Surviving the Match

For thousands of fledgling doctors like Adam Warren, the future hinges on a single day in March.

Every year on the third Monday in March, medical school deans across the nation warn their senior students to stay alert for a pager call. Worse than a late-night code blue, that ring, if it comes, portends terrible news.

Stanford medical student Adam Warren’s pager went off that Monday in 2004, and when he saw the number of the dean’s office on its screen, the blood drained from his face. He called the office, and the staffer on the other end confirmed his fears: After six years of intensive medical training, he’d struck out in the lottery that places students in residency training positions. Without a residency, Warren had no job, no prospects for becoming a surgeon, and no salary to pay off his massive student debt.

Warren had dreamed of being an orthopedic surgeon since high school. An energetic and muscular athlete, he was then a track standout who later played football for UC Berkeley. Between his own inevitable injuries and those of his teammates, he developed close relationships with the athletic trainers and sports medicine specialists, which only strengthened his career ambition. During his pre-med dance at Cal, Warren developed an interest in immunology and supported himself by working in labs, including a stint at Emeryville’s Chiron Corporation. His scientific aptitude earned him a slot in Stanford’s prestigious medical program.

Warren kept an open mind about his prospects. When Stanford researchers, noting his lab skills, urged him to get a Ph.D, he pursued it for two years. But then he returned to med-school classes, concluding he didn’t want to be a scientist.

Pediatric surgery also tempted Warren, and he so impressed Stanford doctors during his third year that one pediatric transplant surgeon offered him a general surgery residency a full year before anyone else could apply. But the job came with strings attached. “There was an unwritten rule that I’d have to first go and prove myself on their surgery trips to the developing world,” Warren recalled. “Plus, neither Stanford nor general or pediatric surgery felt right.” He would have had to toil for five years on adult gallbladder removals and amputations before getting to operate on kids.

Orthopedic surgery was what Warren really wanted. So he did what every medical student must do. He entered the Match.

The Match is the complex lottery used to place medical students in residency programs at the nation’s teaching hospitals. It’s a make-or-break moment in a young doctor’s career. These programs are where physicians are trained in their specialties and become eligible for certification by the state medical board. Across the nation this week, tens of thousands of budding MDs receive the match results that will profoundly affect their life direction. The news will in large part dictate where they live and work for the next three to seven years, what field of medicine they practice, and their future earning potential.

While a medical school acceptance letter is popularly seen as a ticket to autonomy and financial comfort, the Match turns the nation’s future neurosurgeons and cardiologists into hapless supplicants compelled to juggle their hospital duties with applications, interviews, and cross-country hospital visits. The process can be nerve-racking, exhilarating, or devastating. And for those who think strong scores and great letters of recommendation are tickets to success, the inherent subjectivity of the Match can come as a rude awakening. The results can alternatively jumpstart a glorious career at a prestigious hospital or place a fledgling physician in an inferior training program far from where he or she wants to be.

“The Match is stupid,” says David Goldenberg, a journalist whose wife, Sara Thierman, is preparing for the 2007 Dermatology match. The San Francisco couple wants to live near family in Alabama or New York City, but they know they could end up anywhere. “Its full purpose is to drive students crazy. It’s a load of pressure — you may end up here, you may not; might match, might not. Pretty much everyone is unhappy.”

Even in the best-case scenario, the Match sentences recent med-school grads to at least three years of low wages for the privilege of treating the patients of attending hospital physicians at all hours of the night.

In Warren’s case, it left him unemployed.


The Match

The National Resident Matching Program was established in 1952 to make the residency application process less chaotic. Before that, top contenders might sit on offers from multiple programs while holding out for their first choices, leaving less-competitive applicants in limbo for months. For the latter group, this meant eleventh-hour moves across the country as the cards fell where they might. Like pro sports teams, hospitals would compete for prime students by extending offers as early as the sophomore year of medical school. Some sent “exploding” offers that would expire in 24 to 48 hours if the applicant did not reply.

The Match is actually several matches. The largest, which takes place this week, is that of the National Resident Matching Program, catering to internal medicine, family practice, pediatrics, and other specialties. The American Urological Association runs its own match for urology programs. Finally, the San Francisco Matching Program handles ophthalmology, neurosurgery, pediatric neurology, and plastic surgery. Hopefuls submit their applications in the fall, and the newly minted doctors typically start their residencies the following July.

The system compels participants to accept a binding contract. Unlike, say, third-year law students, Match applicants must train at whatever program chooses them. Conversely, hospitals must accept the doctors they are assigned. But the house has the clear advantage: While a law student can negotiate salary and perks, would-be residents have no say regarding pay and working conditions. “It’s not really a free market,” Thierman says. “You don’t get to negotiate job offers.”

That’s too bad for the residents, who in most cases earn between $40,000 and $60,000 annually for grueling eighty-hour weeks, and that’s assuming their program respects the recently instituted cap on working hours. Acknowledging the grind, some programs try to sell themselves as a bit more enlightened: “Residency is hard work. However, a few key features of our program mitigate needless suffering you might be exposed to elsewhere,” promises the Web site for Stanford’s psychiatry residency.

Fairly recently, residents pushed back a bit. In 2002, a group of them filed a federal class-action lawsuit against the Accreditation Council for Graduate Medical Education, which regulates the training programs. They claimed price-fixing, as evidenced by universally low pay for extremely long hours. One month later, the council hastily reversed decades of resistance and implemented an eighty-hour-maximum workweek for residents, although the price-fixing suit was ultimately dismissed.

