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Rigged or Right? The Residency Match Under Fire · Behind The Knife: The Surgery Podcast

• The Match with Bryan Carmody === Speaker: [00:00:00] Welcome back to Behind The Knife. On March 27th, 2026, the House Judiciary Committee subcommittee on the administrative state regulatory reform and antitrust released an interim staff report titled Medical Mismatch, how a Residency Hiring Monopoly Harms Patients, doctors, and The American Public. We've pulled out three tasty quotes from the report to get this. Pods started. The first medical institutions created the match so that residency programs would not have to compete as hard as they would've otherwise in a free market. The next, the match severely constraints competition resulting in feeble wage growth and inflating expenses for medical residents. And the third, the match had stripped medical resident of any semblance of bargaining power and artificially depresses wages. Those are just three. There were so much good stuff in there to pull out. So ostensibly this report is the product of a year long investigation that pulled over 1500 documents from standard setting organizations like the A [00:01:00] MC and R-M-P-A-C-G-M-E, et cetera, and from a number of teaching hospitals. And they transcribed interviews with two physicians who went through the system. And the report's central claim is that the NRMP exercises, monopolistic control of a residency hiring, and that this control causes concrete, measurable harm. So to talk about this, I'm joined by doctors Emma Burke and Dr. Agnes Prem Kumar, both surgical education fellows at Behind The Knife with an interest in surgical education in this very topic. So we're also joined by a special guest, Dr. Brian Carmody. He's a pediatric nephrologist at the Children's Hospital of the King's daughter in Norfolk, Virginia. He's also an associate professor at Pediatrics at the Old Dominion University of Virginia Health Sciences Center, where he teaches the second year kidney module and serves as an associate program director for the pediatric residency program. However, he's probably best known as an analyst and commentator on medical education as his social media alter [00:02:00] ego, the sheer of sodium. I love the name and he's provided detailed commentary and high level understanding of the match process, which we have behind the knife, have followed closely on social media. Brian, welcome. What's your alter ego? The sheer of sodium, all about. Speaker 2: Well, thank you for having me, Patrick. I guess I could tell the story a couple different ways, but the shortest version is that once I started talking about medical education on social media, I wanted a place to, put more durable content so it wasn't just sort of swept up in the current of, daily events. And, believe it or not, the domain name that sheriff was actually available. And so I snatched it up, but. It was a nickname I'd gotten for different reasons back, in residency and so, yeah, he is, I and I am him. Speaker: This is, nephrology humor at its best. Speaker 2: Right, exactly. Speaker: So there's so much to talk about with this report. The most important thing we wanna cover on this podcast is to make sure that our listeners, the [00:03:00] vast majority of which are surgeons are kind of surgery adjacent. Understand that this report is out there because it's generated a lot of, discussion, some consternation, et cetera. And so we'll start with the first few questions, kind of framing this report learning a little bit more about what's in it, and then we'll dive into details about some of the key topics when it comes to things like residency, salary, unionization, et cetera. So first and foremost, Brian, why was the investigation performed and should Congress be involved and or interested at this point in investigating the match? Speaker 2: Yeah, those are good questions. And I like to think I know a lot about the match, but I mean, I can sort of only speculate about why Congress took this issue up now. A couple of years ago there was a congresswoman from Indiana that proposed a bill to, repeal the statutory exemption that allows the match to, be immune from any sort of, antitrust. Claim. And at that time actually that congresswoman, some of her staffers reached out to me. 'cause I, I've talked about this issue and I spoke with [00:04:00] them and I was very curious what her motivation for, for putting forth that legislation, which never got out of committee was. And they characterized it to me as just sort of a, small government. Good business, peel down the guardrails kind of interest. That congresswoman was on the judiciary committee for two terms and then stepped off for this current Congress, which is when this came up. So I sort of wonder if that was the seed that got this planted. I mean, certainly antitrust is specifically. In the purview of the House Judiciary Committee. I mean, it's actually, I mean, they have a specific subcommittee on that topic, so they're certainly well within their rights to reexamine this issue, but I honestly don't know exactly why it came up now. Speaker: Yeah. And you mentioned section 2 0 7 specifically. So, so going back in time, and I'd highly recommend anyone listen to this. A podcast to look up and we'll provide a link for it in the show notes. Dr. CARite's six part YouTube series. They're about 20 minutes or so each [00:05:00] on the match from the history through the current day. It is phenomenal. It's super great content. Really enjoyed listening to it. So that provides a lot of the backdrop, but it's critical to for us to talk about Section 2 0 7 and the J lawsuit. Can you inform everyone what is that, when did that happen, and why is it important to the discussion that we're having now and what's happening in this report? Speaker 2: Yeah, so, I guess as a primer for anyone who's unaware of the sort of relevant history here I guess we live in a country where, in general, you're not allowed to corner the market on something and then drive up prices or run out your competitors or things like that. I mean, we have a, we have multiple pieces of legislation going back over a hundred years that, that sort of preclude that kind of behavior, like the Sherman