The Residency Match Part 1

The Match Described Conceptually

By now you have probably heard the ancient medical school adage that “P=MD” meaning that grades are not important and everyone who passes will be a doctor. I want to refute this and caution you to never adopt this philosophy. Grades do matter as you will see later in this series of articles from my sorry tale which fortunately has a happy ending.

The Match is a annual event during which medical students are placed into residency programs. Almost every specialty uses the NRMP match (National Residency Match Program) but some use their own match. The principles are the same whatever the case and from now on when I say “match” I’m referring to the NRMP match.

In the bad old days before the match, finding a residency program was very similar to the way that most of America finds work. You sent your resume to a program, they interviewed you, and you might be offered a job on the spot. This caused several problems. First, there was tremendous pressure for medical students to sign the first contract that they were offered because it was the proverbial “bird in the hand” even if the program wasn’t where they really hoped to go.

I just matched into Emergency Medicine (on my second attempt as you will see) and at any time this year or last if I had been offered a contract at any program I would have signed it. Sure I have preferences of where I would like to go but I would have rather had a secure spot in my specialty than risk going unmatched later.

Additionally, the programs had the similar problem of either signing an acceptable applicant immediately or holding out for a better one later and possibly not filling all of their spots. Apparently there was a lot of horse-trading and arm-twisting on both sides of the table.

The match is a system that removes the pressure from both the applicant and the program to make a quick decision or settle for something less than they could get if they held out. This, in a nutshell, is how it works. First, applicants apply to various residency programs in their desired specialty. The programs review the application and based on their own criteria (grades, for one) offer to interview the applicant.

After the interview period, the applicant submits to the NRMP a list of the programs where he interviewed and where he would accept a position. This list is sorted in
order of the applicant’s preference with his favorite program ranked number one and his least favorite last. Least favorite, that is, where he is willing to go because you do not have to rank every program where you interview. This is called the Rank Order List.

The residency program for their part submits to the NRMP a list sorted in order of their preference of all the applicants they interviewed and are willing to take. They don’t have to put every person they interview on the list (or “rank” them as we say) because while you might decide that you would never go to a certain program, they might also decide that they do not want you under any circumstances either.

The NRMP puts these lists into a computer which runs a simple algorithm that matches applicants to programs. The algorithm, which used to be cranked out by hand, draws a name from the top of the list and puts him into the program he ranked highest which also ranked him. The next name is drawn from the list and he is put into his highest ranked program which also ranked him. These people are tentatively matched and this goes on until eventually conflicts arise between who is sitting in what slot.

Try to follow me here. If you are tentatively matched at a certain program if another applicant to the same program is tentatively matched the algorithm compares how high he was ranked by the program to how high you were ranked. If he was ranked higher then you are bumped down a spot on that program’s roster. If you are ranked higher than he is put into a spot below yours. Since programs only have a set number of spots, eventually someone is going to drop off the bottom of the list onto the first spot in the list of the program in their next order of preference.

Look at it as one long roster consisting of all of the possible residency spots at all the programs into which you could match. You are initially placed as high up on this roster as you possibly can be. If you are the first in the stack of rank order lists then you will be sitting on the first spot of your favorite program until somebody knocks you down. If the algorithm gets to you later you will be placed as high as you can possibly be placed possibly knocking somebody less favorably ranked by the program down a notch.

So you can see that you can never move up the list once you are tentatively matched. There is no way but down. The strongly competitive candidate will just hold his place, fighting off challengers with his superior ranking mojo.

You can also see that the match favors the applicant as you will be paced as high up on your preference list as you can possibly be. The program might want somebody more than you but since that applicant might have ranked another program higher he’s going to sit there until he is knocked down. They may have to settle for little old you.

So what’s the worst thing that can happen? It should again be obvious. You apply to a competitive specialty with more applicants than open spots and after being forced down the roster by applicants who were ranked higher by every program which you ranked you are forced off of the list entirely.

You are unmatched and are now in a world of hurt especially if you really wanted a competitive specialty like Radiology or Emergency Medicine. Fortunately, you have one more chance at salvaging both your future career and your pride.

The funny thing is that even in a competitive specialty sometimes at the end of the match programs have spots which did not fill. They didn’t rank enough applicants either because they didn’t interview enough people or they decided for whatever reason to only rank some of the people they interviewed.

Now you have to go through something called the “Scramble” where you and every other unmatched person who wants a crack at one of the open spots compete furiously in real time waging war over the phone, the internet, and the fax machine. The match is sedate and rational. For competitive specialties, the scramble is a free-for-all and program directors quickly fill their program from the ultimate buyer’s market. The few unmatched spots in Emergency Medicine, for example, filled in a matter of hours with highly qualified candidates.

In a non-competitive specialty like Family Medicine there are usually plenty of open spots, often several in every single Family Medicine program so if you were lazy, didn’t want to interview, and didn’t really care where you went you could easily get a spot somewhere.

I know all about the scramble because I failed to match last year and as I had no chance of getting one of the only 11 (out of around 1200) open Emergency Medicine spots I threw in the towel and scrambled into family medicine. This turned out to be a costly mistake as I will describe later by telling you what I should have done.

So those are the basics. In the next posts I will describe the actual process of applying to programs and to the match. I’ll also give you some pointers on scrambling…well, not pointers so much as bone-headed things that I did from which you may draw you own conclusions.