The National Resident Matching Program (NRMP) exists "to provide a mechanism whereby program directors and applicants could consider all their options before making final commitments and to establish a uniform date and time for the announcement of residency position appointments" (R00461). Santos et al. (R00462) reviewed the challenges faced in the 1980s to establish a viable Match for general psychiatry programs and subsequent efforts to establish a child and adolescent psychiatry Match, beginning with the pilot "Uniform Entry Plan for Child and Adolescent Psychiatry Training" in 1992. In 1994 child and adolescent psychiatry training directors voted to establish the Child and Adolescent Psychiatry Match within the NRMP. The purpose of this Match "was to create a fair and manageable recruiting process that allows programs and applicants to explore their options and make informed decisions without undue pressure" (R00462). The first Child and Adolescent Psychiatry Match occurred in 1996.

Since its establishment, the integrity of the Child and Adolescent Psychiatry Match has faced significant challenges. Foremost, all child and adolescent psychiatry training programs do not participate in the Match. In 2002, 42 of 114 (36.8%) eligible programs did not participate (R00462). In 2003, following a concerted effort among participating training directors to strengthen the Match by increasing participation, 29 of 114 (25.4%) of eligible programs still did not enroll. In addition, seven of the programs that originally enrolled withdrew their participation. Ultimately 31.6% did not participate (R00463). In 2004, 30% of eligible programs chose not to participate. Also, programs registered with the Match are not necessarily full participants because they are not required to enroll all of their positions in the Match. In 2002 the Child and Adolescent Caucus (hereafter referred to as the Caucus) of the American Association of Directors of Psychiatry Residency Training (AADPRT) reasserted that contracts for positions withheld from the Match should not be offered between the beginning of the recruitment year (July 1) and the completion of the Match.

The NRMP has written consequences for confirmed allegations of Match violations, including possible expulsion from future Matches for up to 3 years (R00465). However, the NRMP allows applicants to withdraw from the Match and allows programs to withdraw positions from the Match until the NRMP deadline for the submission of final rank order lists. That date usually falls within a month of the Match. Therefore, contracts offered or accepted by Match participants after June 30 until the end of the day rank order lists are due are not considered Match violations by the NRMP even though they violate the terms of Match participation established by the Caucus. In addition, expulsion from a future Match for either an applicant or a training program does not carry significant deterrence when participation is voluntary and a significant minority of programs do not participate in the Match.

Lastly, although a Child and Adolescent Psychiatry Match Review Board appointed by the Executive Committee of AADPRT exists, its power is limited. The Match Review Board can investigate and verify alleged violations of the Match or the terms of the Caucus. However, it is not empowered to implement sanctions against those whose violations are confirmed.

The consequences of these challenges to the Child and Adolescent Psychiatry Match are significant. Programs that are enrolled and abide by the terms of the NRMP and the Caucus compete for residents against programs not bound by these terms because they are not enrolled in the Match or have chosen to withdraw positions from it. Those programs can offer applicants the security of a contract during the Match recruitment period. Without sanctions, training programs enrolled in the Match have greater incentive than disincentive to withdraw positions in order to secure an attractive applicant with a contract. Applicants, in turn, face little disincentive for withdrawing from the Match to accept such an offer. Ironically, those training programs abiding by the terms of the NRMP and the Caucus may find themselves more disadvantaged in the competition for residents than in the era preceding the establishment of the Match. The result may be the malignant erosion of participation in the Match that can ultimately threaten its survival.

Recent examples based on actual events highlight existing problems with the Child and Adolescent Psychiatry Match.

Problem 1

Position offered and accepted by Match participant after June 30 and before the Match in violation of the Caucus agreement. Applicant accepts an out-of-Match contract without notifying the program he had encouraged to rank him highly.

An applicant interviewed at a child and adolescent psychiatry program. He was a strong applicant who made a very positive impression on interviewing faculty. They ranked him first on their program’s rank order list. Weeks before rank order lists were due the program director communicated to the resident that he would be ranked highly. The resident stated that he was pleased and relieved, as he wanted to come to the program and would rank the program accordingly. He also told a child and adolescent psychiatry resident at the program that for personal reasons it was very important to relocate to that city. At 5:00 p.m. on the due date for final rank order lists the applicant left a message on the program director’s voice mail stating that he just signed a contract with another child and adolescent psychiatry residency and withdrew from the Match. The next day the program director reached the resident and asked which program offered him the contract he signed. The resident named a program that was enrolled in the Match. The resident was told that that program was in violation of the Caucus terms for programs participating in the Match. He replied that his future program director told him that he was "allowed to remove up to 25% of his positions from the Match for offers outside the Match." When the Match results were published, this applicant was listed as "withdrawn."

Problem 2

The Match result is not honored by the applicant due to "personal circumstances."