Antitrust Act. Well. The match system, the medical match system as you all know, sort of came about in the 1950s and strengthened, and evolved in the years afterwards and in the late [00:06:00] 1990s, early two thousands. It attracted the scrutiny of attorneys with experience in antitrust litigation and they sort of stumbled onto the fact that, the way that these residency positions were assigned is not how it is in the free market and residents. Inability to negotiate their contract. You get matched and you sort of accept the contract sight unseen didn't seem like it would be legally permissible. And so there was a big class action lawsuit that was filed in the federal court in Washington, DC and alleging that the match violated the Sherman Antitrust Act. And and not only, naming as defendants in this lawsuit. Not only naming the NRMP and the A MC and the A-C-G-M-E, but also naming individual hospitals, big academic medical centers that trained residents and, so you had a lot of deep pocketed defendants who were very much at risk if the plaintiffs could show that this was an anti-competitive [00:07:00] price fixing scheme. And one of the key allegations of a lawsuit, which you know, comes up throughout the report was that the existence of this match. Suppressed resident salaries. Anyway like with any lawsuit like that, the defendant's first move was to try to get the suit dismissed. And so there was a lot of litigation toward that end. And ultimately the central claims of the lawsuit survived. So this was something that was headed for trial. Then came this section 2 0 7 addendum to an unrelated piece of legislation. It was a, actually a piece of legislation of all things about how to fund pension equity. So a completely unrelated bill that right before it came up for a vote had an amendment that specifically made. The match off limits for any sort of antitrust proceeding. And at the time a number of senators spoke out against it, but this, this piece of legislation needed to be passed. And so [00:08:00] ultimately it got passed in. And of course, the reason that this occurred, which maybe something that will get back to you later in the PO in the podcast is that hospitals are. Very important and deep pocketed constituents for many politicians. And so, when they were threatened, they went to their friends in Congress and they got this amendment passed. So from that point on, I mean that effectively ended the lawsuit and immunized the match against antitrust claims until the present day when you know now Congress is asserting that they're gonna reexamine that issue. Speaker: Super sneaky. It's a wild piece of history. And so, Brian, that lawsuit had merits, right? Again, it was, I think, litigated to be able to proceed for a year or two or more. So it certainly had merits. And then after that section 2 0 7 was added on, it was immediately dropped, correct. Speaker 2: Yeah, correct. I mean, Congress had spoken, the law had changed. The law had Congress had [00:09:00] specifically said, this is off limits, and the judge accordingly dismissed the suit. But yeah, I mean at the very least all of these hospitals would've gone through expensive litigation and they were under real threat. By law damages for antitrust are tripled. To provide a, a disincentive from big companies trying to, just stonewall and say, well, whatever, if somebody gets this on antitrust, we'll just pay back whatever we, whatever we took in the first place. No, it gets tripled. So, I mean, this would've been devastating. It would've completely, had the plaintiff. Prevailed. It would've been a big blow. It certainly would've ended the NRMP and probably the other, alphabet soup, medical regulatory bodies involved. But also it would've been very damaging for academic medical centers, Speaker 3: so then thinking about how we got from that to now today where we're kind of revisiting this topic of is the match of monopoly, is it a price fixing scheme? A lot of the language in that report was like pretty abrasive upfront. Like clearly [00:10:00] they're against what is happening right now with the match. Is there anything that the report gets right, and does that rhetoric kind of outrun the evidence? Speaker 2: Yeah, that's a good question. In my opinion. The match is anti-competitive. I think it has elements that certainly function to reduce competition, but I think that's a separate question than is the match a good system for society? That's a bit of a separate issue. Speaker 3: Yeah. Speaker 2: So yeah. Speaker 3: So let's talk a little bit more about how it benefits society as the match, like as a current resident, I can't imagine going through another process like this is I expected to be involved in this when I applied to medical school. So overall, what does the match provide for our communities and our hospitals that we can't get otherwise? Speaker 2: Yeah let's think about the benefits of the match. I mean, so one is that positions are allocated very efficiently. Residency programs, they, whatever [00:11:00] you spend some money on a website or, certainly you still have some recruiting. Expenses, but it's not like you're having to hire headhunters or get on ZipRecruiter or, I don't know, program. It'd be unheard of for programs to have to fill their spots that way. At the same time, it makes things efficient. For applicants, you don't have to decide, what order you're gonna interview in or entertain offers. You get to consider all the possible offers that you might have had, rank them in your order of preference, and then get the best possible one for you. So, and when I say that it's an efficient system, I don't even mean in sort of the senses that I've alluded to before. As people probably know, the matching algorithm. It gives you the best. Possible outcome that you could have gotten. And not just you, but everyone else too. If you did not match to a program that you had ranked more highly, it's because they liked someone else more than you. So that's a hard truth, but you could not allocate people more efficiently than [00:12:00] the matching algorithm currently does. Speaker 4: Yeah, I think that's a great point. And another focus in the report is low wages for residents, particularly I think the comparison between advanced