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IMGs Participating in the 2006 Match Must Take Step 2 CS as Early as Possible
(posted April 22, 2005)
International medical graduates (IMGs) who wish to participate in the National Resident Matching Program (NRMP), or "the Match," must have passed all exams required for ECFMG Certification. If you plan to participate in the 2006 Match and need to pass Step 2 CS, you should know that a specific reporting date for Step 2 CS results cannot be guaranteed, regardless of the date on which Step 2 CS is taken. However, if you take Step 2 CS later than December 31, 2005, you are unlikely to have your results in time to participate in the Match.
If you need to pass Step 2 CS to participate in the 2006 Match, you should consider the following:
Demand for Step 2 CS is expected to be heavy throughout 2005, especially in the months preceding the Match.
The scheduling restrictions that are in effect for 2005 test dates may reduce the number of test dates available to you. Additional information on these restrictions is available on this website.
It is unlikely that examinees taking Step 2 CS later than December 31, 2005 will have their results for the Match. However, this is not a guarantee that those who do test by December 31, 2005 will have their results in time to participate in the Match.
You are strongly encouraged to apply for Step 2 CS as soon as you are eligible and to schedule your exam for the earliest possible date. You can apply and schedule by visiting the ECFMG website.
You are also strongly encouraged to monitor the ECFMG website and the USMLE website for further updates on the availability of results.
For complete information on the Match, visit the NRMP website.
Dec 2004:
NRMP Offers Toll-Free Calling for Match Participants
Effective immediately, all Match participants can contact the NRMP at no
cost to themselves, using new toll-free lines recently installed by the
NRMP. Applicants to the Main Residency Match should dial 1-866-617-5838.
Main Match institutional officials, program directors, and medical school
officials should dial 1-866-617-5837. All fellowship match participants-applicants
and program directors-should dial 1-866-617-5834. Using the correct toll-free
number will ensure that your call is routed directly to the staff members
who can assist you best. The fax number remains unchanged: 202-828-4797
Sept 2004:
To: NRMP Institution Officials
This email is the second in a series of communications being sent to NRMP
institution officials in preparation for opening registration for the 2005
Main Residency Match. Applicant registration opened August 15. Institution
and program registration opens September 1.
One of the responsibilities of the NRMP institution official is to ensure
that residency programs provide complete and accurate information to all
applicants. Previously, programs were expected to provide applicants with
a sample contract. Beginning with the 2005 Main Residency Match, programs
must provide a copy of the actual contract that applicants would be expected
to sign if matched to the program. The Match Participation Agreement Between
Participating Institutions and the NRMP has been amended to clarify the
institution's obligation. Section 2.2 of the Agreement, which lists the
responsibilities of the institution official, now reads:
2.2.10 Ensuring that each of the institution's programs provides complete
and accurate information to interviewees, including a copy of the contract
the applicant will be expected to sign if matched to the program and the
institution's policies on visa status and eligibility for appointment to
a residency or fellowship position, as applicable. This information must
be communicated to interviewees in writing prior to the rank order list
deadline. It is recommended that each program obtain a signed acknowledgement
of such communication from each applicant who interviews with such program.
To meet this requirement, it is sufficient to post the contract on the
program's web site and notify applicants that it is available. For the
2005 Main Residency Match, the rank order list deadline is 9:00 p.m. eastern
time on February 23, 2005. Please keep that date in mind.
As always, we will be happy to answer your questions. Please do not hesitate
to contact us by email at nrmp@aamc.org or by telephone at (202) 828-0676.
We look forward to another successful Match this year!
NRMP Staff
August 2004:
CHICAGO, Aug. 16, 2004 – The Accreditation Council for Graduate Medical Education is pleased with the U.S. District Court’s decision to dismiss a resident antitrust lawsuit that challenged the legality of the National Resident Matching Program.
“We are grateful to Congress for establishing law protecting the Match and to the court for issuing the decision that puts this matter to rest,” said David C. Leach, MD, executive director of the ACGME.
The lawsuit, filed by three former resident physicians, charged that the NRMP, along with its member organizations, the ACGME and 29 hospitals and universities, violated the Sherman antitrust act. The Match pairs residents with programs based on computerized ranks of the preferences of the residents and programs, resulting in an orderly process for pairing residents and programs in which 85% of residents are matched with one of their top three program choices.
