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The Match Revealed

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For most fourth-year medical students across the country, thoughts have turned to the tasks of applying for residency programs and enrolling in the National Resident Matching Program (NRMP), commonly referred to as the Match. Being in this situation myself, it seems like a daunting process. After I complete an application and interview at (hopefully) many programs, I will have the opportunity to send a rank-ordered list (with a check, of course) to the NRMP. Then, in a little over three weeks, I’ll receive an envelope that will tell me where I will spend the next three years of my life.

Like most students, I have heard many stories about the Match and the strategies employed by program directors and students to secure their desired fits. One of most common phrases I’ve heard is that the Match “favors the student.” But what exactly does this mean? I sought to find the answer and, hopefully, to demystify the process for others with similar questions.

The Match first originated in response to growing competition in the job market for interns, which caused some hospitals to make increasingly early offers to the most desirable students. Medical school deans raised concerns that students were being approached by residency program directors too early; some started recruiting as early as the end of the applicant’s second year. Students, unsure of whether a more desirable offer would be forthcoming, felt compelled to accept these internship positions often as early as their junior year.

Initial attempts were made to standardize this process by offering a uniform acceptance date. On the appointed day, the applicants received telegrams and were required to respond to these offers. In the event that the top-choice students accepted other offers, the hospitals that were not selected by the applicants had very little time to seek out their second-choice applicants. Frequently students were forced to respond with immediate replies, often by telephone or telegram within the hour.

Thus, the idea for a national centralized clearinghouse emerged and was first tested nationally in 1952. The process was modeled after similar regional pools that had been used with success. Both applicants and program directors found this model to be highly preferable over the previous process, as it produced the best outcomes for both groups and provided minimal incentive for either party to go outside the clearinghouse structure.

Applicants who go unmatched and program directors with open spots remaining enter the “scramble” process. Prior to Match Day (which is traditionally held on a Thursday in March), all students are notified through their dean’s office whether they matched. In the event that a student is unmatched, he or she has 48 hours in which to contact residency programs with open positions. In many schools the dean’s office is influential in facilitating these connections, often enlisting the help of carefully selected faculty within the particular area of interest.

The essence of the Match is the nature of its algorithm. The first algorithm used was developed by Mullin and Stalnaker. It first matched students and hospitals that were each others’ first choice (a 1-1 ranking). Next it matched students who ranked the hospital first but were in the second group of the hospital’s list (a 2-1 ranking, where the first number represents the hospital’s preference and second represents the student’s). The process then alternated and the hospital’s first choice was matched with the student’s second choice (1-2 ranking) until all the slots at a hospital were filled. Subsequent matches were 2-2, 3-1, 3-2, 1-3, 2-3, and so on.

Although this would appear to benefit the student, as his or her preferences were considered above those of the hospital, it actually had the opposite effect. A student who did not secure his or her first choice match would often find that their second-choice hospital had already filled its positions with less highly ranked students, leaving him or her with an even less desirable position.

To overcome this problem, the Boston Pool modification was introduced. It automatically updated student rank order lists and deleted a student from a hospital’s list only after the student had been matched to a hospital that the student preferred. Thus, a student who did not match at his or her first choice would be assured of matching at the second choice hospital, assuming that the hospital was not already filled by students it preferred. In effect, the hospital makes a tentative offer to the student, who can later reject it in the event that a better offer materializes.

The most recent redesign of the Match algorithm occurred 1998. It starts with the student’s preference for a program rather than starting at the top of the hospital’s rank order list. Other updates also include the creation of a couples match system and the assignment of a preliminary one-year position which is contingent upon the applicant’s ability to match in a second-year position (such as in dermatology or radiology).

Although the Match can be confusing, it’s important for medical students to use the program wisely. If you’re interested in learning more, a good explanation of this model can be found on the NRMP website. The following suggestions and strategies have been compiled to help applicants obtain their optimal residency slots.

Applicants are advised to include on their rank order list only those programs that represent their true preferences. It would be preferable to engage in the scramble than to be assigned by the Match to a program that would be an unhappy choice.

Programs should be ranked in sequence, according to the applicant's true preferences.

Factors to consider in determining the number of programs to rank include the competitiveness of the specialty, the competition for the specific programs being ranked, and the applicant's qualifications. In most instances, the issue is not the actual number of programs on the rank order list, but whether to add one or more additional programs to the list in order to reduce the likelihood of being unmatched.

Applicants are advised to rank all of the programs deemed acceptable to them, meaning, programs where they would be happy to undertake residency training. Conversely, if an applicant finds certain programs unacceptable and is not interested in accepting offers from these programs, these programs should not be included on the applicant's rank order list.

Ideally, the applicant should rank at the top of his or her list those programs which represent the absolute highest aspirations, as long as they represent truly desirable options. In the language of guidance counselors, in the most basic sense, this is called a “reach.” In fact, this is seldom done, given the emphasis by students and schools alike on being awarded their first choice. The reality is that if one is matched to the first choice on their list, this only means that they did not aspire as high as they might have.

In the middle portion of the list, the applicant should list those programs which are closer to a genuinely reasonable opportunity. Important to understand is that those programs ranked above this position do not diminish the applicant’s chance of matching.

In the next echelon, or more toward the last positions on the applicant's list, are placed those program selections which are closer to a “sure,” given the presumption that one should make a genuine effort to avoid being unmatched.

Finally, one of the most important concepts is to realize that a given program does not know where they are on your list, unless YOU tell them.

Erin E. Dunnigan, MBA
Vice Chair, Council of Student Members
Ohio State University College of Medicine, 2006

References

NRMP website: http://www.nrmp.org

Robinson S. Tweaking the Math to Make Happier Medical Marriages. New York Times. August 24, 2004.

Roth AE. The Origin, History, and Design of the Resident Match. JAMA. 2003; 289: 909-912.

Back to August 2005 Issue of IMpact

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