practice providers, how much they earn and attending physicians, a lot of language was centered around. Basically doing the same amount of work for the low wages. So do we think that accurately captures those relationships in the healthcare field? Speaker 2: Yeah, there's a lot to unpack there. Yeah. To be honest, I thought that was sort of one of the most, I don't know, disingenuous parts of the report. I'm trying to find the exact language right here because 'cause I think it's important. But you're right, there was testimony which again as Patrick said, came from exactly two physicians who have been through the matching process. And one of them asserted that, the work they were doing as a senior resident was the same as what they did as an attending. And in a way, that's true. If you're viewing it through the eyes of the person doing the work, I rounded on the [00:13:00] patients, I made the decisions. I did, most of the procedure, whatever. But. It's also true that you're a different kind of thing once you finish residency than before. And so, maybe there's a sort of a, ship of thesis problem here about when Exactly. Of course if you're the person going through residency, you're continuously improving and you become an attending and it's not a change, but legally there's a big change. You now assume the liability and you now have credentials that a resident doesn't have. And so. I think you see this in. Many other markets, many other things. You're one type of thing and then you're another, and there's different pay for those things. The PhD student writing a thesis may be doing the same research as the mentor, but it's a different kind of thing. In the area where I. A lot of people work in the shipyards. When you're an apprentice, you make a certain thing. Once you're a master you make something else. So I think that's a little bit disingenuous and that the comparison to nurse [00:14:00] practitioners is somewhat relevant because in many ways hospitals can use nurse practitioners and physician assistants to fill the clinical roles that residents are doing, but in a way. It's it's not exactly an honest comparison because a nurse practitioner, certainly they make more than a resident, but they don't make more than an attending, at least an attending in that field. So if you want to be a nurse practitioner, a physician assistant, you certainly can. But your earnings potential will be sort of capped at the level that's cited in the report. It doesn't, continue to grow. If you're the anesthesiologist, instead of the nurse's. Nurses, then, you make less as a resident, but you make more as an attending. And that's sort of part of the way the system works. So. I felt like those are not really honest examples but even everything I just said, sort of sidesteps, the main thrust of the report, which I don't know, maybe this is something we should start to talk about now is whether the match suppresses residents salaries. 'cause I'll be honest, I'm very skeptical if that's the case. Speaker: [00:15:00] Right. We'll have to get to that because ultimately this report conflates many things. And that's the bottom line. But sticking on this. Resident wages for a minute. Certainly I think we'd all agree that making 60 and 70 KA year for many years is not ideal. But it's also part of a bargain though, like you said, it's like this apprenticeship model. You buy in, you learn, you grow, and then at the end of the training you, make more. Now you could, there's a lot of commentary that can be said about where. Physician salaries are going and that's a whole separate discussion. But Brian, where do resident salaries come from? Another big question, right? Because when we talk about this report conflating things, you talk about the role of GME in the actual, the federal government, even in setting these the funding for GME programs. And this doesn't even touch the, recent changes to student loans and opportunities for low cost loans, et cetera. So there's a lot there. But pick up. Where do you wanna start with that? [00:16:00] Speaker 2: Well, yeah, we can talk about resident salaries. But I guess first I wanna sort of emphasize for any listeners, when you look at the report, I think few of us would say like, everything in medical training or the healthcare system is great. Like everything's perfect, there's a lot of problems, and this report certainly alludes to a lot of problems, about the way that residents are treated or about the way that some people, some patients struggle to access care or, but I think the question is how much of that is attributable to the match, so I wanted to sort of emphasize your point there, but yeah, resident salaries, so the bottom line, I guess is that resident compensation can come from. Any source. Dollars are fungible, but most residency positions in the United States are heavily subsidized by the federal government. So, one element of history that's overlooked by the report is how we got resident [00:17:00] salaries in the first place. And you all may know even my use of the term salary makes some people on academic medicine bristle because. The older term was stipend, and that was because, if you go back to the oldest days of residency training residents weren't really compensated at all. They lived in the hospital and they got trained, and that was their compensation. They literally lived in the hospital. And so that was, how they were paid. And they got a small stipend to cover, living expenses while they were doing that. And that was the model that we had. As residency programs expanded and hospitals grew bigger and you had more residents. Especially at programs in Boston and New York, it started to become impractical to have all the residents living in the hospital. That, and also the nature of medical trainees was changing too. 80, a hundred years ago, everybody was. An unmarried man. As some of the mythical forefathers of residency training would not take a resident if they were married. They felt they [00:18:00] wouldn't be adequately committed to their training. So you had residents who came in and they were married, they didn't wanna live in the hospital, they had families, you not living in the hospital. So, and like I said, hospitals were running outta space, so they