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ARTICLE |
a Treuman Katz Center for Pediatric Bioethics, Children's Hospital and Regional Medical Center, Seattle, Washington
b Department of Pediatrics, University of Washington, Seattle, Washington
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONAPPENDIX: POSTINTERVIEW LETTER...REFERENCES |
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METHODS. A Web-based, anonymous survey was sent after the National Residency Matching Program deadline for submitting rank lists but before match day to applicants who interviewed at our program from 2003 to 2006. Applicants were asked whether our program's position on their rank list would have been influenced more favorably, less favorably, or not at all had they received a telephone call from our program.
RESULTS. The survey response rate was 53% (n = 468). A total of 10.3% (n = 48) of the applicants to our program would have been favorably influenced by a telephone call after their interview. Significantly more applicants reported that a recruiting call from our program would have caused them to rank our program more favorably in 2006 (17.2%) than in 2003–2005 combined (8.4%).
CONCLUSIONS. We identified a vulnerable applicant population whose rank lists are potentially influenced by questionable postinterview communication from residency programs. To protect the integrity and fairness of the match, we call for more explicit guidelines regarding postinterview communication with applicants.
Key Words: ethics • medical education • medical student education • pediatric workforce
Abbreviations: NRMP—National Residency Matching Program
The National Resident Matching Program (NRMP) statement on professionalism encourages "all Match participants to conduct their affairs in an ethically and professionally responsible manner."1 The NRMP match participation agreement encompasses all affairs between residency programs and applicants and must be agreed on by all parties before entering the match. In the section "Restrictions on Persuasion" in the match participation agreement, the NRMP states that applicants and programs "must not make statements implying a commitment" and that "it is a material breech of this Agreement for a participant in the Matching Program to make any verbal or written contract for appointment ... prior to the Matching Program."2 However, the NRMP policy also states that they do allow "both applicants and programs [to] express a high degree of interest in each other and try to influence future ranking decisions in their favor."
Despite these policies and the statement on professionalism, the NRMP is contacted every year by applicants who believed that they were promised a position by a program with which they subsequently did not match.1 Although match violations may occur frequently3–11 and contribute to this outcome, there is also evidence that many students have an inadequate understanding of what constitutes a match violation.11 Furthermore, students may mistakenly take an expression of interest by a program as a guarantee of a match with that program.1 In 1 study, 43% of applicants believed that "informal" commitments were made to them by a residency program.7 The NRMP cautions that statements such as, "We plan to rank you very high on our list," or, "We hope to have the opportunity to work with you in the coming year," may be misinterpreted by students as guarantees or "informal" commitments by the program to the applicant.1
To avoid such issues with miscommunication around the match process, our pediatric residency program at the University of Washington instituted a postinterview no-call policy with our applicants in 2001. The objective of this study was to determine the impact of our no-call policy on the applicants’ ranking of our residency program.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX: POSTINTERVIEW LETTER...REFERENCES |
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Stata 8 (Stata Corp, College Station, TX) was used to perform Pearson 
2 analyses on the relationship between survey year and the "more favorably" response. The content of applicants’ responses to the open-ended component of this question was analyzed for dominant themes.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX: POSTINTERVIEW LETTER...REFERENCES |
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Of those who responded that a call would have had no effect on their rank list, 62% (n = 251) provided an open-ended response. Most simply stated that they respected or liked this policy. The other dominant themes were that the lack of calls helped prevent anxiety, awkwardness, uncomfortable or embarrassing feelings, or pressure; that revealing the no-call policy up-front was vital to their not being positively or negatively influenced; and that a no-call policy seemed most aligned with the spirit of the match. It is interesting that of those who provided comments after answering the question "the same," 9% (n = 22) of these comments carried themes similar to those who answered "more favorably." Ten applicants stated that it would have been nice to have an indication of where they stood with the program, and 8 stated that they felt better about programs that called because it gave them the sense that they were wanted (Table 1).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX: POSTINTERVIEW LETTER...REFERENCES |
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In retrospect, this is not entirely surprising. Today's medical students work to succeed in an increasingly competitive environment, with desirable specialties now accompanied by larger pools of applicants, earlier scheduled interviews, and more impersonal screening processes.9 Anxiety is heightened as applicants place their future in the "hands" of a classified, inaccessible computer algorithm. Furthermore, as they interview, inherent to the applicant's relationship with programs is the applicant's desire to be hired, a position ripe with power inequality. To add to this milieu, applicants proceed through all of this amid the financial and time demands of the interview and match process, a process that all told can require several thousand dollars and can last as long as 5 months.
