Choosing a medical specialty III – applying, interviewing and matching

Aside from taking 4th year medical school classes it’s also the time of year that medical students who plan to graduate in 2009 (like me) are applying to residency programs across the country. This is an interesting process and one that many people outside of medicine are unfamiliar with, and quite surprised by. For one, did you know that we don’t have final say on where we train in residency but that the decision is made by a computer?

It’s true. The process is called “the Match” and it’s a time of great excitement and anxiety for 4th year medical students. For one, there are far more applicants than there are residency positions around the country – largely due to application from foreign applicants. Also, depending on which field you’re applying, there may be many more applicants for each given position than there are positions. So let’s look at some of the match data from the National Residency Match Program that they publish each year (Charting Outcomes in the Match 2008 – PDF) to give you an idea of what a 4th year medical student is facing. Table 1 of the report is enough to give many students palpitations.


Divided by US vs other applicants, this is what your chances are as a 4th year senior for getting into the various medical specialties.


So, now that you’ve chosen your medical specialty what kinds of things can you do to make your chances of matching better? And what’s it like applying for these programs even though you can’t outright pick them, and conversely, they can’t directly pick you? How does this crazy system work? More below the fold…

The match itself is a computer-guided assignment of residency applicants to residency positions based on how applicants rank the programs they interview at, and how the programs rank the applicants. The match algorithm is designed to try to maximize “good” matches – that is the most applicants getting the programs they ranked highest while the most programs get the students they ranked. The results are pretty good, in general most medical students get one of their top three ranked choices, but still, before Match Day (March 19th 2009), students have no idea where in the world they will be training. And there is always the possibility of that terrible outcome – the scramble. But more on that later…

The NRMP has provided a great deal of data on what criteria result in higher probabilities of students matching residency programs and a few things become clear. For one, Step I board scores correlate very well with the level of competition in the match, not surprisingly since it’s one of the few quantitative measures of student performance that is universal across applicants. The number is the median score and the range reflects the 25th-75th percentile of applicant scores:


Research experience of matched applicants, on the other hand, is more closely related to specific residency programs that have more of a research culture:


It’s certainly not a bad thing to be a member of the national medical honors society Alpha-Omega-Alpha for those tough residencies:


Having a PhD doesn’t seem to correlate with match success at more competitive programs, but clearly some programs have a higher draw


But these data are somewhat confusing since there are a lot of factors that play into each candidate’s success. For instance, surgery may have a lower correlation between PhD applicants and match success simply because fewer MD/PhD’s apply for surgery positions. Luckily, they’ve done a regression analysis. That is, they’ve helped us identify which variables – when every other variable is held constant – correlate most highly with match success.


As you can see, several factors stand out as factors correlated with match success, and it’s not a surprise that the big things you can do to increase your chances are to rank more programs (duh), have a PhD, be a member of AOA, and have good USMLE board scores. It’s important to note that they couldn’t tabulate the contribution of grades because many schools are pass fail, or have a wide variety of grading schemes. Many schools also no longer report class ranks.

Now, back to interviewing. You only rank schools where you have interviewed, and based on the number of places you interview, the more likely you are to match.


It just makes sense. The more places that potentially rank you, the more likely that ranking algorithm will find a place for you. Hence, medical students spend a great deal of time traveling all over the country looking for the perfect program(s) for them. And for the highly-competitive specialties it’s even tougher. Even ranking 10 programs you still have a 10% chance of not matching anywhere!

This is anxiety-provoking to be sure. And what happens when you don’t match? Well, you do the dreaded scramble. That is, 3 days before match day you find out you didn’t match. You then show up at your dean’s office, crying and in a panic, and they, along with the other deans of the other medical schools around the country, try to wrangle their students into the remaining residency positions. These may be positions at less prestigious institutions that too few applicants ranked, or at prestigious institutions that failed to rank enough candidates and got shorted in the match! Either way, this outcome is the great fear of every 4th year medical student.

And even those who know they are going to match are still somewhat anxious. You often have ranked more than ten places, and some of those places towards the bottom weren’t your ideal places to live for the next 3-7 years. We do match day in our old lecture hall and read out the matches of students to the whole class. There is lots of cheering, lots of excitement, and often some tears when someone realizes they won’t be living where they wanted or going to the program of their dreams. Then, once that’s all over, there is lots of drinking and misbehaving.

I’m applying for a specialty that, while not one of the most competitive, is just outside of the top 5 (Dermatology, Orthopedics, ENT, Plastics, and Radiation Oncology), so I applied to 17 programs, and will interview at 10 places around the country. I’ve been to about 5 so far and have been lucky in that I’ve found much to love about each of the places I’ve been. I like the idea of being able to rank lots of places I would be happy to attend.

Interviewing is something of a formality – programs typically get hundreds of applicants and interview between 10-20%. All the people they interview would make good candidates, they just want to meet them to help decide if they would be a good fit for the program. Same goes for the candidates. Most residency programs in the country will give you an excellent medical education. What you want to know is will you be happy if you end up spending the next 3-7 years in this environment? Is the program friendly or malignant? Do you get along with the faculty? Are the residents happy? Do they even bother show up to meet the candidates? Is this place better for married couples or are all the residents single? It can suck to be single if everyone else is married since it affects intraclass bonding or if you’re in a town that isn’t single-friendly. Is it friendly to women? I always look for a good ratio of female residents among the ranks as a sign of civilization. Is it a city you can live in? You will spend a lot of time here, if you can’t take living in the ghetto or in a town where the cost of living would force you to live in the next state, you may need to reconsider your rank order. For me I’m additionally looking for strong research in my field of interest, a culture that supports research and fellowships after completion, and that has a strong clinical training program to ensure I’m an excellent clinician and not just a lab rat.

I don’t think I could stand to interview at many more than 10 since all the travel, expense, and missed time from school tends to add up. And I’ll be sure to live blog my match day – unless of course I’m too busy scrambling…