How Not To Match

Let me state the obvious. There are many kinds of doctors and depending on your specialty you will have vastly different experiences in your medical career. Ideally you want to select a specialty in which you are interested. It doesn’t need to be a passion or even a calling but you have to be able to see yourself getting up in the morning for the rest of your life and doing it.

The selection of a specialty is often made by exclusion. I found for example that I absolutely detested rounding so I wasn’t too keen on internal medicine. Some people dislike the OR so surgery is definitely out of the question. It is also difficult to get excited about pediatrics when children make your skin crawl.

You usually narrow down your choice of specialties to a short list of things you like and refine it from there. By “like” I don’t necessarily mean that you are crazy about it, just that the combination of the potential income, lifestyle, and character of the work exceeds some threshold. I can’t believe that most people go into dermatology because of a lifetime interest in rashes. I’m sure derm is not boring but the easy residency hours, good pay, and lack of call probably carry a lot of weight with the academic heavy hitters who match into it.

Or you can go through medical school and find that you really don’t like any of those things you swore in your AMCAS personal statement drove you to apply to medical school. Achieving sainthood seems like a good idea before you actually start working with real patient. You will pick your specialty accordingly maybe deciding that radiology besides being interesting and kind of cool limits the amount of time you will actually have to spend talking to patients not to mention managing their health problems.

Of course, you may have your specialty picked for you by default because you have not positioned yourself in medical school to match into anything other than the typical non-competitive specialties. Matching into some of them requires only a pulse and the desire. Everybody can and does match into something, just not necessarily what they really wanted to do.

A word about specialties and their competitiveness. Some specialties are notoriously hard to get into. Dermatology is one. Radiology is another. Urology, interestingly enough, is also super-competitive and they even have their own match. (Not the NRMP). I’m going to give you my limited opinion on various specialties in a later post but suffice to say that it is a combination of intellectual rigor, potential income, prestige, work hours, and the number of available programs which determine a specialty’s competitiveness. Family Medicine as an example enjoys low pay, little prestige in the medical community, and the easy availability of residency positions almost everywhere. Therefore, although there are some individual Family Medicine programs which are pretty competitive the specialty itself is not and you can always scramble into a spot if you don’t outright match into your first or second choice.

You have to use a little common sense when looking at the competitiveness of a specialty. On paper you might say that Dermatology and Family Medicine are equally competitive because almost everyone who tries to match into either specialty is successful. This is true but self-selection plays a pretty big role in who applies to what specialty. The top students in you class will apply to Dermatology programs and get interviews. The bottom feeders can apply until their computer starts smoking but they will get few if any interviews and their chances of matching are slim to none. Although they’d like to have a cushy high-paying job as much as anybody else they usually save themselves the application fee and apply to less competitive specialties.

So you see while “P=MD”, you might develop a preference for one specialty in fourth year and spending your first three years in medical school just going for the pass might limit your options when it comes to matching. Grades do matter, as does class rank. All other things being equal it is the person with the higher class rank or the higher board score who will both get the interview and be ranked higher by the program. Most competitive residency programs even screen by grades, board scores, or class rank.

The number one way not to match is to get low grades and even worse, low USMLE scores. Many people enter medical school having bought into the premise that they should do something in primary care. Good grades and high class rank are not necessary to match into most of the primary care specialties so this is used as an emotional crutch during pre-clinical years. After all, I’m just going into Family Practice, I don’t need good grades. (But bear in mind that the best family medicine programs are pretty competitive in their own right.)

If you change you mind about your intended specialty you may find yourself in a new higher weight class where you are no longer very competitive. You may get some interviews but not enough to match as you will invariably drop off the end of your rank order list. Not every interview goes well. If you only interview at a few places if one or two places decide not to rank you all of a sudden you are pinning your hopes on the one place that liked you well enough to rank but not enough to rank at a spot likely to match.

A pass is not good enough. Get the best grades you can to keep your options open.

Now. Those of you who are at the top of your class go surf for some porn or something for the next few minutes. What you are doing reading my blog is a mystery as this is the home of the average, blue-collar medical student.

