Match Monopoly

Medical Residency Violates Anti-Trust Law, and Congress Knows It

Every spring, thousands of American medical students take part in a ritual called “the Match,” where an algorithm determines where they will spend the next three to seven years of their lives. It is, for most, the culmination of a decade of grinding work: high school, college, medical school, endless studying, relentless exams. And yet, at the moment of final ascent, they surrender the very freedom they spent years believing their education would earn them.

The National Resident Matching Program (NRMP) is touted as a fair and efficient way to pair residents and programs. In reality, it is a monopoly, a cartel blessed by federal law to extinguish choice, suppress wages, and enforce top-down control over a physician’s early career. It is a system so incompatible with the free market that Congress had to pass special legislation immunizing it from antitrust litigation.¹

It is time to ask a forbidden question: What if we abolished the Match altogether? What if we trusted free markets, not algorithms, to shape medical residency?

The Origins of the Match — and Its Problems

The Match was established in 1952, in response to a hiring “arms race” where hospitals competed for medical students earlier and earlier in their schooling.² Fearing chaos — and more importantly, higher labor costs — the academic establishment invented a centralized system to allocate bodies where needed.

Students rank hospitals; hospitals rank students; a computer shuffles the lists until it produces “stable” pairings. The system was later refined using the Gale-Shapley deferred acceptance algorithm, a 1962 mathematical proof that aimed to optimize match stability and was formally incorporated into Match redesigns in the late 1990s by economist Alvin Roth.³

The algorithm won a Nobel Prize.⁴ It did not win the consent of the people forced to live by it.

Once matched, students are locked in. They cannot negotiate salary. They cannot shop competing offers. They are virtually unable to change programs even if the working conditions are abusive. If they refuse their Match, they lose their only guaranteed path to licensure after spending hundreds of thousands of dollars on education.⁵

If this sounds less like a hiring process and more like indentured servitude, that’s because it is.

The Psychological Cost

The Match’s suppression of autonomy isn’t just frustrating — it’s deadly. Physicians report some of the highest burnout rates of any profession, and lack of career control is one of the strongest predictors.⁶

A 2022 study published in JAMA Network Open found that rates of emotional exhaustion among medical trainees were substantially higher than the general population, and that feeling trapped in one’s position correlated with higher burnout, depression, and suicidal ideation.⁷ Notably, physicians die by suicide at a rate more than double that of the general population.⁸ Suicide is the leading cause of death among male residents and second among female residents during their years of training.⁹

It is no wonder. The Match system begins the process of conditioning doctors to tolerate injustice, powerlessness, and exploitation as the cost of survival. It teaches that suffering is normal and inevitable — a lesson many never fully unlearn. The suicides of physicians like Dr. Lorna Breen, an ER doctor who died by suicide after working through the pandemic, have underscored the lethal costs of medical culture that punishes vulnerability and overvalues endurance.¹⁰

The Economic Toll

Residents are, by definition, overworked and underpaid. According to Medscape’s 2023 Resident Salary and Debt Report, the average resident salary was $63,400 — a figure that translates to roughly $15–$17 per hour when accounting for the 80-hour workweeks most residents endure.¹¹ Meanwhile, the average medical student debt exceeds $200,000.¹²

In a free market, hospitals desperate for labor in underpopulated specialties (like emergency medicine, family practice, and psychiatry) would have to raise salaries or improve working conditions to attract candidates. In the Match, they have no such incentive. Residents are captive — unable to shop around, negotiate, or bargain for better terms.

The result is stagnation, even in the face of glaring labor shortages. In 2023, the Match left 554 emergency medicine residency positions unfilled, a staggering increase from just 14 unfilled positions in 2021.¹³ Psychiatry, internal medicine, and family medicine programs also saw sharp declines in fill rates. These aren’t statistical flukes — they are market signals being ignored. A functional labor market would respond with bonuses, higher pay, or better working conditions. But in the Match, the market is frozen. No matter how undesirable the specialty or setting, hospitals expect residents to fill slots by mandate, not merit.

Instead of wage competition, the Match preserves an artificially low, standardized salary system set more by tradition than by economics.

Congressional Protection of the Monopoly

In 2002, a group of former medical residents filed a class action lawsuit alleging that the Match violated federal antitrust laws by suppressing wages and fixing employment terms. Rather than allow the case to proceed, Congress passed the Pension Funding Equity Act of 2004, which included a rider explicitly immunizing the Match from antitrust litigation.¹⁴

Think about that. Rather than defend the Match on its merits in open court, Congress chose to shield it from scrutiny altogether. Even the government recognized that the Match could survive neither legal inquiry nor market competition.

A Better Way: Free Contracting

Imagine a different system. One where medical students graduate and — like lawyers, engineers, or MBAs — are free to interview, receive offers, compare benefits, and negotiate contracts.

Hospitals would compete for the best candidates, offering higher salaries, better hours, signing bonuses, or loan repayment packages. Candidates would select programs based not only on prestige, but on fit, location, and compensation. Bad programs with toxic cultures would be forced to reform or shutter.

