BTK_CoSEF_beyond the match Ep10 pt1_ pay_final
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[00:00:00] Hello, hello, and welcome to another Behind the Knife episode brought to you by the collaboration of Surgical Education Fellows, also known as COSF. I'm Mackenzie Roebuck, a general surgery resident out of NOVA Fairfax and taking over as COSF's Behind the Knife lead for this year from the lovely Maya Hunt.

She hasn't gone too far, though, and is joining us for today's episode. Thank you, Mackenzie. I'm excited to pass off the reins to you since I go back clinically as a PGY3 at IU in just a couple days. We'll definitely miss you, but glad you're able to be here. Also co-hosting with us are two other COSF members.

Nicole, wanna go first?

Yeah. Hi, I'm Nicole Santucci, former COSF lead, also wrapping up my professional development time at Wash U, and like Maya, going to start back in a, just a couple days as a PGY3. Excited to be here for another episode.

Yes. Nicole was in one of our recent episodes examining the parallels between surgical education and America's literacy crisis.

And newcomer to BTK, Michael, you're up next.

Thanks for having me. Hey, I'm Michael Khabash. I'm a general surgery resident and the current surgical education fellow at the University of Florida. [00:01:00]

So excited to have us all together today. But before we dive into our episode, some of you might be wondering, "What exactly is COSF?"

COSF is a multi-institutional organization of surgical education research fellows working together to foster peer mentorship, networking, and scholarly collaboration.

We meet every week to discuss ongoing research efforts by individuals or by smaller groups within COSF.

If you are a surgical education fellow or a surgery resident interested in education and you're interested in joining COSF, you can learn more about us on our website, cosf.org.

Now that we're all familiar, let's settle in and get comfy because we're gonna be here for a bit. Today is the first episode in a three-part series we're gonna do on the Match, starting with resident compensation.

Hopefully you listened to the recent Hot Topics episode that came out in April called Rigged or Right?

The Residency Match Under Fire, that walks through the House Judiciary Committee's March 2026 report on the NRMP concluding it's a monopoly that violates antitrust agreements.

And I don't wanna rehash that background in detail. I recommend you go listen to it if you [00:02:00] haven't already. It's a great primer for this series.

So what's this series gonna be about, then?

The report names real problems in residency, but the Match is only part of the story. We want to dig deeper into these problems to explore what else is driving them as well as what we might do to actually change them.

And as we'll get into more later, that dual role of residency as education and labor matters a lot.

Institutions can frame residents as learners when discussing compensation and worker protections but rely on them as labor when services need to be covered, essentially nullifying protections as either a trainee or employee.

This is also fundamentally about value. Pay and benefits are not just numbers on a contract.

They communicate how much resident physicians are valued by the institutions that depend on them. When residents are told they are essential to patient care but then receive low pay, variable benefits, and poor working conditions, that sends a message.

Right, and the message many residents hear is, "Your work is necessary, but your needs are negotiable."

So rather than reducing this to whether the Match [00:03:00] should stay or go, this series asks a bigger question: What structures make residents vulnerable, and what protections, funding models, bargaining structures, and accountability systems would actually improve training?

This takes us to the committee's report.

It makes several major claims, and we're gonna walk through them briefly, discussing whether the evidence supports these claims and where the picture may be a bit more complicated.

Let's start with the report's first major argument: resident physicians are underpaid.

On this point, the report's highlighting a real issue.

Hospitals receive substantial federal GME funding, often around $150,000 per resident every year, while first-year residents typically earn only about 60 to $67,000 a year. When you divide that salary by an 80-hour week, many residents are effectively making around $16 an hour, and residents carry tremendous responsibility while often carrying over $200,000 in debt.

So the report is right to question whether compensation adequately reflects the work that residents perform.

But does that mean hospitals are [00:04:00] simply pocketing the difference between federal funding and resident salaries?

Not necessarily, and that's where the issue becomes more complicated. The federal funding isn't intended solely for resident salaries.

It also supports faculty supervision, educational infrastructure, program administration, and other training costs.

But even with that, there is evidence that residents generate substantial value for hospitals. One example that I can think of comes from a neurosurgery residency program that lost accreditation a few years ago and had to replace eight residents with 23 APPs.

That's like a three-to-one ratio, resulting in a fivefold increase in salary costs. So it can be difficult to calculate exactly how much monetary value residents generate, but they're clearly contributing far more than their salaries alone may suggest.

The report also argues that the Match suppresses wages by preventing negotiation.

What do you think?