The uncertainty, competitiveness, and powerlessness to which applicants are exposed during the match creates a vulnerability. This, in turn, promotes a desire for security, affirmation, and reassurance. When this vulnerability of the applicant pool is considered, it is apparent that the spirit and the intent of the match is intimately related to how programs communicate with applicants. Although both applicants and programs are allowed to influence each other per NRMP policy, the integrity of the match hinges on its ability to promote an environment in which both parties "make selection decisions on a uniform schedule and without undue or unwarranted pressure."1 It is this environment that allows applicants to match to "positions that best serve both their needs and the needs of residency programs."9 When communication allows influence to be interpreted as a promise, there is a significant effect on applicants and their rank lists and the integrity of the match.
A second important conclusion from our data is that programs that institute a postinterview no-call policy seem to be disadvantaged by this policy. The NRMP's policy on postinterview communication and recruiting calls is meager on explicit rules. This leaves both applicants and programs struggling with how to interpret implicit statements such as "both applicants and programs may express a high degree of interest in each other and try to influence future ranking decisions in their favor."2 The interpretations are understandably multiple and varied: some programs actively recruit through telephone calls, e-mails, and letters; other programs give feedback only to selected applicants at the top of their list; and other programs do neither. Our study shows that, without uniformity, programs that do not place recruiting calls are at risk to lose the nearly 11% of applicants whose rank lists are favorably influenced by such calls.
A limitation to our study is that its anonymity did not allow us to determine whether those applicants who indicated that they would have ranked our program more favorably had they received a recruiting call actually matched at a competing program that did place a recruiting call. Our conclusion is therefore restricted to stating that programs that do not place recruiting calls are "at risk" for losing applicants, and future studies are needed for additional validation. Furthermore, we did not control for unofficial contact between faculty and resident interviewers and applicants. Although we believe that this is an uncommon occurrence and, moreover, provide all interviewing faculty with NRMP policy regarding communication with applicants before the interview season begins, it remains that any contact that does occur despite our no-call policy could conceivably involve recruiting communication and confound our results. On a similar note, because this survey was sent anonymously to all applicants who interviewed with us, we did not exclude applicants from our own institution. Although we acknowledge that opportunities exist for substantially more informal contact between medical students from our own institution and our faculty and residents, applicants from the University of Washington received the same communication from our graduate medical education office regarding our no-call policy as did other applicants. Last, it is difficult to speculate why our 2006 applicant pool would have been more influenced by a recruiting call than in previous years. This could be a result of changing market forces or perhaps decreased education in medical schools regarding match rules. We did, however, notice a significantly larger number of MD/PhD students applying to our program in 2006 compared with 2005. MD/PhD applicants may rely more heavily on personal communication with programs as they try to align their research interests with those of specific faculty in the program, and this may partially account for some of the differences that we observed.
Given the moderate response rate of 53% and the presence of a leading frame in the survey question, it is difficult to determine whether the 10.3% who responded "more favorably" is an underestimation (as might be expected with the leading frame) or an overestimation (as a result of a sampling bias because of the moderate response rate). We maintain, however, that the actual number who responded this way is less important than that there exist a number of applicants who believe that a recruiting call would influence their rank list. Our survey results quantify this vulnerable group and describe their perceptions. It is this insight that we believe has implications for match policy. Future studies are needed to determine more accurately the percentage of applicants who are influenced by recruiting calls.
