BTK Donna Lamb
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[00:00:00] Hello, and welcome to this episode of Behind the Knife in Surgical Education. We are the General Surgery education team from Cleveland Clinic. I'm Puja Barman, a general surgery resident and surgical education research fellow.

And I'm Judith French. I'm the PhD Education Scientist for the Department of General Surgery at Cleveland Clinic.

I'm Jeremy Lipman. I'm the DIO at Cleveland Clinic and former program director for the residency.

Today we're talking about something that decides every physician's fate in the US the match. Starting in the 1920s, hospitals were offering internships to medical students earlier and earlier in their training to secure the best candidates, pressuring students to make binding decisions with insufficient information and under intense time constraints.

The chaos and inefficiency of that free for all system soared. Until 1952 when a centralized match system was devised to standardize appointment dates. This is what we now know as the National Resident Matching Program or the NRMP, which is employed, an algorithm that [00:01:00] produces stable matches, designed to maximize applicant and hospital preferences, and fills nearly all open positions every year.

We're joined today by the president and CEO of the NRMP, Dr. Donna Lam. Dr. Lam has a bachelor's degree in nursing and MBA and a doctorate in health sciences with a concentration in organizational leadership. She has served as a GME Director and designated institutional officer or DIO in central Florida and the executive director of the A-C-G-M-E review committees for plastic surgery surgery.

And thoracic surgery before transitioning to the NRMP in 2019. We're excited to welcome this leader in surgical education to the show. We are gonna go ahead and start with asking you what is your elevator pitch to a newcomer about how the match algorithm works.

Well first lemme say thanks for having me today.

It's, uh, it's a pleasure being able to speak with you all. You know, the algorithm is really simple. Once the application and the [00:02:00] interview process concludes applicants and programs submit their rank list where they wanna train or who they wanna train in their order of hire. Preference. So once that's done, the algorithm which is mathematical and applicant preference then pairs the preference list of the applicant with those of the programs that they have ranked in order of the highest preference of each.

So if a program ranks an applicant who has ranked them, the algorithm will identify them initially as a tentative match saying. Hey, we've got a whole set of applicants to go through, but tentatively you appear to be matched. And then once all of the applicants and programs have been run through the algorithm, then the applicant and the program who have the highest pairings within the number of positions that the program has put in match are matched together.

Um, let me just be clear though, that doesn't mean that. The applicant or the program is guaranteed to match or even to match at their highest preference. But what it does mean is that when the match occurs, the parties then who are [00:03:00] matched the applicant in the program can be assured that they are matched with an applicant or a program who most preferred them.

So what do you think is the greatest strength and the the greatest weakness of that match algorithm?

One of the strengths of the algorithm is that it doesn't make a decision. The outcomes are based strictly on the choices that are made by the applicants and the choices made by the programs, meaning that no applicant can be placed where they didn't choose to train, and no program can be matched with an applicant that they didn't select.

So that is a strength of the algorithm and how the algorithm is structured. Actually, the greater strength of the match process itself is the framework of the matching process, and by that I mean the processes and the policies that establish that standardized process that allow everyone to participate in the match without any one person having the advantage over the other, A confidential and impartial venue in which each applicant [00:04:00] and program.

Can identify their preferences and express those preferences on the rank order list without fear of retaliation. You know, the match policies that serve to reduce unprofessional practices guaranteeing that you can't have a better outcome than the choices that you made and how those are put together with the choices by the program or the applicant that you.

Shows, and by virtue of the flexibility that the match provides in off-ramp, in the event that a match is not going to be possible for you either through a withdrawal at some point before the match or through the waiver and the deferral process in the event that either the applicant or the program is unable to keep the binding commitment in the match.

So I think the algorithm. Has great strengths in that it does what it's supposed to do and it does it incredibly efficiently. But the larger strength is around these processes and how these processes are applied to the community to ensure that everyone has an equitable [00:05:00] experience in the match.

So if you had the opportunity, and maybe you do in your position, but if you had the opportunity to blow it up and just redesign the whole thing from start to finish, what if any of the elements would you change?

What would look different in the match 2.0 lamb version?

The framework of the match has evolved over years, and so we are constantly looking at what should we be doing different to make it more efficient, less burdensome, to continue to create more agency for the individuals who are in the match.