Well, this is probably the most intuitive argument in the report, I think. Residents generally [00:05:00] cannot negotiate salary, vacation, benefits, parental leave, or working conditions. Once you're matched, those terms are essentially fixed, and the report's right that this differs from most professional labor markets.

Applicants can't leverage multiple competing offers against one another, which limits their bargaining power.

So the Match may contribute to limited negotiation, but it's not the only reason resident salaries remain low.

The report also argues that resident salaries are unusually standardized. What is that about?

Yeah, and that's absolutely true. Salaries are usually set by institution and PGY year. So a second-year surgery resident, medicine resident, pedes resident, and pathology resident at the same hospital essentially all make the same salary, even though their hours, call burden, procedural work, and revenue generation may look very different.

Salaries also often fail to account for local cost of living and inflation. So when you're at a high-cost city like New York or San Francisco or in a lower cost region like the [00:06:00] Midwest, salary differences are often pretty modest.

Sounds like a more productive policy discussion may be whether salaries should be adjusted for regional cost of living and inflation.

Exactly. And also whether there should be more transparency in how these pay decisions are even made. The report also points to limited mobility and physician shortages. We'll talk more about mobility in episode three, but briefly, are those really caused by the Match?

Some of these barriers are related to the Match, but many are not.

Residents can technically transfer after the Match commitment period, but in practice it's really difficult because of available position, accreditation requirements, funding, timing, and professional risk. Similarly, workforce shortages are not simply a Match problem. They are driven by specialty preferences, geographic distribution, and the number of available training positions.

So getting rid of the Match does not automatically make unpopular positions attractive, create more funded positions, or solve geographic [00:07:00] workforce shortages.

The report makes many claims regarding residents' compensation. What's our takeaway?

So the report does a good job in highlighting important concerns about resident compensation and bargaining power.

But many of these issues stem from deeper structural features of residency training, not just the Match itself. Meaningful reform will likely require addressing funding, transparency, and resident compensation from a systems standpoint rather than just dismantling the Match.

We've talked a lot about resident salaries, but compensation is more than just a paycheck, so let's focus on resident benefits.

While salary often gets the attention, benefits can have an equally large impact on quality of life during training.

One of the biggest problems is that resident benefits are wildly inconsistent across institutions, and that's striking when you think about it. Residency training is otherwise highly regulated.

The ACGME has detailed requirements for work hours, supervision, and educational activities, yet the support given to residents [00:08:00] and benefits is still largely left up to institutions.

So two residents going to the exact same specialty at different programs may have completely different experiences when it comes to parental leave, retirement contributions, parking costs, meal stipends, educational funds, fertility coverage, and even basic workspace resources.

And just to be precise, the ACGME does require some baseline support, things like health insurance, disability insurance, liability coverage, leave, and access to behavioral health services. But there's no national ACGME salary floor, no cost of living adjustment requirement, no retirement contribution requirement, and no standard requirement for things like childcare, fertility coverage, parking, meals, or educational stipends.

Exactly, and these really aren't luxury perks. They are things that residents feel every day. Parking and food may sound small, but if you're paying to park at the hospital where you're required to work or taking overnight call without reliable meal support, that can negatively affect your daily experience and [00:09:00] financial wellbeing.

Educational costs are another example.

Yes. Licensing, board exams, question banks, conference travel, specialty specific equipment like loops, all of these are requirements for our training, and they can add up pretty quickly. Some programs cover all of that, others cover very little, which means, uh, residents may pay thousands of dollars out of pocket for things directly related to their training and required by their programs.

And then there's family planning and childcare. More than half of graduating medical students are now women, including in general surgery, and many residents are training during their prime reproductive years. Yet fertility benefits and childcare support remain highly variable.

And childcare is not a fringe benefit when residents work nights, weekends, holidays, and very unpredictable schedules.

It's a workforce issue.

One of my co-residents told me that he pays over $2,500 a month for his one child to be watched while he's at work. That's [00:10:00] probably almost half his monthly salary, and we get paid pretty well at my program. Oh, and we need to mention the retirement plans.

We were talking to some of our other COSF members, and while some of us have a decent match in our 401s, other programs don't even give their trainees the option to open an account in the first place.

Yikes. And there's also a lot of variability around leave. The ACGME has a minimum requirement, but residents still face a lot of uncertainty around implementation. So how leave affects vacation, graduation timing, board eligibility, and the burden on co-residents when people take leave.

Exactly. So the issue is really not just whether benefits exist on paper, it's whether they're usable, equitable, and honestly, whether they're adequate for the realities of residency.