began to provide a stipend that was larger. In exchange for what they would've provided in room and board. And so that's how we got this base level of resident compensation, which has really only grown at the rate of inflation ever since. Now in the 1960s. Medicare began to pay components of resident training because it was, well actually, I guess I should back up, before Medicare even did it, private insurers would sometimes pay a small portion. Onto the fees that they were paying hospitals for the care that was provided to residents. And so when Medicare became a dominant insurer, they began to do the same thing. And they said, we'll subsidize resident training. In so far as it's a public good and it's the right thing to do, we'll subsidize resident [00:19:00] training, in proportion to the, this new Medicare insurance program. And they intended this to be a temporary solution. But of course. An entitlement, like that's hard to ever pull back. So, they began providing what's called direct graduate medical education funding. And so if you train residents, you get a payment that's prorated based on the, amount of Medicare patients that your hospital takes care of. And the amount of your resident FTEs. But that payment is intended to offset the training costs of the residents, to pay the program director to pay the resident's salary and cover some of their benefits. So most resident positions are subsidized by these DGME payments, and then later on in the, eighties and nineties and since as Medicare payment systems have evolved. There's been a new payment, this indirect medical education payment which gets tacked on to the, you know, DRG related payments that Medicare provides to the hospitals. So there's a, an additional funding [00:20:00] stream, again, that's proportionate to the amount of Medicare patients that your hospital takes care of, and your number of FT residents, the cap that you're allowed. So many resident positions probably. Have federal subsidy that exceeds the amount of money that's paid to the resident. E even inclusive of their costs and the, the space that they need and the program director and their benefits and so on. So, there is a generous funding stream, for residents. Now, having said that, one thing that gets kicked around a lot on social media is oh, but the residents, there's a cap on residencies and that's sort of. True, but not in the way that it's often talked about or seemingly understood on social media. So, time was when if you created a residency position, well guess what? You could have it federally subsidized. And in that environment, why wouldn't you have a residency position? For crying out loud, you get access to cheap labor. The government's gonna cover it, give me a residency, it doesn't matter [00:21:00] if we need that residency position. It doesn't matter if someone qualified is gonna take it. Every hospital would certainly wants to do that and it's expensive too. So, that sort of reached a crisis point in the 1990s and so that as part of the Balanced Budget Act of 1997. There was a cap on the number of GME positions that, that Congress would fund at that level. And so if your hospital was training residents in that era, well, however many you were training, then that's what your cap is. If you have a hospital that was not training residents, that is never trained residents. You can still actually access that. You just have to build up your cap based on however many residents you train in your first five years. And there are high priced consultants that will help your fig your hospital figure out how to do this as rapidly and, financially beneficially as possible. However, even if your residency, even if you're operating at your cap, there's nothing keeping you from making more residency [00:22:00] positions. You just gotta, pay for it some other way, which again, like I say, dollars are fungible. So residents certainly. Provide financial benefits well beyond what they're paid, and it's gonna be a better than break even proposition for hospitals almost all the time. And so, unsurprisingly, even with this cap, the number of residency positions has continued to grow, Speaker: right? And so the government has its hand in this process through Medicare, GM, E caps, A-C-G-M-E accreditation, et cetera, et cetera, coming back to this report, this is again focusing on the match, and we talked about this conflation. So is there any contribution of the match to this wage gap, you think itself, or are we really talking about different structural features that some of which you just went through and also can you make a comment, another, you talked about on social media, things flying around this I think it was New Mexico where a neurosurgery residency was disbanded and then they this famous of how many apps it took to replace them and looking at salary through that lens too. [00:23:00] Speaker 2: Yeah, right. I guess I could say a lot of things about this. So first of all, the wage gap as cited in the report, the fact that, when you're an attending, you make a lot of money. When you're a resident, you make a little, I don't think that changes if you do away with the match. I really don't think that it does. Because I'm of the opinion that residents salaries won't change. And the reason that an attending physician makes more, it has to do with like all the things that I said before. You're one type of person. When you finish residency, you're a different type of person. On June 30th, the day before you finish residency, even if. In terms of your skill or even what you're doing on a dayday basis, even if it's the same on July 1st and June 30th, you're a different kind of person. And that's really what explains that gap. Now the New Mexico thing that you're mentioning, so this is, it's sort of a useful I mean it's anecdotal, but it's a very instructive sort of case study in the value of a resident because like I say the government subsidizes GME heavily and and you can look up how much a given [00:24:00] institution received, . It's still a little bit hard to tell, there, there's a lot of calculations that go into this. The pro rating and adjustments that get made by CMS rules for, where in the country you are and stuff. So it's a little bit more. Hard to put a