The lawsuit, Paul Jung, MD, et al v. Association of American Medical Colleges et al was filed May 7, 2002, in the U.S. District Court for the District of Columbia. On February 11, 2004, the district court dismissed the complaint against some of the defendants. In April Congress passed legislation, part of the Pension Fund Equity Act, exempting the Match program from antitrust regulations.
On Aug. 12, 2004 the district court granted motions to dismiss the case.
July 2004:
TO: NRMP Institutional Officials
Over the course of the next few weeks, you will receive several communications
from the National Resident Matching Program (NRMP) highlighting policy
and procedural changes as we prepare for the September 1st opening of the
2005 Main Residency Match for institutions and programs. In this first
e-mail, we want to emphasize one of the basic tenets of our matching program:
if any of an institution's programs participates in the Main Residency
Match, all of the institutions programs must accept U.S. allopathic medical
school senior students only through the NRMP, unless the program participates
in another national matching plan.
This policy is codified in section 2.0 of the Match Participation Agreement
Between Participating Institutions and the NRMP:
2.2.4 Ensuring that all of its programs that offer positions to senior
U.S. allopathic students are enrolled in the NRMP, and that all such programs
select senior U.S. allopathic students only through the Matching Program.
If any position is offered to U.S. students outside the Matching Program,
the institution will be in material breach of this Agreement and may suffer
the penalties described in Section 9.0.
Other national matches, such as the San Francisco Matching Program and
the AUA (Urology) Match, are for PGY-2 positions that require a year of
prerequisite training. When an applicant matches to one of those positions,
the institution typically reserves a designated preliminary position in
the same institution's Internal Medicine, Surgery, or Transitional Year
program. When those designated preliminary positions are offered to U.S.
allopathic seniors, they must be filled and accounted for in the Main Residency
Match. Some programs now list those positions in the Match as categorical
programs in the PGY-2 specialty. We ask instead that you create a special
track of your preliminary program, such as Med Prelim/Neurology, and advise
U.S. allopathic seniors to place that program on their rank order lists.
The following Glossary of Terms is from the ACGME web site:
Preliminary Positions (see also "Graduate Year 1") - Positions for residents
who are obtaining training required to enter another program or specialty.
Some residents in preliminary positions may move into permanent positions
in the second year. Preliminary positions are usually 1 year in length
and usually offered for Graduate Year 1. Internal medicine, surgery, and
transitional year programs commonly offer preliminary positions.
Graduate Year 1 (GY1) - Used in connection with residents and with residency
positions to indicate the first year of training after medical school.
Individuals in GY1 positions who plan to complete the entire program are
counted as enrolled in Graduate Year 1 (GY1), Categorical. Individuals
in GY1 positions who are using their first year in a residency program
as a prerequisite to enter another specialty or subspecialty program are
counted as enrolled in Graduate Year 1 (GY1), Preliminary. Not all specialties
offer GY1 although by definition residents in GY1 positions are not required
to have prior GME, some residents who fill such positions may have had
previous training.
Preliminary Designated Positions - Residents matched by/for other specialties.
The resident is designated as having a permanent position after completing
the preliminary year(s). Specialties that do not designate preliminary
positions will use this option to indicate preliminary positions.
Preliminary Non-Designated - Residents accepted into the program for 1
or 2 years of training; these residents do not have designated permanent
positions in the current program or another program at time of acceptance.
Transitional Year Program - Broad-based clinical training in an ACGME-accredited
residency program that provides a balanced GME curriculum in multiple clinical
disciplines. Developed for the year between medical school graduation and
a specialty residency program, the transitional year is designed to facilitate
the choice of and/or preparation for a specific specialty; it is not meant
to prepare participants for the independent practice of medicine. To sponsor
a transitional year program, an institution and its affiliate must conduct
two or more ACGME-accredited programs that participate in the transitional
year.
As always, we will be happy to answer any questions. Please email us at
nrmp@aamc.org or call 202-828-0676 and speak with one of the Help Desk
Specialists. We look forward to another successful matching season!