Initially, there was only a single process of running the algorithm and the NRMP has continued to evolve over the years, first into the more formalized scramble. Then in 2012, it involved in soap, the formal process that runs after the matching algorithm. If I had to say I would do anything different. I would consider the possibility of a two phase match, meaning that the NNP would retire the SOAP process in favor of [00:06:00] running the algorithm twice within the footprint of the current matching cycle.

Um, and while there are several considerations around that, and of course there's pros and cons that have made this a little bit challenging to think through, would it really work? It would allow for a less compressed. Time period in which unmatched applicants in unfilled programs could reevaluate their needs, have the opportunity for an abbreviated second application and interview process, and the opportunity for each party to submit a preference list the second time around.

So in addition to kind of decompressing the two phase match could increase the agency of applicants because they are able to submit a preference list rather than just. Submitting an application and waiting for multiple rounds, and it could give programs the opportunity to engage in that abbreviated second interview period where maybe they see somebody they haven't seen before, or maybe they confirm what they knew about an applicant who by chance happens to still be available.[00:07:00]

So what would the barriers be to doing something like that? A lot of education leaders have supported that idea.

When we put out the last public comment, which was two and a half years ago, maybe about 60% of the applicants felt like it would be a good thing. Program's biggest concerns, really centered around an extended recruitment period, having two application and interview periods, and the impact on the resources of the program.

How that might affect their trainees, who obviously are now shifting some of the resources of their faculty over to a longer period of application and interviews than you have in the current cycle. That said, it was close to programs. Indicated that they would be willing to look at this type of a matching structure, but there was really a lot of concern around, we moved this application and interview period back even further where you had to have a rank order list in earlier.

Did they [00:08:00] have sufficient opportunity to see the applicants and review all of. The applications initially, are we gonna miss some applicants because maybe they haven't completed some rotations and then don't feel comfortable applying to some programs that they might. Be more comfortable applying to and interviewing with.

At a later point, do we reduce the number of international medical graduates who might be available due to visa issues or other issues? So there was a lot to think about. There was support, but there were a lot of concerns and we're continuing to discuss it as an organization and, and as a.

Shifting gears a little bit, we have data that suggests over application is a problem in the modern match and could be exacerbated by virtual interviews in the post COVID era.

And we know that this constitutes a significant financial burden on applicants and an administrative burden on programs. So we're curious about what the NRMP has done or what the [00:09:00] NRMP could do to curtail the problem of over application.

We get asked about that a lot. So let me just clarify, folks conflate the match with the application and the interview process, and those are processes that are separate and distinct services of.

Other organizations, whether that be A A MC or liaison with the residency cast application. From that standpoint, because we don't control the application or the interview phase, we certainly have some thoughts around application, but we don't have control over how the application is executed or how it's used across the United States.

So one of the ways that we look at that as, number one, we control our own costs. Uh, to ensure that, uh, the match is as reasonably priced as it can be, uh, based on the services that are being provided. And we have really worked in the last couple of years to focus on how can we provide. More [00:10:00] information that is appropriate for what applicants need to be able to vet programs in the most transparent way possible.

So curtailing a problem to me kind of begins with information. There's been a lot of changes across graduate medical education over the last couple of years that continue to more and more of applicants, you know, how can. More informed programs about their interest. How can applicants, more informed programs about whether or not they're really interested in a specialty or in a program?

And you see this expressed through the application process, through supplemental applications, through preference signaling, through individual program applications, and then into the interview and post interview period. My concern. And the concern of the NRMP is that applicants don't have a lot of information back from programs.

So it's not being reciprocated that this information transfer in a way that allow [00:11:00] applicants to feel like they have suspicion information about a program or what makes them eligible for a program. And I.

I don't know. And therefore, I'm going to apply to as many programs as I can because I'm just gonna see who might find me eligible. You know, there's other issues. If you're an international medical graduate, you might be applying to more programs than you need to simply because you know your visa status is dependent on you being able to stay in the country, and so you're casting a wide net.

So there's lots and lots of things that are driving. This over application issue. I mean, I'm sure somebody will object to me saying it, but I mean, med school advisors tend to tell students, go ahead and apply to more programs because you wanna make sure you have sufficient interviews. All of these are drivers.

