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Vital Signs:
Match legislation was championed from Dartmouth

When a federal class action lawsuit charged that the National Resident Matching Program (NRMP) has been violating antitrust laws, DHMC's governmental relations director, Frank McDougall, set out to help preserve the system that has long "matched" medical-school graduates with residency positions at academic medical centers.

Working with the American Hospital Association and the Association of American Medical Colleges (AAMC), as well as with the Vermont and New Hampshire Congressional delegations, McDougall lobbied for legislation that would exempt the Match from antitrust laws. Academic medical centers and teaching hospitals have relied on the Match for over 50 years.

"If the Match was dissolved . . . was ruled to be an antitrust violation," explains McDougall, "then we'd have a whole new system that would cost a whole lot of money and not be as effective as the one we have."

The NRMP, established in 1952, uses a computer algorithm to match medical school graduates to residency programs. Prior to the 1950s, medical students had to seek out residency positions on their own, program directors often pressured students to make decisions before they were ready, and students who "knew someone" were apt to land the better positions. Commitments were often broken— by students as well as programs— resulting in further confusion.

Choices: Now, after they interview at the programs they're interested in, students list their choice of programs in rank order, and program directors likewise rank the applicants; the computer then matches students with programs—maximizing a high choice for each side. About 24,000 students from U.S. and foreign medical schools compete for some 20,000 positions annually; 85% of U.S. medical students get into one of their top three choices.

In 2002, three medical residents filed an antitrust class action lawsuit against seven nonprofit organizations and 29 teaching hospitals, charging that the Match violates antitrust laws by limiting competition and preventing medical residents from negotiating for higher pay, shorter hours, and better working conditions. Typically, residents earn $40,000 a year and work up to 80 hours per week.

"The system in place, although not perfect, is better than the chaos that existed before," according to Peter Chin, M.D., who graduated from DMS in 1999, recently completed a residency in neurology at the University of Washington in Seattle, and is now a Robert Wood Johnson (RWJ) Clinical Scholar at UCLA.

System: There are, however, some drawbacks to the current system. For one thing, "residents barely make minimum wage," points out Kavita Patel, M.D., who is also an RWJ Scholar at UCLA as well as a former president of the American Medical Student Association, the nation's largest independent medical student organization.

But teaching hospitals are facing a number of financial challenges—such as cutbacks in Medicare and Medicaid reimbursements, soaring premiums for malpractice insurance, rising medical costs, and higher patient demand for expensive services— and are not eager to assume additional expenses.

Furthermore, a court battle over the Match could cost tens of millions of dollars in fees and legal costs, which would be shared by all academic medical centers and ultimately passed on to patients and taxpayers.

Legislation: To help the nation's academic medical centers—including, of course, DHMC— deal with the challenge presented by the lawsuit, McDougall approached New Hampshire's senior U.S. senator, Judd Gregg, and asked him to cosponsor retroactive protective legislation. Gregg, who chairs the Senate Health, Education, Labor, and Pensions Committee, and Massachusetts's senior senator, Edward Kennedy, cosponsored an amendment to a major pension bill that Congress passed and President George Bush signed into law in April.

Provision: Under the amendment, the Match cannot be considered an antitrust violation nor can it be used as evidence in an antitrust case. In August, a federal district judge in Washington, D.C., dismissed the residents' lawsuit, citing the amendment's provision that the Match cannot be used as evidence in an antitrust case.

That may not be the end of the story, though. The New York Times reported that one of the lawyers for the residents who brought the suit "said the plaintiffs would 'certainly continue their fight for fair wages and safe work hours.'"

Chin and Patel would not be surprised to see changes that address some of the concerns raised in the lawsuit. After all, the Match and residency programs have undergone a number of changes since the 1950s. In fact, a 1950 graduate of Dartmouth Medical School, Harvard pediatric surgeon Hardy Hendren, M.D., was instrumental in refining the algorithm in the year the Match was inaugurated.

Changes: The algorithm has been modified a few times since, including in 1984 to accommodate married or partnered students who wished to train in the same institution or region. In the mid-1990s, then-DMS Dean Andrew Wallace, M.D., chaired a national committee that instituted an electronic instead of a paper system for handling the residency application process. In the late 1990s, the algorithm was tweaked again when it was discovered that it was subtly biased in favor of programs' choices over students'. And last year, a change was made in the length of residents' workweek, when the Accreditation Council for Graduate Medical Education mandated a reduction in resident work hours from more than 100 hours a week in many cases to a maximum of 80.

Role: Meanwhile, McDougall, who has received national congratulations for his role in saving the Match, is working on a number of other issues—on the federal level as well as in both New Hampshire and Vermont—that could have substantial financial ramifications for DHMC.

Still, changes to the residency system "may cost more in the short term, but [be] better solutions in the long term," says Chin, who has experience in public policy. He is a member of the American Academy of Neurology's legislative committee; he served two terms on the national administrative board of the AAMC's student section; and he was one of two student members on the Liaison Committee on Medical Education, the accrediting body for U.S. medical schools.

"The issue is not going to die down," agrees Patel.

Laura Stephenson Carter

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