An applicant informed a program director that he liked his program best of all the programs in the region where he and his wife wished to live. They were sure they wanted to relocate, as they had friends there and had always thought it would be a great place to raise children. His wife had several career opportunities there, and they were confident she would find employment in her field. The applicant communicated that he planned to rank the program first on his rank order list. Likewise, the faculty of this program had a very strong impression of the applicant and ranked him first on the program’s rank order list. The applicant matched at this program. The contract for the first year of training was sent to the resident. It was not returned. After 4 weeks the training director called the resident. The resident explained that his wife was in the final stages of negotiating her new position. He was reluctant to sign the contract until her new job was secured. After another month, the contract had still not been received. The training director called again and left a message on the resident’s answering machine. His call was not returned. One week later he reached the resident at home. The resident told him that he was glad he called and proceeded to tell him that his wife could not reach an agreement with her potential new employer. She did not have a job, and other prospects looked dim. They decided not to relocate.

Problem 3

Match Review Board is limited in its ability to enforce consequences for identified Match violations. New training directors may not be oriented to the terms of the Caucus until 3 months after their first recruitment season.

A program director observed that several applicants who interviewed at her program withdrew their applications within a period of several weeks. Several other applicants scheduled for interviews canceled their interviews. All communicated that they accepted positions at another program listed as enrolled in the Match. These recruitments appeared to violate the terms of the Caucus for programs participating in the Match. The incidents were reported to the Child and Adolescent Psychiatry Match Review Board. The new program director at the site that secured these residents was quite apologetic and explained that he was never made aware of the Caucus terms. He became program director 6 months before the Match and 9 months before the next Caucus meeting where he would be oriented to those terms. The withdrawal of his program’s positions from the Match to secure these contracts was not a violation of the NRMP rules, though it was a violation of the Caucus agreement. There were no consequences.

Problem 4

During the recruitment season an applicant accepts a contract from a program not participating in the Match rather than risk not matching at a program he prefers to attend. Other programs continue to include him in their rank order lists.

A resident registered in the Match interviewed at a program participating in the Match. That program’s director emphasized to him that all positions would be offered through the Match. The applicant also interviewed at a program not participating in the Match. That program’s director offered him a contract immediately. While preferring the program that participated in the Match, the applicant accepted the contract offered to him by the director of the program not participating in the Match. When the Match results were published, the applicant was listed as "withdrawn." Though not ranking him first, the program participating in the Match had ranked him above a number of other applicants on their Match rank order list.

Problem 5

Applicant disregards Match results and enrolls in the subsequent Match. No mechanism is employed for the identification of repeat enrollment or for the determination of why the original Match was not honored.

An applicant matched at a child and adolescent psychiatry training program in a medical center that required a pass of USMLE STEP III for all residents at his level of training. During his interview the resident communicated that he was scheduled to take the STEP III and would have sufficient time to retake it before beginning child and adolescent psychiatry training should he not pass his initial attempt. After the Match a contract was sent to the resident with a start date contingent on passing STEP III. Several months later the resident called the program director to communicate that he wanted to postpone his entry into the program by several months, as he had postponed his STEP III examination. He explained that he wanted additional time to study because it was so important to him. His program director also communicated to the awaiting program director that correspondence with the Accreditation Council for Graduate Medical Education (ACGME) clarified that this resident would not complete his general psychiatry training until at least several months following his originally scheduled start date in the child and adolescent psychiatry program. The director who sent the contract communicated to the resident and his current program director that his position would be available upon completion of his general psychiatry requirements and a pass on the STEP III examination. Later that summer the resident communicated that he now preferred to postpone his entry into the child and adolescent psychiatry program and remain in his general psychiatry program until the following July, one year after his originally scheduled start date. The child and adolescent psychiatry program director told him that if he passed the STEP III examination there would be a place for him. Unbeknownst to that program director, the resident proceeded to reenroll in the next Child and Adolescent Psychiatry Match. After further interviewing, the resident told another child and adolescent psychiatry program director that he wanted to attend her program. Only weeks before the deadline for the submission of rank order lists he and that program director reconfirmed that they would rank each other accordingly to assure a match. When the Match results were published, the resident was not matched. He was listed as withdrawn from the Match. That program director called the resident to inquire what happened. The resident apologized, thanked her, and told her that he signed a contract with another program. The resident had essentially committed to yet a third program! The program director at the child and adolescent psychiatry residency where the resident first matched, still expecting the resident to begin that July, noticed that this resident was included in the new Match results although listed as withdrawn. He also called the resident to inquire about this. The resident apologized and explained that he signed a contract with another program because of his anxiety about the STEP III requirement. The program director later learned that this program also required a pass of the STEP III examination.

The above vignettes illustrate many of the problems with the Child and Adolescent Psychiatry Match as it currently exists. Participation in this Match is voluntary. Non-participating programs continue to recruit outside the Match throughout the recruitment year. Programs abiding by the rules of the NRMP and the terms of the Caucus may also compete against programs that abide by the NRMP rules but do not abide by the terms of the Caucus, offering contracts until their rank order lists are due. The NRMP allows this. It also allows applicants to withdraw from the Match until their rank order lists are due. These options provide opportunities for training programs anxious to fill positions and for applicants anxious to secure positions to violate Caucus terms. Compounding these vulnerabilities, there is no standardized orientation to explain the terms of the Caucus to new training directors. The Caucus may not be aware of a change in a training director, who may not attend their first Caucus meeting until after their first recruitment season.

