The residency match system, the founders of which were awarded a Nobel Prize not even fifteen years ago, is now being investigated by an antitrust panel.
What happened?
Earlier this year, in March, the U.S. House Judiciary Committee’s antitrust panel launched an investigation into the medical residency matching system, aiming to determine whether the hiring practices for medical residents contribute to stagnating wages, limited mobility for aspiring doctors, and worsening physician shortages across the country.
Let’s break down what this investigation means, why it matters, and how it could impact the future of healthcare in America.
Residency Matching System Background
First, a little background.
The National Resident Matching Program, or NRMP, also known as The Match, is an algorithm that pairs graduating med students with residency programs. It’s designed to be a fair way to distribute residents across different specialties and hospitals.
Before The Match, things were a mess. Hospitals had to fight over students, offering them jobs as early as their second year of med school. Students had hours to decide, often by telegram.
Dr. William Darrach, dean at Columbia University, was one of the first to say this system was ridiculous back in 1927, but nothing changed until 1951, when a group of Harvard med students, led by W. Hardy Hendren III, called out the original algorithm for being unfair.
Major organizations—like the AAMC, the AMA, and the American Hospital Association—finally tweaked the model before the first National Interassociation Committee on Internships Match in 1952.
In 1953, it became the NRMP. In 1998, they switched to a new algorithm—the so-called “applicant-proposing” model—because the old one favored hospitals too much.
Economist Alvin Roth, building on Lloyd Shapley’s work, helped refine the Match’s algorithm using game theory throughout the 1980s into the 2000s. And in 2012, the year I started med school, Shapely and Roth won the Nobel Prize in Economics for their work.
However, The Match has gotten a lot of flak over the years, with people saying it doesn’t do enough about fair pay and working conditions for residents.
In fact, back in 2002, a federal class-action was filed challenging the medical residency system, but it was dismissed after an antitrust exemption was adopted in 2004.
Let’s take a look at the three main critiques being raised.
1 | Restricted Wage Growth
First up, the pay.
Residents’ salaries haven’t kept up with inflation, even though their workloads have gone up. The argument is that The Match keeps wages artificially low.
Last year, I reacted to a video comparing what employees make at Target to what resident doctors make—and it wasn’t clickbait. Many residents working 70 to 80 hours a week were earning less than retail staff, and being retail staff doesn’t require 8 years of training or a quarter million dollars of debt. It was a wake-up call about how undervalued doctors-in-training are, linked in the description.
Some people argue that since residents are still in training, they should be paid less than fully-trained doctors. While that sentiment is absolutely fair and no one can reasonably argue that, making less than a retail worker does not adequately reflect the training they have or the value they provide.
The average salary for a resident in the US is $67,400, with most first-year residents starting around $60,000. That might sound decent at first, but here’s the catch: Residents often work 60 to 80 hours a week, which brings their hourly wage down to roughly $15 to $25.
For context, mid-level providers working alongside residents, such as PAs and nurse practitioners, whose training isn’t nearly as long and is far less rigorous, are making twice as much as resident doctors. On top of that, mid-levels only work around 40 hours a week, which is nowhere near what’s asked of residents.
In addition to the long hours and modest pay, most medical residents are also burdened by massive student debt. The average med school graduate finishes with $260,000 in student loans, and that debt doesn’t just sit there. It starts accruing interest immediately after graduation, snowballing while residents are still stuck earning low wages.
While some hospitals try to ease the pressure with housing stipends, food allowances, or subsidized health insurance, these benefits vary and often don’t match the cost of living, especially in high-rent cities like New York City, San Francisco, or Boston.
The result? Many residents are left stretched thin, financially and emotionally, during some of the most formative and challenging years of their careers.
One of the biggest problems with the NRMP is that it eliminates salary negotiation. Once you’re matched, you can’t negotiate, opt out, or shop around for better offers. You’re locked in, regardless of the cost of living or workload.
2 | Limited Mobility
Next is the limited mobility within the Match system.
Once a resident is placed in a program, they have little to no ability to switch programs without restarting the entire application process. This is a huge burden if the program turns out to be a poor fit and can severely impact a resident’s mental and physical wellbeing, as there’s little to nothing they can do to improve their situation.
If the stress of residency wasn’t clear enough, the suicide crisis among medical providers is worsening, with approximately 300 to 400 physician suicides each year.
When residents are unable to transfer to programs that better align with their goals, they miss out on crucial clinical experiences and advanced training. This lack of flexibility can delay entry into their desired specialties or subspecialties, and it also limits their ability to adapt and develop professionally, ultimately reducing the overall quality of training.
IMGs face additional barriers that affect their integration and growth inside US residency programs and are often left to fight over less-than-ideal positions. Even after years of proving themselves in residency, often working as cheap labor for hospitals, they do not have the flexibility to move to a more desirable or better-fitting program easily.
3 | Ongoing Physician Shortage in the US
And lastly, the growing doctor shortage.
Some lawmakers are arguing that restrictive residency policies discourage medical students from pursuing certain specialties or staying in the US healthcare system. And not only that, but since many physicians will retire within the next decade, it’s projected that the country will face a physician shortage of 86,000 by 2036.
Physicians are already experiencing increased workloads due to a shortage of colleagues, which leads to burnout, not only affecting physicians’ mental and physical health but also compromising the quality of care they provide.
Patients face longer wait times for appointments and, in some cases, a lower quality of care as doctors are running on empty to meet the needs of the hospital. Rural areas, where medical professionals are scarce, are particularly affected, leaving communities underserved.
Failure to expand residency slots exacerbates the shortage, leading to increased healthcare costs and reduced access to essential services.
Fortunately, the Resident Physician Shortage Reduction Act of 2023 aims to add 14,000 new Graduate Medical Education, or GME, positions over the next seven years. This initiative has received support from key healthcare organizations like the AMA and seeks to address the growing demand for medical professionals, especially following the challenges of the pandemic.
What Might Happen After the Investigation?
Alright, what could this mean for the future of US healthcare and training?
For one thing, if the antitrust barriers fall, residents might form unions to negotiate collectively for better wages, hours, and working conditions, leading to standardized resident contracts across entire regions or even the US as a whole. Hospitals may need to create HR departments specifically for resident relations.
We covered the unionization of doctors in residency in a previous article.
It could also lead to decentralized matching systems, meaning the NRMP could be replaced by regional or specialty-specific matching systems, allowing for more localized control and flexibility. This could lead to greater variation in resident compensation and program offerings, potentially attracting residents to underserved areas with higher pay or incentives. However, this also opens the door to potential bias and unfairness if mismanaged.
Another potential is that residency programs could be required to disclose detailed information about resident workloads, compensation, and program outcomes, which could incentivize programs to improve their training and reduce the hours residents are expected to work, or at least pay them what they deserve.
If residency positions become more competitive, medical schools may change admissions criteria and medical school curricula to make their graduates more desirable to residency programs. You could make the point that medical schools would focus more heavily on hard metrics like USMLE Step 2CK and research items, which is valid given the ease of quantifying and comparing candidates, but I’d wager it would rely even more heavily on letters of recommendation and standardized evaluations, since residency programs ultimately want competent and effective doctors, and program directors are already emphasizing these metrics in their selection processes.
But this is all hypothetical at this point. What’s most likely is we’ll see more competition among residency programs, hopefully leading to fairer pay and better working conditions.
And if that sounds good, remember that any big change to the system will face challenges, such as legal complexities, cost increases, and restructuring a long-standing system.
So, what do you think? Is this antitrust probe a good thing for residents, or will it add even more complexity to an already complex training process? Let us know what you think in the comments.