July 2004:
The National Resident Matching Program (NRMP) is investigating the
feasibility and desirability of conducting a two-phased Main Residency
Match - commonly referred to as the "Second Match". This is the NRMP's
second consideration of the second match concept - the first occurring
during the period 1997-1999. Because the NRMP was in the midst of
converting to the R3 web based system during the 1997-1999 time period,
deliberations regarding a second match were tabled until experience with
the new R3 system could be evaluated.
A committee of the NRMP Board of Directors has been reviewing the
discussions and findings from previous second match deliberations and
has developed a model of how a second match would be conducted. This
proposal will be disseminated widely to all participants i.e., program
directors, applicants, institutional officials, etc., in the NRMP Main
Residency Match.
(The proposal is available on the APDIM website at
http://www.im.org/AAIM/PublicPolicy/Docs/SecondMatchProposal.pdf.)
October 2003:
Directors of the National Resident Matching Program (NRMP) last
week voted to require all residency programs to let Match applicants
review the contracts they will be asked to sign before they rank
programs and participate in the Match. The new requirement will take
effect with the 2005 Match.
For the past three years, the NRMP has recommended that training
programs allow applicants to see copies of the contract they would have
to sign to enter training programs. The organization will now require
training programs to give applicants a copy of those contracts in
advance.
In a press release, the American Medical Student Association (AMSA)
said that Match applicants need an opportunity to compare the different
salaries, benefits and working conditions of training programs.
In related news, the NRMP voted last week to link its Web site to the
site of the Accreditation Council for Graduate Medical Education. That
move will help Match applicants track the accreditation status of
different training programs.
The NRMP-along with more than two dozen teaching hospitals and medical
organizations-is the subject of an antitrust lawsuit. The litigation
claims that the Match limits choice and applicants' ability to negotiate
better salaries and benefits.
A press release from the NRMP is online at
http://www.savethematch.org/news/pressreleases.aspx?NewsID=320916105.
The AMSA press release is online at
http://www.amsa.org/news/pr/03/1028.cfm.
October 2003:
The National Resident Matching Program (NRMP) is one of 36 defendants in a lawsuit about resident stipends and duty hours, issues with which the NRMP is not involved. The lawsuit threatens to destroy the Match and return medical students to the chaotic residency selection process that existed before the Match was created. The NRMP has only one purpose – to run a computerized matching program that optimizes the matching of medical students with residency programs based on their individual preferences.
On Tuesday, October 21, 2003, the National Resident Matching Program launched www.savethematch.org - a new Web site that provides information to medical students, residents and fellows, residency program directors, medical school officials, and practicing physicians about the antitrust lawsuit in which the NRMP is a defendant.
It is important for all residents and fellows to have complete and accurate information about the NRMP, the role that it plays in medical education, and why stipends and duty hours will not improve if the Match is destroyed through the lawsuit.
We sent this announcement to all directors of programs participating in the Match. Please forward this email to other program directors and to anyone else you know who has an interest in the Match.
NRMP Executive Director
ADVISORY
NRMP PARTICIPATING INSTITUTIONS AND PROGRAMS
September 12, 2003
Applicants frequently ask the National Resident Matching Program (NRMP) about the availability of appointment contracts for programs that participate in the Main Residency and Specialty Matches. Specifically, applicants want to obtain a copy of the contract for a program where they have interviewed so they know and understand the requirements and conditions of an appointment before they include the program on their rank order list. Advance knowledge of the contract is important because the NRMP's Match Participation Agreement requires applicants to accept a position if a match occurs.
The responsibilities of the NRMP institutional official are delineated in Section 2, Institutional Official Responsibilities, of the Match Participation Agreement for Institutions. Section 2.2.10 states:
"In addition to the general responsibilities of the institutional official for overseeing the match process and communicating with the NRMP, the institutional official is responsible for:
2.2.10. Ensuring that each of the institution's programs provides complete and accurate information to interviewees, including a sample contract and the institution's policies on visa status and eligibility for appointment to a residency or fellowship position, as applicable. This information must be communicated to interviewees in writing prior to the rank order list certification deadline. It is recommended that each program obtain a signed acknowledgment of such communication from each applicant who interviews with such program."
