Crozet Annals of Medicine: A Stable Marriage


By Dr. Robert C. Reiser

I have seen the future of U.S. healthcare and it looks very bright. I attended Match Day ceremonies recently and found the most amazing energy and optimism in the senior medical students as they found out in one grand reveal what their future holds.

The Match is unique to medicine; no other professional school graduates obtain their first job based on a computer algorithm. Unlike law school, dental school, business school or any graduate school, for medical school graduates there is no financial competition for the best graduates or the best jobs. No offers are made to be considered or rejected. Graduating medical students are offered no choice, just an envelope handed out at noon EDT on the third Friday in March with a single assignment to a job that will last for the next 3 to 7 years, depending on specialty. What a drama. Here’s how it works and why.

Approximately 20,000 U.S. medical students (MDs and DOs) will graduate this year. By statute they will need at least one year of internship in a hospital in order to obtain a license to practice medicine and at least three years in a hospital residency in order to become board certified in a medical specialty. This ensures that U.S. physicians are very well trained. This also represents a large, cheap labor pool for U.S. hospitals. Salaries are fixed by the hospitals at relatively low rates and are not subject to negotiation by the residents.

In the distant past, hospitals competed for medical school graduates. Because graduates could hold several offers until the last minute, at the end of the process many hospitals found themselves without the requisite manpower when the new MDs finally committed to a single program. The hospitals responded by locking in medical students earlier and earlier in their training, eventually extending binding offers to second year medical students, many of whom were not even sure of their specialty choice, let alone the type of hospital where they wanted to train.

In addition this forced the hospitals to gamble on the students too early in their medical school career before their academic or clinical prowess could be fairly judged. Many hospitals were eventually unhappy with their recruits and many medical students came to rue their choices as well. Economists call this result an “unstable marriage,” a matchup in which one or both partners would be happier with another partner who would also be happier with them. Like real marriages, economically “unstable marriages” frequently collapse with upheaval to the employer and worker.

This flawed system existed for nearly 50 years until 1952, when the medical schools intervened and formed a central clearinghouse (the NRMP) to take over the process of matching graduates to hospitals. With no training in economics or mathematics they cobbled together a natural algorithm that attempted to create what game theory economists would later call a “stable marriage” between the residents and the hospitals. In a stable marriage no partner (resident) would be happier with a different partner (hospital) who would also be happier with them than another resident. The economists and mathematicians who solved the theoretical stable marriage problem received the Nobel Prize in Economics in 2012 based in large part on research showing that the game theory mathematical modeling that solved the stable marriage problem in theory was the same algorithm the NRMP had worked out empirically more than 50 years earlier.

And so the Match was created and refined by hand computations. Students interviewed at hospitals and submitted a ranked list of programs in order of preference. Hospitals conducted the interviews and submitted their ranked preference lists. Factotums laboriously matched the top choices of the hospitals with the top choices of the students, going to the next best fit when the top choice was no longer available. Once all the calculations were done, the students and hospitals were “matched.”

In order to prevent gaming the system, the Match results, currently done by computer, are closely held and only released at a single time and date each year for the entire 20,000 students, creating a high drama indeed. Some students will get their first choice, some will get their last choice, and a few unfortunates will go unmatched. All this will play out as a surprise in front of all of the students’ peers, family, friends and faculty in a large auditorium. Mercifully, the unmatched students are notified a few days in advance and have a chance to make other plans.

Many traditions have grown up around Match Day. Some schools call up students individually to open their envelope and read the result out loud to the assembled body. Since about 50 percent of students get their first choice, there is often great joy and relief expressed. On the other hand, some students will open the envelope, glare at the result and storm off the stage without announcing the result. Most schools gather the students in an auditorium, distribute the envelopes and then all the students open them at the same time, seated with their friends and family.

I like to go to the Match ceremony when I can. The students dash up to the stage to get their envelopes, usually mounting the stage in a single leap and dancing and hugging their way across the stage. They go back to their seats surrounded and supported by family and friends. They tear open their envelopes at noon with whoops and cheers and the occasional tear, which quickly turns into an accepting smile. Champagne flows.

In the face of the frequent cynicism that seems to have infected modern medical practice, it truly warms my heart to see how delighted each new generation of medical students is to be given the privilege of long hours of grinding servitude at low wages in service to the most vulnerable in our society.

The future of medicine is in very good hands indeed.