Print this Article 
Send to a Friend
Editor's Note:
Dr. Wilcox is Professor Emeritus of Surgery and former Chief of Cardiothoracic Surgery at the University of North Carolina at Chapel Hill, NC. USA. He was President of the Society of Thoracic Surgeons in 1995. He is currently a member, and former President of the Board, of the National Residency Matching Program (NRMP).
For 20 years, the Resident Matching Program has served Thoracic Surgery well. The discipline itself, program directors, and applicants have all benefited from its fair and efficient operation. However, a recent decline in the size of the applicant pool has caused concern about the stability of the Match.
When we were active in the Directors Association, Hermes Grillo and I encouraged our fellow directors to support the Match[1]. Rereading those words recently, I find they still have meaning for our specialty. The editors have graciously agreed to reprint that piece and to allow me to update my remarks by commenting on the present situation.
TABLE I
|
Thoracic Surgery Match | |||||||
|
Match Year |
Number of Programs |
Positions Offered |
Number of Matches |
Percent Filled |
Number of Applicants |
Programs Ranked Per Applicant | |
|
Mean |
Median | ||||||
|
1997 |
95 |
138 |
133 |
96% |
175 |
7 |
6 |
|
1998 |
95 |
137 |
128 |
93% |
156 |
8 |
8 |
|
1999 |
95 |
139 |
128 |
92% |
156 |
8 |
8 |
|
2000 |
94 |
141 |
135 |
96% |
148 |
na |
na |
|
2001 |
94 |
144 |
131 |
91% |
149 |
8 |
8 |
|
2002 |
93 |
144 |
123 |
85% |
145 |
8 |
8 |
|
2003 |
92 |
141 |
132 |
94% |
161 |
9 |
8 |
|
2004 |
92 |
138 |
121 |
88% |
134 |
8 |
9 |
|
2005 |
91 |
139 |
100 |
72% |
104 |
9 |
9 |
|
2006 |
90 |
126 |
84 |
67% |
91 |
9 |
7 |
|
NRMP Data Bank |
|
|
|
|
na = not available | ||
In 2006, only 91 applicants participated in the Thoracic Surgery Match (Table I), a drop that underscores a trend of decreasing numbers of applicants over the past several years. Our specialty has responded to this trend in a number of ways. Pressure from some quarters to simply shorten the residency was countered by the thoughtful development of a more flexible curriculum. We have encouraged an active role for women in the leadership of our specialty: a move that we hope will, among other things, encourage applications from that half of modern medical school classes that we have been slow to attract to our residencies. We have changed our attitude regarding international graduates, recognizing that among them are many of the best and the brightest candidates[2]. We have incorporated work-hour restraints so that our residents now function in a humane and, I believe, more productive environment. The American Board of Thoracic Surgery, the Thoracic Surgery Directors Association, and the Residency Review Committee for Thoracic Surgery are cooperating as never before to be sure that training programs are true educational experiences. All this has been accomplished in the face of mounting administrative demands and daunting financial exigencies faced by our beleaguered program directors.
Job Market
Perhaps the major reason for the decline in applications is the perception, reinforced in the professional and lay press[3, 4], that the job market in cardiac surgery is depressed. Other circumstances most certainly are contributing factors, and I have expressed my opinion on this subject in the past[5].
What is the truth about the job market? Thirty years ago, we were a relatively new discipline, and our practitioners were young. This is no longer the case. As demonstrated by the attached chart and pointed out by Fred Grover in his presidential address to the STS[6], a significant percentage of thoracic surgeons are retiring.
This surge in retirements comes at a time when other factors may call for an increase in our numbers. For example, the aging of the “baby boom” generation will require more services to treat the widely anticipated increase in heart disease and cancer in that population. Also, according to recent articles in the Journal of the American Medical Association, changes in our methods of practice may result in more thoracic procedures being performed. One of those studies showed that computed tomography screening for lung cancer resulted in a ten-fold increase in resections for cancer over the expected number of operations[7]. Similarly, another study demonstrated that the opening of a cardiac specialty hospital in an area was associated with an increased rate of coronary revascularization in Medicare beneficiaries [8].
However, in my opinion, despite the number of retiring surgeons and the possible increased need in some areas, our discipline will require fewer than the 130 or so new surgeons we produced annually in years past. There are various reasons for this, the most compelling being the changing face of vascular disease due to improved medical management. (E.g. Urologists: transurethral resections are decreasing from 400,000/year in 1987 to around 70,000/year at present [5]).
None of us can predict with certainty what the future holds for our specialty. However, we do know that the world will continue to need well-qualified thoracic surgeons for the foreseeable future. It is our job to educate those individuals to the best of our mutual abilities. An integral part of that educational process is being able to assure both applicant and program director a fair “match” of the talents each has to offer. This goal can only be accomplished if program directors and candidates are able to conduct the selection process free of the evils of “arm-twisting” negotiations and administrative chaos that accompanied the process before the Match was instituted.
Program Directors
Some directors will be tempted to go "outside" the Match to ensure their positions are filled. Applicants should be warned that such individuals will be willing to bend the rules in other matters as well. These directors are more interested in warm bodies as a labor force than junior colleagues in an educational process. Other program directors may claim that they have a responsibility to their parent institutions and so select only from within. This denies the greater responsibility to their institutions and to the specialty to attract the best possible candidates to the field. Such an insular training program is not a contributor to our discipline.
