Friday, March 17, 2017

The Match encourages physician passivity, which hurts health care - Slate

Friday marks another iteration of the National Resident Matching Program—"the Match"—perhaps the best-known bottleneck for aspiring U.S. physicians. Every year, this complex computerized algorithm assigns senior medical students to the next phase of their clinical training. Upon selecting a medical specialty, applicants make a list, ordered by preference, of whichever residency programs grant them an interview. After a few months of waiting, an inscrutable bit of software tells them where to go.

Binding contracts must be signed well in advance to honor these results, whatever they may be. At most American medical schools, Match Day involves the ceremonial distribution of envelopes to be opened at a designated time, sometimes onstage, in front of one's assembled family and friends. Within minutes, a full range of emotions is usually on display—elation or ambivalence, surprise or heartbreak. As a rite of passage, the whole thing requires a certain resignation to fate, the strain of which is often more visible after that fate is sealed.

The Match originated more than 60 years ago, supplanting a more traditional, decentralized market in which job offers were extended one by one, often along progressively unreasonable timelines. The original algorithm has since undergone multiple revisions, most recently in 1998 by the economist (and later Nobel laureate) Alvin E. Roth. The system maximizes efficiency as a proxy for contentedness; last year, 94 percent of participating U.S. medical students secured a residency position, and 96 percent of available training positions were filled.

I have gone through the Match twice now, first for residency and later for fellowship, and for all its aggregate expediency, I recall the individual experience as a stressful one. Both times, I felt the usually taut thread of my life slacken and begin to fray. During my interviews I was buoyed by the false sense that my life was somehow underwritten by several backup trajectories; after submitting each rank list, I settled into a prolonged funk, simultaneously questioning my preferences and wondering if they'd be honored. Not knowing if I'd be moving north or south, inland or to the coast, I settled into a dreamy headspace in which all possible outcomes seemed partially true. Match participants reckon with this peculiar fraction of agency—too little to guarantee a happy ending, too much to feel martyred by a sad one.

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