Emergency Medicine Residency Applicant ... - Wiley Online Library

Emergency Medicine Residency Applicant Perceptions of Unethical Recruiting Practices and Illegal Questioning in the Match R. Jason Thurman, MD, Eric Katz, MD, Wallace Carter, MD, Jin Han, MD, Eve Kayala, MD, Nicole McCoin, MD and Alan B. Storrow, MD

Abstract Objectives: The authors hypothesized that unethical recruiting practices and illegal questioning occur during emergency medicine (EM) resident recruitment. The objectives were to estimate the prevalence of specific unethical recruiting practices and illegal questioning by EM programs based on the perceptions of residency applicants and to measure the effect of these perceptions on applicant appraisal of programs. Methods: This was a cross-sectional survey of all applicants who matched to U.S. EM programs in 2005 and 2006. The survey questionnaire was developed by the study authors and was validated by pretesting on a small group representative of the study population. The survey addressed specific questions regarding program recruiting behaviors and interview questioning. The hyperlink to the secure anonymous online survey questionnaire was distributed to all EM program directors, asking them in turn to forward the hyperlink to their newly matched incoming residency class. All data were calculated with Score method with continuity correction and reported in proportions with 95% confidence intervals (CIs). Results: The authors received 671 survey responses. Among respondents, 56 (8.3%, 95% CI = 6.4% to 10.7%) stated that they were specifically asked to disclose at least one program’s position on their rank list by a program representative, and 44 (6.6%, 95% CI = 4.9% to 8.9%) reported that they matched at a program residing lower on their rank list than at least one other program that had informed the applicant they were ranked to match. Furthermore, 201 respondents (30.0%, 95% CI = 26.5% to 33.7%) believed that they were asked at least one illegal question during their interviews, the most common of which was inquiry into their marital status (189 respondents: 28.2%, 95% CI = 24.8% to 31.9%). Respondents were 11 times more likely to move a program to a lower position of preference on their rank order list (12.2%, 95% CI = 9.8% to 15.0%) rather than a higher position (1.1%, 95% CI = 0.5% to 2.3%) as a result of perceiving unethical recruiting behaviors or illegal questioning. Conclusions: These results demonstrate that among survey respondents, some perceived unethical recruiting behaviors and illegal questioning in the 2005 and 2006 Match. Perceptions of such behaviors appeared to have a negative impact on applicant appraisal of EM residency programs. ACADEMIC EMERGENCY MEDICINE 2009; 16:550–557 ª 2009 by the Society for Academic Emergency Medicine Keywords: ethics, resident education, professionalism, recruitment, match

From the Department of Emergency Medicine, Vanderbilt University Medical Center (RJT, JH, NM, ABS) Nashville, TN; the Department of Emergency Medicine, Maricopa Medical Center (EK), Phoenix, AZ; the Department of Emergency Medicine, New York Presbyterian (WC), New York, NY; and the Department of Emergency Medicine, Valley Medical Center (EK), Renton, WA. Received November 26, 2008; revision received January 14, 2009; accepted January 26, 2009. Presented at the 2007 Society of Academic Emergency Medicine (SAEM) National Meeting, Chicago, IL, May 17, 2007. Address for correspondence and reprints: R. Jason Thurman, MD; e-mail: [email protected].

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ISSN 1069-6563 PII ISSN 1069-6563583

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or many medical students applying for emergency medicine (EM) residency positions, the matching process is an exciting and enjoyable journey during which the exploration of varied programs and geographies leads to a fulfilling entry into residency training. For others, however, the employment of unethical recruiting practices and illegal questioning by residency programs may taint the process. A review of available literature suggests that medical students sometimes question the professional recruiting conduct of residency representatives, often resulting in anger and disappointment with their National Resident Matching Program (NRMP) outcomes.1 The NRMP is contacted

