Nephrology has been facing a very
troublesome period for trainees. In the
midst of declining interest in nephrology, there has come a point of conflict
amongst the training directors- should we go through the match or stay out of
the Match.
Almost 10 years ago, nephrology was not part of the Match and candidates were solicited
directly from training programs. I remember that my year was the last year that
we were a “non-Match” based field. It was fall of 2005 (start of my second year
of residency), I had to make a decision about a subspecialty choice and then
also a choice of the right program that fit what I wanted in a fellowship
program. Why did nephrology go into the Match? It’s simple:- Match-based
fellowship ranking is PRO candidate.
When there are enough positions and competitive number of candidates, the Match
works for the favor of the candidate. Even
when applicant numbers decline, the Match still works in the favor of the
candidate allowing them to have access to even more potential program. It also
takes away the problem of having an early and late interview based biases that
some candidates have to face with certain programs. The simple fact is that
without the Match, desirable positions will be taken up early making it
difficult for an applicant to find a spot later in one’s residency training. It
also allows for candidates an opportunity to look at a variety of programs with
no pressure to “sign the letter” on the spot.
Take a look at what happened when
GI abandoned
the Match in the early 2000’s.
“Over the past 5 years, the
application, interview, selection, and notification process has become
increasingly chaotic and unfair to applicants. Interviews have been occurring
earlier and earlier each cycle, forcing applicants to apply during their
internship year before they have time to do electives, conduct research, and
obtain letters of recommendation. The timing of interviews is such that not all
programs interview during the same time period, eg, “early-interviewing” vs
“late-interviewing” programs. Additionally, a short time to accept an offer
places the applicant in the awkward position of accepting a premature offer
before being able to interview at all programs. We have undoubtedly lost
promising applicants because of their reluctance to decide in their internship
whether or not to specialize in gastroenterology.”
The advantages of a Match are
myriad and include order and fairness to the system, time to allow the
applicant to decide to enter a particular, and placement of applicants in the
program that is the most appropriate fit for them. In areas where Matches
exist, fellows are more mobile, invigorating the field of interest and programs.
When I asked few fellows
anonymously about what they would prefer, here are few answers I got
“No Match!!!, Match is a like a
lottery, unpredictable!!”
“I prefer the Match. I think it’s
hard to know if you want to go somewhere on the spot and making a decision if
its offered to you right away maybe impulsive instead of thought out.”
“I think it will be depressing if
the Match went away!!”
“Having no Match can make the
programs think outside the box and how to make them more marketable.”
“Match only helps large academic
programs”
“Match is the best for small
community programs and actually will help them the most!”
As one can see that just from a
small sampling, the fellows are divided. When there is a competitive specialty
such as gastroenterology or cardiology, Match programs can help benefit the
applicant and allow them the best possible chance of getting a top fellowship
program that fits the candidate. Keep in mind, in early 2000s, GI was not as
competitive as it is now. When you have a less competitive field as ours (let’s
be real), does the Match process help?
Does it help when there are more open spots then there are
candidates? The answers to these
questions are not the reason to have or not have the Match, but are questions
that many programs might ask to decide if they need to go with the Match. But, we have to be fair to the residents and
going via the Match is the fairest approach to the process.
This year, the ASN
has responded with a Match task force (similar
to what GI did in the early 2000’s) and is mandating that all ACGME programs in
nephrology go via the Match process. You are either all in or all out. Why did
this group mandate such a strong statement? This is because nephrology is in
jeopardy in losing the Match. When programs and applicants feel that the
majority of positions are outside of the Match, the process itself will degrade
to a point where is not sustainable. It just stops working. This is what was
happening in the last few years of the Match. Therefore, the committee made the
difficult decision to mandate that all positions join the Match. What drove
this decision? This decision hinged on a fear of losing the Match if the
current environment continued. Also, the very real downstream consequence, if
the Match was abandoned, of having even a lower number of applicants pursue nephrology.
If the status quo continued and more and more programs made the decision to
offer spots on the fly (as a way to stay competitive) then ERAS was only
serving as a means to collect applications. The intended purpose of helping
applicants choose a program was lost.
While many programs
might like this idea, there might be program directors that might not be in
complete agreement with this process. There are a few programs that have never
participated in the Match, and now are obliged to participate in the Match.
There are many reasons why they should join.
1. Continuing the Match
will help ensure a healthy applicant pool for the entire field.
2. The potential for more
applicants will interview at your program
3. Applicants will not
feel pressured to sign up and thus will make a more informed decision.
How does one help the
program directors and programs where their medicine department or health system
put pressure on them to go out of the Match? It is shocking that this even
happens. If the medicine department or administrator puts that much pressure on
a program that they feel compelled to offer positions outside the Match just to
fill: it is an environment that values the work and service and not the
applicant and education.
We don’t know the answers to
these questions or thoughts but as a community that trains nephrologists, we
need to have unity and fairness in the process. The “all in” approach is a good
first step in the right direction. It is PRO candidate, PRO trainee and PRO
unity in nephrology. The Match task
force was left with the decision to mandate an “all in” approach. The current
system in place is not working and if it was left up to the program (as it
currently is). Then the current
degradation of the system would only continue and thus we would be in jeopardy
of losing the Match.
We would like to hear other
thoughts on this as it’s an important component in this year’s Match process.
Kenar D. Jhaveri and Matthew A. Sparks
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