Program Noncompliance in the National Resident Matching Program: Prevalence and Consequences
The National Resident Matching Program (NRMP), also referred to as The Match, sponsors the Main Residency Match and the Specialties Matching Service to place students and graduates of US and international medical schools into residency and fellowship training positions at US teaching institutions. This program provides services to more than 50 000 applicants and 9000 programs each year.1,2
To register for The Match, participants are required to electronically sign The Match Participation Agreement, a contract between participants and the NRMP that codifies eligibility criteria, Match policies, and consequences of noncompliance. The agreement is designed to promote fairness and encourage professional and ethical behavior; those who violate the agreement are subject to an investigation and sanctions. This Perspective, which is a companion to an earlier article examining applicant noncompliance,3 documents areas of program noncompliance from the 2013 through 2017 Match seasons and actions taken by the NRMP to preserve the integrity of the matching process.
Areas of Program Noncompliance
The Binding Match Commitment
Under the agreement, programs and applicants are contractually bound to offer and accept a position if a match occurs. If that binding commitment will not be honored, a waiver must be requested from the NRMP. This waiver policy gives the NRMP sole discretion to grant waivers to ensure that similarly situated programs and applicants are treated the same. Unless and until a waiver has been granted, programs and applicants are prohibited from making alternative arrangements for training.
A significant percentage of program waiver requests are due to hardships created by applicant ineligibility for training (eg, failure to graduate on time, credentialing problems, visa issues) or applicant unwillingness to honor the binding commitment. Between 2013 and 2017, 627 of 700 (90%) program waiver requests were attributable to applicant ineligibility or failure to honor the binding commitment, and 584 (93%) of those requests were approved. The remaining 73 requests were based on a range of issues, including program closure, loss of program accreditation or funding, and applicant legal or performance issues. Of those requests, 59 (81%) were approved. If a waiver is granted, the program can recruit a replacement candidate. If a waiver is denied, the program and applicant are expected to honor the binding commitment. If the binding commitment is not honored, the NRMP initiates an investigation to determine whether the circumstances violate the agreement.
Although most programs are cognizant of the requirement to seek a waiver, some fail to do so. Between 2013 and 2017, 55 program investigations were conducted, and 24 of those (44%) were the result of programs discussing, interviewing for, or offering a matched position prior to obtaining a waiver, or offering a position to an applicant with a binding commitment to another program. An additional 6 programs were investigated for failing to honor the binding commitment. Of the combined 30 investigations, 24 (80%) resulted in a confirmed violation and sanctions for the program.
Supplemental Offer and Acceptance Program
In 2012, the NRMP launched the Supplemental Offer and Acceptance Program (SOAP) to establish a uniform process for offering unfilled positions in the Main Residency Match to applicants who are partially or fully unmatched after the matching algorithm has been processed. To maintain an orderly process, the agreement requires programs to offer positions only to SOAP-eligible applicants and to fill positions only through SOAP. The agreement also prohibits individuals or entities from contacting unfilled programs about unmatched applicants until the program initiates contact. Between 2013 and 2017, 14 of 55 (25%) program violation investigations were the result of programs offering or filling positions outside the SOAP process or providing unsolicited recommendations of unmatched applicants to unfilled programs. Of the 14 cases investigated, 12 (86%) resulted in confirmed violations.
Disclosure of Complete, Timely, and Accurate Information
Under the agreement, residency programs are required to provide applicants with complete, timely, and accurate information about visa requirements, pre-employment screening policies, and any other institutional policies that determine eligibility for appointment. The information must be made available to applicants prior to the rank-order list certification deadline. Between 2013 and 2017, NRMP received 7 reports of program failure to disclose information critical to an applicant's decision whether to rank a program. Of the 7 cases investigated, 5 (71%) resulted in a confirmed violation for the program.
Restrictions on Persuasion
The agreement states that applicants and programs must be able to make training selections without coercion or unwarranted pressure. Research suggests that coercive practices occur more often among competitive specialties, such as orthopedic surgery, radiation oncology, and dermatology,4–6 where 20% to 32% of surveyed applicants reported feeling pressured to reveal ranking intentions or to give assurances that the program would be highly ranked. Applicants have also reported fear of being viewed unfavorably by programs if they do not send postinterview thank you notes expressing their interest.7 Such fears are not unfounded since programs have reported viewing applicants who do not send thank you notes less favorably than those who do.8
Two cases of program coercion have been investigated by the NRMP in the past 5 years, and both programs were found to be in violation of the agreement. However, concerns that the problem is vastly underreported due to applicant fear of retaliation led NRMP to post to its website in September 2017 a Violation Report Form for Applicants that allows for anonymous reporting of program noncompliance. To date, 17 reports have been submitted, 13 of which have detailed applicant experiences with inappropriate interview questions. Three investigations have already been initiated.
Ensuring Integrity of the Matching Process
The procedures for investigating alleged breaches of the Match Participation Agreement are set forth in the NRMP Violations Policy.9 Upon receiving an allegation, the NRMP gathers information from interested parties and prepares a preliminary report for its review. The case is adjudicated by a review panel that includes the NRMP chief executive officer and 2 members of the board of directors, who review all collected information and determine whether a violation occurred. If a violation is confirmed, the panel also levies sanctions consistent with the agreement, prior similar cases, and the egregiousness of the circumstances. The panel's findings can be disputed through the American Arbitration Association.
The NRMP encourages any individual with knowledge of a possible Match violation to report the matter, and the table presents program investigations conducted between 2013 and 2017 by reporting party, reason, and percent sanctioned. Of the 55 program violation investigations, 21 (38%) were reported by applicants, and 17 (81%) of those resulted in sanctions. Programs reported violations in 30 (55%) cases, and 23 (77%) of those resulted in sanctions; of the 30 cases (73%), 22 were self-reported by programs that committed a breach of the binding commitment, failed to comply with SOAP policies, or provided inaccurate information about institutional policies for appointment. Medical school officials reported violations in 3 of the 55 cases, and all resulted in sanctions. One case of a program's failure to honor the binding match commitment was reported by an interested third party, resulting in sanctions against that program. Although the annual number of alleged program violations has increased modestly over time, the reasons for investigation have remained largely unchanged. The most common reasons for program investigations are discussing or offering matched positions absent a waiver and violating SOAP policies. The new Violation Report Form for Applicants may result in increased reporting.
Sanctions for programs with confirmed violations can include a 1- to 3-year or permanent bar from future Match participation; a 1- to 3-year or permanent flag as a Match violator in the NRMP Registration, Ranking, and Results (R3) system; and issuance of a final report to the appropriate review committee at the Accreditation Council for Graduate Medical Education. The sanction for the majority of programs is a 1-year flag because the NRMP believes that barring programs from the Match would have a deleterious effect on applicants by reducing the number of available positions. Programs that commit egregious violations (eg, use coercive tactics or another individual's credentials to access the R3 system) receive a 2- or 3-year flag. The final report is also sent to the program director, the NRMP institutional official, and all parties who provided information during the investigation. An Institution and Program Violations Report is available in the R3 system to provide applicants and medical school officials with information about programs with confirmed violations. Sanctions are effective; programs rarely commit subsequent breaches of policy, likely because program directors are concerned that a confirmed violation will discourage future applicants.
Trust in the Matching Process
The NRMP is committed to maintaining a fair, transparent, and reliable matching process and will investigate and levy sanctions against those who do not conduct their affairs in an ethical and professionally responsible manner. The willingness of participants to report alleged violations of the agreement is critical to supporting NRMP's commitment and ensuring the integrity of the Match for all.
Author Notes
