Happy Monday! I am doing something a little different today. With Match Day only being 11 days away, I have asked Jake to take over my blog. I have asked him to explain what exactly this residency “Match Day” I’ve been talking about nonstop is. I have people asking me daily what residency is and what Match Day is, so what’s better than having an expert answering these questions?
Jake: Courtney has asked me to write a post explaining how exactly the process of residency match works. Having met a ton of Uber drivers and Airbnb hosts during interview season these last few months, I’ve realized that pretty much nobody outside of medicine knows much about how this match process works, so hopefully this post can clear up a lot of questions you may have about things. Let me know if you have any other questions about the match process!
To start with, I often meet people who don’t know what residency is. Residency is the process by which doctors become specialists in a particular field. When a medical student graduates, we can’t just go out and pick a specialty and start working in it on our own. We have to undergo a period of training in that specialty, which ranges from 3 years to 7 years. Essentially, we are apprentices in the specialty for that period of time. We work directly underneath doctors who have completed residency (these doctors are called attendings); the attendings help teach us while also being there to oversee final decisions on the patient’s medical care. And to answer another question you probably had, nope, residency is not anything at all like it is depicted in the new and terrible-yet-hilarious show “The Resident”.
After finishing residency, a doctor then may take the board exam for their specific specialty; timing on this varies between specialties, but usually occurs within a year of finishing residency (with the exception of those who go on to do a fellowship directly after residency). A fellowship allows a doctor to specialize even further. Probably the most well-known fellowship is cardiology; to become a cardiologist, one must first complete a 3-year internal medicine residency, then do a 3-year cardiology fellowship.
ERAS AND APPLYING
As for the actual process of applying to residency, you send in your application on September 15 of your last year of medical school. This is done online using a system called ERAS. In ERAS, you essentially input your medical school “résumé”, including all of the research, leadership, honors/awards, volunteering, or other extracurricular activities you did during medical school. You also have attendings write and upload letters of recommendation for you on ERAS. The final aspect of ERAS is your board scores, which are probably the most important factor in your application. You take your first board exam, the USMLE Step 1, after your 2nd year of medical school. You then take your 2nd and 3rd board exams, USMLE Step 2 CK and Step 2 CS, sometime during your 4th year of medical school. Step 2 CK and Step 2 CS are usually not very important, and many students wait until after applying to residency to take these tests. However, Step 1 is enormously important. It is routinely cited by residency program directors as the single most important factor when it comes to selecting residents. An excellent Step 1 score can result in you having your choice of specialties and/or specific programs, while a bad Step 1 score can prevent you from getting the residency you want. Step 1 is an 8 hour long test of about 250 questions, so one day pretty much decides the entire rest of your life.
Once you send your application off, the waiting begins. This is one of the worst parts of the whole process! Thankfully, I started to hear back from programs a couple days after sending my application off. Once you start getting invitations to interview, things start to get a bit tricky. Results will vary based on how strong your application is, but everybody is definitely going to apply to more programs than they can actually go to for interviews, as you’re not going to receive interview offers from every program you apply to. The tricky part comes with deciding which interview offers you will accept, and then scheduling those dates. As someone who has a really hard time eliminating options, I applied to a lot more programs than I needed to, and was fortunate enough to get a lot of interview offers. Many programs are now thankfully starting to use online scheduling systems where you can immediately schedule your interview, but some programs unfortunately still require you to email them your chosen date and you have to wait to get a confirmation back from them. I had one time where a program gave me 3 interview dates and I had to email them my choice; while I was waiting to hear back from them, another program offered me an interview and the only date I could do was the date I had just emailed the other program. The logistics of scheduling all these interviews gets very complicated and expensive!
Interviews go pretty much the same at most programs. The night before the interview, applicants meet the residents at a local restaurant for dinner and drinks. This is where applicants can really get the “inside scoop” on the program and ask all the questions that we don’t feel comfortable asking attendings; these are questions like how many hours the residents work in an average week, what things they dislike about the program, if they would still choose to go to that program if they had the chance to do it all over, etc. It’s essentially hanging out with your potential future coworkers and asking all the questions you need to know about the “office” but don’t want to ask your future boss.
The next morning, you meet at the hospital for the interview day. This is pretty straightforward. You’ll start off with a presentation, usually given by the residency program director, telling you all the specifics about their particular program (curriculum/rotation breakdown, salary and benefits info, how call works there, what hospitals you will work at, etc.). After that, the rest of the day consists of interviews with several attendings, lunch, and a tour of the hospital(s). Then it’s a quick scramble back to the airport to fly home and have a day or two off before you fly out for your next interview. Interview season is an exhausting grind!