ª 2009 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2009.00413.x

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yearly by applicants who believe that an error has occurred because they did not match with a program promising them a spot, only to find after investigation that they were not ranked highly enough by that program for a successful match to occur.2 Further evidence suggests that applicants may be deliberately misled by residency program representatives and may face illegal questioning in the resident recruitment process.3–6 In 2004, the Council of Emergency Medicine Residency Directors (CORD) formed a task force to address unethical practices in resident recruiting. This committee concluded that the prevalence of unethical recruiting practices among EM programs is unknown and hypothesized that such practices and illegal questioning do occur during resident recruitment.7 This study takes root in the discussions of the CORD Ethics in Resident Recruiting Task Force and attempts to explore the scope of this problem within the EM community as perceived by its residency applicants. Ethical behavior and the highest levels of professionalism are cornerstones of the medical profession.8 As a result of the inherent imbalance of power in the interview process, medical student applicants may find themselves in a vulnerable position. Consequently, student applicants, who often have no control over the questions they are asked, may feel unduly pressured to answer anything posed during the interview itself and in the time period that follows.9 Furthermore, due to the potential ramifications of how medical students answer such questions, they may feel pressure to answer dishonestly in order not to sabotage their potential for a successful match.3,10 All EM programs participating in the NRMP must enter into a legal binding agreement with specific rules and regulations governing the process.11–13 Additionally, programs are obliged to conduct their employment practices in a lawful manner, as specified under Title VII of the Civil Rights Act of 1964.14 Should transgressions against either set of standards occur, they should be identified and definitively remedied such that the collective professional behaviors of program representatives are consistent with the virtues of the specialty of EM.15 Our objectives were to identify whether or not applicants perceived that EM residency programs employed specific illegal questioning and unethical recruiting practices during the 2005 and 2006 recruiting seasons and to estimate the prevalence of such behaviors if indeed they were perceived. We also attempted to measure whether or not such perceptions might have a positive or negative impact on applicant appraisal of programs. METHODS Defining Unethical Recruiting Behaviors The NRMP Statement on Professionalism clearly establishes the expectation that all Match participants are to behave in an ethical manner: The NRMP maintains the highest professional standards in the conduct of the Match and in its interactions with all participants: applicants, program

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directors, institutional officials, and student affairs deans. The NRMP expects all Match participants to conduct their affairs in an ethical and professionally responsible manner. All applicants, program directors, institutional officials, and deans of student affairs are required to comply with the terms and conditions of the Match Participation Agreement. The right of applicants to freely investigate program options prior to submission of their final rank order lists must be respected.2 Furthermore, the NRMP states that there is one ‘‘cardinal rule’’ for both programs and applicants to follow: There is one cardinal rule for both programs and applicants: neither must ask the other prior to the Match to make a commitment as to how each will be ranked (emphasis original). Each party may express a high level of interest in the other; however, references to how each will rank the other should be avoided and should definitely not be solicited. Neither programs nor applicants should consider these comments about interest as commitments. Candor and honesty are important for both programs and applicants.16,17 Historically, infractions of this cardinal rule have been among the most commonly reported violations of the Match Agreement according to the NRMP: A program director asks for verbal or written confirmation from an applicant about how he ⁄ she intends to rank the program. Although the Match Participation Agreement does not prohibit either an applicant or a program from volunteering how one plans to rank the other, it is a violation of the Match Participation Agreement to request such information.2 Taking these statements from the NRMP into account, it follows that ethical behavior consists of following the established rules of the Match Participation Agreement, and among these rules is that programs not solicit references as to how an applicant will rank them on his or her personal rank order list. Therefore, for programs to ask applicants to disclose their position on the applicant’s individual rank order list is defined as an unethical recruiting behavior. In addition, the NRMP maintains that honesty is an important aspect of ethical match behavior while the American College of Emergency Physicians Code of Ethics emphasizes trustworthiness as a virtue.18 Therefore, dishonest or deceptive behavior on behalf of program representatives is also defined as an unethical recruiting behavior. The issue of misleading communications is addressed by the NRMP: Each year, the NRMP is contacted by applicants who believe that an error has occurred in the Match because they did not match to programs whose directors had promised them positions (i.e., had promised to rank them high enough to ensure a match). In every case, the NRMP has determined