In addition, Section 5.1 of the Match Participation Agreement for Applicants and Programs states:
"The listing of an applicant by a program on its certified rank order list or of a program by an applicant on the applicant's certified rank order list establishes a binding commitment to offer or to accept an appointment if a match results. Each such appointment is subject to the official policies of the appointing institution in effect on the date the program submits its rank order list and is contingent upon the matching applicant meeting all eligibility requirements imposed by those policies. Those requirements must be communicated to applicants in writing prior to the rank order list certification deadline. It is recommended that each program obtain a signed acknowledgment of such communication from each applicant who interviews with such program."
THE BINDING NATURE OF THE MATCH MAKES IT ESSENTIAL THAT APPLICANTS UNDERSTAND FULLY THE CONDITIONS AND REQUIREMENTS OF A PROGRAM WHERE THEY HAVE INTERVIEWED AND WHERE THEY MAY MATCH. THEREFORE, THE NRMP STRONGLY RECOMMENDS THAT, PRIOR TO THE RANK ORDER LIST DEADLINE, INSTITUTIONS AND PROGRAMS PROVIDE INTERVIEWEES WITH A COPY OF THE CONTRACT THEY WOULD BE REQUIRED TO SIGN THE SUBSEQUENT JULY 1 (OR SUMMER) IF A MATCH OCCURS.
At its May 12, 2003 meeting, the National Resident Matching Program (NRMP) Board of Directors voted to delay implementation of the new NRMP rule previously scheduled to become effective with the 2004 Main Match. The rule would have required all institutions that register for the Main Match to place all their residency programs and positions in the Match.
The delay in implementation is the result of recommendations and comments received over the past eighteen months from NRMP participating institutions, programs, program director organizations, medical schools, and applicants. The Board will study the effects of three major issues:
1) Changes in the processing and timely acquisition of visas for international medical graduates
2) Limiting the rule to PGY1 positions
3) Making the rule program-based rather than institution-based, e.g., all programs (not institutions) registered for the Main Match must place all their positions in the Match
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PROFESSIONAL ISSUES
Lawsuit could gut resident Match program
Some experts believe the complaint, alleging the process restricts competition, stands a good chance of getting to trial.
By Myrle Croasdale, AMNews staff. May 27, 2002. Additional information
A lawsuit filed in federal court this month in Washington, D.C., aims to eviscerate the 50-year-old National Resident Matching Program, setting up a competitive system that could put some hospitals at a disadvantage and give residents more of a say in their salary and work hours.
The lawsuit, which was brought by three physicians, names as defendants the NRMP, its supporting medical organizations and hospitals that hire residents. It asks for class-action status, which, if granted, would put the number of plaintiffs at more than 200,000, according to the plaintiffs' attorneys.
"The current residency system puts patient care at risk and is clearly unfair to resident physicians," said Michael Freed, a Chicago attorney and one of a national team of lawyers on the case.
Resident salaries average less than $40,000.
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"This is going to be a lollapalooza if this goes through," said David Aron, MD, associate chief of staff for education at Louis Stokes Cleveland Dept. of Veterans Affairs Medical Center. "I don't think we can predict what all the consequences are going to be. Whatever they are, it will happen in the context of a health care system that's under a lot of stress already."
The lawsuit contends that the NRMP and those who employ residents restrict competition by assigning resident physicians to a single, mandatory position via the Match. Resident wages are artificially depressed through the exchange of salary information, says the complaint, which also alleges that the Match process deprives residents of the ability to negotiate other employment terms, including work hours. Lastly, the complaint said the regulations of the Accreditation Council for Graduate Medical Education are anti-competitive.
An end to these constraints and unspecified monetary damages are being sought. In a written response, the NRMP categorically denied that it illegally restrains trade or is engaged in any wrongdoing in the matching of prospective residents to residencies.
Impact would vary
Dr. Aron theorized that academic medical centers that already find it a challenge to fill resident positions could see the situation deteriorate, unless they're able to offer more money.
"This will be enormous for some hospitals and some fields where it's not as competitive in filling the Match," Dr. Aron said. "Primary care, internal medicine and family practice will be at considerable risk. For those places that are very attractive because of their reputation or specialty, the impact is likely to be less."
If the case pushes through shorter work hours for residents, errors from fatigue could decline, but errors from the transition of patient care from physician to physician are likely to increase, Dr. Aron said.
Residents work 60 to 100 hours a week, with shifts of 36 to 48 hours.