So what's the solution? Should benefits be left up to individual institutions to decide?

I don't think so. We've seen what happens with the current system, enormous variation and inequities between programs. Although the ACGME [00:11:00] does establish minimum standards, those are very vague and leave it up to programs to decide.

For example, the ACGME says institutions must provide financial support and benefits, but it leaves it up to programs to decide what that looks like. One option would be for the ACGME to establish national minimum standards for resident benefits kind of similar to how it establishes standards for duty hours, supervision, and educational requirements.

Another approach would be legislative or regulatory action requiring certain baseline benefits nationwide. This could be minimum retirement contributions, educational stipends, mental health services, and coverage of mandatory training expenses.

The key point is that residents should not have to rely only on institutional goodwill for benefits that are essential to their education, well-being, and professional development.

And look, we can belabor the point that salary and benefits aren't adequate all we want, but I don't think it really hits home just what that [00:12:00] means until you see what this actually looks like for residents.

Absolutely correct. Compensation is not some abstract policy issue for residents. It impacts how close to the hospital you can live, whether you can afford childcare, like Mackenzie's co-resident, or even start a family.

Wait, what do you mean even start a family? I mean, I know fertility benefits aren't great everywhere, but is there something else I'm missing?

We're gonna talk more about unionization later in the episode, but I studied the motivations around it in general surgery residence for my master's thesis, and I heard some pretty gut-wrenching statements.

A resident who qualified for food stamps because of their child and their low salary, another that was on government assistance for childcare, but the one that stuck with me most was a resident on the West Coast whose partner was also a surgical resident and told me it's cheaper for them to drop out of residency to have a child than it is for them to have a child there on two resident salaries.

So that's two professionals in their early 30s essentially being forced to decide between their career and children for entirely artificial reasons. And to [00:13:00] what end?

I've even heard of residents going into credit card debt to freeze their eggs for fertility preservation.

It's really sad. And the residents that I spoke to who were the most financially stable had some kind of external support, either from family or had a partner with a high-earning income.

If low wages persist for residents and only those with external support are able to afford being a resident, then we will see furthering of inequities and essentially narrowing who gets to become a doctor to only the wealthy. There's been a lot of discussion actually recently about how to make surgery more family-friendly, and this seems like the most obvious thing to change that would make the biggest impact to actually move the needle on making surgery family-friendly to current or future parents.

Just real financial support.

You're so right, Maya. Increasing compensation would likely have the largest impact on those who are caregivers or with financial responsibilities outside of themselves, but there's actually a lot of reasons why compensation should be increased, and these stories are not isolated [00:14:00] examples.

For decades, residency has been framed as a temporary sacrifice. Training is short, attending compensation eventually makes up for these years, and residents are primarily learners rather than workers. But for many trainees, that bargain feels increasingly strained. Residents are entering training with larger educational debt burdens than previous generations, housing costs have risen dramatically across the US, childcare expenses continue to climb, and family planning often overlaps directly with residency and fellowship, meaning that some of the most financially demanding years of adulthood occur exactly at the same time as some of the lowest earning years.

Not to mention that in pretty much every field, fellowship is becoming more and more expected, prolonging the state of low salary. Also, there's a lot of uncertainty that comes with residency training.

Exactly. Residents are taking on financial responsibilities as they relocate across the country, support partners, help aging parents, and pay for licensing exams, board preparation, moving expenses, [00:15:00] and other costs that aren't always obvious from the outside.

And then there's the reality of the job itself. When residents are out on parental leave, medical leave, or vacation, the work doesn't disappear. It just gets absorbed by co-residents. Many residents feel increasing clinical responsibilities, service demands, and expectations. Meanwhile, compensation has largely failed to keep up with inflation.

Honestly, the relationship between work and compensation just feels more and more disconnected, especially as things become more expensive.

Right, and that's happening at the same time that medicine itself is changing. More physicians are employed by large health systems rather than building independent practices, and so the promise that you'll simply make it up later feels much less certain.

Which gets us back to the bigger question. If everyone agrees resident salaries feel artificially low, why doesn't the market just fix it like the report suggests? Get rid of the match and let the competition solve the problem.

I like the way Dr. Carmody framed it in the prior episode, that resident pay doesn't [00:16:00] have normal price discovery.

Right. In a typical labor market, wages get tested through offers, counteroffers, competition, and ability to walk away. If no one accepts a job at a certain salary, the employer may have to raise the salary or improve the benefits. Residency doesn't work that way. Applicants are not choosing between multiple negotiated offers.