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that the applicant did not match to the desired program because, contrary to the applicant’s expectation, the program did not rank the applicant high enough on the program’s rank order list for the applicant to match there.2 Defining Illegal Questioning Federal law, under Title VII of the Civil Rights Act of 1964, prohibits employment discrimination based on race, color, religion, sex, and national origin. Although the asking of questions related to such subject matter does not directly constitute unlawful behavior defined under Title VII, an applicant may have legitimate grounds for a discrimination complaint to the Equal Employment Opportunity Commission if asked such a question in the interview setting. For this reason, questions regarding race, color, religion, sex, and national origin are widely referred to as ‘‘illegal interview questions.’’19–21 In essence, such interview questions could be viewed as evidence that the interviewer is seeking information about the applicant that might be used in a discriminatory manner in the hiring process or, in this case, where to place the applicant on a program’s rank order list. Therefore, illegal questioning is defined as program inquiries that could give rise to discrimination lawsuits under the provisions of Title VII on the grounds that an applicant …demonstrates that a respondent [program] uses a particular employment practice that causes a disparate impact on the basis of race, color, religion, sex, or national origin and the respondent [program] fails to demonstrate that the challenged practice is job related for the position in question and consistent with business necessity…22 and thus establishes that the program has behaved in an unlawful manner under federal statute. Study Design and Population We utilized a cross-sectional survey design and were granted exempt status by the principal investigator’s local institutional review board (IRB). In addition, our study was endorsed by representatives of the Emergency Medicine Residents Association (EMRA).23 Due to restrictions on our ability to identify all EM match participants, we limited our study to applicants who matched with a U.S. EM residency program in the 2005 and 2006 NRMP. We distributed the hyperlink to a secure anonymous online survey within the body of a cover letter explaining the purpose of the study to all EM program directors included in the CORD online listserv (135 programs in 2005 and 140 programs in 2006), asking them in turn to distribute the hyperlink and cover letter to their newly matched incoming residency class. The cover letter itself included a brief explanation of the background and purpose of the study, an overview of survey content, a clear statement that the survey would be completely anonymous, and an acknowledgement of both local IRB exemption and EMRA endorsement of the study. The survey was based on the Web site http://www.surveymonkey. com.24

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ETHICS IN RESIDENT RECRUITING

Survey Content and Administration The survey instrument was constructed by the authors of this study who served as members of the CORD Ethics in Resident Recruiting Task Force, all of whom participate yearly in resident recruiting. The selfadministered online questionnaire design featured forced-choice questions asking survey recipients to quantify the number of EM programs that they perceived to have exhibited unethical recruiting behaviors or to have asked them illegal questions in the interview process. The particular questions chosen for the survey questionnaire were selected based on NRMP references, indicating the most commonly reported match violations and statements on misleading communications,2 as well as references descriptive of commonly asked illegal interview questions.19–21 Prior to distribution, the survey (see Data Supplement S1, available as supporting information in the online version of this paper) was pretested on a small group of resident physicians who had participated in the match within the previous 2 years to assess the clarity, face validity, and content validity of the questions, as well as the ease and completion time requirement. This pretesting group was selected as representative of the study population based on their recent experience of participating in the residency matching process and the fact that they had come from a variety of geographic locations. Debriefing interviews were performed by the primary investigator after the pretest group had completed the survey questionnaire. No modifications to the questionnaire were made because debriefing interviews with the pretest group indicated the questions were clear and had a high degree of face validity and content validity and the survey was easy to understand and complete in a timely manner. Among the questions posed, the survey questionnaire asked whether or not applicants had experienced unethical recruiting practices as defined under NRMP Match Participation Agreement rules by any of the programs with which they interviewed.11–13,16,17 Specifically, the survey directly inquired if any programs had asked them to disclose their position on the applicant’s individual rank order list (a material violation of the NRMP Match Agreements).11–13,16,17 The survey also asked applicants if they matched at a program that was positioned lower in preference on their personal rank order list than at least one other program that had informed them they were ranked to match. Being ‘‘ranked to match’’ at a program was specifically defined as a situation where the applicant ‘‘would be guaranteed to match at the program if [the applicant] ranked the program #1 on [his or her own rank order] list.’’ Additionally, the survey asked our study population if they had been asked illegal questions19–21 and thus may have faced unlawful employment practices as defined by Title VII of the Civil Rights Act of 1964.22 These questions specifically identified program representative inquiries into the applicant’s marital status, whether or not the applicant had or planned to have children, and questions regarding the applicant’s ethnicity and religious preferences. Because inquiries regarding sexual orientation are illegal in some states and municipalities, the survey also asked applicants if they were asked about their