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"If you change medicine to shift work, you increase the number of handoffs and you have more errors with handoffs," he said. "We would need better ways to deal with very sick patients whose condition is changing and you have new people coming on all the time." Also, if residents are working shorter hours, hospitals would need to hire more of them to ensure proper patient coverage or find other ways to address the decline in staff hours.
Michael Reichgott, MD, PhD, associate dean of clinical affairs and graduate medical education at the Albert Einstein College of Medicine for Yeshiva University, Bronx, N.Y., said the lawsuit misses the mark when it comes to reforming residencies.
"Bottom line, I think the lawsuit against the NRMP is based on a failure to understand what the world was like before the Match existed," Dr. Reichgott said. "Before the Match, participants were put in fairly stressful, uncomfortable situations. 'We'll give you the slot. Tell me if you want it by tomorrow or I'll give it away.' The Match makes all offers at the same time. It's not anti-competitive, as I would see it."
Residents' work weeks can be 60 to 100 hours long, with shifts of 36 to 48 hours. According to the Assn. of American Medical Colleges, resident salaries average just under $40,000.
Residents in New York state have been limited to an 80-hour week since 1989, however the law was not strictly enforced until fairly recently. No studies have been done on whether the restrictions have been accompanied by changes in the quality of care.
Trade-off
David Webster, PhD, a health care consultant and president of The Webster Consulting Group based in Lehigh Valley, Pa., said residents trade off longer hours and low pay for higher wages down the road.
"Physicians have benefited a long time from a restricted supply of entrants into the system," Dr. Webster said. "If the lawsuit was successful, residents might be able to entertain competing offers from different institutions, and high-quality candidates would have their salaries bid up. In return, health care providers and hospitals would push on the antitrust process to allow free entry into the physician market -- bringing in more overseas physicians or changing the laws that limit the supply of medical students in the United States. Ultimately, there'd be more competition among physicians later in their career, and their wages would be lower later on."
Jeff Miles, an attorney and chair of the American Health Lawyers Assn. antitrust committee, said the lawsuit has a good shot at being heard.
"This case has the potential to destroy the Match program or at least require major changes that would gut what the Match program tries to do," Miles said. "If the facts are true, the case is likely to go to trial."
Miles sees several key points. The Match does limit competition in that medical school graduates have to use it to get into most residencies. But the defense could argue the Match generates substantial efficiencies in placing residents, which may offset antitrust violations. Since the Match is not a commercial activity there may be more leniency in antitrust laws.
Back to top.
Matchmaker, matchmaker
The Match program is the way most medical students and residency programs hook up. In 2001 there were:
- 3,955 resident programs
- 22,875 residency positions
- 31,956 applicants
National Resident Match program stats also indicate that of applicants, 15,726 were graduates of U.S. medical schools and 16,230 were independent applicants or sponsored graduates.
Back to top.
Copyright 2002 American Medical Association. All rights reserved.
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Is the Match Illegal?
Sanders H. Chae, M.D., J.D.
The recent announcement that a class-action lawsuit has been filed against the Accreditation Council for Graduate Medical Education (ACGME) and several teaching hospitals on the grounds that "the Match," or the National Resident Matching Program (NRMP), violates the nation's antitrust laws has extended the discussion about reform of residency programs. Residents work long hours and are poorly compensated. The lawsuit raises several important questions and may prompt substantial changes in graduate medical education. In this article, I consider the merits of the lawsuit and its potential consequences for teaching hospitals.
Background
The Match was first created in 1952 to protect medical students. In those days, there were twice as many residency positions as there were graduates of medical schools. Less competitive programs struggled to fill slots, so these programs attempted to strong-arm medical students into positions by interviewing early in order to handpick students during their second or third year of medical school. Programs also started to give "exploding offers," which required the student to accept within a limited period or the offer would be revoked.1 Some students accepted the first position they were offered for fear of coming away empty-handed, but such a hasty acceptance prevented them from being interviewed by many programs. "Insiderism" also played a prominent part in the selection of residents. The Match addressed this problem by permitting students and programs to submit lists of preferences to a computer that matched them on a fixed date.1 This structured system of offers eliminated hard-nosed tactics such as exploding offers, enabling students to be interviewed at many programs.