When it comes to applying to programs, don’t be squeamish. Apply to enough programs to get enough interviews to increase your chances of matching. And unless you absolutely despised a program and you are certain you would only last a week or two there before you killed somebody and ran screaming into the bayou, rank every program where you interview. Seriously. When you don’t rank a program what you are saying is that if it came down to it you’d rather try to scramble into a better program, sit out a year, or scramble into one of the unpopular specialties none of which are very good plans.

First of all, if you couldn’t match into your specialty, the scramble is not exactly going to be a cake walk. Most competitive specialties fill and if they don’t there are plenty of people better qualified than you who will probably get the few open spots. I’m sorry. I’m the biggest optimist in the world (I mean I did risk everything this year to match into Emergency Medicine) but you probably won’t get the open spot for the same reason you didn’t match.

Don’t count on the scramble.

As for sitting out a year, don’t do it unless it is for something that you can justify the next time you apply. “Took a year to set up a TB clinic in Moldavia sounds pretty good. Hung around the house playing video games not so good. Almost nobody outright sits out a year if they don’t match. What most people with any sense do is scramble into what is called a transitional or preliminary year. Most Medicine and General Surgery Programs have a number of one-year positions available every year in addition to their Categorical spots. The preliminary year is separate intern year with no guarantee of any further training at that institution. The advantage of doing a preliminary year is that some programs require one and even if you had matched you would have still had to have matched (or scrambled) into one. On your next attempt you would have this year under your belt which is not a bad thing. Your preliminary year is also a time to get new letters showing that despite your class rank, you are a real hard-charger. This is not a bad thing either.

Some programs do not require a preliminary year so if you match, you will have to repeat your intern year.

What not to do, and what I am sorry to say I did after not matching, is to throw in the towel and on the spur of the moment decide to lower your sights by scrambling into something safe which you either never considered or were ambivalent towards. I never really disliked family medicine but I never liked it enough to consider it as a career. I was pretty demoralized after not matching into Emergency Medicine and as I had just had my 40th birthday I was pretty sure I was finished. So it looked like the easiest thing to do, especially as the scramble was definitely not going my way.

What can I say? I didn’t have a plan. If I had stepped back and considered things for a second I would have walked upstairs to my school’s medicine department and taken one of their preliminary spots of which they always have a surplus. What I have learned since then is that I would rather quit medicine and go back to my previous career (structural engineering) than spend my life in a medical specialty to which I was always cool toward and of which my opinion did not improve by closer association. Still , I accepted a categorical position because I felt, and see if you can spot the irony here, a preliminary position would be a wasted year and I might as well get started on my lowered career goals today.

Folks, its only a year. 365 days. For all the trouble it took to apply and interview as a categorical intern not to mention the hurt feelings and the awkwardness of appearing indecisive when I told my program it wasn’t worth it. Not by a long shot.

Another thing to consider is that you are only fully-funded by Medicare for the length of the first program into which you match. Since I matched into Family Medicine which is three years and am now going to Emergency Medicine which is also three years, I am only fully funded for two years of the new residency and half-funded for the third year. Some programs, particularly large academic institutions don’t really care about this because losing a little money on their residents is not an issue. For some smaller programs it might be a deal-breaker. I was told by several programs that they would not consider applicants who weren’t fully funded.

I am unsure of the how this rule applies to preliminary positions so do your research.

Bottom line:

1. Keep your options open. You will change you mind about specialties. Better to have the grades and scores to match into Opthalmology but decide on family medicine than the other way around.

2. For God’s sake suck it up and do a preliminary year, especially if you are young. One year measured against your career is insignificant. Not to mention that you will be a pretty confident intern if you have to repeat your first year.

3. On the first day of medical school, with the usual allowances for the occasional dumb-ass who slipped through the cracks, anybody can do any specialty. You might have to apply yourself a little harder but you can do it.

Coming Soon: My totally biased, non-scientific, take-it-for-what-you-paid-for-it opinion on various specialties in which I try to debunk some of the hype surrounding primary care.

Caution: Not to be read by zealots or compassion fascists.