The Match for US Pediatric Gastroenterology and Nutrition Fellowships

In 2007, for the first time, residents will be able to participate in a match for pediatric gastroenterology and nutrition fellowships. Although discussed by fellowship program directors for some time, it was not until recently that serious consideration was given to participation in a formal match for our fellowship selection process. How did we get where we are today? By 2004, there was increasing interest by fellowship program directors to participate in a formal match sponsored by the National Residency Matching Program (NRMP). To qualify for participation, a specialty group must ensure that 75% of the programs will commit to joining the match. After extensive survey of the Accreditation Council for Graduate Medical Education-accredited pediatric gastroenterology programs in 2004, there remained many programs that did not want to participate in the match. An alternative to the match was conceived in which programs would interview applicants as usual with offers only made on a specified "uniform offer date." This approach allowed approximately 80% of programs and applicants to delay the interview and decision process by 3 months. The "uniform offer date," January 10, 2005, was an unqualified disaster that might have been named "Black Monday" by the fellowship program directors except that distinction had already been applied to the collapse of the stock market in 1929 and a downturn in the market in 1987. Programs were asked to withhold offers until January 10 at 9:00 am EST. As the postmortem revealed, this informal process was open to abuse, disadvantaged the West Coast programs and increased anxiety for both the fellowship programs and the applicants. The chaos caused by the "uniform offer date" prompted programs to abandon this method of selection for the fellowship class of 2007. With the failure of the "uniform offer date," fellowship programs were again polled regarding their willingness to participate in the NRMP. The ensuing poll in the spring of 2006 yielded different results from those in 2004 and 2005. After aggressive efforts to contact programs, it was determined that at least 78% of Accreditation Council for Graduate Medical Education-accredited programs in the United States, which represented 92% of the training slots, favored the match. The Canadian programs had not planned to participate in the match because they were largely content with their own selection process. With more than 75% of programs representing a plurality of the fellowship positions in the United States, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) has now endorsed the NRMP for Pediatric Gastroenterology and Nutrition, with plans to solicit final commitment of programs in October 2006 for a match in the winter and spring of 2007 for fellowship positions beginning in July 2008. When does the interviewing season start for this year? Although candidates for fellowship may be interviewed at any time, programs participating in the match should consider delaying interviews until January 2007, when the match opens. Nonparticipating programs are free to interview and make offers for positions at any time. To inform applicants of programs participating in the match, a notation of programs participating in the match has been included in the listing of programs on the NASPGHAN Web site. We have also instructed applicants to contact any programs in which they might have interest to determine when the programs will begin interviewing candidates for 2008. The process for enrollment in the match is simple for applicants. Applicants go to the NRMP Web site at www.nrmp.org, identify the pediatric gastroenterology/nutrition program (when it is opens on January 3, 2007), log in and enter their data into the appropriate fields. Many will already be in the system because they used NRMP for their residency match. Below is the timeline for the proposed match:TableAs the chair of the NASPGHAN Training Committee, I applaud the fellowship program directors for their collective decision to select their prospective fellows using NRMP. There are a number of significant advantages to the NRMP that benefit both programs and applicants: During the last several years, the interview process has started earlier in the second year of residency. Some fellow applicants have been interviewing as early as August for a fellowship almost 2 years later! Residents were forced to make career decisions after only modest exposure to our specialty. Premature career decisions may be disadvantageous to the applicant. In a group of internal medicine residents surveyed in 1994-1995, 50% of second- and third-year residents had changed their minds about fellowship decisions, and two thirds were uncomfortable about making decisions during the second year of their residencies (1). Uncertainty about career decisions by residents is further supported by an additional survey of internal medicine residents, polled at entry into their residency, which suggested that only about half of the residents who were inclined to pursue training in a subspecialty area actually pursued training in that field (2). The match offers applicants additional time to gain more exposure to the specialty and allows a more informed decision about a career choice. It is likely that with a later decision date, there will be less tendency to renege on an applicant's choice. When offers are made to an applicant, the offers commonly are time dependent. These "exploding offers" may pressure candidates to make decisions without exploring additional, potentially better opportunities. It is understandable why a program would place a time limit on an offer, because their goal is to fill up their fellowship positions, and they cannot make more offers than available positions. Under the match, computerized matching of applicants and programs occur on a specified date. If applicants do not match, a list of available positions can be provided to them to pursue these opportunities. There is uniform support for the match by fellows in training in our specialty (R. Graham-Maar, personal communication). Although concern has been raised that the match favors larger programs, there is little evidence to support this theory. If anything, the match "levels the playing field" and allows programs and applicants free access to each other over several months before the final match is completed. What are the potential limitations of the match? Concern has been raised that the match is an inflexible process. Although there are prescribed rules by the match, there is some flexibility that allows programs to offer positions to foreign-trained residents and "fast-track" residents. Because most foreign-trained residents require a commitment to a program as a prerequisite for obtaining a J-1 visa, these applicants would be given fellowship positions outside the match, and the program would proportionately reduce the number of positions that could be filled through the match. The match encourages residents to interview at more programs to ensure that programs will have an opportunity to rank them for the match. This may lead to added expense for applicants and programs and additional time for faculty spent in the interview process. Despite the added expense and time expended, the limitation may actually advantage both the applicant and the program despite added expense. Both will benefit from evaluating a larger pool of programs and applicants, with the potential outcome of a better fit for each. There have been concerns raised that programs or applicants may end up mismatched, that is, a fellow would end up in a program he or she does not want or a program ends up with a fellow it does not want. There is a simple solution to this problem: simply do not rank any candidates or programs that are unacceptable. Historically, there has been concern that a match would not work unless there were an excess of applicants. This appears to be untrue because there are programs, such as pediatric nephrology, which have had successful matches for several years despite an excess of fellowship positions to applicants. Although data are not available, it appears that there are more applicants than fellowship positions in our specialty. Therefore, the disparity in numbers should not be a legitimate reason to avoid the match. On balance, the advantages of the match appear to outweigh the disadvantages, and the application of the match to the fellowship recruitment process should advantage both parties. It is hoped that with success of the inaugural match, additional uncommitted programs will participate in the future. As a postscript, there has been strong interest in the use of a uniform application for all programs using the Electronic Residency Application Service program. Unfortunately, because of timing issues, the Pediatric Gastroenterology and Nutrition fellowship programs will not be able to use Electronic Residency Application Service until the 2009 fellowship positions are matched. James E. Heubi, MD Chair, NASPGHAN Training Committee Division of Pediatric Gastroenterology, Hepatology and Nutrition Cincinnati Children's Hospital Medical Center Cincinnati, Ohio

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