precise number on a given hospital, a given resident, how much is received for that person. It can be a little bit trickier than you might think, and so sometimes people debate, well, the University of New Mexico provided a very useful real life case study when their neurosurgery program lost accreditation, and so all of a sudden you had. Neurosurgery residents who were providing all of this care and then you didn't. And when they were replaced by nurse practitioners and physician assistants it took, and I don't remember the figure off the top of my head. It was in the neighborhood of two or three to one, and the cost was was something similar. It was several multiples of what it would've taken to, to have the residents. So, [00:25:00] and that's. Even neglecting any subsidy available. So I think it's a case study that shows that residents provide valuable service and it I'll leave it, I guess at that for now. Speaker: Yeah. And so do you have a sense, again, let's just say in 2026 the vast majority of residents and the report makes note of it doesn't really matter what specialty you're, and everyone's making the same no matter what that specialty. Polls in terms of revenue for the hospital, but let's just say we're at like 60 to 80 K for residents across their training time. Is there some kind of back of the napkin type math that you have seen about how much funding a hospital gets or an institution gets and how much they're paying? Are we talking, are they, is it double, triple? If you do confront institutions, I've seen a few articles about this. They talk about the funds outside of just the salary itself when it comes to healthcare, when it comes to these other costs. Can you provide us a little [00:26:00] more information on that, because I think that's something that a lot of people are interested in knowing. Speaker 2: Yeah. Like I said, the figures are a little bit. Hard to interpret, but you can look them up. I mean, there's a spreadsheet you can pull from a federal website, which I've done before, and you can look and see how much each hospital received for training its residents. You can see the DG ME payment and the IME payment, and you can look and sort of figure out how many residents. There are trained at that hospital and divide and get accrued estimate. So you certainly can do that. When you take all comers, and I have a video on this topic and, but I don't recall the exact figure. It's over six figures is the average payment, for residents. And of course that exceeds residents salary. And so people who say. That the hospital's losing money on residents or that residents aren't a financial winner. There's multiple lines of evidence that argue strongly against that. And I guess honestly, the strongest is probably just the empirical observation that. Even in the absence of a federal subsidy, if you're at a program that's capped, [00:27:00] those programs have continued to grow. They've continued to add positions, and that's just not really what money savvy hospitals do. If they're losing money on something, is let's grow it bigger and let's grow it bigger and let's have more of this thing that we're losing money with. That doesn't make sense. Speaker 3: I wanna pivot from talking about salaries to what the report actually puts up as what residents have had to turn to. And they say because of all the mistreatment and because of these low wages, many residents have turned to unionization. And we know that there's been a dramatic increase in the number of residents in unions across the United States. Does the rapid growth of these resident unions actually suggest that the system is more responsive than the. COJ report claims, or is this just activism through a different channel? Speaker 2: Yeah, that's an interesting part of the report because you're right the tone in the report sort of regards that as a problem. Like, it's all these reasons that the match is bad and there's a lot of reasons the match is bad and one of 'em is that residents are unionizing. Certainly that's not something we want. [00:28:00] There's a lot I can say about this. The way I see it is, sometimes, actually, I guess I'll try to link it to the discussion we were having before about what is a resident worth and sometimes people get upset and they say, my hospital is taking in, let's say $150,000 in CMS payments for my position, and I'm getting paid $80,000. That's unfair and certainly that sounds unfair. But that's not really how we value things in our economy is, by how much profit it enables. You could make similar arguments. The people who I don't know. The lowest paid job for something on an airplane, for instance, it's still a necessary job. And so you could say, well, this job, it enables all these funding streams and therefore this person should be paid more. And in a sort of a moral sense that I think that argument resonates, but in an economic sense, that person is gonna be paid. [00:29:00] What it would cost to replace them. And if I can find someone else who can do that job just as well as them for a lower price than I would. And that's how we determine your wage, right? And that's the problem that residents have is that once you've been trained, once you finish your residency, you have a lot of skills that are very valuable in the market. But when you start residency on day one. You're very replaceable and I mean that it should be obvious to you that there, there's a line of people behind you that would've liked to have that position that you have. And this is true for almost any residency position, and you are very replaceable. And so you're not gonna earn very much in that economic. Sense, just like you wouldn't, somewhere else. Having a nanny might allow you to work outside the home and make a large salary, but that doesn't mean that your nanny is gonna make, the same as your salary. It means your nanny's gonna make whatever it would cost you to get a [00:30:00] similar replacement nanny. That's the logic. So the way that workers in any industry workers who are individually replaceable. But collectively are very valuable. The way that they negotiate is collectively they form unions. An individual coal miner is very replaceable, but if all the coal miners quit, then the mine can't operate, and the