What is “Match Day”?
After years of hard work, graduating medical students’ fates are handed to them in an envelope.
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It feels surreal that it has been 10 years since my “Match Day.” Match Day is the day that graduating medical students find out where they will be going for residency. After four years of college, a longer-than-intended foray into classical music, followed by two years of graduate school in biomedical sciences, the MCAT (more than once; okay, more than twice), four years of medical school plus a research year between my 3rd and 4th years, enduring the first two of three national medical licensing board exams, dozens of applications, and around 15 interviews, my entire fate was sealed in an envelope, delivered to my medical school, and handed to me at exactly noon, Friday March 16, 2012.
Here's a picture one of my classmates took of me right before I opened the letter that would tell me where I would spend the most formative years of my training. You can tell I’m nervous, but happy. I at least knew I had matched somewhere and that, come July, I’d be starting my training as an emergency physician. (That information had arrived via an email four days earlier.)
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I truly had no idea where I was headed, though. For most of medical school, I had been a mediocre student, at best. But I had peaked late. During my senior year, I did two “away” rotations, spending a month in the emergency departments at New York University/Bellevue Hospital and another at NY Presbyterian’s Columbia-Cornell combined program. I had done reasonably well in those ERs (plus a month in the ER at my home institution, Mount Sinai). But overall, medical school had been a rough ride for me. The rote memorization had been harder and more soul crushing for me than I anticipated. But once things began to feel real—and nowhere was that feeling more acute than in the ER—things started to fall into place for me.
After finishing all of these rotations and going on the interview trail, which back then meant driving and flying to actual places, I told NYU they were my first choice. The chair of the NYU department was a legend in the field and Bellevue Hospital had a storied past and present. Even though Mount Sinai’s emergency department was where several up-and-coming stars in our field were, I had decided I wanted to be apprenticed to the great masters—the ones who had literally written the textbooks. I was told by a respected faculty member who I had gotten to know a bit at NYU that I had a chance to match there. At the time, I took that to mean I had a reasonable chance but was not a shoe-in. In hindsight, I now understand that this had been code for “unlikely.” Though there are strict rules about this, when a residency program wants you, they find a way to tell you pretty explicitly.
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The residency matching process is both transparent and opaque. The matching algorithm is public (which I was not aware of until recently, though how it worked was seemingly common knowledge).
Here’s how it goes. Early in the calendar year, every student submits a list to a computer system ranking their preferred choices among the hospitals where they interviewed in the fall. The hospitals also submit lists of their preferred students. All of this is kept totally confidential; the students can’t see the hospital’s lists, and the hospitals can’t see the candidates’ lists. The matching algorithm then attempts to fill the approximately 35,000 slots (these days there are more applicants than positions).
The algorithm itself favors applicants. If an applicant ranks a hospital program with 10 slots as their first choice, and that program ranked the applicant at all, a tentative match is made. But if 10 other applicants also ranked that same program as their top choice, the applicant with the lowest ranking on the hospital’s list is then removed from the match list. That candidate is then tentatively matched into their second-choice program, and the process repeats itself until all the spots nationwide are filled. (This video from the National Residency Matching Program nicely lays out how it works).
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My problem was that after interview season, I had no idea which programs were interested in me. There was no way of knowing whether I’d landed high on a program’s rank list, low on their list, or nowhere at all (although this is less common). Generally speaking, if a program interviewed 100 candidates for 15 slots, anyone the program ranked higher than 30th would be considered “ranked to match.” This means that if the student ranked that program as their top choice, it would be likely that they’d end up matching there. (Even the best programs can’t fill up a 15-person class with their top 15 choices).
I remember intensely debating my rank list for weeks, wondering if there was some game theory that implied that I should rank a slightly less competitive program very high on my list. But the reality was (and is) that the algorithm favors the students. If NYU didn’t want me, and my 2nd-through-10th choice programs didn’t want me (or rank me high enough), I’d land at my 11th-choice program, if they wanted me. So ranking that program in my top 3 wouldn’t have changed the outcome. The only difference would have been that the mega-computer would have matched me to that program 10 milliseconds sooner. But if it had turned out that my 4th choice program actually had ranked me high up on their list, I never would have known. Long story short: students should rank their programs as if the decision was entirely theirs. The computer takes care of the rest.
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Nevertheless, I still feel like the system is too opaque. I actually wrote about this shortly after I began my intern year at the Mount Sinai emergency medicine residency program—which had been my #2 choice. In that essay, now nearly ten years old, I wrote about the picture above, specifically pointing out the scene unfolding over my left shoulder. “Look at the man-hug going on in the background,” I wrote. “I’m actually not joking when I say that that’s just too much happiness!” If students were not kept in the dark for so long, deprived of any sense of how the process had gone, the catharsis would not have been so intense, I wrote.
Overall, though, the algorithm itself is not the problem. In fact, it probably delivers the best results possible, and is a long way from the old system of a bunch of people running around rooms with note cards.
Still, I wish there were a way to make the system a bit less anxiety-provoking. And there’s a lot of “hidden curriculum” that would be better unhidden. There are also equity issues which need solving.
But by far the biggest problem is something that goes beyond any of this. The physician pipeline is starting to break down. This year there were 42,000 applicants for 35,000 residency slots. Time was that the hardest part of getting to become a doctor was getting into medical school. Now some graduates are not even guaranteed a residency spot, a painful and potentially financially ruinous end to an arduous journey.
In some fields, like emergency medicine, another problem has surfaced; there are now more graduating emergency medicine residents than there are desirable jobs waiting for them after their training. If more medical schools and some new residency programs continue to open (albeit the residency spots have not been keeping pace), but there are not enough jobs in the market at the end of the journey, that will be the ultimate mismatch.
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