An implication of this study is that to maintain the fairness and the integrity of the match, the language of the current NRMP policies on "Restrictions on Persuasion" and its "Statement on Professionalism" should be made less ambiguous. We agree with others that there is a need for the NRMP to enforce its policies and educate applicants and programs about them.5 We also suggest that the NRMP policy of allowing program directors and applicants to "express a high degree of interest" in each other needs to be reexamined or have its boundaries more explicitly defined. Without a clearer directive, there will continue to be inconsistency in residency programs’ policies regarding recruitment communication. We acknowledge, however, that this issue of enforcing the integrity of the match is decidedly more complicated. For instance, the NRMP itself runs the match at the behest of 5 program sponsors, the American Board of Medical Specialties, the American Medical Association, the Association of American Medical Colleges, the American Hospital Association, and the Council of Medical Specialty Societies, such that the charge for policing the behavior of all match participants quite possibly should lie less on the NRMP and more on 1 or some combination of these program sponsors. In addition, we believe that partial responsibility for maintaining match integrity rests with program directors, student affair deans of medical schools, and medical student organizations. As a way to begin the process of realizing this responsibility, we agree with Borman,12 who suggested that "to reduce the quagmire of misleading communications" and bolster the professional and ethical behavioral standards of the match participants, "program director groups could adopt a policy declining to provide" any postinterview information on an applicant's competitiveness level to their program.
A second implication is that the vulnerable applicant population that we identified in this study is capable of being exploited by residency programs that use postinterview recruiting calls. Aside from perpetuating confusion on how the match is designed to work within the general applicant pool, it has been demonstrated that recruitment communication has the potential to promote dishonesty, deception, and other unethical behaviors.4,8,10 Exposure to unethical situations by medical students influences them to perceive unethical conduct as appropriate.13 This creates a troubling paradox for the medical profession: we demand complete integrity of our physicians yet align ourselves with a process of choosing new physicians that lacks integrity.7,10,12,14–16
Lewis and Wagoner9 stated, "We challenge those in responsible positions to proceed with the changes necessary for reestablishing high standards of conduct." We propose a change that would move the entire match process significantly in such a direction. Until a more effective suggestion is instituted, we suggest a new interim policy for residency programs throughout the country: "Don't ask, don't call, don't tell."
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APPENDIX: POSTINTERVIEW LETTER EXPLAINING THE NO-CALL POLICY TO APPLICANTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX: POSTINTERVIEW LETTER...REFERENCES |
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As the interview season draws to a close, I want to thank you for the time and energy you spent in interviewing with us here at the University of Washington Pediatric Residency Program. During your interview day here in January, we talked about how choosing a residency program is really about finding the best match for your personal and career goals. I sincerely hope that your travels and interviews have allowed you to feel secure in this important process.
Furthermore, I hope that the time you spent in Seattle provided you with a clear understanding of the strengths of our training program and the unique opportunities afforded by our geography and our regional relationships. Most of all, I hope that you came away with a real sense of the wonderful people who make up our house staff and our faculty.
I also want to let you know that we do not place recruiting calls at the end of the interview season. Our policy is intended to maintain the spirit of the match as an applicant-centered process. Please do not perceive the lack of a phone call as a reflection of any disinterest on our part. On the contrary, we feel extremely fortunate to have had such a highly qualified group of students interview with our program this year and welcome your communication with us at any time.
If you have any questions or would just like to chat with any residents or faculty to confirm a gut feeling, please don't hesitate to call or e-mail me at [phone number, e-mail address]. I will be happy to help you directly or put you in touch with the right person to answer your questions. Any of us, including [Residency Director, Associate Residency Director, and Pediatric Residency Manager names], would be delighted to speak with you as you make your final decisions on where you would most like to do your residency training.
Choosing the right place to train, and your home for the next three years, is an exciting opportunity. We appreciate the chance to be a part of your decision. We wish you the best of luck in the upcoming match.
Sincerely,
Chief Resident, Department of Pediatrics, University of Washington
On behalf of: Residency Director, Associate Residency Director, Pediatric Residency Manager
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FOOTNOTES |
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Address correspondence to Douglas Opel, MD, Treuman Katz Center for Pediatric Bioethics, Children's Hospital and Regional Medical Center, Metropolitan Park West, M/S: MPW 8-2, 1100 Olive Way, Suite 500, Seattle, WA 98101. E-mail: djopel{at}u.washington.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX: POSTINTERVIEW LETTER...REFERENCES |
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