owners are really hurting at that point. And this is how, people who clean hotel rooms or people who work on the assembly line, or people who work at the docks, or, people who do jobs that are. Their job is necessary and it contributes value to society, but at the same time, on an individual level, they're all replaceable. I think that unionization is a natural consequence of the labor market, the actual labor market that residents work in, where when they start, when they take their position, I mean, despite their impressive qualifications, sort of in an absolute sense. They're individually easily replaceable and the [00:31:00] way that they get better benefits, the way they get better salaries is by acting collectively. Speaker 3: I think one of the funny parts of the report is they insinuate that if we did away with the match, residents would negotiate their salaries and I don't think I would have the confidence to beg my now program director for more money like that. Somebody else would do the job for cheaper and then I would be on a job. So I thought that was Speaker 2: exactly, yeah, it's probably time to confront that head on because you hear this a lot, you hear if not for the match. Residents, applicants would be able to negotiate better contracts because what they'd be able to do is play offers off of one each, one another. I got an offer from Duke, what's Stanford gonna give me now? And it sort of sounds good. If you remove yourself from any sort of firsthand recollection of what residency selection was like, which is, applicants stuffing their cv, wordsmithing every detail, because these tiny degrees matter. You never know one little line in your letter of [00:32:00] recommendation, a point on the U-S-M-L-E. Maybe the difference between you getting in and not. The idea that the average applicant is gonna be able to say, Hey, I'd like to come to your program, but I need to not work weekends, or, I need $10,000 more. The idea that the program director is gonna say anything other than, well, good luck to you, is honestly laughable. It really is laughable. No program is gonna pay. Very few programs, I guess I should say, are gonna pay that. And instead because again the fundamental thing to remember here is that we have more residency applicants than we have positions. And when you have more people who want a certain type of thing, I. Prices for that thing they're not gonna rise, they're going to fall. You think about it in a very real sense. This year's match, you look at the, the numbers. It looks like probably 70%, maybe lower than that. Match rate for neurosurgery, something similar, maybe a little bit better for orthopedic surgery. If you are one of the 30% of people who didn't get an orthopedic surgery position, [00:33:00] are you gonna take a pay cut so that you could get one? Yeah, you would, you wanna look at all the people who were unmatched who did not get a residency position at all? I mean, how much of the pay are you gonna take? You wanna take 75 cents on the dollar, you wanna take 50 cents on the dollar?, You honestly would have people offering to work for free, who were kept out of the current system. They would say, I'll work for free. I and that's sort of hard to argue with. And I guess I should say in this report, like I say, there's a lot of pointing at different problems, but it's unclear what problem they're primarily trying to fix. Exactly. But if resident salaries is the problem you're trying to fix. I don't think removing the match does it? I think the best case scenario is that you'd see a greater spread of resident salaries. There wouldn't be quite the standardization that we have now, and it's possible that some of the biggest name institutions who are competing for the quote unquote top applicants, they might even increase salaries. I mean, it's possible. Speaker: Doubt it, Speaker 2: but certainly, yeah. But certainly at the lower end of the market where you're talking about [00:34:00] people going unmatched or matching to, a program that many people would consider undesirable salaries are gonna drop, they absolutely are gonna drop. There's no way that salaries are gonna rise at that level of the market. Speaker: And you had mentioned the supply and demand of residents to programs was flipped in the past, right? So pre-med, yes. It was flipped and meaning we had less residents and more programs going unfilled. And so what happened, Brian, exactly. Back then with salaries then? Because that would be, yeah. Optimal time. Prem Max exactly. Didn't exist. And it's in the favor of the trainee at that point. But resident salary did not go up, correct. Speaker 2: Exactly, Patrick, you hit the nail on the head. So back in the early days of the match, if you think about why the match formed and the history that led into that. The basic, quick version of that story is that as hospitals expanded. The value of having physicians to take care of patients in the hospital 24 hours a day, seven days a week. That's [00:35:00] extremely valuable service that it's hard to get in the free market with when you're talking about attending physicians. Hospitals had a strong appetite. For having resident physicians, but the number of people graduating from US medical schools was significantly lower than that. And this is of course also in a time when there weren't really pathways for international medical graduates. To come to the United States. Not easy ones, not like now. That evolved in, in response, to physician for hospitals appetite for residents in subsequent years, and there weren't Caribbean medical schools and things. All you had were US medical schools and there weren't enough graduates to fill all the available residency positions. And so what that meant was a certain number of hospitals were fighting to fill their spots. And the alternative was that. If they were gonna go unfilled, and that's why hospitals began all these high pressure tactics. The take it or leave it offers the exploding offers, things like that. But it's curious because at that time, as you said, if [00:36:00] there were a time for residents to negotiate higher salaries, that was it. There was, there were significantly more hospitals that, that had a strong incentive to get a resident, any resident, and