In December 2020, the Association of American Medical Colleges sent an unprecedented letter to program directors, student affairs officers, designated institutional officials, and medical students describing residency interview hoarding and maldistribution. The letter highlighted that students in the highest tiers of medical school were receiving a disproportionate number of interview invitations, leaving fewer opportunities for other students.1  The COVID-19 pandemic exposed fault lines across society between the haves and have nots,2  and medical education was no exception. Behaviors such as hoarding (eg, hand sanitizer, interviews) can be predicted by inherent inequities in systems like the residency Match within which people act in their own self-interest.

The term “match” denotes both the process of connecting 2 things and a contest in which people or teams compete against one another. Current participants in the residency Match spend ever-increasing amounts of time, energy, and money for diminishing returns, often displaying behaviors rooted in fear and half-truths.3  Despite multiple calls for reform, the problem continues to worsen.4,5  Most proposed solutions do not fully address the underlying motivators and at best offer limited improvements.6,7  Building on the recent discourse in the medical literature,5,812  we use the concept of the “prisoner's dilemma” to explore drivers of student, program, and institutional behaviors. Although others have used this framing in the past, we delve further into underlying motivations behind the actions we see in the Match and suggest a different path forward. We challenge academic medicine to devalue normative comparison in favor of high-level reproducible competence as the criterion for medical school graduation and residency selection.

In the 1940s, Neumann and Morgenstern developed game theory after considering differences in strategies between chess, a game with “perfect information” in which all potential pieces and moves are visible, and poker, a game of “imperfect information” in which players hide their liabilities and assets to gain advantage.13  Medical schools, applicants, and residency programs play games of imperfect information every year. For example, applicants may prioritize location, curricular flexibility, or prestige, but infrequently share this information with programs. Residency programs rarely list interview criteria in the public domain,14  and medical schools have long produced documentation that program directors find unhelpful.15 

In the 1950s, Flood et al described the prisoner's dilemma, a set of behaviors and outcomes common to games of incomplete information.16  In the story of the prisoner's dilemma (Figure), 2 suspects are arrested and taken to separate jails. Jailers have enough evidence to convict each suspect on lesser charges, but they need a confession or an accusation by either suspect to convict the other of a major crime. There are 4 possibilities. Jailers tell the first suspect that the second suspect has already defected or “ratted him out,” and if this first suspect “holds out” and cooperates with the other suspect, he will receive 20 years in jail, while the second suspect will receive only 1 year. The second suspect is told the same thing about the first. If both suspects cooperate with each other, they will each receive only 2 years in jail, but if they each defect on the other, each receives 16 years in jail. The best outcome (1 year) is called the temptation, and the worst outcome (20 years) is known as the sucker's payoff. Most studies of rational players show that in a prisoner's dilemma, mutual defection is the dominant strategy, not mutual cooperation even when the players agree beforehand to cooperate.17,18 

We characterize 3 prisoner's dilemmas in the Match—each arises from human impulses and powerful forces within the US medical education system.

Medical School Versus Medical School

Medical schools compete with one another. Facing pressure to match medical students to the “best” residency programs (the temptation) and to have no students fail to get a desired match (the sucker's payoff), schools produce untrustworthy assessment data that do not reliably predict future performance.1921  Several reasons for this behavior exist.5,8,22  Grading systems based on normative comparisons, especially in the clinical years, produce perverse incentives for learners. Students show only strengths to their teachers to get the best possible grades or recommendations; in contrast, sharing the need for growth, or sharing that growth has even occurred, are perceived as weaknesses.23  Even if a school's assessment system can capture a student's weaknesses, sharing this information with residency programs represents risk if other schools do not share similar information about their students. Some schools will not terminate students for academic reasons unless serious non-remediable professionalism issues arise, leading to the well described “failure to fail” phenomenon.24  Medical schools could cooperate and share a more complete truth about their students, but if some schools choose not to, those schools would have an advantage over schools that share, and so nearly all schools defect.

Applicant Versus Applicant

Applicants compete directly with one another. Most applicants could apply to fewer programs, as the vast majority eventually match within their top 6 choices.25  However, fear of not matching, the sucker's payoff, may underlie students' sense that those who do apply to fewer programs risk being greatly disadvantaged. The resulting mutual defection leads to a vicious cycle. The “best applicants” (idiomatically stated) get the most interview applications, crowding out the “weaker applicants.”1,26  This leads the weaker applicants to apply to more programs. Stronger applicants then feel the need to apply to more programs, which in turn leads weaker applicants to do the same, and so on.

Program Versus Program

Residency programs also compete. Programs have accommodated the increase in applications by conducting more interviews,5  and the vast majority of programs match well above the bottom of their list.25  Programs could cooperate and decide to interview fewer applicants, but programs that decide not to cooperate gain the theoretical advantage of having more applicants to choose from, and so nearly all programs defect.

A prisoner's dilemma ends when the temptation diminishes and/or the sucker's payoff improves. Can the temptations of the Match be reduced? Empirical studies of dominance hierarchy, a core primate behavior, show that members of social groups competing for limited resources often form ranking systems to reduce conflict.27  At present, participants in the residency Match employ a similar strategy. As each participant vies for the “best” outcome, they face pressure from multiple sources, some clearly external, such as medical school advisors pushing students toward higher ranked programs, and others less visible, including a student's sense of worth tied to school status or future salary of a desired specialty. “Best” programs need to know who the “best” applicants are, otherwise how would they define themselves as “best”? “Best” applicants need to know they are “better” than other applicants, otherwise how would they know they are “better”?

