The Game Continues: Seeking Clarity in the Radiation Oncology Match.

Though the previous Gaming the Match agreement offered guidance to programs on how best to approach the Match process, guidance for applicants remains inconsistent. Here we review and propose guidelines by which the spirit of the Match may better be achieved for both program directors and applicants alike.

In 1952, the National Resident Matching Program (NRMP) debuted the Match, an algorithm that processes rank order lists to produce the most “top matched” applicant–program pairings possible. In theory, the Match serves as an ideal selection process for both programs and applicants. Functionally, the supply of residency positions in radiation oncology outpaces the demand of resident interest, potentially leading to greater competition between programs for the qualified pool of applicants. This is paired with a persistent concern about a shortage in quality jobs, leaving applicants to vie for positions at institutions often based on perceived prestige, with hope that prestige will translate into employment. This combination of factors may lead to pressure to amplify the gamesmanship of the Match.

A consequence of these pressures is that the Match becomes a high-stakes gambit and inevitably portends gamesmanship to push the odds in one’s favor. Gamesmanship can take many forms: unsolicited post-interview thank you notes, backchannel networking and advocacy, letters of interest, and letters of intent (affectionately coined a “love letter”) in which applicants share that a program is their number-one choice. Perpetuating this gamesmanship are reports from other specialties revealing these tactics are indeed successful4, 5, 6 and may even affect an applicant’s rank list.

Post-interview communication is traditionally a popular area of gamesmanship across medical specialties that has gained considerable attention in recent years. Berriochoa and colleagues surveyed 2079 applicants across specialties, observing that 70% of applicants wrote letters of intent. More than three-quarters of these applicants reported doing so in hopes of increasing their rank position, with 70% noting discomfort doing so. One in 5 applicants reported changing their rank order list based on their post-interview communications.

The use of gamesmanship in radiation oncology was assessed by Holliday et al who echoed these sentiments. They found the majority of radiation oncology applicants felt pressured to provide programs with misleading assurances, felt dishonest when disclosing which institutions also extended interview invitations, and felt uncomfortable with receiving unsolicited post-interview communications.

In the era of coronavirus disease 2019, “preference signaling” has added a new dimension to pre-interview gamesmanship. New companies like Signal Token offer the ability for applicants to purchase up to 12 “tokens” to signal interest to their top choice programs, for a $25 fee. This has created controversy within radiation oncology as Program Directors (PDs) have been directly solicited for their buy-in, with discussions ongoing as to how this may affect the upcoming application season.

In response to the discomfort of gamesmanship, Wu and colleagues published “Taking the Game Out of the Match.” They underscored this behavior is attributed to PDs and applicants alike, arguing this practice deviates from the true spirit of the Match. They offer a series of recommendations for programs to follow, summarized here:

Commit to the letter and spirit of the National Resident Matching Program rules on department websites and during interview days.

Avoid soliciting information regarding rank order list position and discourage post-interview thank you letters from applicants.

Discourage programs from directly or indirectly divulging to applicants their rank list position and post-interview communication in general.

Advise applicants to communicate exclusively with program coordinators to avoid solicitations of rank orders.

This proposal was agreed to by the authors and other PDs throughout the country, although no master list of participants exists to our knowledge. These guidelines address the behavior of programs more so than the behavior of applicants. The language is vague regarding applicant communication (eg, rank order list discussion is “discouraged”). It is unknown to what extent a faculty member’s knowledge of this information may influence an applicant’s rank, never mind backchannel communications between department chairs and faculty.

From an applicant’s perspective, things are hazier. For instance, thank-you notes are often considered “unnecessary.” However, applicants may wonder if these love letters would be helpful or at the very least make one more memorable? There is wide variation as to whether applicants are encouraged or discouraged from communicating rank order lists from mentors both within and outside of radiation oncology. Consequently, although gamesmanship may have been reduced by residency programs, it remains unaddressed for applicants.

As applicants, it is apparent which programs are participating in gamesmanship and which are adhering to “Best Practices.”, Notably, after the Match agreement, radiation oncology as a specialty appears to have the highest rate of programs explicitly discouraging post-interview communications. Despite the agreement, however, only 44% of programs adhere to these guidelines and the degree of commitment is unclear. Without expected negative consequence, applicants succumb to internal and external pressures to draft letters to favorite programs. This is reinforced by anecdotes shared via online forum or via current residents. Two authors of this article can attest that they were given substantially different advice from mentors and even medical school deans: one was told that communication post-interview would be viewed as a Match violation and an instant de-rank, whereas the other was directly advised to write a letter to programs post-interview to improve their rank position.

Given the upcoming applicant cycle in the era of coronavirus disease 2019, with online interviews, ambiguity of interview caps for both applicants or programs, and lack of opportunities for away rotations, thinking intentionally about how we adjust for these prospective applicants is critical. With falling radiation oncology applicant numbers, online condemnation of programs participating in the Post-Match Supplemental Offer and Acceptance Program process, and a general lack of in-person contact with potential applicants, gamesmanship may play an even greater role compared with previous cycles. As a small specialty in such an atypical year, it may be challenging for PDs to differentiate applicants without the biases of gamesmanship influencing their rank lists.

Furthermore, uniquely for this year, PDs are now faced with the choice to accept or reject signaling tokens or like services, and applicants are left to wonder if these means would be beneficial to increase the chances of their Match prospects. Moreover, application saturation has taxed limited program resources, inviting discussion of capping the number of applications or interviews: recent modeling has demonstrated that without a 12-interview cap, if all applicants accepted all interviews due to the convenience of the virtual interview process, nearly half of applicants could receive 0 to 1 interviews during this upcoming cycle. The gamesmanship this would inevitably engender may seriously endanger the ultimate spirit of the Match.

Inevitably, if pre- and post-interview communications from applicants are not explicitly discouraged, then pressure on applicants to participate in such communication will persist. It is the opinion of the authors that the prohibition of post-interview communication should be broadened to include applicants as well. This will remove the ambiguity in expectations that applicants experience, leading to improved adherence to the spirit of the Match while leveling the playing field for both applicants and programs. This should be clearly communicated to applicants by the leadership of the programs during the interview process. Furthermore, we recommend refraining from post-interview communications unless it is to answer specific questions related to the program by the program coordinator, which is an accepted communication from Wu’s editorial. Although this will surely not stop all avenues of gamesmanship, we believe if both applicants and PDs alike mutually commit to reducing gamesmanship during this uniquely tempting time, we can progress toward improving the experience for all participants of the Match in radiation oncology.