Ethics and the Orthodontic Match
In the last issue, I wrote about what I perceive to be the overuse of disclaimers in modern society. This month, I must begin by saying that the opinions expressed here are my own and do not necessarily represent any official stance of this journal or The Edward H Angle Society of Orthodontists.
It is November and in a few weeks, on the 21st, final Match rankings are due to be submitted by both applicants and postgraduate orthodontic programs here in the US. The orthodontic Match program is a triumph of modern digital society, creating order out of the chaos that was once the orthodontic residency acceptance process. But, at the same time, for many applicants and programs, the Match is a demonstration of the failure of an ethical system that was supposed to make the playing field level and fair for everyone.
I think that everyone reading this would agree that THE most important characteristic that should be nurtured in young aspiring orthodontists is their ability to live their professional lives based on strong ethical principles. After all, they will soon be joining our specialty and someday leading us into the future. We would like them to represent us to the public by displaying the highest level of moral behavior. We want them to provide the best care they can to patients and to be honest and caring individuals who contribute meaningfully to their communities. We want them to reflect the values that we hold.
How do these up and coming professionals become ethical human beings? Is it something that is taught to them in a classroom? After all, orthodontic residency admission is still quite competitive and most of the serious contenders have done very well in school. So, they should also have performed well in Ethics 101, right? The Council on Dental Accreditation (CODA) takes this issue very seriously and the very first standard for orthodontic education (Standard 1-1) states: Graduates must receive instruction in the application of the principles of ethical reasoning, ethical decision making and professional responsibility as they pertain to the academic environment, research, patient care, and practice management. We all know, however, that actual ethical behavior is very hard to TEACH to anyone. People are brought up to be honest and selfless, or they are not. Our students learn by observing the behavior of their mentors: their parents, their teachers, the leaders in their field. Leading by example is perhaps no more important in any area than it is for developing the quality of ethical behavior.
For our aspiring orthodontists, the first significant, professional exposure they have to the specialty is through the orthodontic admissions process. It is imperative that this process be performed ethically by us as leaders in the field. We must lead by example. About 20 years ago, a group of dental students representing the American Student Dental Association (ASDA) came before the education leaders gathered at the annual session of the American Association of Orthodontists (AAO) and implored the postgraduate programs to adopt the Match program for postgraduate admissions to make the process fair and manageable. The Match is a computerized admissions process in which applicants submit their list of school choices in order of preference and the schools submit their list of applicant choices in order of preference and then the applicants and schools are “matched” together. It is commonly used in the medical resident admissions process as well. The majority of educators present at the AAO session voted to abide by the conditions of the orthodontic Match program and enroll new residents by adhering to its guidelines. This process was endorsed by the AAO 20 years ago! And yet, to this day, there has never been uniform adherence to the conditions of this agreement.
The application process is the first experience that new orthodontists share with their specialty colleagues. Before they even begin, applicants to orthodontic programs in the US are immediately faced with a decision about whether they should apply to Match schools or non-Match schools or both. The AAO website lists 64 accredited US (non-military) orthodontic postgraduate programs. 51 of those participate in the Match and the remaining 13 do not. I would estimate that roughly 25% of the total number of positions available are non-Match positions. The problem really becomes most palpable for applicants interested in both Match and non-Match schools. An even worse scenario occurs for someone primarily interested in Match schools but applying to a non-Match school as a backup. You might be surprised at some of the big name schools that do not participate in the Match program.
The following is a fictitious example that I, unfortunately, see played out in reality year after year. Let's say you are an applicant and want to go to “Hometown University” which is a Match school and maybe you also want to check out “Most Prestigious University” which is also a Match school but a longshot considering the high number of applicants to that school and the small class size there. Your best chance of actually getting in anywhere might be at “Most Expensive University” which is a non-Match school with lots of positions available, so you also apply there as a backup even though it will be a stretch for you to actually pay the high tuition. You interview at all 3 of these schools. They all seem like they offer basically a good educational experience, and you send in your choices for “Most Prestigious University” and “Hometown University” to the Match system. The Match announcement date is on December 3, 2014 (the actual date this year). However, on November 24, “Most Expensive University” calls you and offers you a position. In order to accept the position, you must give them your decision in 2 days and also provide proof that you have withdrawn your application from the Match; otherwise they will offer the position to someone else. Should you take the sure position at “Most Expensive University” or should you gamble and try to get into one of the Match schools? Is it ethical to ask you to play this game before you have even started your specialty education?
I advise dental students every year regarding the admissions process and I tell them not to apply to non-Match schools at all if they want to attend one of the Match schools. Why apply to schools that you would turn down if they offered you a spot? I have seen students turn down the sure thing and then, luckily for them, match with their preferred program. I have also seen students turn down the sure thing and not get in at all. Perhaps most sadly, I have seen students take the sure thing even though it is not where they really wanted to go.
This issue is obviously a tough one to resolve. It's been a problem for 20 years (and, actually, the admissions “wild frontier” landscape was even worse before that). I am certainly not the first person to raise this issue during that time; I remember Lionel Sadowsky, in particular, so eloquently explaining his strong stance several times. Match programs would like to make participation mandatory and non-Match programs raise various reasons why they do not want to participate. CODA does not want to be the admissions regulator by making this a requirement for accreditation. The AAO does not want to alienate individual orthodontic programs by taking a position one way or the other.
Times change and the orthodontic specialty is facing different challenges than it was 20 years ago. Perhaps it is time to look at this problem once again. Take a good, hard look. What is the ethical example we are trying to set? Can we afford NOT to take a stance? There is a way to make the admissions process manageable and fair.