Match Week Is a Scam That Exploits Medical Residents
Every year, an algorithm assigns thousands of medical students to residencies they can’t leave, can’t negotiate with, and can’t refuse. The Match system creates a captive workforce that stiffs residents and generates billions for the health care industry.
Medical residents make about one-sixth of what they would make for doing the same work as regular practitioners. The industry portrays residency as an apprenticeship, but it’s really a windfall for health care corporations at the expense of workers. (Alexandra Garcia / Washington Post via Getty Images)
Every third Friday in March, the American medical establishment celebrates Match Day. There are media walls emblazoned with school logos, clusters of balloons, and an unseen algorithm that calculates the perfect distribution of thousands of medical students among hospital programs that will, for the next three to seven years, hold immense power over their lives. Unlike a conventional job application process, a law clerkship, or a PhD program, the pairings announced on Match Day are, essentially, binding precontracts that strip workers of their negotiating power. Quitting later or even attempting to negotiate terms is treated as a professional breach of contract, punishable by a systemic, industry-wide freeze-out.
Medical students who aspire to practice have little choice but to enroll in a medical school that registers with the National Resident Matching Program (NRMP), a nonprofit organization that has overseen nearly every accredited residency placement since 1952. Over the summer and fall before Match Week, medical students apply and interview for programs where they wish to train; afterward students and programs submit a ranked list of their preferred partners to the NRMP and its algorithm, which purportedly exists “to make the best possible match for all participants.”
Once matched, residents enter a liminal period of their lives, during which they might work eighty-hour workweeks but are still considered trainees rather than full-time workers. Because of that assigned status, programs often feel justified in offering poor compensation without overtime pay, while residents burn themselves out in the hope of being rewarded with a stable, well-paying, and respected job in the future.
However, as medical school debt and the cost of living climb far beyond what their stipends can cover, residents are perceiving the limits of the arrangement. They’re growing emboldened to unionize and fight their employers. And they’re starting to see the Match system not as an acceptable requirement that culminates in balloons and a wave of relief but as a highly exploitative structure that extracts maximum work from residents for minimum pay and abysmal working conditions.
“The Match is an incredible gatekeeping mechanism, because it boxes residents into a position where the program they’re matched with holds much more power,” Lydia Mazze, a second-year resident and bargaining team member at Temple University’s Committee of Interns and Residents unit, told Jacobin. “There are more medical students than residency positions, and so you’re fighting with thousands of people, interviewing with twenty-plus places, and the fear of not being matched drives you into making decisions without full knowledge or any real comfort.”
The NRMP would have aspiring doctors believe they are actually spoiled for choice, claiming to “empower” the physician workforce using terms like “applicant proposing” to frame the process as balanced. But this institutional rhetoric belies a highly stilted dynamic. In reality, larger hospitals and the private companies that run smaller community hospitals are often flush with cash, while would-be residents saddled with student loans cannot enter the medical practice and effectively pay off their loans without first graduating from a residency program. Because failing to match results in financial and professional ruin for medical students, the process of submitting a rank list is fundamentally coercive. The real choice for most residents is between risking their entire potential career by applying only to a few programs where they genuinely want to work, or risking egregious exploitation by padding their lists with safety programs to, hopefully, guarantee a match.
No genuinely free exchange of labor exists when the alternative to working is destitution, as it is throughout our economy. But the match system takes it to an extreme. Workers in most other industries can, in theory, pit competing offers against one another, negotiate a starting wage, or quit a toxic workplace without facing long-term or permanent exile from their profession. Beyond the illusion of choice presented at the beginning of the match process, the resident only receives one offer and cannot negotiate a higher stipend or transfer to a different residency program without their current program director’s approval or an NRMP waiver that only makes exceptions for “unanticipated serious and extreme hardship” like terminal illness. If a resident quits without either of those documents, the NRMP slaps them with a “match violation,” a shameful label that blacklists them from the system — and any chance of finding another residency — for one to three years.
Greg Care, a lawyer who has represented resident physicians, told Jacobin that while contracts vary across programs, the match system itself and various rules imposed by the Accreditation Council of Graduate Medical Education (ACGME) naturally skew contracts in favor of the employer. “When the contract recites what the institution or program is obligated to do, you see all kinds of squishy language, like ‘we will use our best efforts’ as opposed to concrete or unqualified promises to provide something. It’s meant to give themselves an out for one reason or another,” he said. “When it comes to what a resident is required to do, it is worded in mandatory terms. There is no wiggle room. It is definite.”
A Captive Workforce Worth Billions
Residents’ captivity is good fortune for the entities that manage US health care systems. First-year residents working in the United States earn a stipend worth only $68,166 on average, with medical institutions framing the wage as an act of charity for mere apprentices “receiving very valuable training that is expensive for institutions to provide.”