yet that's not what medical students did. And I've pondered this for a while because it seems kind of curious because today I think that's very clearly what would happen. And I think it's just a different era. We're talking about the early 1950s and students and we're also talking about a mindset where, like I said, the idea that residents were paid at all was somewhat. A new concept, and I think there was greater acceptance of this fact that you're not really working, you're getting your training and we just give you a living stipend. I think there was greater acceptance of that, but it showed also that students, they really wanted to get the best program. They wanted to get the best training. They wanted to go to the place that they wanted to go. That's what they prioritized. They didn't prioritize the money even when they had the leverage. To force that. [00:37:00] And certainly, hospitals were not eager to increase their stipend. Hospitals could have. Competed with money and said, we don't want to go unfilled, so we're gonna double our competitors' offer. And hospitals didn't do that either. Certainly, the match one of the provocative quotes you had at the beginning, sort of, allude to that history with, the match was set up to keep hospitals from competing. It was to keep hospitals from competing maybe in a certain way, from, to keep them from having to compete on money. You could compete by getting there faster, by sealing up people sooner. Speaker 4: Yeah. I think that whole topic of it being a free market, if we abolish it, it's probably. Not what's really gonna happen. Right. And another aspect of the report that was really stressed was the emotional toll of the match. And we've all been through it and it's a very stressful week if you don't match what that entails for your career, for your family. Right. It's definitely a very big thing. But I think the report does conflate the emotional toll of going through that [00:38:00] process, but also just being a doctor and being a resident and learning how to get through that educational time as a resident. Speaker 2: Yeah, you're right. There was a quote from the report that I think it came from material they'd gotten from the a OA, the American Osteopathic Association. And it was this quote about how, going through the soap was the worst experience of their life. And I, I don't doubt the truthfulness of that person's experience. It sucks. But again, like you said, does getting rid of the match fix that? I guess we might not have a soap anymore, but you're gonna have the same number of people who win and who lose. And I think if you lose, you're gonna be gutted and you're gonna be just as gutted, whether that's in the soap or whether you know all the spots that you wanted or taken by someone else. For whatever reason, I think it's a property of the thing. It's not a result of the match. It's the, the cruel realities of a system that everybody's not gonna get what they want. And that's true of the system, however you [00:39:00] choose to assign positions Speaker 4: that we also interesting to see if disparities, in competitive specialties and things like that, if everyone is just competing for spots on an open market per se. Speaker 2: That's the thing that I think people overlook is we take it for granted that competition is a good thing, that's the premise of all this antitrust litigation is that, we benefit from competition, competitors trying to do a better job and win business and, lower prices and things like that. That benefits society in general. So there's an assumption that, the competition is good, but. Without a match, I think there's still gonna be competition. And so I think what you gotta ask is that the way that we want applicants to compete or not? Because right now, when residency salaries are sort of standardized, programs and I do, like I say, I think that is an anti-competitive property of the match, or that's certainly enabled by the match. It means that, applicants. For better or worse, they're competing in some way on quality. Programs want the people that they [00:40:00] perceive to be of the highest quality, and we can debate and have a vigorous debate about whether the metrics that we use are the right ones. Mm-hmm. Or whether they actually measure quality, but nobody's picking a resident because they think it's cheaper, or because they're willing to sign a contract sooner, and that changes if you allow people to take. Contracts whenever they want, at whatever terms that they want. And I don't think a lot of applicants are gonna like that. If you actually war game it in your head and you think about what's that actually gonna look like? If a program can offer positions outside of the match, what's that gonna look like? Well ask yourself, who you think is gonna get those positions? It's gonna be the person who did the away rotation. The program director's gonna be like, Hey, you did a good job on your rotation. I wanna lock you up on the spot. Or you're from this medical school. I'm gonna offer you right now, or you're the department chair's son, and I'm gonna offer you right now, is that the system that we want, or do we want people to be able to consider their offers? The most vigorous group [00:41:00] of students that I hear on social media are, it's, sadly, it's the group of chronically unmatched applicants, who say, the match is unfair. And to them it is unfair. Because it's an artificial restraint on their ability to sell their services more cheaply. And be in the game instead of sitting on the sidelines. It's a system that ices them out. It's true from their standpoint, it's an unfair system because why shouldn't they be able to sell themselves to the lowest bitter? Why not? But if you stand back and say, if you sort of get back behind the veil of ignorance and say, well, I don't know, maybe I'll be matched, maybe I won't. What's the best system? What's the fairest system? What's the system that has the best return for society? I don't think it's that, I don't think we necessarily want residents competing with each other on price. I don't think we do. Speaker: So regardless of this report and its findings, are we better off with the match, Brian, or without it? Speaker 2: I say we're better off with it. I guess