The National Resident Matching Program (NRMP) was designed to provide a fair, reproducible, and confidential means of matching medical students and graduate medical education programs.1,2 During the recruitment process, residency programs and applicants actively communicate with one another to gather information to make more informed decisions. When these communications occur after interviews, but before rank order lists are submitted, they are termed “postinterview communications.”
To prevent abuse, the NRMP provides strict regulations regarding the content of these communications. Its official policy states, “Both applicants and programs may express their interest in each other; however, they shall not solicit verbal or written statements implying a commitment.”3 Additionally, neither party can suggest that his or her own rank order is contingent on promises from the other party (ie, the residency program promises to rank an applicant to match if the applicant promises to rank the program No. 1). Unfortunately, postinterview communications are frequently misleading, as applicants and training programs make false or ambiguous statements in order to garner some perceived benefit from the other party.4
Previously, the nature and prevalence of postinterview communications were presented from the perspective of the applicant.5 To address the alternative perspective, in 2014, we surveyed residency program directors in multiple specialties within our institution and nationally via specialty mailing lists about postinterview communications and the influence they have on the recruitment process. We achieved an overall response rate of 23.2% (268 of 1156), with 107 responses from pediatrics programs, 58 from diagnostic radiology, 45 from internal medicine, 26 from internal medicine–pediatrics, 17 from pathology, and 9 responses from other specialties (with 6 nonresponses).
Communications From Applicants to Residency Programs
Communications from applicants to residency programs have been consistently high over the past 17 years, occurring in up to 94% of surveyed respondents.5,6 Applicants feel pressure to contact programs because they believe it will improve their ranking, but there is little evidence to support this assumption.7–9 In our survey, only 5.2% (14 of 268) of program directors reported that they always or usually move applicants up their rank order lists after the applicant promises to rank their program No. 1. There is also no mechanism in place to prevent an applicant from telling multiple programs that each of them is his or her first choice. A recent study found that only 1.1% of applicants admitted to telling more than 1 program they were ranked No. 1. However, in our survey, 52.6% (141 of 268) of program directors reported that at least once a year 1 or more applicants falsely claim they are ranking their program No. 1. Additionally, multiple studies spanning a decade have demonstrated that applicants deliberately exaggerate their interest in certain training programs.5,10,11 Applicants may feel there are few repercussions to making false statements, but when the extent of hyperbole and the number of offenders get critically high, it calls into question the authenticity of all postinterview communications.
Communications From Residency Programs to Applicants
Communications from training programs to applicants occur in 46% to 95% of surveyed respondents from studies dating back as far as 2000.12–14 These communications can have a strong impact on applicants, with previous work showing that 17% to 51% of applicants changed their rank order lists based on these communications.5,14,15 Many residency programs realize the stress brought on by the NRMP Match process and want to provide reassurance to competitive applicants.
Unfortunately, this brings a potential for abuse as well. Up to one-third of applicants have reported that they were misled by residency program leadership, and in 1 survey, 8.3% of applicants reported that residency programs directly asked them how their program would be ranked, which is in violation of NRMP policy.5,6,16 In our survey, 64.6% (173 of 268) of program directors reported that they never share any information with applicants about their likelihood to match, signifying a disconnect between the reporting on either side. Prior work has shown that applicants are 11 times more likely to move a program down their rank order list if they perceive unethical recruiting behaviors.16 Residency applicants are very impressionable during the application process. Any positive language remotely related to matching with a program (ie, “You would be a great fit at our program”) may be easily misinterpreted as a promise to be ranked to match.
A Proposal to Reduce Misrepresentation
The prevalence of potentially misleading language in postinterview communications is troubling. Deliberate misrepresentation flouts expectations for ethics and professionalism in physician training. The residency application process is competitive for both applicants and residency programs, and both desire to maximize their chances for success. While this is no excuse for violating policies or misrepresenting the truth, when there is a pervasive belief that everyone is engaged in the same process, it feels like less of an egregious offense.
The simplest solution to stopping abusive postinterview communication practices is for the NRMP to ban all communications.10 This approach would be highly effective at leveling the playing field, and in our survey, was supported by 45.5% (122 of 268) of program directors. A simple abstention system would remove any ambiguity from the process and eliminate the temptation for abuse and mistrust. Unfortunately, this approach would also prevent appropriate forms of communications that help both sides make more informed decisions and provide reassurance when possible. Since applicants and residency programs will be matched for 1 to 7 years, it is important to make sure that all questions and doubts are addressed up front before a binding commitment is made.
A more realistic middle-ground option would limit postinterview communications to objective questions about training programs (box). Toward this goal, the Alliance for Academic Internal Medicine recommends that programs “should discourage routine thank you notes or e-mails from interviewed applicants,” and that questions should be directed “only to individuals on the program's approved contacts list.”17 By setting clear universal expectations about the types of permissible communications on interview day, residency programs could reduce the flow of misleading information in both directions. If additional oversight is needed, (ie, programs with a history of NRMP violations), all postinterview communications could be forced to pass through a messaging service on the NRMP website.9 Furthermore, if all communications are logged for potential future review, then individuals would be inclined to behave in a more ethical fashion.
Set clear expectations for applicants on interview day about appropriate forms of postinterview communications
Limit postinterview communications to objective information
Provide a point person to handle all postinterview communications
Consider logging all postinterview communications to safeguard ethical standards
Initiate dialogue on a national level within specialties to create specialty-specific consensus guidelines
Since medical students usually go through the application process once, the onus is on the residency programs to lay out clear expectations for appropriate behavior. An approach that designates a single individual within the residency program to handle all postinterview communications is likely the most practical. We also suggest that the approach should allow each specialty to set its own communication guidelines, as the number of applicants, size of residency programs, duration of training, and competitiveness are unique to each specialty. Our survey shows that each specialty differs in the type, frequency, and influence of postinterview communications. By allowing each specialty to set its own policies, this also allows programs to feel more engaged in the process, and thus more likely to follow the guidelines.
We encourage residency program directors in all specialties to talk with their colleagues and propose sensible regulations for postinterview communications to reduce the widely prevalent misrepresentation and unethical behavior that has come to be synonymous with the residency application process.