Applicants are also affected by these problems. They face inconsistent recruitment rules and the risk of undue pressure that compromise their ability to freely evaluate the strengths and weaknesses of each training program. They must consider how each program is recruiting. Is it in the Match? If so, is it abiding by the Caucus agreement? Or, can a contract be arranged outside of the Match against the Caucus agreement? Will a position listed as in the Match remain available in Match? One program may tell a resident that they participate in the Match and abide by the Caucus terms while another may pressure the resident to sign now or risk losing the position.

While violations of the Caucus agreement may be reported to the Child and Adolescent Psychiatry Match Review Board, the Board cannot lever meaningful consequences for confirmed violations. The Match Review Board is presently limited to confirming violations to the parties involved. The strength of this as a deterrent is questionable. The NRMP does have the ability to ban individual applicants and programs from the Match and can label individuals and programs as "Match violators." Such actions may have little effect when programs can readily fill positions without the Match.

Lastly, there is no system to identify and screen residents who match with a program, delay their training, and reenroll in a subsequent Match. Residents who disregard their commitment to the Match and are not yet identified as Match violators can reenroll in another Match without clear repercussions. Training programs that match residents who ultimately do not arrive for training are left with the difficult option of attempting to force a resident to abide by their agreement and train where they now do not want to be.

Several steps can be taken to address these challenges to the integrity of the Child and Adolescent Psychiatry Match. First, all applicants and all child and adolescent psychiatry programs should be required by the ACGME to use the NRMP Match. As Santos et al. (R00462) noted, the Match for general psychiatry was greatly strengthened once the ACGME stated that "programs should participate in the NRMP." The Caucus should recommend to the ACGME Residency Review Committee for Psychiatry that all child and adolescent psychiatry programs participate in the NRMP. Only positions not filled through the Match should be available for contracts after the Match. Second, the Child and Adolescent Psychiatry Match Review Board should be empowered to create and enforce consequences for Match violations. Letters of censure could be sent to relevant administrators of program sites including the Department Chair and the Chair of the Graduate Medical Education Committee. A list of programs and applicants violating the Match could be distributed to child and adolescent psychiatry program directors. ACGME site visitors could include reported Match violations in their reports, with repercussions as determined by the Residency Review Committee (RRC) for Psychiatry. Lastly, a system should be developed to identify applicants matched in a Child and Adolescent Psychiatry Match who do not honor their contract commitment and/or attempt to enroll in a subsequent Child and Adolescent Psychiatry Match. National Resident Matching Program approval for enrollment in another Match should be linked to the clarification of the reason for the violation by interviewing the applicant and the director of the program where the resident originally matched. Such an investigation could be delegated by the NRMP to the Child and Adolescent Psychiatry Match Review Board.

Some programs may resist required Match participation, perhaps because the voluntary system works well for them or because they prefer to have no Match at all. Program autonomy to choose to participate in the Match would obviously be a casualty of required Match participation, but a system of recruitment with clear and consistent rules for applicants and programs would be achieved. The most fair alternative to mandatory match participation is to do away with the Match altogether and return to an open recruiting field for all programs.

Another potential objection to a mandatory Match is the strain that would occur if the number of applicants fell well below the number of available positions. Indeed, according to the statistics for 2003, 39 programs, or 50% of those enrolled in the Match did not fill (R00463). In 2004, 22 programs, or 27% of those enrolled in the Match, did not fill (R00464). However, the solution to recruitment difficulties is not to perpetuate a process currently marked by inconsistency and ambiguity, but to address the discrepancy between the number of available positions and the number of applicants. Programs that do not consistently fill should offer fewer positions voluntarily or through RRC intervention. The RRC for Psychiatry could also reduce positions in programs that violate Match rules. Alternatively, recent efforts to increase recruitment into child and adolescent psychiatry may yield more applicants, relieving the pressure program directors feel to fill outside the Match.

The Child and Adolescent Psychiatry Match was developed to promote a fair recruitment environment for applicants and training programs. As noted by the NRMP, "the success of the Match depends on a high level of trust among all participants in the Matching Program" (R00461). Unfortunately, experiences during the initial years of this Match reveal weaknesses of design and enforcement that challenge its integrity and undermine trust. Unless these flaws are addressed, child and adolescent psychiatry program directors may increasingly question the wisdom of remaining in the Match. The survival of the Match will be threatened.

The problems identified in the initial years of the Child and Adolescent Psychiatry Match also present opportunities for the implementation of effective solutions. The ACGME should require all child and adolescent psychiatry programs to participate in the Match. Empowerment of the Child and Adolescent Psychiatry Match Review Board to lever meaningful repercussions is also needed. Lastly, previously matched applicants should be restricted from reenrolling in subsequent Matches without review of the circumstances that led to their initial Match violation. With adequate attention to its present weaknesses, the Child and Adolescent Psychiatry Match will be more viable, and the goal of greater fairness in recruitment can be achieved.