The National Resident Matching Program (NRMP) was established in 1952 to mitigate the effect of “take it or leave it” offers that programs provided to residency candidates. The NRMP algorithm placed the final decision in the hands of the trainee and leveled the field for hospitals and residency programs. This system functioned well for more than 50 years, and has survived legal challenges.
The San Francisco Match program was established approximately 40 years ago, and manages the match for 2 residency and 23 fellowship programs. In the main dermatology residency match, there are a limited number of exemptions—essentially all positions are filled through the match.
I am a strong proponent of the match process. While the majority of training positions are filled through the match, a few fellowship societies using the San Francisco Match allow programs to accept candidates outside of the match. The most common reason is to train a current resident within his or her local institution's residency program.1 This avoids a move for the trainee, and fills the position with a well-known individual.
The majority of programs participating in the San Francisco Match do not allow for exemptions, and the policies of those that do are restrictive. For example, in the 60 cardiothoracic surgery fellowships and 52 critical care anesthesiology programs, there are about 3 to 4 exemptions per year. In contrast, the number of spots filled outside the match for micrographic surgery and cutaneous oncology has increased over the last 5 years (table). The Mohs Surgery Match is the only fellowship program for which the San Francisco Match routinely receives complaints about the number of positions offered outside the match (San Francisco Match, personal communication, 2017).
A number of program directors have never used a match exemption, while others use the exemption frequently, as is shown from data on the American College of Mohs Surgery website.1
Those who support exemptions note the following reasons:
Residents accepted outside the match save time and resources by not having to interview and by avoiding complex family planning issues.
For new programs, a given resident may be the impetus for starting the fellowship, and the director may be concerned about matching without a history of success.
A fellowship director and a resident may have a strong bond and wish to continue this professional relationship.
If an internal candidate will be ranked first and has a strong interest, it may be misleading to have others interview for what is in reality a closed position.
All of these are reasonable arguments. They must be balanced by arguments against match exemptions:
Taking a resident outside the match deprives the trainee of the opportunity to interact with other fellowship directors during interviews.
Institutions that routinely take their own residents outside the match do not allow other programs the opportunity to compete for those residents.
Medical student awareness that a given institution routinely offers fellowships outside the match affects the residency match process.
Many strong fellowship candidates come from programs without a fellowship.
An article about the integrity of the NRMP match process2 was published in Surgery Clinics of North America in 2005, noting that “the moving target of positions available through the match penalizes the most desirable sponsored applicants and any independent applicants who chose to remain in the match, as well as any programs that chose to play it straight. The reputation of . . . among applicants as a specialty is tarnished by these recruitment behaviors.”2(pp1515,1516)
I have had many discussions with program leaders who routinely take fellows outside the match. One of their arguments for avoiding the match is that match violations are often overlooked. I agree that this is a problem and a motivating factor for taking a candidate outside the match.
I find it difficult to reconcile that a process that works for most other specialties does not work for this community. Residents should have the opportunity to explore their options prior to making a commitment. While almost all programs match a fellow, many residents who wish to train in Mohs surgery do not match. For that reason alone, we need to be as fair as possible.
I recommend a limit on the number of match exemptions for a given program. I would continue to support exemptions for new programs, military and foreign trainees, and programs with dual pathways that operate on a different academic schedule. For all other programs, the number of times a fellowship can offer an exemption should be restricted. We can do better than having 37% of our slots filled outside the match. I feel that the impact on our fellowship programs would be positive.