They are ranking programs in a system where salary and benefits are mostly fixed ahead of time, and where the primary goal is usually to match into the specialty and training environment that they need.

And that means that programs are not forced to compete on compensation in the same way that other employers might be.

So they might compete on reputation, case volume, geography, fellowship match, or culture, but not usually on salary.

To be fair, there's a dual role to consider here. Residency is both work and training. Residents generate clinical value for hospitals, but we're also receiving training that allows us to practice independently later.

And we all know that residents are partly paying for that training by accepting lower [00:17:00] wages during residency. I don't think any of us are arguing that residents should be paid like attendings, but the current amount still feels hard to justify when you look at the hours, the responsibility, the debt, the cost of living, and the degree to which hospitals rely on resident labor.

So the Match is part of the structure, but the larger issue is that residency itself is not a

normal job market.

Right. So saying just negotiate assumes that trainees have leverage. But for most applicants, turning down a residency position isn't like turning down a job offer. They're potentially delaying an entire career.

Dr. Carmody made an interesting point in the episode. Even if the Match disappeared tomorrow and residency became a completely open market, there's no guarantee resident salaries would suddenly increase. In fact, I mean, basic economics suggests that the opposite pressure could exist. There are more people who want residency positions than there are available positions.

So when demand

exceeds supply, employers often gain leverage, not workers. So the concern is that applicants might end up competing against each other in ways we wouldn't actually [00:18:00] want. Like, instead of competing based solely on qualifications, applicants could end up competing on who's willing to accept lower pay or fewer benefits, less parental leave, or worse working conditions.

The applicants with the fewest financial resources would end up being the most vulnerable.

Now, that doesn't mean the current system is perfect. It's actually far from it, but it does mean that we should be cautious about assuming that removing the Match automatically creates meaningful bargaining power.

Yeah, because bargaining power isn't just about being allowed to negotiate. It's about having enough leverage to negotiate successfully.

And that's why conversations about resident compensation have to move beyond individual negotiation and toward bigger questions about funding, transparency, and collective power.

Right. So if we can't just open up the market, how do we address the compensation issue? Where does the money for resident compensation actually come from?

So the answer is actually quite complicated, but the short version is most of it comes from the federal Graduate Medical Education funding, [00:19:00] primarily through Medicare and Medicaid or CMS funding.

Right. And this is something Dr. Carmody talked about in the prior episode, so we're not gonna go fully rehash that history here. Uh, but there are two big categories listeners should know, DGME and IME. You guys wanna explain?

Sure. DGME stands for Direct Graduate Medical Education. It's the funding stream intended to support the direct costs of training residents, especially their salaries and benefits, as well as some faculty teaching costs.

IME is Indirect Medical Education. That is additional Medicare funding meant to account for the higher patient care costs associated with teaching hospitals, more complex patients, more resource use, and the inefficiencies that come with training. So most of the money from CMS is actually designated as IME.

A key caveat is that Medicare is not cutting a check directly to residents. These dollars flow to institutions, and how that money moves inside the hospital can look very different from place to place. As we were fact-checking this section, I talked with the DIO, and that was one of the biggest takeaways.

Every institution is different. [00:20:00] At some places, GME leadership has a direct role in tracking and distributing funds, as you might expect. At others, money may flow more broadly through hospital finance, and GME receives a part of that for salaries, benefits, and educational costs. So I don't think this should be framed as residents versus GME leadership.

Many GME leaders are advocating for residents, but they're doing that within a larger financial structure that can limit what they're able to do.

Look, and here's the thing, training residents is expensive. It's not just salary and benefits. There are program directors, associate program directors, coordinators, accreditation costs, simulation, workspace, call rooms, and a lot of administrative work that's needed to document residents correctly so institutions can actually claim reimbursement.

And in surgery specifically, training can add real clinical costs. Cases take longer, extra OR time's expensive, and the residents may order more tests or need more supervision than someone who's done with their training.

The residents are also not just an educational [00:21:00] expense. Residents provide clinical care, cover services, assist and perform operations, respond to pages, teach students, and keep hospitals functioning around the clock.

If a hospital suddenly lost its residents, that work would have to be replaced by attendings, APPs, moonlighters, or other staff, which would be incredibly expensive, as we heard in the earlier example with the New Mexico program.

So both things are true. Residents are expensive to train, and residents are expensive to replace.