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sexual orientation, although such an inquiry does not violate federal law. For clarification and accuracy, subjects were instructed to report these specific inquiries by EM residency program representatives only if this information was not specifically conveyed in their application. Residency program representatives were defined in the survey instrument as being the department chair, residency program director, associate ⁄ assistant program director, chief resident or other resident(s), or ‘‘other.’’ Finally, the survey questionnaire inquired whether or not respondents changed a program’s position on their personal rank order lists based on perceptions of unethical recruiting behaviors or illegal questioning by that program using forced-choice yes or no questions. The survey instrument was distributed twice each year of the study in hopes of maximizing the number of responses, collecting data following the 2005 Match and the 2006 Match. Distributions occurred initially in the weeks immediately following match day (April 2005, 2006) and again coinciding with residency matriculation (July 2005, 2006). A Web Link Collector system was utilized to ensure that only one response could be received from any individual computer in an attempt to prevent duplicate surveys. We elected to make the survey completely anonymous, hoping to ensure that respondents would feel protected from any possible retribution for reporting of illegal questioning or unethical recruiting behaviors. Data Analysis We chose to dichotomize the survey responses quantifying the number of programs perceived to have exhibited unethical behaviors or to have asked an illegal question to facilitate analysis. A response of ‘‘0’’ to these questions was interpreted as indicating that the respondent had not perceived an unethical behavior or illegal questioning by a program, while a response ‘‘1’’ or greater was interpreted as indicating that the respondent did perceive such practices in the match. All data are reported in proportions with 95% confidence intervals (95% CIs). The 95% CIs are based upon the binomial distribution and were calculated with Score method with continuity correction.25 Additionally, we performed a sensitivity analysis and calculated the proportions of each question using the total number of matched EM applicants over the 2-year study period. This provided the assumption that every nonresponding matched EM applicant would have answered that he or she was never asked a program’s rank position by a program representative, did not match at a program that was ranked lower in preference on his or her own rank order list than at least one other program that had informed them they were ranked to match, and that he or she was never asked an illegal question. The sensitivity analysis data are reported in proportions with 95% CIs with the same calculation methods described for the primary data analysis.

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response rate) responses to our online survey; 334 and 337 survey responses were received in 2005 and 2006, respectively. The actual response rate cannot be known, because we do not know how many matched applicants actually received the survey from their program directors. Because responses were not statistically significantly different between the 2005 and 2006 groups, we present the following percentages as aggregate data. Of the 671 survey responses, 583 (86.9%, 95% CI = 84.0% to 89.3%) reported contact after the interview by at least one program representative expressing a recruiting interest. The methods of contact used as well as the program representative initiating contact varied (Figures 1 and 2). Among the responses, 56 (8.3%, 95% CI = 6.4% to 10.7%) stated that they were specifically asked to disclose at least one program’s position on his or her individual rank order list by a program represen-

Figure 1. Program representatives initiating contact with applicants following interview. Percentages do not total 100% because multiple respondents reported more than one person initiating contact with them.

RESULTS Main Results During the 2005 and 2006 NRMP periods, 2,439 applicants matched in EM. We received 671 (28% estimated

Figure 2. Methods of applicant contact by program representatives. Percentages do not total 100% because multiple respondents reported more than one method of contact with them.

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Figure 3. Illegal questions reported by applicants. *Inquiries about sexual orientation are not protected under Title VII, but are illegal in some states and municipalities.

tative, a material breach of the NRMP match agreements.11–13 Furthermore, 44 (6.6%, 95% CI = 4.9% to 8.9%) reported matching at an EM program residing lower in preference on his or her rank order list than at least one other program that had informed the applicant that he or she was ranked to match. Proportions of responses reporting that they were asked specific illegal questions as previously defined are reported in Figure 3. Inquiry into an applicant’s marital status was the most common illegal question reported (189 respondents: 28.2%, 95% CI = 24.8% to 31.9%). When asked whether or not they moved a program to a higher or lower position of preference on their personal rank order lists as a result of perceived illegal questioning or unethical behaviors, 1.1% (95% CI = 0.5% to 2.3%) of respondents stated that they moved a program to higher preference due to such behaviors, while 12.2% (95% CI = 9.8% to 15.0%) reported that they moved a program to a less preferred rank order position and thus were 11 times more likely to lower a program than raise it based on such perceptions. Sensitivity Analyses We performed a sensitivity analysis using 2,439 (the total number of matched residency applicants in 2005 and 2006 combined) rather than the total number of survey responses as the denominator for generating proportions, thus employing the assumption that all nonresponders would have answered ‘‘no’’ or ‘‘0’’ to all questions. Assuming the above sensitivity analysis parameters, 2.3% of responses (95% CI = 1.8% to 3.0%) stated that they were specifically asked to disclose at least one program’s position on his or her individual rank order list by a program representative, a material breach of the NRMP Match Agreements. Additionally, 1.8% (95% CI = 1.3% to 2.4%) reported matching at an EM program residing lower in preference on his or her rank order list than at least one other program that had informed the applicant that he or she was ranked to match.