And then of course, the anxiety of the fact that this is a high stakes process and everyone [00:12:00] wants to match knowing full well that there are more applicants and there are positions available. So. From the curtailing perspective, you know, I think what NRMP can do and, and what we've been working on doing is providing as much information as we can, creating new types of reports that inform applicants as to what a program is, what a program is doing, and how that might fit into what they see as, uh, important for their training future going forward.

Let's switch gears and talk about communication. So there are certain forms of communication in the process of match the match agreement that is not allowed. Why do you think that is so important to have that?

Well, it's important 'cause applicants and programs need to be able to make decisions based on what's best for them in their program without feeling or their, or their personal [00:13:00] selves without feeling unduly influenced or coerced.

NRP has been fairly strict when it comes to policies around communication. 'cause we get a lot of complaints from applicants and we get complaints from programs about. Questions being asked that were intentionally or unintentionally biased in a way that made an applicant feel like. They wouldn't have any chance of being in the program.

And we deal with those alleged violations all the time. We've done some work, uh, in the internal medicine community looking at inappropriate communications. You know, what kind of questions were you asked? You know, are you going to have children? Are you gonna have children while you're in my program? We have concerns from the Native American community asking about.

Percentage blood for Native Americans. And these are all questions that are intended to understand more about an applicant, but which potentially create bias and [00:14:00] create concerns for applicants about whether or not those types of questions are intended to kind of weed them out of the competitive group of applicants.

And we're pretty adamant about maintaining our policies around communication to, you know, ensure that. Appropriate questions are asked that applicants are being reviewed on a more holistic basis, are being interviewed and and considered fairly.

We get commonly these letters of intent and we get asked by our students about, you know, how do I send it?

And what's your advice? It seems like a very common thing where it's like this promise to match someone or rank someone high, but often we'll get these letters and then the list comes out. And maybe it wasn't quite as, as honest as we thought.

My advice is, let's stop all of that. I understand where this comes from, right?

We all kind of grew up being told it's polite to write a thank you letter, and that's essentially what these are. Thank you. I love you. I'd like to come to your program. Please invite me to your [00:15:00] program. But you know, the reality is. For programs. Applicants have already told you that they like you, they are interested in your program.

Just by virtue of the fact that they've applied, they've sent a preference signal, they've come and interviewed, um, whether that's virtual or in person. Applicants obviously would like to have a lot more information from programs, but programs aren't writing them letters. Back and saying, Hey, we really enjoyed seeing you.

You know, we sure hope you rank our program. They may say that in person, uh, and that needs to be a very careful conversation, but they're not. So when people ask me, my advice is. Discourage this practice. You guys have said everything that you need to say during the interview, and if there's post-interview communication, it should be clarification around program needs curriculum.

I heard this about your community. Can you tell me more? It shouldn't be, and it shouldn't need to be for the purpose of the applicant saying, please pick me. Or a program, you know, reaching out and saying, Hey, we hope you rank us. All of [00:16:00] that should because that leads to perceived coercion and persuasion.

It really upset applicants and programs when they find out that somebody didn't match them.

Next I wanna ask you about dual applicants. So we know that many applicants apply to multiple specialties due to having multiple interests or feeling they need a backup when they're applying to a highly competitive specialty. And we know that it's a violation of the match agreement for programs to inquire whether an applicant is dual applying.

What advice would you have to applicants who are dual applying and to programs who are interviewing dual applicants and might be afraid of the flight risk?

You know, for the applicant, it would just be focused on your interview. You are there to learn all you can about the program and to get a sense for the people who are going to become potentially become your future training program, your future peers, your mentors, and that you could be affiliated with for the rest of your [00:17:00] life.

So focus on the reason that you're there, regardless of what other specialties or programs you're interviewing with. 'cause you just don't know, right? Like this may end up being the program that you choose or the specialty that you choose, even though you didn't think you were gonna, for programs kind of the same but the other direction.

Focus on your applicants, focus on their interest in your program and your specialty. Because applicants change their mind all the time and they may not be firm when they come in in their decisions. You may have a conversation that really makes a lasting impression that makes them. Change what they thought they were gonna wanna do.

So really it's just kind of focus on each other because you're here for a reason. Even if the applicant isn't certain what they wanna do, or they're multispecialty applying and considering because they think they want a certain specialty. Applicants change their mind all the time. But just focus. That's, that's my best advice.