The problem is that both sides of the equation are hard to see from the outside. We need to know how much GME funding comes in, how much does it actually cost to train a resident, how much clinical value does that resident generate, how much goes to salary, benefits, how much to support education, and how much to support the broader hospital operations that are happening to support this.

Without transparency, it's hard to know whether public funding is actually achieving the goals we say we care about.

But we can't really talk about this issue until we take something else into account, and that's hospital finances Many hospitals are operating on really thin margins, and labor [00:22:00] costs are rising across the entire healthcare system.

So if Medicare or Medicaid funding is cut or when hospital revenue is strained, unrestricted money may understandably get absorbed into broader institutional needs.

Right. And that still does not make resident needs less real. Residents should not be the pressure release valve for every financial or workforce problem in healthcare.

But many hospitals are also not sitting on easy money that they can just redirect to us overnight.

Which is why unfunded requirements alone are not enough. If we say, "Pay residents more or give us better benefits," but we can't figure out where that money's coming from, that may not be realistic for a lot of institutions.

Exactly. But the reverse is also true. More GME funding alone is not enough if there are no expectations for how that money should be used. If the goal is to support residents, then the funding has to be designed to actually reach residents and training programs. That could mean more protected support for GME infrastructure, funding that goes directly to [00:23:00] GME leaders, salary floors, cost of living and inflation adjustments, benefit standards, or reporting requirements that show how much money comes in and how it's actually used.

So depending on the goal, the policy lever may be different. Better resident compensation, stronger benefits, and more training positions in needed specialties or regions are not all the same problem, and they may not be solved by the same funding mechanism.

And this is where resident voice still matters.

National policy is important, but every institution has different pressure points. At one program, the biggest need may be parking or meals. At another, it may be childcare, parental leave, call rooms, board fees, or coverage when someone's sick. So residents should know who represents them at their local resident council and who sits on their GMEC, or G-mec as we call it at my program, the Graduate Medical Education Committee.

Those are the places where institution-specific GME issues are discussed, and they can be a practical way to advocate for what your program actually needs.

But local advocacy [00:24:00] also has limits. Residents can identify the problem and push for change, but if the funding structure does not support the change, advocacy alone may not be enough.

And national mandates can help create a baseline, but if they're unfunded, they can backfire.

ACGME requirements can be important, but adding requirements without resources can force programs to shift limited dollars around or add administrative burden without actually improving resident life. So to bring it back to the report, if Congress is genuinely worried that residents are underpaid and overworked, the biggest lever may not be blowing up the match.

It might actually be asking what strings should be attached to the billions of dollars already flowing into GME, and how additional funding could be structured in a way that actually reaches residents and training programs. The match is a visible target, but resident compensation sits inside a much larger system: GME funding, hospital margins, Medicare and Medicaid policy, accreditation requirements, workforce planning, and institutional priorities.

A simple solution would be great But this is not [00:25:00] a simple problem. The goal should be to build a better system, one with enough funding, better transparency, stronger resident protections, and clearer accountability for where the money goes. And that brings us to another form of accountability: collective power.

Yeah, and that is where unionization comes in again. As individuals, residents have very little negotiating power, but when they band together, they can have a huge influence.

Also, it's so much easier for a hospital or program to replace a single resident compared to, say, a majority of residents in a program.

For sure. Individually, residents are really vulnerable, but collectively, we're essential to the functioning of hospitals. This is why collective bargaining becomes one of the more realistic ways that residents can push negotiations over pay, benefits, and working conditions. The congressional report framed unionization partly as evidence that residents are dissatisfied with the current system, which

I think is

fair.

Yeah, I think it's fair, too. But we also need to be careful about equating unionizing as a response to the Match rather than as a [00:26:00] response to the broader system and power imbalances that constrain residents.

So why do unions create change? What do they actually do?

At a practical level, collective bargaining can put a lot on the table.

Salary and cost of living adjustments, sure, but also things residents don't always think to ask about individually, especially new graduates. This includes the benefits we walked through earlier, like parking, meals, childcare, but it could even include moonlighting and extra shift pay or coverage expectations when someone's out sick.

And unlike an advisory committee, a union contract can create enforceable obligations. They are required by law.

And a lot of those things, they're not really extras. They're the stuff that determines whether residency is survivable. And as we've mentioned, that enforceable piece matters. Resident councils and GMECs can be helpful, and residents should use those channels, but they are often advisory.

They can recommend and flag problems, but they can't have the same enforcement power as a contract can.

So sounds like it's not [00:27:00] the only lever, but probably one of the few ones with real teeth.

