To the Editor: Response to Norris et al

We appreciate the letter from Dr. Norris et al. However, we did not suggest abandoning the Match. Instead, the eulogy described potential consequences if we fail to address the factors currently placing immense pressure on applicants and driving application fever. The eulogy was dated 2028, and intended as a warning—akin to Charles Dickens’ ghost of Christmas future—that there is still time to act, to change a difficult post-Match future characterized by “chaos and remorse.”¹

While lotteries have potential, they bring their own problems. Most lotteries promote equality, not equity, for applicants.² Lotteries may also be perceived as unfair, and not acceptable to most North American trainees.³ We appreciate the approach suggested by Norris et al to continue allowing applicants to rank programs. For any lottery approach, the devil will be in the details in terms of equity and perceived fairness.

To be clear, we do not believe the Match algorithm itself is the source of selection problems. Rather, the core problem is lack of trust between undergraduate medical education (UME) and graduate medical education (GME).³ GME does not trust UME to prepare graduate learners who are competent to perform as residents, and thus GME focuses on recruiting the “best” candidates. UME does not trust GME to truly perform holistic review on its graduates, and thus continues (mostly) to provide normative comparisons (eg, class rank, honor societies) that are biased and not predictive of future performance.

Thus, the remedy, whether it includes a lottery or not, lies in us building a future where every UME graduate meets a high standard and is “good enough” to train at any program. In turn, every GME program is prepared and equipped to train each graduate, even those who need extra help. This future is the cure we hope for to avoid falling into “chaos and remorse.”