Without orderly functioning of the Match, program directors will likely be faced with an increased number of dropouts who were forced to make early decisions and then changed their minds about further training. The national scope of the selection process would be severely limited, to the detriment of applicants and program directors. The reduced number of applicants would be further compromised as residents were picked off by overzealous and/or fearful program directors. Also, there would be no consequences as presently imposed by the National Resident Matching Program if residents decide to break their contracts.
It is worth noting that historically, such selfish behavior resulted in loss of integrity in the Gastroenterology Match and severely damaged graduate education in that specialty[9, 10]. To everyone’s great relief, the GI program directors have now successfully reinstituted their Match. Thoracic Surgery must not go down that self-destructive road. We simply cannot ignore the benefits of this process that has been so successful for so long.
Applicants
Concerns have been expressed that the candidates will destabilize the Match by withholding participation. The scenario goes like this: In a "buyer’s market," applicants will elect to forgo expensive travel required of them to participate in interviews. The argument is that because there are more openings than qualified applicants, one can always obtain a position through the “scramble” after the match. This story overlooks the fundamental nature of thoracic applicants who are congenitally competitive as well as smart. They want the best education available, and they know that only through the Match can they maintain their competitive advantage. Surely the opportunity to assess firsthand how well one may fit in a particular environment is an opportunity they will not casually surrender. The fact that the average number of programs listed by an individual applicant is nine suggests that they want to leave little to chance. (See Table I above). They also know that without the Match, selection will move to an earlier time in their training and thereby require a decision sooner than is ideal for them or the program director.
Program Loss
In my view, the most serious consequence of abandoning the Match would be the inevitable closure of a significant number of excellent training programs. If that were to happen, there is the certain danger that we could be reduced to training residents at only 10 or 15 sites. As it is now, our programs are affiliated with only about two-thirds of the medical schools in the country. If a further reduction in the number of programs occurs, Thoracic Surgery will be removed from the mainstream of graduate medical education. In addition, the diversity that multiple programs offer to our residents would be lost and with it the contributions of many splendid minds. If one examines the leadership in all aspects of Thoracic Surgery, we see that so many of our best people come from what might be identified as smaller centers. If these centers are deprived of their academic stimulus, we will be the poorer for it.
Alternative Option
Abandoning the Match thus being unacceptable, what more can be done to address this issue of fewer applicants to our programs? An approach that appeals to me is voluntary limitation of the number of residents in each program. No institution would be allowed to have six or nine or even 12 residents in a given year, as is now the case. This can be accomplished by requiring every program to implement a three-year curriculum, including tracking if desired, and admit only one resident per year. Each program would thus have three residents at any one time. I believe that this would result in an optimal educational experience for student and teacher. Parent hospitals would be forced to employ adequate support personnel for the service element of patient care, and faculty could focus more easily and intently on the limited number of residents. Service would thereby become only a part of the process and not the end as is the case in too many instances today. Residents’ clinical assignments would be based on educational opportunities, not workforce needs.
A three-year curriculum and training only three residents at a time would allow every resident to be the "Chief" in their particular year. They would be subordinate only to the faculty responsible for that portion of their curriculum. With only one resident admitted per year, graduated levels of responsibility could still be exercised by customizing the curriculum for each resident. Should something necessitate the absence of a resident for a period of time (maternity leave, illness, or changing career goals, for example), two residents would remain in the program for educational purposes. Because the "service responsibilities" would be covered by the hospital’s service employees, one resident’s absence would not affect the other residents’ educational experience or the program’s clinical commitments.
Lest this is thought to be too far-fetched an idea, look at the numbers.
TABLE II
|
Potential Position Redistribution Table | ||||
|
Number of Positions Offered Each Year |
Number of Programs |
|
Positions Redistributed if go to One per Year |
Positions if All offer One per Year |
|
1 |
40 |
|
0 |
40 |
|
2 |
28 |
|
28 |
28 |
|
3 |
10 |
|
20 |
20 |
|
4 |
1 |
|
3 |
3 |
|
variable |
7 |
|
2 |
2 |
|
Totals |
86 |
|
53 |
93 |
|
ACGME Database – columns 1 and 2 | ||||
This table demonstrates that if we were to institute a policy of one position per program per year, approximately 93 positions would be available. (The disparity in the numbers of positions and programs is introduced by the programs with variable numbers.) The 90-plus accredited programs (See Table I) would produce 90 positions if all programs were limited to admitting one resident per year. Last year, there were 91 active applicants in the match. To date (03/8/07), 79 applicants have registered for the 2007 match (for 2008 appointments), a number that is in line with this stage of the Match in previous years.
The disparity between the number of applicants and positions offered is much less threatening when viewed from this perspective. Also, “leveling the playing field” in this manner, where each program is vying for just one resident, leaves us with a full complement of programs. The competition will be keen, and less competitive programs will have to improve or close, but they will have that choice, as opposed to having the death sentence imposed upon them.
Above all the Match must not be allowed to go under. We must keep the faith and continue to think innovatively. Ours is such a grand calling. For the well-being of our patients and residents alike, we cannot falter in these changing times.