Last month, fourth year medical students around the country gathered on March 18th to learn where they would continue their training as residents. Known as Match Day, it brings nervousness and excitement to med students (and their families/significant others) each year. And, it isn’t a simple process where you log-in to your National Residency Match Program account on the morning of March 18th (alone, with sweaty palms poised above your laptop). Instead, at many institutions, you get up on stage in front of your entire med school class, friends, and family to receive your residency assignment. At some schools everyone opens their decision envelopes together at the same time. No pressure.
This day is the culmination of a long road of hard work and figuring out the game of the Match process. I recently Skyped with my friend, Sharon Wolfson, a fourth year medical student who matched this spring. (To her first choice – Medicine-Pediatrics Residency at Baylor College of Medicine!) Sharon is passionate about gastroenterology, and specifically pediatric diseases such as Hirschsprung’s disease, inspired by her mom’s experiences with Hirschsprung’s. This is a photo of Sharon and her adorable family at the University of Miami Match Day:
At first glance, the job application doesn’t seem too daunting. Sharon explained that, “Applications open in the summer after your third year of medical school. You submit on September 15th. It’s a common app that includes your CV, a personal statement, board scores, a dean’s letter, and letters of recommendation.”
The residency application is a common app and there is no secondary or supplemental application for individual residency programs. “Applying to all those places is so easy. To send that application to all the schools—there are literally just check boxes. You just have to check it!” Sharon mentioned that this leads to certain programs receiving an overwhelming number of applications. “Imagine Harvard—everyone is going to check off Harvard! You don’t have to do any work.” The only catch is a $30 fee for each program you check.
And then it gets a bit crazy. “You submit your application September 15th at 9am, as soon as it opens, because places immediately start downloading the application. I got my first interview that afternoon. The thing is, the only things that get submitted on September 15 are your board scores, personal statement, and CV.” The recommendations and dean’s letter are not submitted until October. As a result, the early days of the process favors applicants with higher board scores.
“People argue that board scores shouldn’t be such a big contributor to deciding who gets an interview, because those don’t correlate with being a good doctor. They correlate to being a good test taker.”
The original intention of the board exam was to test if trainees were qualified to be physicians. If you put a pass score at a certain level, everyone above that threshold should be competent. “[It tested], ‘Can this person be trusted?’ But it’s turned into this system where they have these charts where you can look up scores required for certain specialties. There are people who have wanted to go into orthopedics their entire lives and you have one chance to take this test. If you got a 240, time to change your life plan. And is someone with a 240 not qualified to become an orthopedic surgeon? Or a plastic surgeon? No, 240 is a really good score. The average is like 220.” The blog USMLE Gunner (gotta love that name!) presents some interesting data about the Step 1 exam.
Next, students are invited for interviews. These are one to two day affairs that occur some time between the Fall and the the first week in February. Students often interview at many programs because the competition is quite high and they are searching for the right fit. However, the interview process requires investment of both energy and money. “They say you burn out after ten [interviews]. And they were right, it was ten.” On the cost side, “…it’s insane. It’s really expensive—they don’t pay for any of it. [Companies hiring for] a regular job often pay for that stuff.”
After interviews, the final step of the process is officially ranking the programs. Of the places you interviewed, where do you want to go for residency? “You don’t have to rank all of them [the places you interviewed]. But you have to decide, ‘would I rather not match than go here?’”
Sharon elected not to rank a few schools for two major reasons. At one program, “Their website said they had a clinic, but when you showed up and asked about the clinic, it turns out it got terminated—which is a red flag.” In addition, some programs lacked specific training in areas she was most interested. “There are certain things I want to be able to accomplish and it was important to me that I go to a program where I would be able to achieve my career goals. You want to go to a place where you’re going to be successful and you’re going to have a good education.”
The ranking is where the Match becomes a game. The students rank the residency programs and the programs rank the students. A computer algorithm performs the matches. If a program and a student both rank each other #1, that match is more or less guaranteed. Interestingly, the 2012 Nobel Prize in economics recognized the Match algorithm amongst a body of research that asked the question: how do you find the perfect match?
“With college and med school applications, there is a range in the number of students that can come. [The school says] alright, if we accept this many applicants and expect that this many will come. It’s okay if it’s a little more or a little less.” However, residency programs must find a perfect match between spots and students. “With residency, they may have five spots. They can’t have four come because they won’t have enough staff to take care of patients.” And they can’t offer too many students jobs because hospitals only receive government funding for a certain number of residency positions.
“They should rank you based on your application, but they also take into consideration, ‘Will this person rank us high?’”
This is where it gets tricky. “As a student, you want people to think you want to go [to their hospital], but you also don’t want to lie and burn bridges. Communities are getting smaller now. If you tell four people that they are your first choice [and they put you as their first choice], if you don’t match there then they know that you lied.” And these people are your future colleagues, collaborators, and bosses.
Between the application, the interviews, the expenses, and ranking system, one might ask: is this the right way to go about finding a residency?
Sharon explained that part of the need for a Match system is that there are many fewer spots compared to other types of jobs. This necessitates some sort of system to organize the available positions and ensure that spots are filled at each hospital and students have the best educational opportunities. Additionally, there is reduced ability to negotiate for salary or benefits because many residency programs are funded by the government. This standardized pay protects young doctors from accepting abnormally low salaries during periods in which they are still in training and cannot practice independently.
Despite these necessities, there are several components that certainly could be changed, amongst which are the importance of board scores and the expenses associated with residency applications and interviews. However, both of these changes would require systemic overhauls to the matching system and perhaps a change in perspective on the importance of test scores.
Until then, brace yourself. It’s going to be a wild ride!