Medical Residents Challenge Exploitative Match System and Seek Unionization

TL/DR –

The National Resident Matching Program (NRMP), a non-profit organization that has overseen nearly every accredited residency placement since 1952, is being criticized for exploiting medical students. The NRMP’s Match Day, where medical students are assigned to residency programs, is seen as a binding precontract that limits students’ negotiating power and is viewed by some as a highly exploitative system. Additionally, medical students are burdened with mounting debt, and the cost of living often surpasses their stipends, leading some to push for unionization to fight for better compensation and working conditions.

The Controversial NRMP Match Day and Its Impact on Medical Resident’s Lives

Every third Friday of March marks a significant event in the American medical sector known as Match Day. This event determines the fate of thousands of future medical practitioners using an unseen algorithm. But unlike conventional employment processes, the placements, once announced, are binding. Any negotiation or quitting after Match Day is seen as a breach of precontracts, resulting in an industry-wide freeze-out.

The National Resident Matching Program (NRMP) oversees the placement of the majority of medical graduates into residency programs since 1952. Medical students apply and interview for programs they wish to join. Both students and programs then submit a preferred partner list to the NRMP. The algorithm it uses aims to deliver the best match for everyone involved.

However, upon matching, residents enter a liminal period where they work extremely long hours while receiving poor compensation. As medical school debt and cost of living increase, many residents feel exploited, leading to a growing trend of unionizing to fight for better working conditions.

The NRMP may claim to empower the physician workforce, however, the negotiation power is heavily skewed in favor of larger hospitals and private companies running smaller community hospitals. This forces students to pad their lists with safety programs, hoping to guarantee a match, due to the risk of financial ruin if they fail to secure a placement.

There’s no genuine free labor exchange in this match system. If a resident decides to quit, the NRMP labels them with a “match violation.” This effectively blacklists them from the system and any chance of finding another residency for one to three years. It’s also worth noting that residents cannot negotiate a higher stipend or transfer to another program without approval from their current director or an NRMP waiver.

The Cost of the Match System

First-year residents in the US earn an average stipend of only $68,166, while the institutions frame this wage as a charitable act for apprentices undergoing expensive training. However, if hospitals had to actually compete for medical graduates, the wage justification would collapse.

Recent studies show that the billable value of a junior resident is significantly higher than their received stipend. In 2020, the Journal of Neurosurgery estimated this value to be about $344,757 annually. Meanwhile, the federal government contributes billions of dollars annually to teaching hospitals, with funding per resident amounting to approximately $150,000 in 2019.

The NRMP and the Association of American Medical Colleges (AAMC) also charge students extra fees for every additional program they apply for or rank, causing a significant anxiety tax. Students may find themselves paying hundreds of dollars in extra costs due to the NRMP’s all-or-nothing system.

Unionizing as a Viable Recourse

Given the restrictions placed by the Match, medical residents’ only viable recourse is through collective action. For example, in May 2023, over 150 resident physicians at New York City’s Elmhurst Hospital went on strike due to low pay. This led to the hospital meeting their demands within three days.

While unions can help balance power, critics argue that they alone cannot overturn the underlying exploitation of the Match system. The system has also been subjected to high-profile lawsuits alleging it constitutes a price-fixing conspiracy. However, a 2004 act of Congress shielded the Match system from federal antitrust laws, essentially legalizing monopsony in the medical field.

In recent years, some legislators have proposed weakening these protections, but these efforts have seen little progress so far. Meanwhile, unionization continues to expand, with demands and rhetoric increasingly criticizing the medical establishment as a whole, rather than just individual residency programs.

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