So, um, I wanted to talk a little bit about international medical graduates. Not that [00:18:00] long ago, we had matched someone here that we could not figure out a way to get them to actually come because of their immigration problems. And you called me to try to figure out a workable solution and I was really impressed that you were getting down to the single applicant level to try to make this work.

But what is the NRM P'S role and responsibility as visa restrictions keep changing to help those trainees or to make the process fair?

You know, that's a really good question, Dr. Lipman, because we ask ourselves that too. Clearly we don't have any control over. E-C-F-M-G is the Dean's office for International medical graduates.

But from our perspective, our responsibility is to ensure that the community knows what their options are and to try and optimize the option that. Allows these international medical graduate applicants the best chance of coming in and training these issues around visa processing [00:19:00] or immigration stops or processing stop, like what just happened the other day with another, what, 20 countries or so are not the fault of the applicant.

So our responsibility in our goal that is to make sure that the community knows, and that you knew when I called you what your options are and to encourage. The option that least risk their training deferring to another year, letting somebody start off cycle. And unfortunately, at times we do have to provide a waiver because of immigration issues, but our responsibility is to make sure you know what those options are and can optimize those options with your applicant.

So let's talk cost. The match process can be financially burdensome, especially for applicants from disadvantaged backgrounds. So how does that reality impact the NRM P'S decision making?

So when we talk about the match process, that tends to include the cost of the application, which again is completely separate and apart as is travel and everything else.

For interview, [00:20:00] the match itself is a $75 fee for the registration to the match. 20 ranks on your rank list results, reporting, access to soap if you need it, and the program list, we absolutely. Consider costs in our fees to applicants. Our board talks about it frequently. We review our fees annually to ensure that we are, number one, meeting the needs of applicants, but also number two, making sure that the fees are appropriate to enable us to continue to provide the services that we provide.

We review them regularly. We lean heavily on the learners on our board. You may or may not know we have three. Medical students on our board and three residents in addition to our senior directors. And we lean heavily on them in these discussions to talk about what they feel like from a learner perspective is reasonable and what isn't.

We recently saw that there has been some recent congressional scrutiny suggesting that the [00:21:00] match functions as a monopoly and should not be exempt from antitrust laws. And we saw your, your letter to the medical community addressing that. We wanted to ask you on our episode, how credible do you think this threat is, and could you help us to understand what the process would look like if the match went away today?

I think anytime you get a letter from the House Judiciary Committee and in particular the subcommittee on antitrust, you should consider it a credible threat. Their job is to ensure that antitrust isn't happening. You know, we've had several conversations with them in addition to the actions that you all have seen that they've taken, which is the letter that we received in March, the hearing that they held in May.

What is clear to us, uh, and what you saw in the letter that the community has. Several misunderstandings about the structure of medical education, of the transition to residency. You know how GME salaries are determined and paid, and [00:22:00] they even have some misunderstandings about the scope and the breadth of the antitrust exemption that was made law in 2004.

The mere fact that they're looking at us, you have to. Take that very seriously. But also the fact that there's a lot of conflating amongst the organizations of what NRMP actually does and what the meaning of the exemption is. Uh, we have to take into consideration that if we don't clear that up with the Judiciary Committee and ensure that the community knows what's going on, then that does pose even more of a credible threat.

So just to be clear, you know, the antitrust exemption. Doesn't prevent competitive matching programs. And then clearly there's the San Francisco match or all match military, and while the letter in the hearing didn't name the other matches, these actions also affect them. So it's, it's a credible threat, not only to.

Us who were named in the letter a, CG, me, who was named in the letter, but also all of the organizations who got a letter [00:23:00] that weren't named and the other matching organization. And it's important that we clarify the role of the match, that we clarify the matching exemption and that we continue, uh, to work with the congressional members and the staff members and council for the judiciary committee to help them kind of understand what this process is and what would be lost.

So. When you ask, what would we lose? Well, the exemption is narrow and it's limited to recognizing the benefits of having a match, whether it's US or San Francisco, match doesn't matter. What the exemption does is it immunizes the act of sponsoring and conducting, or even participating in a matching program that uses the algorithm to pair preferences.

So it is very focused. The exemption itself is called the matching algorithm exemption. The exemption states very clearly that it immunizes you, uh, and protects you if you choose to participate in matching algorithm. And it also states very specifically that this does not [00:24:00] immunize you from things like price fixing and contract malfeasance.