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Figure 4. Sensitivity analysis. Illegal questions reported by applicants. *Inquiries about sexual orientation are not protected under Title VII, but are illegal in some states and municipalities.

Similarly, we performed a sensitivity analysis of our illegal questioning data. The results of this analysis are reported in Figure 4. DISCUSSION Our purpose was to identify whether or not student applicants perceived that EM programs employed unethical practices and illegal questioning in resident recruiting and, if so, to what degree. Because of the large percentage of nonresponders among the matched applicants in our sample population, it is challenging to draw accurate conclusions regarding the prevalence of these problems, and thus, the scope of the problem is difficult to define. However, the implication of our results is that some EM applicant respondents, albeit a significant minority, did perceive unethical recruiting behaviors and illegal questioning by EM residency representatives in the 2005 and 2006 Match. The sensitivity analysis offers what may be considered as a ‘‘best case’’ scenario in the assumption that all nonresponders would have answered ‘‘no’’ to all questions posed, but this likely offers an underestimation of what the actual perceptions of this group would have been. For programs to enter into a binding agreement with the NRMP13 to compete for medical student applicants, and then break the rules they have agreed to uphold, is clearly unethical. Our data demonstrate that some EM programs, despite their obligation to abide by NRMP rules, appeared to the applicants to have committed material violations of the Match Participation Agreement by asking candidates to disclose their position on personal rank order lists. The fact that some respondents to our survey reported matching with a program lower in preference on their personal rank order list than another program that had informed them they were ranked to match indicates either markedly significant misunderstandings between these applicants and EM program representatives or, quite possibly, dishonest communication. A substantial minority (30%) of respondents to our survey perceived being asked at


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least one illegal question during the interview process, indicating that EM program representatives may have conducted their interviews in a manner that could be considered discriminatory under federal civil rights law.14 Our data further suggest that applicants were much more likely to move a program to a less preferred position on their personal rank order lists than to a more preferred position as a result of perceived unethical behaviors or illegal questioning by program representatives, suggesting that such behaviors may have a negative effect on applicant appraisal of a given program. In 1999, Anderson et al.3 asked the question ‘‘Is Match Ethics an Oxymoron?’’ and concluded from their study that ‘‘Students are being introduced to their new profession, which holds honesty and integrity among its highest values, through a process that promotes mutual distrust and gamesmanship.’’ Although Anderson’s observation may suggest that we in EM are certainly not alone, we are solely responsible for our own actions. Educational efforts could be considered as a means to curtail behaviors that might lead to the perception of unethical recruiting practices and illegal questioning of applicants in the matching process. These educational initiatives could be executed at both the residency program and the medical student levels and should be appropriately designed to adequately equip recruiting personnel and empower applicants with a comprehensive understanding of the fundamental principles of ethical and legal conduct in the residency selection process. However, knowledge of NRMP rules and the law may not be enough: steadfast personal commitments to uphold the highest professional standards of conduct expected of us as ambassadors of our specialty can help preserve the integrity of our recruiting process. LIMITATIONS The greatest limitation of our study is the estimated 28% response rate. We do not know how many program directors actually distributed the survey, forcing this estimation of the response rate based on the total number of matched EM applicants. The low response rate limits our ability to accurately estimate the true prevalence of perceptions of unethical recruiting practices and illegal questioning among residency applicants in a quantitative analysis, but may not limit our conclusion that at least a substantial minority of medical students experienced these perceptions during the recruiting process. It is possible that the true scope of the problem lies somewhere in between the results of our sensitivity analysis (best case scenario) and our main results (worst case scenario), but due to the limitations of this study this cannot be reliably concluded. Our distribution scheme relied on program directors to forward our survey to their incoming first-year classes. Program directors who were aware of or concerned about the presence of questionable recruiting tactics by their own programs might have chosen not to distribute the survey to their own residents, leading to an underestimation of perceptions of unethical recruiting practices and illegal questioning. The converse is also a