that my thoughts on this [00:42:00] are a little bit complicated. Sometimes when we talk about this stuff, there's a tendency to conflate, the match, meaning, the system through which these positions are assigned with the match, meaning sort of everything in residency selection. And the match as far as how residency position? Yeah, exactly. If we're talking about the match, meaning like what the NRMP does and assigning programs, I really think that's as good as it gets. It may not be as good as it gets for you as an individual. I already highlighted one example of, like I said, if you're chronically unmatched and you're willing to, to work for $10,000 a year. The match keeps you from being able to capitalize on that advantage that you have over other applicants, so it's not best for every given person, but on a system level, I think positions could not be allocated more efficiently. I think that's why the match algorithm got a Nobel Prize for economics. But if you're talking about residency selection, yeah. I mean there's a lot of problems there, and a lot of them demand solutions, but I don't think the solution is to get [00:43:00] rid of the match. We have poor evaluation metrics. We have a residency system that's very inflexible and unfair. The fact that once you're in a program. That you don't have easily the ability to sort of vote with your feet and leave, I think that perpetuates a lot of resident mistreatment. It's not necessarily the assignment of the position, but it's the fact that you can't leave it easily without being significantly penalized. You know that allows a lot of mistreatment and bad culture to persist. So, yeah, I think we are better off with the match. I think if the antitrust exemption wherever to go away, that's what the NRP would assert. They may make some other tweaks, but they would assert that, there are pro competitive benefits of these restraints and that they're justified. And I think that courts would take that argument seriously. But whether it would prevail or not, who knows? Speaker: Yeah. I'm behind the knife. One of our. Episode types is we look at journal articles. And when you look at a journal [00:44:00] article, you have the opportunity to dissect it and talk about its strengths and its weaknesses. And so to close this off, I think the report is roughly 46, 47, something along that page. And so if you're not gonna read the entire article, then you have the benefit of listening to us. I'm behind the knife who've taken the time, and we have the expert on this. Brian with us. But it's probably worth talking a little bit about the quality of the report. And overall it's pretty poor. The report is really a piece of advocacy and it's kind of dressed in the clothing of an oversight investigation, and I think it should be read that way. We've talked about a lot of extraordinarily important topics. Are included within the report, but the report itself has some serious analytical and methodological problems. First of all, the evidence base is extraordinarily thin, and one of the best examples of this is the fact that the report transcribes interviews from exactly two residents. Right. Two trainees, both of whom have some degree of grievances with the [00:45:00] process. The report alleges that 1,580 documents were utilized for this from a variety of sources. If you look at the report and look at the footnotes and the citations, those documents are not in there. The exact same documents, mostly emails in other, and the transcribed interviews are the make up the corpus of the actual support for. The report they also mentioned the exact verbiage, multiple times of direct evidence, right? We have direct evidence that implies a level of investigative discovery that did not occur with this report. There are some key distinctions too when we talked about, and we touched on this when it comes to salary things like comparing a resident salary to a an A PP salary, it's instructive on multiple levels. And it could be used to support what may be appropriate increase in resident salary. But it ignores the greater context of physicians in training and what the bargain is when [00:46:00] they end that training. And most importantly, I think we mentioned the word conflate. I think we said it in multiple times. The report conflates the match itself with so much else. That's, that is wrong. Issues that we can, should continue to address in GME. Things like long hours mistreatment. Depression physician shortages, even if there are if that is true which is debatable too. But that all comes back on, on the match and there's a lot more to this process. And Brian, you just talked about that than the match or the NRMP itself. And so, if you do read the report or if you choose not to it's probably best understood as a prosecutor's brief, not an actual investigation. Per se. So hopefully that's helpful to to frame the piece itself. There's so much more we could talk about in this topic. And in fact, we're gonna have our SEF team who are one of our education team is actually gonna dive in pretty deep on the match topic and gonna talk more deeply about some of [00:47:00] these key components that we really just. Barely scratched the surface on today, but I do think we did our job and went through a good portion of this report and are thrilled, Brian, that you could join us today. I really, again highly recommend watching Brian's six part series on the match. Again 20 minute videos on YouTube. We'll link him in the show notes, highly informative and definitely be sure to visit his blog post. The sheriff of sodium.com. Lots of really great content. I've actually already read Brian just last night I was reading a bunch of the articles and I really enjoyed 'em. Highly relevant, very practical stuff, which is fantastic. So, Dr. Carney, anything else you'd like to end with today? Speaker 2: Oh, man. I mean, there's lots more I could say, but I don't know how much more you wanna hear from me on this topic at this point. Speaker: Well, maybe we'll be able to have you background again, and we look forward to continuing to follow your investigation and sharing of information around the match. So, again, we really appreciate it. Thank you Agnes and Emma. And for everyone listening, dominate the day.