Such a system would not only be more humane to residents; it would ultimately improve patient care. Physicians who choose their workplace based on informed preference are less likely to burn out, more likely to stay in their fields, and more likely to advocate for their patients.

Some modest steps toward market principles already exist. The Supplemental Offer and Acceptance Program (SOAP), which allows unmatched students to seek open positions after Match Day, introduces a limited marketplace. But SOAP remains tightly regulated and bureaucratic, not a true free market.¹⁵

The Usual Objections — and the Rebuttal

Defenders of the Match argue that it prevents “chaos” — that without it, top students would hoard multiple offers, hospitals would overextend themselves, and poor programs would collapse.

Good. They should. That’s what happens in every other professional labor market. Law firms compete for law students. Tech companies compete for engineers. Academic departments compete for PhDs. Chaos is the sound of competition — and competition is how you find out which businesses deserve to survive.

Another objection is that smaller, less prestigious programs would be unable to fill their slots. But if a program is so undesirable that no one will work there voluntarily, perhaps it should not exist. Or perhaps it should offer better incentives to attract talent.

Markets are ruthless. But they are also fair in a way that bureaucracies can never be.

Let Doctors Choose

The Match infantilizes doctors at the moment they should be stepping into full adulthood. It teaches that passivity, not agency, is the way to survive medicine. It selects for compliance, not courage.

If we want a generation of physicians who think independently, advocate fiercely for their patients, and refuse to tolerate injustice — we should start by trusting them to choose their first job.

The Match teaches doctors to obey. It’s time we taught them to decide.

1. Pension Funding Equity Act of 2004, Pub. L. No. 108-218, § 207, 118 Stat. 596 (codified at 15 U.S.C. § 37b). Available at: https://www.congress.gov/bill/108th-congress/house-bill/3108. Accessed May 1, 2025.

2. National Resident Matching Program. History of the Match. Available at: https://www.nrmp.org/about/history/. Accessed May 1, 2025.

3. Gale D, Shapley LS. College admissions and the stability of marriage. Am Math Mon. 1962;69(1):9–15. doi:10.2307/2312726

4. Roth AE. The evolution of the labor market for medical interns and residents: a case study in game theory. J Polit Econ. 1984;92(6):991–1016. doi:10.1086/261272

Roth AE. The origins, history, and design of the resident match. JAMA. 2003;289(7):909–912. doi:10.1001/jama.289.7.909

5. Association of American Medical Colleges. Medical student education: debt, costs, and loan repayment fact card. Available at: https://store.aamc.org/medical-student-education-debt-costs-and-loan-repayment-fact-card.html. Accessed May 1, 2025.

6. Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2020. Mayo Clin Proc. 2022;97(3):491-506. doi:10.1016/j.mayocp.2021.11.021

7. Dyrbye LN, Burke SE, Hardeman RR, et al. Association of clinical specialty with symptoms of burnout and suicidal ideation among medical students. JAMA Netw Open. 2020;3(7):e209593. doi:10.1001/jamanetworkopen.2020.9593

Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004;161(12):2295–2302. doi:10.1176/appi.ajp.161.12.2295

8. Gold KJ, Sen A, Schwenk TL. Details on suicide among U.S. physicians: data from the National Violent Death Reporting System. Gen Hosp Psychiatry. 2013;35(1):45–49. doi:10.1016/j.genhosppsych.2012.08.005

9. Yaghmour NA, Brigham TP, Richter T, et al. Causes of death of residents in ACGME-accredited programs 2000 through 2014: implications for the learning environment. Acad Med. 2017;92(7):976-983. doi:10.1097/ACM.0000000000001736

10. Watkins A, Rothfeld M, Rashbaum WK, Rosenthal BM. Top E.R. doctor who treated virus patients dies by suicide. The New York Times. July 11, 2020. Available at: https://www.nytimes.com/2020/07/11/nyregion/lorna-breen-suicide-coronavirus.html. Accessed May 1, 2025.

11. Medscape. Resident salary and debt report 2023. Available at: https://www.medscape.com/slideshow/2023-residents-salary-and-debt-report-6016224. Accessed May 1, 2025.

12. Association of American Medical Colleges. Medical student education: debt, costs, and loan repayment fact card. Available at: https://store.aamc.org/medical-student-education-debt-costs-and-loan-repayment-fact-card.html. Accessed May 1, 2025.

13. National Resident Matching Program. Results and Data: 2023 Main Residency Match. Available at: https://www.nrmp.org/wp-content/uploads/2023/03/2023-MRM-Results-Data-FINAL.pdf. Accessed May 1, 2025.

14. Pension Funding Equity Act of 2004, Pub. L. No. 108-218, § 207, 118 Stat. 596 (codified at 15 U.S.C. § 37b). Available at: https://www.congress.gov/bill/108th-congress/house-bill/3108/text. Accessed May 1, 2025.

15. National Resident Matching Program. Supplemental Offer and Acceptance Program (SOAP). Available at: https://www.nrmp.org/soap/. Accessed May 1, 2025.