Antitrust Law
The basic thrust of the antitrust laws is to protect free markets by preserving competition against large, powerful cartels with so much bargaining power that they can eliminate competition and set prices. The most widely understood example is a monopoly that unfairly sets high prices so that it can gain excessive profits.2 The relevant statute is Section 1 of the Sherman Act, which prohibits "every contract, combination . . . , or conspiracy, in the restraint of trade."3
A basic approach to antitrust law applies three different standards to horizontal agreements among competitors in the same market under Section 1.4,5 The main standard that governs most arrangements is the "rule of reason," under which courts weigh the anticompetitive and procompetitive effects of an agreement to determine whether it restrains trade.6 Application of the rule of reason frequently involves economic analysis of an industry, which can be expensive and time-consuming. Thus, the Supreme Court has articulated a more expeditious standard, the "per se" rule, to judge blatantly anticompetitive practices, such as price fixing, whose pernicious effects are so well understood that they are "conclusively presumed to be unreasonable" and "illegal per se."7,8 Much is at stake in the choice of a standard, since courts infrequently find an antitrust violation under the rule of reason, whereas the per se rule was once frequently applied to anticompetitive behavior. Recently, a more conservative Supreme Court and more sophisticated business practices have resulted in greater reliance on the rule of reason. A third standard, the truncated or "quick look" rule of reason, applies in cases in which an agreement is not illegal according to the per se rule, but its anticompetitive character is evident. Parties to the agreement must demonstrate that the arrangment is reasonably necessary in order to achieve procompetitive benefits.9
An interesting variation of the antitrust laws applies to the Match. The laws were conceived in response to a cartel of sellers who wielded excessive bargaining power and unilaterally raised prices. The Match represents the opposite situation, called a monopsony, in which a buyer or group of buyers exercises so much power that it can unilaterally lower the prices that it pays sellers. Ordinarily, cartels consist of few members, because the incentive to cheat causes cartels to fall apart. However, if a cartel polices its members effectively, it may be large. Notably, the antitrust laws apply equally to a conspiracy of buyers or sellers.10,11,12
How the Match May Be Anticompetitive
The antitrust lawsuit against the ACGME claims that the Match is anticompetitive because it eliminates the influence of free markets on salaries. Although the Match does not technically fix prices, it prohibits residency programs from making offers outside of the Match. This rule wipes out the market for medical residents and undermines price competition, because it prevents students from negotiating with the different hospitals. Without an offer in hand, students have no power to negotiate with the programs, and programs do not need to compete for residents through salary or other monetary benefits. Programs are also deterred from increasing salaries to compete for students, because they cannot be guaranteed that the students whom they really want (and whom they believe are worth a higher price) will be matched with them. Therefore, programs have, in effect, set a flat salary of roughly $40,000 for all members of house staff throughout the country, irrespective of the specific demand for their labor.
The legal foundation for the antitrust claim rests on the Supreme Court's hostility to arrangements that eliminate offers and impede the operation of the free market. In National Society of Professional Engineers v. United States, the Court struck down an agreement among engineers that prohibited competitive bidding for engineering projects, noting that it "is not price-fixing as such, [but] the ban on competitive bidding, like price fixing, impeded the ordinary give and take of the market place."7 The Court concluded that courts may presume anticompetitiveness when a restraint disrupts the ordinary interplay of the market. In Federal Trade Commission v. Indiana Federation of Dentists, the Supreme Court reaffirmed this principle when it struck down an agreement among a group of dentists to withhold radiographs from insurance companies because it "disrupt[s] the proper functioning of the price-setting mechanism of the market."4
Another precedent for the lawsuit is the draft of the National Football League (NFL). In Smith v. Pro Football, the District of Columbia Circuit Court held that the NFL draft that allocates college football players to professional teams represented an illegal boycott because it prohibited teams from dealing with college players outside of the draft.13 A settlement with the players' union changed the draft and permitted its ongoing use, but the analogy lends valuable insight.14 Although the Match and the draft are different, the critical similarities in terms of antitrust law are that employer and employee are matched and that negotiation outside of the central mechanism is disallowed, suppressing competition.