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possibility; program directors who adhere to highly ethical recruiting practices may have viewed the survey topic as irrelevant and declined to forward it to their own residents, potentially leading to an overestimation of the prevalence of these perceptions. Further significant limitations of this study lie in multiple possibilities of sample bias. The sample populations included only those applicants who actually matched to EM programs in 2005 and 2006. The implications of this limitation are unknown: it is possible that we have underestimated applicant perceptions of unethical recruiting practices and illegal questioning by EM programs by surveying only a portion of those who entered into the match as unmatched EM candidates were not surveyed. Another consideration is that because the excluded group consisted of those who did not match, the possibility that some in this group were targeted with inappropriate program behaviors that resulted in their being ranked too low to successfully match must be considered, again leading to an underestimation of the perceptions of unethical recruiting practices and illegal questioning. However, one might also surmise that we have overestimated the prevalence of the perceptions of such behaviors, given the possibility of a selection bias introduced by the notion that the most desirable candidates might be more likely to face aggressive recruiting than those applicants who failed to match. Those applicants who failed to match at their desired program might be more motivated to respond, whereas those content with their match might have reservations about disclosing unethical program behaviors. Furthermore, those applicants who perceived themselves as victims of prohibited behaviors might have been more likely to respond to the survey, while those who did not face such behaviors may have felt there to be little point in participating. Additionally, although our cover letter clearly stated that the survey was completely anonymous, applicants may still have feared potential retribution if their answers became known and thus may have either declined to answer the survey or answered it dishonestly, leading to an underestimation of perceptions of unethical conduct. In addition, it is possible that duplicate surveys could have been submitted. Although measures were undertaken in online survey design to prevent duplicate responses from the same computer, applicants could have answered the survey more than once if they used a different computer to do so. Applicants could have forwarded the link to the survey to others or themselves to allow for survey responses from different computers and duplicate survey responses. The reporting of specific unethical recruiting practices and illegal questions measured may have been disproportionally accounted for by a few outlier EM programs not representative of the group as a whole. We did not ask respondents to identify the specific programs they perceived to have engaged in such behaviors. Therefore, multiple respondents interviewing at the same few programs (or even single program) may have perceived similar improper recruiting practices and reported their perceptions, leading to a potentially errant presumption that these practices are widely prevalent.

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An additional bias may have been introduced by the survey questionnaire itself. In an attempt to remove potential response biases, that which the study defined as unethical recruiting behavior was not clearly differentiated from acceptable behavior within the questionnaire (such as the act of merely contacting an applicant after the interview). It is possible that although the pretest group did not report any confusion on this matter, some respondents may have considered all survey questions regarding program recruiting behaviors to be descriptive of unethical actions. Thus, responses to the questions on moving a program to a more or less preferred location on personal rank order lists may have been biased by a misunderstanding of which program behaviors would actually be considered unethical. Misunderstandings between program representatives and residency applicants do occur. As a consequence of unintentional miscommunications between a program and applicant, or perhaps even naive misinterpretations on behalf of the applicant, the applicant may have had the impression that the program was misleading and behaved in an unethical manner. For example, a program representative conveys only a strong interest in an applicant stating, ‘‘We plan to rank you very highly,’’ but this message may be interpreted by the applicant as being ‘‘ranked to match.’’ It follows that the percentage of respondents who reported that they matched at a program residing lower in preference on his or her rank order list than at least one other program that had informed the applicant that he or she was ranked to match may in part reflect such a misunderstanding rather than blatantly unethical behaviors on the part of program representatives. In addition, applicants may have recalled discussions of their marital status, family or family planning, ethnicity, sexual orientation, or religion in the interview setting but forgotten that they themselves brought this subject matter into discussion via verbal or written communication rather than being asked for such information by the interviewer. In this light, it is critical to note that this is a study of applicant perceptions of unethical recruiting behaviors and illegal questioning by EM residency programs, not of the actual behaviors themselves. CONCLUSIONS Our results demonstrate that some EM applicants responding to our survey perceived unethical recruiting behaviors and illegal questioning in the 2005 and 2006 Match. Perceptions of such behaviors appeared to have a negative impact on program standing in applicant rank order lists. The authors acknowledge Pam Dyne, MD, Past President, CORD, and Comilla Sasson, MD, Past President, EMRA.

