The National Resident Matching Program: An Outdated Business Model Due for Reform

Introduction

The National Resident Matching Program (NRMP) was created in 1952 to protect graduating medical students from predatory hiring practices and to establish a system that would best align the preferences of medical students and residency programs. ¹ However, in the past 70 years, inflation in applications has led to increased revenue earned by ERAS through rising application costs for students without any notable improvement in the business model of the NRMP for either applicants or programs in response to this application surge. ¹ Similar problems have been observed over the past decade in the Canadian Resident Matching System (CaRMS) which is heavily modeled after the NRMP; however, this system continues to adapt with needed quality improvement as the needs of its stakeholders and medical education landscape evolve. ²

While previous studies have examined trends in NRMP, most studies utilized a very short time frame, focused just on 1 specialty when providing solutions, and failed to explore the differences in trends between the non-surgical and surgical specialties. Thus, in this study we aim to examine the trends across the entire NRMP application cycles from 2007-2008 to 2022-2023, specifically exploring trends across competitive surgical specialties to assess the efficacy of the existing NRMP business model and provide evidence-based recommendations to better address the current needs of both applicants and programs.

Methods

A cross-sectional study was conducted to explore trends across all NRMP specialties in 16 residency match cycles from 2007-2008 to 2022-2023. Data was collected from the publicly available NRMP report archives. ³ Specialties were classified as surgical according to the American College of Surgeons’ list of surgical specialties. ⁴ The data was then further stratified to identify the 5 most competitive surgical specialties in 2023 by match rate. Surgical specialties not utilizing the NRMP and preliminary surgery matches were not included in the analysis of surgical specialties. The mean number of applicants and the mean number of total ranked positions per applicant across surgical, non-surgical, and the top 5 most competitive surgical specialties were determined. Trends in these outcomes over the 16 match cycles were calculated as percent change from 2008 to 2023.

Results

Trends Across Surgical Specialties

Over the last 16 match cycles, there was a 47.99% increase in the mean number of applicants to surgical specialties (Figure 1a). From 2008 to 2023, the mean number of total ranked positions per applicant to surgical specialties increased by 88.07% (Figure 1b).

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Figure 1.

(a) Mean number of applicants to surgical, top 5 most competitive surgical, and non-surgical specialties from 2007-2008 to 2022-2023. (b) Mean number of total ranked positions per applicant to surgical, top 5 most competitive surgical, and non-surgical specialties from 2007-2008 to 2022-2023.

Discussion

These findings of increased congestion in the NRMP are comparable to results from a previous study by Claus et al which analyzed trends in the Physical Medicine and Rehabilitation match and found an increase in the number of applicants in addition to increased rank order list length for matched applicants across 11 match cycles. ⁵ However, this study did not examine trends across multiple specialties, thus limiting any conclusions regarding the NRMP as a whole.

Significant concerns regarding the NRMP business model remain especially when considering the inflation in the average number of applications submitted each cycle in conjunction with the transition to virtual interviews. While the increased number of applications is driven by applicant choice, there is a clear incentive for mass application to improve match outcomes in the current model. Additionally, although virtual interviews provide significant cost reduction, these savings are partially negated by the increased number of applications that applicants submit to improve match outcomes and paradoxically worsen match congestion through improved interview accessibility. This also leads to increased utilization of screening metrics by programs to filter huge application loads which impedes the program’s ability to gauge sincere applicant interest, leading to a distribution of interviews heavily reliant on metrics. ¹

To enhance the NRMP business model and relieve some of the burden of congestion from applicants and programs, one approach is to limit the number of interviews an applicant can attend during the match cycle, which can provide more equitable opportunities in the face of increased congestion. Furthermore, with the increase in revenue produced by additional applications, the NRMP may consider allocating a fraction of these funds to lobby for or provide partial funding for additional surgical residency training positions. However, given the complex nature of residency program funding through the Accreditation Council for Graduate Medical Education, the NRMP may also partially subsidize application costs as a temporary solution to ease the financial burden on applicants. ⁶

Further recommendations that can improve the effectiveness of the NRMP business model by reducing congestion in the match include providing applicants and programs with avenues to express interest and identify well-suited candidates respectively through continued utilization of newly introduced preference signaling. ¹ The incorporation of preference signaling has already shown promising potential, with a recent study finding increased interview rates for Otolaryngology applicants utilizing signaling in the 2021 match cycle. ⁷

This study is limited by a lack of analysis regarding individual applicant characteristics or program-specific attributes, which may have allowed for the development of more targeted recommendations. However, our study still provides insights into the weaknesses of the NRMP business model as well as practical solutions. Future studies should explore other areas in the NRMP business model that have negative implications on outcomes for applicants to drive the impetus for reform in the match system.

Conclusion

Trends across the past sixteen NRMP match cycles indicate increasing congestion in the match system, with the burden of this congestion being heavily placed on applicants. The insufficiencies of the NRMP business model have negative implications on residency programs and applicants alike. As such, crucial modifications to the NRMP business model are desperately needed to allow the needs of applicants and residency programs to be met and to reduce the burden of congestion on applicants and programs. Future research is required to further explore flaws in the NRMP business model to allow for more definite reform in the match system.