So the biggest thing that would be. Loss if the matching algorithm were to go away is the protection that allows organizations to participate in a match without fear of being sued by everyone who's not satisfied with the outcome. Because those types of fears reasonably lead to changes in recruiting practices.

Higher costs because programs aren't certain whether or not they're gonna fill some programs who would have to make a decision as to whether or not they could even recruit folks. So you have a potential for a reduction in the number of positions filled that would impact your physician workforce. And of course, underserved and rural are likely to be disproportionately affected.

You have a chance if the matching algorithm. Were to go away, that medical education could exert downward pressure on resident salaries. If you have fewer residents available, or you have fewer positions available, and your financial resources are increased in your recruiting practices, you may not have the same [00:25:00] amount.

Of money to pay residents for their salary that you might otherwise. So that is a real concern around the market forces. That would change if the matching algorithm went away. You could have disparity and inconsistency in your primary care distribution. You could have adverse impact to care if programs go un filled.

I mean, there's lots of things that could happen. Could the match run without a matching algorithm? Yes. Match has been in place since 1952. The algorithm exemption. What wasn't put into place in 2004, so it could, but the impact of the exemption going away would be more felt on the institutions and medical schools and would affect recruiting practices and potentially affect the number of positions available across the United States.

Last question. What's the future of the match look like? Where is it going in the near and long term future? What are the the goals of the NRMP to take the match to the next level?

[00:26:00] Interesting that you ask. We're working on our strategic plan as you speak. Some of our current priorities, we're continuing to talk about the two phase match.

Is the structure of the match, does it meet the needs of the community or is it time for it to evolve into something that allows for less reliance on the SOAP process, we are beginning to develop med school report, institution report, and program reports. That are intended to help each of those entities understand the outcomes of their students, if you're a med school, or the outcomes of the recruiting processes, if you are an institution or a program, and these reports are intended to not only help you understand what's happened.

Across your program longitudinally, but also how you compare nationally with other programs. These are brand new. Uh, we're only in our second year of the med school report and we're about to put out a second year of an institution report program. Reports coming out later this year. One of the. Priorities [00:27:00] around these reports is to give schools, institutions, and programs a couple of years to look at them and see how the actual data aligns with their recruiting practices and admission and names of their programs.

And then we intend to publish those reports so that students can use those reports of actual outcomes over time to better inform their decisions around program selection, institution selection. We're working on new IMG registration data to allow us to better understand this population, how they move in.

We have a big project going on right now that is, uh, gonna be my priority for the next probably two years or so around unmatched applicants and. You know, what are those attributes and characteristics globally, but by specialty? And also moving into some of the fellowship work around that so that we can see what's actually happening in the subspecialty too, because we don't have a lot of understanding of what actually happens with folks who are either unmatched or partially matched beyond, you know, how many matches [00:28:00] did they participate in and how successful were they over time, which pretty high over time for US grads.

But we've got a lot of questions around the igs that we're beginning to work on. We're doing a lot of work with partner organizations. Uh, a high priority for us is to understand how preference signaling is working in terms of ranking and matching, because that's not something that we understand very well right now.

I mean, a MC and Alma and residency cast have a bit of an understanding of how it's impacting the interview, but. We don't really have a good understanding yet of how it's impacting ranking and matching. And as I always say, when I talk to the A A MC, if it's changing the interview landscape, that's great, but if it's not positively impacting ranking and matching, and ultimately the matching outcome, then is the juice worth the squeeze?

And I'm not sure we have an answer. Or that we will have an answer to that anytime soon because preference signaling has [00:29:00] changed so much over this first three years of its implementation. Those are the big things we're working on right now. How do we continue to analyze and figure out how to get data out to the community that informs decisions and data that is applicant oriented?

Because we feel like applicants are in a little bit of a black hole and they need more information than they have.

That sounds incredible, and I'm sure most of the listeners will be excited to watch all those things evolve. Actual last question, who gets to push the button to run the match?

That's funny.

Jeanette, Callie, she actually pushes the button.

I feel like you should send a video of that that we could include as a link.

It would be so anticlimactic. You would be surprised. It's so automated at this point that it's literally dark.

Well, Dr. Lamb, thank you so, so much for taking [00:30:00] the time to share this with us.

We really appreciate it and look forward to another successful match ahead.

Thank you so much. It's been great talking with you all today. Thanks for.