How the Match May Survive Antitrust Litigation
The supporters of the class-action lawsuit will encounter substantial difficulties in making their case. The most important legal obstacle is the "learned professions doctrine," which suggests that traditional antitrust rules may be inappropriate outside of conventional business contexts.15 Since antitrust law is intended to curb anticompetitive behavior by entities that are attempting to maximize their profits, arrangements by professions committed to public service or ethical norms, such as medicine, receive deference because economic harm is less predictable and less certain.7,15 However, this doctrine does not grant professions immunity from antitrust prosecution.5,7,15
It seems likely that the pivotal case will be United States v. Brown University, in which the Justice Department sued a consortium of Ivy League colleges and the Massachusetts Institute of Technology (MIT) for sharing financial aid information in order to offer admitted students the same financial aid package. After truncated review, the district court ruled that such an exchange of information was illegal, finding it anticompetitive and lacking any procompetitive virtue.16
On appeal, the Third Circuit Court of Appeals reversed the decision, holding that the lower court had failed to consider adequately the procompetitive benefits of the agreement.5 The Third Circuit Court found that the agreement increased the choices available to consumers by offering more financial aid to more students. The diversity of the student body was also enhanced when aid was made available to more students.5 The district court had rejected these arguments under Supreme Court rulings that justifications claiming procompetitive benefit must be economic explanations and cannot be based on considerations of social welfare or worthy purposes. The case was ultimately settled, but it made justifications claiming procompetitive benefit a controversial issue, because the claims made by MIT appear to be arguments based on social welfare that are labeled as economic justifications. The ruling implied that nonprofit institutions with educational missions, such as teaching hospitals, may offer defenses of anticompetitive practices on the grounds that they serve worthy purposes. Resolution of this ambiguity will be fundamental to the outcome of the lawsuit, because defenders of the Match will claim similar defenses. Specifically, the Match appears to increase the choice of residency programs for medical students by allowing them to interview at multiple programs. It also prevents insiderism and thus might enhance diversity.
Another substantial legal difficulty is that the Match might not have anticompetitive effects. Antitrust claims under Section 1 must show that the restrictive practice has anticompetitive consequences, such as an inefficient transfer of wealth due to higher prices, a reduction in output, or a diminished quality of goods or services.4,5 It is not obvious that teaching hospitals are underpaying residents in order to transfer wealth from resident to hospital as excess revenue or profit. However, there may be a transfer of wealth when residents care for the private patients of attending physicians who do not participate substantially in resident training. It is also hard to believe that the Match reduces output by decreasing the amount of health care that teaching hospitals provide. Indeed, low salaries might increase output by enabling teaching hospitals to hire more residents, leading to more health care. A final difficulty is that Medicare pays salaries through a fixed sum paid to the hospitals. If Medicare would not provide higher salaries in a free-market system, the Match might not be responsible for low salaries.
Another impediment to proving the antitrust claim against the Match is that it offers the important procompetitive virtue of decreased transaction costs. Negotiations, interviews, and bargaining consume time and money. These transaction costs can be diminished efficiently by a practice that streamlines these processes. The reduction of transaction costs by the Match serves the goals of antitrust law by distributing house staff among the hospitals without wasting social resources and thus maximizing social wealth. However, the counterargument is that the Match may increase transaction costs by increasing the number of interviews with students who are afraid of not being matched.