RANK LIST AND MATCHING
This is by far the aspect about the Match that people have the most questions about: what determines which residency program you actually end up at? If you are familiar with sorority rush, it works pretty similar to that. Using your account on the National Residency Matching Program’s website, you generate what is called your rank order list. This list is where you rank your choices in order; the place you put #1 on your list is the program you most prefer to end up in, and so on. Programs do the same thing, ranking applicants in order of who they want to come to their program. Then, the NRMP and their computers work their magic, using an algorithm that won a Nobel Prize in Economics to create the optimal match of applicants and programs based on both sides’ rank order lists. This whole process is probably explained much more clearly here.
There are a couple important things to note about ranking. One is that the algorithm is thankfully in the favor of applicants’ desires! So if you interviewed at Program X but didn’t really like it so you put them lower on your rank list but Program X really likes you and ranks you #1 on their list, you will not end up there unless you fail to match at any of the programs you ranked above them. Another important thing, which even a few applicants I met did not understand, is that you should truly rank in order of your preference. Some people I met were scared to rank “reach” programs #1 and thought they should rank a “safety” program #1 instead because they worried that ranking reach programs high would negatively affect their ability to match at the safety programs. That is NOT how the algorithm works; if a safety program ranks you on their list in a position to match, where you rank them will have absolutely zero effect on your ability to match there if you don’t first match at programs you have ranked above them.
CATEGORIGAL AND ADVANCED PROGRAMS
Residency programs may be classified as either categorical or advanced. A categorical program is one where you only rank them on your rank order list, and you spend your entire residency working with that program. An advanced program is one where you spend your intern year working with a different program doing primarily internal medicine or surgery, depending on your desires. You then join up with your advanced program at the start of your 2nd year of residency, spending the remainder of your time there. Specialties where many programs are advanced include radiology, ophthalmology, dermatology, radiation oncology, as well as some anesthesiology and neurology programs.
With an advanced program, your intern year can either be what is called a preliminary (prelim) year or a transitional year (TY). Prelim years are either in internal medicine or surgery; you will spend that year as a member of either the IM or surgery departments, working with all the other residents who are doing their whole residency in those fields. TY’s are more of a rotating internship, where you will spend the year doing a much wider variety of things than in a prelim year. TY programs tend to have better work hours than most prelim programs, so these programs are extremely competitive and difficult to match into.
When ranking an advanced program on your rank order list, you have to include what is called a supplemental rank order list. This is where you rank the order of which prelim or TY programs you would like to match at for a given advanced program. And you can make a different supplemental list for each advanced program! For instance, if you interviewed at an advanced program in Denver and an advanced program in Dallas, you might want to rank Denver prelims or TYs high on your supplemental list for the Denver program, but then rank Dallas prelims/TYs high on your supplemental list for the Dallas advanced program. Many applicants do this to decrease the chances of having to move cities twice in 2 years.
Your rank order list is finalized in late February a few weeks after interview season ends, and the NRMP takes a few weeks to process the results and get everything ready (this amount of time is waaaaaaaay longer than they actually need, but I won’t go on that rant here!). Finally, Match Week arrives about 3 weeks after rank order lists go final. On the Monday of Match Week, you get an email telling you IF you matched. If you did not match, you go through what is called the SOAP process (Supplemental Offer and Acceptance Program); this is colloquially referred to as scrambling. I don’t know a whole lot about the specifics of how this works (and I certainly hope I won’t ever have to learn them!), but my understanding is that you go into your school’s student affairs office and they help you through the process. You are given a list of programs who did not already fill up all of their residency spots, and you pick out which ones you want to apply to. Those programs can then choose to offer you an interview, and you undergo sort of a “speed dating” process where you interview with many programs via phone or video conference in a short period of time. This allows applicants a second chance of matching prior to Match Day. You can read up more about the SOAP process here.
Match Day finally arrives on the Friday of Match Week (March 16). Medical schools nationwide have a wide variety of ceremonies, but the common theme they all have is that at noon Eastern time, applicants finally get to find out where they will be spending the next 3 to 7 years of their lives! It is the culmination of years of hard work and the most important day in medical school other than graduation.
There are a few other topics that I left out in the interest of not making this post any longer than it already is. First of those topics is the concept of couples matching. This is what match applicants who are married/engaged/dating another match applicant do to try to match in the same city as their partner. It basically works the same as regular match, except couples choose in the NRMP system to have their lists linked together. The concept is explained in much more detail here.
Also of note, this only refers to the NRMP match for MD students. There is also a separate match system for DO (osteopathic) medical students. DO students may choose to participate in the NRMP match instead, however. I believe this system is going away in 2020 as there is a gradual merger going on, but I don’t know a lot about that.
Finally, there are some folks who match prior to Match Day. Urology and ophthalmology use a different match system than the NRMP system, but I believe it works essentially the same. People going into these specialties match in January; however, if their program requires a prelim or a TY, they will have to do that through the NRMP match, so they will match into that aspect of their residency on the normal Match Day in March. Military applicants also match a couple months early.