Many have suggested strategies to reduce temptations of the Match, but if we are correct in our description of the Match as a prisoner's dilemma, these approaches may not succeed.6,7,2830  Changing the United States Medical Licensing Examination (USMLE) Part 1 to pass/fail will almost certainly increase pressure on students to excel on USMLE Part 2.22  Similarly, making USMLE Part 2 and/or medical schools entirely pass/fail will shift the pressure: residency programs may create their own examinations, rely more heavily on the historical prominence of students' medical schools or undergraduate colleges, or even ask for Medical College Admission Test (MCAT) scores or Scholastic Aptitude Test (SAT) scores. Strategies such as limiting applications or interview slots,10  creating multiple Match rounds,29  or preference signaling12  (Table) will all advantage the “best” applicants, and sorting “best” from “worst” will simply occur in a new way. The temptations of prestige, opportunity, pay, and self-worth are too great to be removed or even reduced.

Can the sucker's payoff be mitigated? In theory, it should be possible, and precedents in other industries offer guidance. In the late 1960s, tobacco companies Phillip Morris and RJ Reynolds competed in a classic prisoner's dilemma. If each advertised heavily on television and radio, they would both make less money than if they did not, as advertisement dollars ate into profits.18  They could have agreed to stop advertising, but if one company defected on this agreement, it would take in significantly more revenue than the other. Predictably, each advertised heavily with lower returns. In 1970, President Nixon signed the Public Health Cigarette Smoking Act banning cigarette ads from television and radio, and both Phillip Morris and RJ Reynolds significantly increased their profits.18  Regulation had immediately removed the sucker's payoff. Plea bargaining in legal cases accomplishes essentially the same result by improving the sucker's payoff.

Practices such as regulation and plea bargaining have consequences, and each solution to a particular prisoner's dilemma creates its own set of winners and losers. The same holds true for medical education. The Table lists a set of potential solutions to the prisoner's dilemma of the residency Match and describes the trade-offs and possible behaviors and consequences of each approach.

It is unlikely that participants in this medical education dilemma would tolerate many of the concepts presented in the Table, and this may be why the Match has been so difficult to reform. Currently, the US population is not receptive to limiting choices or to relying solely on chance. In this context, we wonder if medical education's embrace of competency-based medical education (CBME) holds promise for addressing our prisoner's dilemma.31  CBME does not rely on normative comparisons and instead shifts from “better than” to “great enough.” CBME defines high bars for criterion referencing requirements. We imagine this CBME approach applied to the Match. Would residency programs fear the sucker's payoff if every medical school graduate had guaranteed requisite knowledge, skills, and attitudes to begin residency? Would applicants apply to 30 programs if they knew every program was demonstrably great enough to meet their needs? Would medical schools obfuscate information about students if they knew their graduates were competent and would go to capable programs?

Johnson suggests that, when faced with polarities, such as normative comparisons versus criterion referencing, those who wish to solve the conflict should maximize the upsides of each pole (“and” instead of “or”).32  In the current normative-dominant world, identifying and achieving the “best” outcomes in the Match from everyone's perspective is the temptation, and accepting less is the sucker's payoff. In a criterion-based world, every applicant and program would be great enough, and the sucker's payoff would be eliminated—an ideal, but unrealistic possibility. Applying Johnson's framework of polarity management, can we imagine a world where the best and worst are both fully competent, and the sucker's payoff is reduced? In this framing, the bar of “pass” would be high enough that it makes “the best” irrelevant, and the terms “pass” and “good enough” would not be pejoratives but would be accepted, high level, meaningful standards for students and programs alike. Although comparison of health care to aviation is overused and oversimplified, the example works here to illustrate this point: there probably is a best airline pilot, but identifying this person is irrelevant if every plane lands safely every day.

Currently, the residency Match is mired in multiple prisoner's dilemmas in which people cannot improve their own strategy unilaterally, and we all defect. In this context, human inclinations such as dominance hierarchy induce the prisoner's dilemma, and temptations of the Match appear to be irreducible. Short of drastic measures such as a lottery, the most promising way out of the prisoner's dilemma is to improve the sucker's payoffs. We believe CBME offers a concrete path to do so. This shift would require medical education to share a mental model of required skills, choose proven frameworks of assessment, determine thresholds of progress and competence, develop impartial clinical competency review teams, create coaching and other structures to support growth and performance, identify those who should not continue and facilitate their transition, link data and analytics across space and time, and provide longitudinal oversight of learners at all stages of the continuum.33,34  We recognize what we suggest would be a substantive change for medical education; however, examples of each of these concepts exist now. Projects such as Educating Physicians Across the Continuum have connected these ideas and shown that competency-based promotion is possible.35  To escape the prisoner's dilemma we must decrease investment in identifying the “best students” or the “best programs” and instead realize our ideals: all graduates are highly qualified to match and prepared to succeed, and all programs are able to meet graduates' needs.

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