"Make Me a Match": All-In and Other Trends in the Nephrology Match

Nephrology entered the National Resident Matching Program (NRMP) Medical Specialties Matching Program (MSMP) in 2009 to improve recruiting for candidates and training programs by implementing a structure where both sides could explore all available options in a proscribed manner and time frame (1). Initially successful, within 6 years, nephrology fellowship positions filled in the Match declined 27%, leading to the MSMP’s first All-In policy (24). We review nephrology Match outcomes since All-In, discuss how nephrology training has evolved, and examine new developments that could affect nephrology recruitment.

Since the American Society of Nephrology (ASN) implemented the All-In policy, training programs have abided by their commitment outlined in the Memorandum of Understanding and offered all open positions through the MSMP. But is the sanctity of that agreement intact? Compliance is monitored by both the NRMP and ASN’s Match Oversight Committee, which has investigated concerns regarding the disappearance of highly eligible candidates from the Electronic Residency Application Service and the abrupt cancellation of interviews. Yet, to date, there is no evidence of an All-In violation, and nearly all reported concerns involve applicants who accepted out-of-Match positions in other specialties. Nephrology has led the way in supporting fair play in recruitment, and four other medical subspecialties have followed in implementing All-In (5). Still, the majority of subspecialties have not adopted similar policies, and out-of-Match offers in those specialties continue. Unfortunately, the result of this is felt particularly strongly in nephrology because as many as two thirds of candidates also apply to another medical subspecialty(s).

As expected, the first All-In Match saw a 25% uptick in offered positions, likely attributable to inclusion of slots previously allotted for internal house staff recruitment. Yet, fellowship positions continue to grow as new training programs become accredited. The appointment year 2022 Match had record highs in both participating nephrology training programs (148 programs) and offered training tracks (e.g., clinical or research, of which a program may offer one or more; 178 tracks), with nephrology critical care comprising an increasing number of the tracks offered. Although matched fellow totals stabilized after All-In, they remain below previous levels, even after adoption of virtual interviews during the coronavirus disease 2019 pandemic (Figure 1). However, first-year nephrology fellow totals have remained steady over this period (range, 411–476 first-year fellows compared with the 254–369 matched candidates over the same period) (6,7), with as many as 41% of slots filling in the post-Match scramble. An anonymous survey of incoming ASN fellow members confirms this, with 28% of respondents obtaining their position after Match Day (ASN membership survey, 2016–2022, Kurtis A. Pivert, MS, personal communication).

Figure 1.Figure 1.Figure 1.

Fellowship slots filled in the Match recovered after implementation of the All-In policy, yet remain below previous levels. Nephrology fellowship positions filled in the Match—Medical Specialties Matching Program appointment years 2009–2022. COVID-19, coronavirus disease 2019; NRMP, National Resident Matching Program.

The All-In policy was designed to primarily change the experience of applicants during recruitment season. Without pressure to respond immediately to offers, applicants would have the opportunity to explore a broader range of programs before selecting institutions that best fit their training and career needs. This increased flexibility comes with a cost for programs, often extending recruitment campaigns. With available positions still outnumbering applicants in the field, there has been increasing competition among programs, which are courting the same relatively small cohort of applicants. Neither small nor large programs are immune to these pressures. Additionally, with fellowship programs equally uncertain about their recruitment outcomes until Match Day, many programs attempt to maximize their likelihood of success by interviewing more applicants and promoting their programs on social media, which has been associated with a higher match success rate (8). Whether the All-In policy is the precipitating cause of recruitment changes and exacerbating the scramble is up for debate; however, programs have had to adapt knowing that the Match timeline will be the same for all programs due to the All-In policy.

Recruitment has also been forced to evolve under the pressures of the coronavirus disease 2019 pandemic, which pushed interviews into a virtual format. There were programs that had offered virtual interviews prior to 2020, but the practice was not widespread until travel restrictions obviated traditional recruitment conventions. Although many saw this as a lost opportunity to see new programs, hospitals, and cities up close, the shift to virtual interviews has allowed applicants to surmount a variety of limitations from cost considerations to schedule constraints. Virtual recruitment has leveled the playing field for all applicants and is undoubtedly here to stay.

Another effect of the All-In policy has been the shift in recruitment to the so-called “scramble,” the period after Match Day during which unfilled programs attempt to sign unmatched applicants to vacant positions. A full 24% of fellows who began fellowship training on July 1, 2021 were signed to their positions through the scramble process (6). Many have even suggested that some applicants may forego the Match process and simply wait to contact programs after the Match. This strategy, however, has a number of shortcomings. Applicants would only have the opportunity to vie for positions among programs that did not fill, and programs would only be able to meet such applicants if they did not fill their quota through the Match. Given the large number of applicants who enter the specialty during the scramble, this process deserves more attention to provide programs and applicants a safe place to find viable solutions during a stressful period of uncertainty.

What is next in the nephrology Match landscape? The All-In policy—which places the needs of the candidate and, hopefully, the future nephrologist first—looks to be here to stay, but there are still questions beyond this. It is clear that All-In is not a panacea for nephrology or the other four medical subspecialties to adopt the policy. However, the alternative—potentially sacrificing our future workforce’s fellowship search experiences solely for the expediency of allowing certain programs to fill their slots in June rather in December by pressuring interviewees to accept on the spot offers—is not viable for nephrology in the short or long term. With Match rates stable but still lower than historic levels, rightsizing discussions continue (9). The nephrology community continues to debate whether this rightsizing should be on the basis of fill rate, program size, geography, ability to meet competency requirements (including those around procedures), and/or board pass rate. Over a 13-year period, small fellowships (those with fewer than or equal to two first-year fellows) made up half of the training programs, although they have lower mean fill rates (61% versus 76% for large programs with three or more first-year positions). Does the breadth of programs help the Match process and nephrology as a field? Are smaller programs more nimble and better able to serve nephrologists who plan to enter clinical practice? These questions remain.

Building on a premise of the musical Fiddler on the Roof, can our field and its processes help applicants and programs find their perfect match? Recruitment efforts to fill and replenish our pipeline continue (10). How can we as a field continue to evolve, attracting and supporting creative talent that can invigorate nephrology and improve our Match rate? There remains a vigorous discussion defining nephrology and its place in medicine, including the role of procedures, subspecialization into different areas of nephrology, and newer techniques, such as point-of-care ultrasound. We continue to feel that the future of nephrology is bright. Although challenges remain, the current All-In process is the right match to support this.

Disclosures

K.A. Pivert is an employee of ASN. All remaining authors have nothing to disclose.

Acknowledgments

The content of this article reflects the personal experience and views of the author(s) and should not be considered medical advice or recommendation. The content does not reflect the views or opinions of the American Society of Nephrology (ASN) or CJASN. Responsibility for the information and views expressed herein lies entirely with the author(s).

Author Contributions

S.C. Cheng, K.A. Pivert, and S.M. Sozio conceptualized the study; K.A. Pivert was responsible for data curation; K.A. Pivert was responsible for formal analysis; S.C. Cheng and S.M. Sozio were responsible for methodology; K.A. Pivert was responsible for resources; K.A. Pivert was responsible for visualization; S.M. Sozio provided supervision; S.C. Cheng, K.A. Pivert, and S.M. Sozio wrote the original draft; and S.C. Cheng, K.A. Pivert, and S.M. Sozio reviewed and edited the manuscript.

Copyright © 2022 by the American Society of Nephrology

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