A tale of two systems: Pathology resident recruitment in and out of the National Resident Matching Program.

The recruitment of most first-year pathology residents currently occurs via 2 systems: the National Resident Matching Program (NRMP), known as the Match, and an underground Out-of-Match process. Out-of-Match recruitment is not a sanctioned option for American medical school seniors. Recent declines in American seniors choosing pathology has intensified pressures to recruit good international medical graduates (IMGs). Pressures by programs on IMGs and by IMGs on programs result in the Out-of-Match recruitment of many IMGs who initially enroll in the NRMP. IMGs may be offered unsolicited Out-of-Match positions with a decision deadline even though they are still interviewing. Some are told if they decline an offer, they will not be ranked by that program in the NRMP process. To enhance apparent recruitment success, programs also feel pressured to participate in the Out-of-Match process, as well as offer positions before they have interviewed all applicants. Coercion of applicants and programs contravenes the spirit of the NRMP, compromises the ability of applicants and programs to best match needs, taints constructive interactions among program directors, and does not enhance pathology's image among applicants or in the broader medical community.