If hospitals actually had to compete with one another for medical graduates to staff their floors, the “apprentice” justification for suppressed wages would collapse. Thankfully for them, the match algorithm locks in a safe pipeline of highly skilled but undervalued labor; while hospitals present themselves as gamely accepting the cost of eager trainees at their own expense, the data reveals a different story. In 2020, the Journal of Neurosurgery calculated a single junior neurosurgery resident’s billable value at $344,757 annually – roughly six times the amount of the average resident’s stipend. In 2018, the Journal of Surgical Education found that replacing a standard thirty-person residency program with other providers would cost the hospital anywhere between $3.1 million and $9 million. Meanwhile, the federal government pours billions of dollars into teaching hospitals every year. In 2019, that money accounted for a total of about $150,000 per resident.
When a hospital’s labor costs are suppressed, the surplus generated by residents does not translate to lower patient bills or higher wages for mid-level practitioners. Instead, they pay for multimillion-dollar compensation packages for the executives of for-profit and nonprofit hospitals alike, as well as private equity firms that have been turning smaller community hospitals into moneymaking machines. More than two-thirds of the federal money for teaching hospitals is designated as indirect medical education (IME) payments for the express purpose of covering the perceived inefficiencies of hiring residents; much of it ends up paying for opaque administrative overhead, aided by the fact that such funding comes with almost zero transparency requirements.
Meanwhile, the NRMP and the Association of American Medical Colleges (AAMC), which runs the application part of the match process, levy a no-match anxiety tax by supplementing their baseline fees with penalties on each additional program a student might apply for or rank. According to the NRMP website, students must pay a $70 registration fee to enter the Match and rank twenty programs. Each additional program costs an additional $30. Students driven to desperation by the NRMP’s own all-or-nothing system might rank more than one hundred programs, which in addition to costing them $2,400 in extra-rank costs, will run them another length-of-list surcharge that ranges from $50 to $200. If two medical students are married or in a relationship and want to stay in the same geographic area, they have to enter the Couples Match, which costs another $45 per partner. The AAMC also charges an $80 fee to unlock the student’s medical school transcript. Collectively, the charges account for a large portion of the NRMP’s $12.5 million and the AAMC’s over $300 million in revenue per year.
Breaking the Match System’s Hold
Because the Match blocks residents from individually shaping their own contract, the only effective recourse available is collective action.
In May 2023, over 150 resident physicians at New York City’s Elmhurst Hospital, in the borough of Queens, went on strike over low pay — the first resident strike in New York City in thirty-three years. When they walked out, the hospital found itself scrambling to hire temporary attending doctors just to keep the facilities functioning. Within three days, the Mount Sinai Health System accepted their demands for wage parity with their colleagues in the Manhattan branch.
Even the mere fact of unions may help applicants regain some agency in the match process. According to Cary Lane, a union representative for University of Buffalo residents, the growth of unionization has given them a decision-making variable that exists independently of the medical establishment and can tangibly affect their working conditions.
“After we went on strike two years ago and got a better contract, the university got really worried about the upcoming Match because they thought their reputation might be tarnished,” he told Jacobin:
Well, we did attack their reputation because it was not a good workplace. It was not a safe and supportive workplace. But lo and behold, Match went really well. And what I told management was that I thought it went really well because this program is now unionized, and residents were able to negotiate for safety and support and respect in their workplace through the union contract.
While unions can even the balance of power, critics of the Match say that unions, in their current form and alone, cannot outweigh the underlying exploitation. “Unions act as a safeguard, bridging the gap, but it’s a narrow bridge. It doesn’t always have the means necessary to support everyone completely,” Mazze said. “Some of the defenses are literally just bringing people from different specialties together to sit in a bargaining meeting in front of the administration and say, this, this, and this are not working. And then the administration says, how come no one has brought this to our attention before? As if the problem hadn’t existed for years and they hadn’t noticed.”
What really needs to change, Mazze continued, is “the way that we think of what a resident is, what their training and skills are worth, what their time is worth. And the Match doesn’t do that.”
The seemingly obvious antitrust violation inherent to the Match has invited high-profile lawsuits in the past. In 2002, a group of former residents sued the AAMC, arguing that the Match functioned as a massive price-fixing conspiracy that artificially depressed wages and forced exhausting work conditions on young doctors. The federal district court initially allowed it to proceed, but before the case could actually reach trial, the hospital lobby used its political leverage. In 2004, Congress quietly attached to the Pension Funding Equity Act an unrelated rider that explicitly shielded the Match system from federal antitrust laws, forcing the court to dismiss the lawsuit and essentially legalizing monopsony in the medical field.
In recent years, some legislators have proposed repealing or weakening those protections, but such efforts have made little headway so far. Unionization, however, continues to expand not only in numbers but also in demands and rhetoric that increasingly criticize the medical establishment as a whole, rather than just members’ individual residency programs. Behind every unfair contract is the Match, and the manufactured wholesomeness is far less convincing than the realities of labor exploitation.