AMA Journal of Ethics^®

While most students will change during training, not every student will emerge from the training pilgrimage with a set of character traits that insures that ethical and professional standards are always maintained. This, in turn, places a heavy burden on those who help select medical students for admission to medical school. Medical school admissions committees do very well, but, sadly, there is no gold standard to identify with precision those students whose character flaws may prevent them from developing the kind of ethical and professional attitudes that society wants and demands of its physicians.
Mark Siegler [1]

Playing the Game

Professional self-regulation, rather than government regulation, is one of the unique aspects of medicine. Professional codes and ethical guidelines, such as the American Medical Association’s Code of Medical Ethics, instruct members of the medical profession to act primarily in the interest of patients and society. Arguably, these codes and guidelines also serve to cultivate virtuous qualities in medical professionals that they then use to advance the health of individuals and society. Some parts of the medical training process, however, specifically medical school and postgraduate training recruitment, may actually undermine efforts to do this. From the moment a medical school applicant or medical residency candidate applies for the next stage of training, ethical challenges appear. Concerns that deceit and dishonesty have become commonplace in the residency match process raise the question of whether or not the current structure of residency recruitment promotes the virtuous qualities expected of those in the profession.

First, what problems exist? In the residency match process, postinterview communications seem to tempt both training programs and applicants to engage in duplicitous behavior. For example, a recent study reported that 1.1 percent of applicants to residency programs reported telling more than one training program they had ranked it first, and 59.9 percent of applicants to residency programs told more than one program that they ranked it highly in an effort to persuade those programs to rank them highly [2]. In the same study, 18.6 percent of candidates reported feeling assured by a program that they would match there (implying that the program had ranked them highly) and ranking that program first, but not ultimately matching there. When another residency program, which experimented with a policy against postinterview recruitment calls, surveyed applicants, 10.3 percent reported that they would have changed the program’s place in their rank lists if they had received a recruitment call from it [3]. Other problems include residency programs and candidates covertly entering into agreements outside of the match process and refusing to honor their matched selection [4]. D. Micah Hester argues that competiveness fostered by the current match process undermines core values medicine places on working together to solve human problems [5].

Dishonesty, commitment-breaking, and misleading comments threaten the integrity of residency matching. The National Residency Match Program (NRMP) allows programs and applicants to express interest but prohibits the “solicit[ation of] verbal or written statements implying a commitment” [6]. Allowing these vaguely defined statements of interest may fuel what Dr. Karen Borman calls “playing the game” [7], which works against the traits of the virtuous physician the profession seeks to cultivate.

Why does it matter if people in medicine are “playing the game,” something that seems part and parcel of much of American life? It matters because it contradicts the medical profession’s mission and duty—to benefit society—and could compromise its integrity, based in part on the virtues I will discuss next. Philosopher Alasdair MacIntyre writes, “the ability of a practice to retain its integrity will depend on the way in which the virtues can be and are exercised in sustaining the institutional forms which are the social bearers of the practice” [8]. The medical profession is “a practice” in that it is a form of human activity that is partially defined by standards of excellence to achieve laudable goods [9]. Sustaining ethical thought processes and behaviors within the institutional form of the match and the practice of medicine in general requires some housekeeping in areas vulnerable to “game playing.”

Turning to Virtues

When someone speaks of a virtue, what exactly does that mean? MacIntyre explains:

A virtue is an acquired human quality the possession and exercise of which tends to enable us to achieve those goods which are internal to practices and the lack of which effectively prevents us from achieving any such goods….We have to accept as necessary components of any practice with internal goods and standards of excellence the virtues of justice, courage and honesty. For not to accept these…so far bars us from achieving the standards of excellence or goods internal to the practice that it renders the practice pointless except as a device for achieving external goods [10]….

The virtues…are to be understood as those dispositions which will not only sustain practices and enable us to achieve the goods internal to practices, but which will also sustain us in the relevant kind of quest for the good, by enabling us to overcome the harms, dangers, temptations and distractions which we encounter, and which will furnish us with increasing self-knowledge and increasing knowledge of the good [11].

The primary external good the match is intended to achieve is the “best” pairing of applicant and program to get residents the training they need to become competent physicians. Programs’ and applicants’ understanding of what constitutes a “best” fit are influenced by perceptions of consonance between the applicant’s personality and the program’s culture, the applicant’s qualifications, the program’s prestige, geography, and so on. A match process that allows dishonesty about ranking positions risks losing the internal goods to be had, including honesty and fairness. To protect these goods, the match process must be as fair and transparent as possible, which requires truthfulness and ethical action by programs and applicants.

When the medical profession accepts a “playing-the-game” mentality, it neglects an opportunity to reinforce holistically the virtuous behaviors it seeks in its medical trainees and physicians. In requiring professionalism (which is to say, ethical behavior) at some points—it is assessed during medical school and in postgraduate training—but not at others, the profession in essence treats ethical behavior as an instrument, only to be engaged in when it can achieve external goods for self or society. Allowing dishonesty in any form compromises the development of internal goods irrespective of the moral standing of the external goods to be achieved. MacIntyre argues, “Lack of justice, lack of truthfulness, lack of courage, lack of the relevant intellectual virtues—these corrupt traditions, just as they do those institutions and practices which derive their life from the traditions of which they are the contemporary embodiments” [12]. Although the moral gravity of dishonesty in the match process might not equal the moral gravity of a physician’s lying to a patient, allowing—or fostering—a fissure of unethical behavior in the internal practices of the medical profession puts at risk its overall character. Furthermore, it risks the trust relationship medicine has with society.

So why do participants engage in this behavior? Possibly because they recognize that “the possession of the virtues—and not only of their semblance and simulacra—is necessary to achieve [internal goods]; yet the possession of the virtues may perfectly well hinder us in achieving external goods” [13]. The behavior of both applicants and program staff indicates a concern that they must choose between internal and external goods, that they would have to sacrifice all other goods if they prioritized ethical behavior because of the way the system works.

This perceived choice could be eliminated by changing the rules and incentives of the match process. What changes might occur if the match process included more explicit rules guiding communication and actions between programs and applicants? One might expect that, instead of those who “play the game” successfully garnering the choicest spots, those who behave honestly would have an increased likelihood of securing them, thus facilitating standards of excellence for achieving internal and external goods. By prioritizing virtues in the practice of the match, the process could reward achievement and character.

In order to improve the “quest for the good” in the medical profession, we must bolster the ethical guidelines of the residency match. I suspect the gains from making the match process more transparent and equitable by providing more explicit guidelines outweigh the losses. The perceived losses from applicants not going to their “best program” or programs not getting their “best candidates” do not justify turning a blind eye to dishonest behavior. Doing so works against the virtues the profession seeks to instill and grow in its professionals at a formative juncture in medical training.

Changing the culture of the match process might prove difficult, but the time to do so cannot come soon enough. As ethicist William May writes, “in professional ethics today, the test of moral seriousness may depend not simply upon personal compliance with moral principles but upon the courage to hold others accountable” [14].