Exactly. And I do wanna be careful not to oversell unions. It's not a one-size-fits-all solution. At some institutions, it's going to do a lot of good, and at others, less so.

Negotiations can stall, contracts can be disappointing, union dues cost money, and getting to a contract can take a lot of uncompensated resident time.

It's also worth saying surgical residents specifically tend to participate less than other specialties in unions. Part of that is just time. When are you supposed to attend a union meeting on a surgery schedule?

A lot of us don't even have time to eat lunch usually, much less attend a lunch meeting. The other part of it is culture. Surgery still carries a strong hierarchy, and there can be real hesitation about anything that looks like pushing back against the program.

I'm really glad you pointed that out, Nicole, and we'll link this in the show notes, but a 2024 paper by Foote et al actually supports the lack of surgery resident participation, and time was [00:28:00] absolutely one of the factors.

I also heard this a lot reflected in my thesis participants. Many feared participating in a union even if they were supportive of it due to fears of being seen as transgressing the hierarchy or even being seen as being rebellious. So this was particularly felt by women, people of color, and those on visas.

In his episode, Dr. Carmody made a point that workers who are individually replaceable gain real leverage the moment they act collectively. But he also makes a point that I think doesn't get said enough: unions don't create new money. They redistribute money, power, and resources that already exist Which is actually a fair question to sit with.

If resident compensation goes up through collective bargaining, where does that money come from? Is it hospital margins or admin budgets? Somewhere else in the GME pipeline? It's not a reason to dismiss unionizing, but it is a reason to ask the question honestly instead of pretending the money just appears out of nowhere.

So it's not free, in money or in time.

Definitely not. And unionization also [00:29:00] varies enormously by state. Some states even restrict collective bargaining for public employees, which includes residents at public institutions. So the tool itself is not equally available everywhere.

So maybe a union can improve your contract, but on its own can't fix the structural problems underneath the whole system.

Right. That's really the heart of it. We still need some kind of national baseline so that whether a resident has real protections doesn't just come down to which hospital they matched into or which state that hospital happens to be in.

So to bring us home, I wanna come back to where we started. The congressional report is right to name that resident compensation and bargaining power, those are real problems.

Resident physicians are highly educated, clinically essential, and often working long hours during some of the most financially vulnerable years of their lives.

But where we differ from the report is in the solution. Simply getting rid of the match does not automatically mean residents can negotiate better salaries, afford childcare, get paid parental leave, or have better health insurance.

[00:30:00] It does not automatically move more GME funding into resident pockets.

And when we talk about compensation, we need to think beyond base salary. Benefits matter. These are not luxury add-ons. They affect whether residents can actually live sustainable lives during training and start to set themselves up for the future.

Exactly. And since, as individuals, residents have very little leverage, we have to be realistic about where that power can come from. Some of that may be institutional advocacy, like through GMX, resident councils, and hospital leadership. Some of it may be from national standards like CMS, ACGME, or legislation.

And for some institutions, collective bargaining may be one of the very few mechanisms that gives residents enforceable negotiation power.

So the takeaway from this episode is not that residency should stop being educational or that hospitals do not spend real money training residents, because they do The takeaway is that residents are also workers.

They generate real clinical value, and the current system heavily relies on that [00:31:00] labor while giving residents limited ability to negotiate over the terms of it. Better

pay and benefits would not solve every problem in residency, but they would be a concrete signal that resident labor and resident lives are valued.

And these reforms do not have to be all or nothing. We can preserve the benefits of the Match while still demanding more transparency around GME funding, stronger benefit standards, cost of living adjustments, and better mechanisms for resident voice.

Look, ultimately, it's not just whether the Match is good or bad.

It's rather what kind of training system we're building and who that system is designed to protect.

And that brings us to our next episode. Today, we focused on what happens once residents are in training: pay, benefits, and bargaining power. But before any of that happens, applicants have to survive the application process itself.

Which is its own kind of chaos. Applicants are submitting 40, 50, 80 applications, spending thousands of dollars because they do not really know where they are competitive.

And programs on the other side are trying to review hundreds, often [00:32:00] over 1,000 applications while still claiming to do holistic review.

Yeah, it's just not possible to do that even in the best of intentions. Both sides are responding rationally to a system with too much uncertainty and not enough transparency.

So our next episode will be moving upstream over application, signaling, interview hoarding, program transparency, and how we make residency selection more efficient without making it more inequitable.

I'm excited. We hope you'll join us next time for episode two of Beyond the Match.

Thank you for listening to Behind the Knife. And as always... Dominate the day