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References 1. Borman K. Professionalism in the match process: the rules and ethics of recruitment. Surg Clin N Am. 2004; 84:1511–23. 2. National Resident Matching Program. NRMP Statement on Professionalism. Available at: http://

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www.nrmp.org/res_match/policies/professionalism. html. Accessed Apr 25, 2006. Anderson KD, Jacobs DM, Blue AV. Is match ethics an oxymoron? Am J Surg. 1999; 177:237–9. Carek PJ, Anderson KD. Residency selection process and the match: does anyone believe anybody? JAMA. 2001; 285:2784–5. Williams E, Bania T, Weinstein J. Dissemination of unfavorable information and illegal questioning during the emergency medicine residency interview [abstract]. Ann Emerg Med. 2002; 40:S89. Carek PJ, Anderson KD, Blue AV, et al. Recruitment behavior and program directors: how ethical are their perspectives about the match process? Fam Med. 2000; 32:258–60. Council of Emergency Medicine Residency Directors. Ethics in Resident Recruiting Task Force Meeting. Meeting held at 2004 Society for Academic Emergency Medicine National Meeting, Orlando, FL. Wallace Carter, MD Committee Chairperson, May 2004. Council on Ethical and Judicial Affairs. Principles of Medical Ethics. AMA Web site. Available at: http:// www.ama-assn.org/ama/pub/category/2512.html. Accessed Mar 5, 2007. Miller JB, Schadd DC, Crittenden RA, et al. Communication between programs and applicants during residency selection: effects of the match on medical students’ professional development. Acad Med. 2003; 78:403–11. Young TA. Teaching medical students to lie. Can Med Assoc J. 1997; 156:219–22. National Resident Matching Program. Match participation agreement for applicants and programs. Available at: http://www.nrmp.org/res_match/policies/ map_main.html. Accessed Aug 12, 2004. National Resident Matching Program. Match participation agreement for institutions. Available at: http://www.nrmp.org/res_match/policies/map_ institution.html. Accessed Aug 12, 2004. National Resident Matching Program. Match participation agreement for medical schools. Available at: http://www.nrmp.org/res_match/policies/map_ medschool.html. Accessed Aug 12, 2004. U.S. Equal Employment Opportunity Commission. Title VII of the Civil Rights Act of 1964 (Title VII). Available at: http://www.eeoc.gov/policy/vii.html. Accessed Mar 15, 2005. American College of Emergency Physicians. Code of Ethics for Emergency Physicians: II, C, 5. Relationships with Trainees. Available at: http://www. acep.org/practres.aspx?id=29144. Accessed Jan 25, 2007. National Resident Matching Program. User guide for institutional officials, institutional administrators, and program directors, August 2008. Available at: http://www.nrmp.org/res_match/userguide/2009_ instprog.pdf. Accessed Feb 21, 2009. National Resident Matching Program. How the NRMP process works: ranking. Available at: http:// www.nrmp.org/about_nrmp/how.html. Accessed Dec 20, 2008.


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18. American College of Emergency Physicians. Code of Ethics for Emergency Physicians: II, A, 3. Virtues in emergency medicine. Available at: http://www. acep.org/practres.aspx?id=29144. Accessed Jan 25, 2007. 19. Anonymous. Illegal Interview Questions. USA Today. January 29, 2001. Available at http://www. usatoday.com/careers/resources/interviewillegal. htm. Accessed Feb 21, 2009. 20. Krannich RL. 38 Illegal, Sensitive, and Stupid Interview Questions…and How to Respond. The Washington Post April 11, 2003. Available at http:// www.washingtonpost.com/wp-dyn/articles/A89632003Apr11.html. Accessed Feb 21, 2009. 21. Anten T. How to Handle Illegal Interview Questions. Available at: http://hotjobs.yahoo. com/interview/How_to_Handle_Illegal_Interview_ Questions__20021118-1632.html?subtopic=Interview+ Preparation. Accessed Dec 28, 2008. 22. U.S. Equal Employment Opportunity Commission. Title VII of the Civil Rights Act of 1964 (Title VII), Unlawful Employment Practices, SEC. 2000e-2. {Section 703}, (k) 1Ai. Available at: http://www.eeoc. gov/policy/vii.html. Accessed Dec 29, 2008.

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23. Emergency Medicine Residents Association’s formal endorsement. Received via electronic mail from acting EMRA president Comilla Sasson, MD. April 28, 2005. 24. SurveyMonkey.com online survey site. Available at: http://www.surveymonkey.com. Accessed and original surveys created February 24, 2005. 25. Newcombe RG. Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med. April 30, 1998; 17:857–72. Supporting Information The following supporting information is available in the online version of this paper: Data Supplement S1. Survey. The document is in PDF format. Please note: Wiley Periodicals Inc. is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.