the courts is to interpret and apply the statute, not to second guess."4
The plaintiffs have vowed to pursue legal action for better wages and working conditions for residents, suggesting that an appeal is likely. While the legal process continues to unfold, there is also new pressure from within. At the recent biannual meeting of the American Medical Association (AMA), the California Medical Association introduced a resolution to reform the Match. The resolution includes many of the provisions from the lawsuit. It mandates that the process be transparent, follow antitrust laws, recognize residents as labor, and bill programs instead of students for administrative costs. On June 15, 2004, the AMA House of Delegates voted to review the resolution before a national committee. If adopted as AMA policy, this resolution may spur broad reforms, since the AMA sits on the board of the National Resident Matching Program (NRMP).
Much of the debate hinges on whether a residency is a job or a continuation of medical education. Senior physicians argue that residency training provides invaluable educational opportunities — exposure to interesting cases, supervised clinical care, daily conferences — and contacts that are necessary for a lifetime of practice. The competition for spots in the leading residency programs remains stiff: in 2004, the internal medicine program at Brigham and Women's Hospital in Boston received approximately 2300 applications for 68 spots. Many senior physicians argue that abolishing the Match might backfire, driving down salaries in the most competitive programs. Whether the same is true for less prestigious programs is unclear, since residency positions outnumber the American medical school graduates available to fill them.
Many residents argue, however, that hospitals rely on house officers as cheap labor, expecting them to perform administrative tasks that are not educational. Residents routinely track down medical records, transport patients, coordinate inpatient studies, and schedule outpatient appointments. In 1999, the National Labor Relations Board agreed, declaring resident physicians employees instead of students. In its decision, the board compared house staff to apprentices or professionals who receive additional training while employed. This ruling allowed residents at private hospitals to organize labor unions and bargain collectively for the first time. Although the decision aroused fears about residents striking, few actually did.
The Match was not designed to maximize students' bargaining power, and that may ultimately be its greatest weakness. In the current system, students sign binding work agreements on entering the Match, and few feel comfortable negotiating before they secure a spot. Most residents rely on hospital administrators and regulatory bodies to represent them, but competing interests may compromise reform efforts. As hospitals respond to declining reimbursements by reducing staff and streamlining care, the administrative burden carried by residents often escalates unchecked, compromising the quality of education. In addition, many residents face financial hardship as they juggle low salaries and an average educational debt of $110,000. Although salaries increase after training, most physicians lose 7 to 14 years of earning potential after college, and residents' salaries are among the lowest in the health care industry.
Despite these flaws, the Match has survived for 50 years with few changes, and its strength still lies in its clear organization and ability to streamline a potentially chaotic system. The Match has been so successful that New York City used it as a model for assigning spots at public high schools this year, and 30 percent more students were assigned to their first-choice school as a result. The current residency-match algorithm favors students by moving down their rank lists first before considering programs' preferences. The Match also enables couples, such as ourselves, to apply to programs together, allowing us to give priority to personal relationships over a particular program. Finally, it offers students and program directors a set date when both parties will know their future.
The ACGME's work-hour regulations were the first national effort to standardize residents' working conditions, apart from the Match, and despite many shortcomings, they may now serve as a model for reform. If the Match is to remain shielded from antitrust legislation, many believe that hospitals, program administrators, and regulatory bodies must ensure that residents have a voice in controlling their salaries, their work hours, and most important, the quality of their education. By empowering residents to negotiate for better working conditions through collective bargaining, unions, and equal representation on all national boards, including the NRMP, we may free the Match to fulfill its original promise — pairing students with residency programs in a fair manner. We owe this much to future physicians and their patients.
Source Information
From Brigham and Women's Hospital, Boston.
References
150 Cong. Rec. S3991-92 (daily ed. Apr. 8, 2004) (statement of Sens. Bingaman, Feingold, Kohl, and Craig).
Jung v. Association of American Medical Colleges, 300F. Supp. 2d 119 (D.D.C. 2004).
Pension Funding Equity Act, H.R. 3108, Sec. 207, April 8, 2004.
Jung v. Association of American Medical Colleges, No. CIV.A. 02-0873, 2004 WL 1803198 (D.D.C. Aug. 12, 2004).(Alexi A. Wright, M.D., an)