A final legal challenge to the antitrust claim is the argument that a residency is traditionally viewed as an educational opportunity rather than a job, so the antitrust laws should not apply. This is the least compelling legal objection to the antitrust claim. First, under Brown University, antitrust law applies to educational programs, so teaching hospitals would have no immunity from prosecution. Second, employees in many fields — such as law, investment banking, and architecture — receive training, so it is hard to understand why a residency should be different. Third, in a recent ruling, members of house staff were found to be laborers rather than students when house officers at Boston University sought recognition for their labor union to permit collective bargaining.17 Finally, the architect of the current form of the Match has compared the residency market to a labor market, observing that the Match's algorithm is based on the idea that residents enter a labor market.1
Implications of a Successful Lawsuit
A successful lawsuit would have several implications for residents. The most important potential benefit lies in reform, in the form of higher salaries or fewer hours of work. Many residents need salary reform because they face serious financial pressure during residency. The most substantial change that has created this financial distress has been the rising cost of medical school tuition. Tuition for four years exceeds $100,000 at many schools, forcing many students into substantial debt. However, lenders and the government do not treat residents as students, so interest accumulates on loans during residency. With depressed salaries, many residents must seek debt forbearance because of financial hardship. A recent survey documents this financial adversity. Of 4128 residents who responded to a questionnarie, 42 percent carried $50,000 of debt and 19 percent carried more than $100,000 of debt throughout their residency. Forty-three percent noted that their monthly disposable income was $100 or less.18 If residents serve as undercompensated laborers, a competitive system might raise salaries and address their financial hardship. Debt relief might also reduce the appeal of high-paying specialty careers. Students might be less deterred from careers in primary care or academic medicine, which tend to be less remunerative.19
Another set of implications involves the reform of training. Residencies have changed as managed care and the Balanced Budget Amendment have imposed a financial crunch on hospitals in which maintaining or increasing the volume of patients has been critical for survival. These financial pressures have caused house officers to spend more of their day on work, precipitating a shift in training from learning to labor. A successful antitrust claim could reinvigorate the emphasis on education over labor by reducing total hours of work or decreasing the amount of uncompensated, uneducational labor required. Having these extra hours could free up residents to develop other career interests, such as research or public service, or to devote more time to studying the medical literature. Residencies demanding fewer hours might better preserve professionalism, compassion, and empathy toward patients, virtues that are often degraded as house officers become exhausted.20
For teaching hospitals, the implications of a successful antitrust suit are enormous. Reform of residencies has been expensive and could impose a huge financial strain on institutions that already have financial troubles. Hospitals would need more money either for higher salaries or to pay physician assistants and nurses to care for patients if residents work fewer hours. Hospitals could seek more funding from Congress, which in turn could raise Medicare taxes or redistribute funds within the federal budget. Neither of these actions seems likely in the current political climate, in which cuts in taxes and spending are embraced, particularly when Congress has already considered whether to remove funding for graduate medical education from Medicare and make it an annual appropriation.21 Teaching hospitals could try to charge insurance companies directly for a resident's services, but this would drive premiums higher, making health insurance even less affordable. One could even imagine that a market system would lead programs to evaluate residents on the basis of the number of procedures performed or the number of patients seen. In all of these scenarios, the already climbing cost of health care would rise further.
Another potential implication is that the number of residency positions could decline dramatically. With a fixed amount of money from Medicare, teaching hospitals might hire fewer residents and redistribute money among the remaining residents. The hiring of fewer residents would ultimately result in a reduction in the number of physicians. Although this reduction might raise compensation for physicians in the long run, it would hurt patients by decreasing access to care, particularly if fewer physicians provided primary care. Alternatively, some teaching hospitals might abandon clinical education altogether and focus on patient care and research. Like all employers, academic hospitals have an inherent disincentive to engage in training, because laborers can leave and take their skills elsewhere. For teaching hospitals, this disincentive to train is particularly strong, because most residents work elsewhere after residency. The use of physician assistants who stay at a hospital for the long term makes more sense economically than the use of residents. Furthermore, health care costs at teaching hospitals are higher than those at other facilities, presumably because their patients are sicker as well as because the training of doctors results in the ordering of more tests, which raises costs.21 For struggling hospitals, higher labor costs might make the provision of clinical education economically indefensible.
Conclusions
The class-action lawsuit claiming that the Match violates the antitrust laws has a reasonable chance of success. The structure of the Match is anticompetitive, and residents have suffered harm, working long hours at flat salaries. Under a competitive system, residents might secure higher salaries or better working conditions. To succeed, the lawsuit will have to show an anticompetitive effect, such as an inefficient transfer of wealth or a reduction in output. Moreover, the plaintiffs must convince a court that antitrust liability is appropriate for teaching hospitals in the light of Brown University. Neither task will be easy. A finding that the Match violates the antitrust laws could place an additional financial burden on academic teaching hospitals. Some hospitals might abandon residency training if the cost proved insurmountable. On the other hand, the case might elicit much-needed reform of the residency system.
Source Information
From the Columbia University College of Physicians and Surgeons, New York.
Address reprint requests to Dr. Chae at the Department of Medicine, Columbia University College of Physicians and Surgeons, 622 W. 168th St., New York, NY 10032, or at sanderschae@post.harvard.edu.
References
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