the US By Mark Andrew Tobias

“The Match”- A Brief History of Training Physicians in the US

By Mark Andrew Tobias

One day after the drafting of this article, September 27, 2022, roughly 47,675 medical school seniors will have submitted their applications to about 36,627 US PGY-1 residency positions through the National Resident Matching Program (NRMP), also called “The Match.”1 This year marks the 70th anniversary of the Match in the US2 and as of 2022, will have generated around 6.5 million dollars a year for the NRMP from student application fees alone. This process is one of the most important annual events in modern medicine in the US. It’s the source of pride, excitement, fear, disappointment and many other emotions for medical students across the world, but what exactly is “The Match,” what did we do before? and how did we get to this point?

“The Match” process itself is a real-life example of the “Stable Marriage Problem” in mathematics. It is defined as “the problem of finding a stable matching between two equally sized sets of elements given an ordering of preferences for each element.” Another example of this type of algorithm would be a speed dating event with two equal numbered groups, split by attraction to the other group, all getting matched with a date by the end of the night. Additionally, the Stable Marriage Problem is called stable, because “there does not exist any pair (A, B) which both prefer each other to their current partner under the matching,” which means that all the pairs are as happy as possible with their partners given all of their preferences and how they were matched up. This algorithm is not to be confused with the “Stable Roommates Problem,” where instead of two groups being matched to a member of the opposite group, there is instead one group matched within themselves by order of preference to each other. So, how did we end up using this algorithm to play cupid between medical student and residency, in order to explain the birth of the match we must travel far back in time.

Let us begin in the ancient times where there was no such thing as the Match, medical school or even acetaminophen! During these times “physicians,” if one could call them that, were usually men, who declared themselves pupils to the philosophy of medicine, anatomy and illness. Notable figures included Hippocrates of Kos, Alcmaeon of Croton and Charaka of ancient India and others. This style of “physicianhood” continued for many years until during the renaissance, religious control of the profession decreased, medical discovery was more evidence based and most physicians took up apprenticeships under established physicians to learn the trade. Fast forward to 1765 when the first medical school in the US, the College of Philadelphia, was founded by John Morgan and Willian Shippen after they finished learning and teaching medicine abroad. By 1813, Yale School of Medicine was

founded, marking the 5th medical school in the US after which there was an explosion of new medical schools opening up, many of which were done so by individual physicians with no affiliation to any hospital or university. States began to respond to the increase in medical schools and decrease in education quality by creating medical examiner boards that required state exams to be taken for physician licensure, beginning with the state of Connecticut in 1821 and culminating with the founding of the American Medical Association (AMA) in 1847.

Around 40 years later in 1889, two men by the names of Dr. William Halstead and Dr. William Osler devised the first residency programs in the United States for surgery and medicine, respectively, at Johns Hopkins University.3 This concept would spread across the country and laid the foundation for all modern residencies as we know it. Only graduating medical students at the top of their class would have the privilege of being accepted to the early residencies and there was no formal system in place to acquire a position.

While American medical education suffered from its growing pains due to events like the Flexner report, the state of medical residency matriculation continued to deteriorate. Up until 1945, hospitals would commonly scout medical students for residency, even into their second year of medical school and lock them into one sided contract, which students would take as the only other option was to risk graduating without a residency position. To finally combat the recognized problem the Association of American Medical Colleges (AAMC) implemented the “Cooperative plan,” where medical schools would not release student information until a specific date in their senior year. Although well intentioned, this led to residencies offering spots with a time limit on a reply, and by 1949 residency offers lasted less than 12 hours with some hospitals requiring an immediate reply via telephone.

To combat this new problem Dr. F.J. Mullun, the dean of students at UChicago School of Medicine proposed a rank-order list solicited from students and residencies that would be used to produce a centralized match. Thus in 1952, the first American medical residency match was performed. This of course was not without its own set of problems, biggest of all, was the match algorithm used for the first match which could lead to students losing all matches or matching very low on their list if they decided to pick a “reach” program as their top program. This problem was fixed with the implementation of the Boston-Pool algorithm and then fixed again in 1998 with the switch to the Roth-Peranson algorithm which prioritizes students lists over program’s ones.4

More recently in the history of the Match, couples were officially able to match together starting in 1990 whereas before, in the 1970s, couples would ask permission from their schools’ dean to rank together. The Match was extended to medical fellowships in the ‘80s and ‘90s leading to a more systematic approach to continued education. Before 2010, if one did not match during match day, they would enter a period of time known as “The Scramble,” in which they would have hours to days to get in contact with as many programs as possible to pander for an unfilled position. This chaotic and stressful breakdown was changed in 2010 with NRMP replacing it with the Supplemental Offer and Acceptance Program or “SOAP,” where all forms of communication for unfilled positions are done through the Electronic Residency Application Service (ERAS).5 Lastly, as of this year, 2022, supplemental applications are being implemented in 15 specialties, up from only 3 last year and United States Medical Licensing Examination (USMLE) Step 1 and Comprehensive Osteopathic Medical Licensing Examination (COMLEX) level 1 are pass and fail.6

To paraphrase the Greek philosopher, Heraclitus,

“The only constant is change” and this holds true for not only the practice of medicine, but also the journey to becoming a physician. There have been many changes over the years in the process of training physicians and it seems that there will continue to be for the foreseeable future. There is now talk of increased use of exams such as Casper, which are designed to test “situational awareness” for use in residency applications among other things. As a current 4th year medical student in the United States, I feel the process still needs major revisions, that at present are above my head, but moving forward with the knowledge of the past makes things a little more bearable by putting it all in perspective.

References 1. National Resident Matching Program, Results and Data: 2022

Main Residency Match®. National Resident Matching Program,

Washington, DC. 2022. 2. 2. Roth AE. The Origins, History, and Design of the Resident

Match. JAMA. 2003;289(7):909–912. doi:10.1001/jama.289.7.909. 3. Cameron JL. William Stewart Halsted. Our surgical heritage. Ann

Surg. 1997 May;225(5):445-58. doi: 10.1097/00000658199705000-00002. PMID: 9193173; PMCID: PMC1190776. 4. Roth AE. The Origins, History, and Design of the Resident Match.

JAMA. 2003;289(7):909–912. doi:10.1001/jama.289.7.909 5. “Eras Soap® Information.” Students & Residents, AAMC, 2022, https://students-residents.aamc.org/applying-residencies-eras/erassoap-information. 6. “Specialties Participating in the Supplemental ERAS® Application.”

Students & Residents, 2022, https://students-residents.aamc.org /applying-residencies-eras/specialties-participating-supplementaleras-application.

Mark Andrew Tobias is a medical student at the University of Incarnate Word School of Osteopathic Medicine, Class of 2023. He is interested in Psychiatry.