By BRYAN CARMODY, MD
Surely every resident has had the experience of trying to explain to a patient or family what, exactly, a resident is. “Yes, I’m a real doctor… I just can’t do real doctor things by myself.”
In many ways, it’s a strange system we have. How come you can call yourself a doctor after medical school, but you can’t actually work as a physician until after residency? How – and why – did this system get started?
These are fundamental questions – and as we answer them, it will become apparent why some problems in the medical school-to-residency transition have been so difficult to fix.
In the beginning…
Go back to the 18th or 19th century, and medical training in the United States looked very different. Medical school graduates were not required to complete a residency – and in fact, most didn’t. The average doctor just picked up his diploma one day, and started his practice the next.
But that’s because the average doctor was a generalist. He made house calls and took care of patients in the community. In the parlance of the day, the average doctor was undistinguished. A physician who wanted to distinguish himself as being elite typically obtained some postdoctoral education abroad in Paris, Edinburgh, Vienna, or Germany.
By BRYAN CARMODY
Let me show you some data.
I’m going to show you the Match rate and mean Step 1 score for three groups of residency applicants. These are real data, compiled from the National Resident Matching Program’s (NRMP) Charting Outcomes in the Match reports.
- U.S. Allopathic Seniors: 92% match rate; Step 1 232.3
- U.S. Osteopathic Seniors: 83% match rate; Step 1 225.8
- International Medical Graduates, or IMGs (both U.S. and non-U.S. citizen: 53% match rate; Step 1 223.6
Now. What do you conclude when you look at these numbers?
In the debate over the U.S. Medical Licensing Examination’s (USMLE) score reporting policy, there’s one objection that comes up time and time again: that graduates from less-prestigious medical schools (especially IMGs) need a scored USMLE Step 1 to compete in the match with applicants from “top tier” medical schools.
In fact, this concern was recently expressed by the president of the National Board of Medical Examiners (NBME) in an article in Academic Medicine (quoted here, with my emphasis added).
“Students and U.S. medical graduates (USMGs) from elite medical schools may feel that their school’s reputation assures their successful competition in the residency application process, and thus may perceive no benefit from USMLE scores. However, USMGs from the newest medical schools or schools that do not rank highly across various indices may feel that they cannot rely upon their school’s reputation, and have expressed concern in various settings that they could be disadvantaged if forced to compete without a quantitative Step 1 score. This concern may apply even more for graduates of international medical schools (IMGs) that are lesser known, regardless of any quality indicator.”
The funny thing is, when I look at the data above, I’m not sure why we would conclude that IMGs are gaining advantage from a scored Step 1. In fact, we might conclude just the opposite – that a scored Step 1 is a key reason why IMGs have a lower match rate.
There’s a larger question here about why the scholarly world allows itself to be judged by secretive Scandinavian committees sitting on endowments funded by money made selling explosives. But let’s put anti-Nobel polemics aside.
The announcement today that Alvin Roth and Lloyd Shapley won this year’s award in economics came with the explanation that they had devised systems for matching buyers and sellers that led to more rational outcomes than existing markets.
Shapley, a contemporary of “A Beautiful Mind’s” John Nash, introduced an elegant theory 50 years ago to explain the (relative) stability of marriage pairings despite the fact that individuals have complicated preferences when choosing a mate. Shapley’s idea is that the person you end up with is the best match given everyone else’s preferences.
You might prefer someone else more than your current mate, but that person has you lower on her list, and so on. Imagine Larry. If he could Larry would have definitely married Elizabeth Taylor. But she was taken so now Larry is happy with his actual wife. (To sum it up in a way that would make an economist cringe.)
Alvin Roth built on that early theory. He designed actual markets that used the matching principle, also known as the deferred acceptance algorithm, as a guiding principle. The most famous example of a Roth market is the Residency Match.
Medical residency is a job that lasts three to seven years, depending on the program, and follows graduation from medical school. It is required for a doctor to complete a residency in order to be licensed to practice.
In the “old days” medical students would apply to hospitals and rank their preferences in a way that was visible to those institutions. A hospital would first review those applicants who had indicated them as the first choice. If spots remained to fill, a hospital would then look at those who had picked it second, and so on. You can quickly see how this system punished people who shot high and missed. They would end up at one of their last choices because the best places would fill up quickly.