Despite the Match’s drawbacks, Philip Pizzo, the dean of Stanford Medical School, says it helps students and hospitals achieve their mutual goals. “I believe it is a fair and proven mechanism that streamlines a complex process in a manner that favors students and assists training programs,” he says.

But many medical students feel otherwise. Their postings on Web bulletin boards under usernames such as PathHopeful, DrMcNinja, and Arrhythmia7 reflect increasing anxiety in the days preceding the Match. “I am a nervous wreck,” one writes. “I wanted to start planning but I feel like my life is on hold until March 15.” Another posts a mock prescription for alcohol twice a day for neuroticism. Debate abounds over the Match’s value. “I honestly think we could have come up with a better solution,” another student opines. “There are plenty of other industries and professions that have to hire graduates in batches, and they seem to function fairly without a Match. It takes months of miscommunication and politicking and other assorted reindeer games to facilitate the Match.”

David Goldenberg favors the MBA model: If the business school lets them, companies extend limited-time job offers to students. “It’s not great, but it’s better than the Match,” he says.


Getting There

Simply getting to Match Day requires incredible dedication. After spending two years memorizing anatomy, biochemistry, and pharmacology, medical students embark on hospital rotations, where they get hands-on training in different medical fields. All must learn the basics of obstetrics and gynecology, internal medicine, surgery, pediatrics, and psychiatry. Fourth-year students do rotations in specialties that interest them, spending two weeks to a month with doctors they hope to emulate. Many also do “audition” rotations at their dream hospitals, traveling to distant cities at their own expense, in the hope that they will be noticed by residency program directors.

Adam Warren wanted to stay in the Bay Area, so he tried to maximize his face time at Northern California hospitals. He did five month-long surgery rotations, including a stint in SF General’s trauma unit, and orthopedics rotations at St. Mary’s, Stanford, and UC San Francisco. From June through November of 2003, he spent nearly all of his time assisting in operating rooms and tending to patients, showing up early and leaving late. He still paid tuition to Stanford, but essentially worked for the hospitals for free. Knowing he was being scrutinized as a potential resident, he tried to be perfect in every possible way; affable yet academic, compassionate but still competitive.

UCSF felt like a pressure cooker due to a surge in visiting medical students doing orthopedic surgery rotations that year — fifty or so did stints prior to the Match. During his time there, Warren became friendly with several residents and faculty members. Through them, he learned that the administration considered him clinically superior to the other “rotators,” but that most of them had medical board exam scores in the 99th percentile, while his were below the 91st. The latter, according to Warren, is an unofficial cutoff for the hospital’s prospective orthopedics residents.

Warren approached the school’s program director to ask what else he might do. The response: More research tailored to orthopedic surgery. So he applied for a research fellowship as a backup. In the meantime, he put in for the Match through the Electronic Residency Application Service, an online system that charges $60 for the first ten applications and progressively more for each additional one. He provided letters of recommendation, medical board exam scores, a personal statement, and his status as a member of the Alpha Omega Alpha honors society. From a list of nearly one hundred orthopedic surgery residencies, Warren applied to forty, as many as he could afford.

Then it was time to wait. As the weeks went by, his Stanford colleagues filled their calendars with interviews, tried on suits, and spent hours a day looking for cheap airfares. Warren scored interviews with three programs: Stanford, St. Mary’s, and UCSF.


Playing the Game

In considering a career path, students must seriously weigh their chances of landing their desired specialty. While heart and brain surgery were among the most competitive fields a generation ago for their prestige and high pay, the drive to play God has given way to the drive to play golf. Increasingly, students aspire to specialties that offer more money for less effort. Dermatologists, for instance, are well compensated and rarely get called into the hospital at odd hours. And because patients often pay for skin procedures in cash, dermatologists face fewer of the insurance hassles that plague modern doctors. But there’s intense competition for the few available residencies.

Money isn’t always the motivation. Dermatology applicant Josh Spanogle is a nontraditional Stanford medical student who majored in humanities at Yale and dabbled in acting before applying to medical school. He’s the author of a medical thriller, Isolation Ward, and is writing a second book.

Spanogle considered orthopedics, but was drawn to dermatology by its more reasonable work pace, and also the death of his stepfather from melanoma. “If I don’t get in, I’m going to do a year of research and apply again,” he says. “The life of an orthopedic surgeon would not let me pursue writing.”

He’ll be competing against the cream of the crop this year. Many of his rivals boast board scores in the 95th percentile and up. Trying to match in a cosmopolitan city or sunny state requires incredible luck and an unblemished record. That’s because a dermatology residency — even in a desert town a long, miserable drive from Los Angeles — is more or less the Holy Grail for California medical students.

Case in point: Last year, according to one Loma Linda medical student, the dermatology program director at Loma Linda University Medical Center considered only applications with minimum board exam scores around 250 (185 is barely passing; 270 and up is astronomical). And the program rarely interviewed students who didn’t have Alpha Omega Alpha status, which less than 10 percent receive.

Competitive programs often use such cutoffs to filter the deluge of applications, but because they won’t tell applicants what those cutoffs are, students waste hundreds of dollars applying for residencies they have no chance of getting. Meanwhile, med-school deans have been known to push top students into the more-competitive specialties, telling them they would “waste” their high board scores on less prestigious fields such as family medicine. The association of high scores with surgical or “lifestyle” specialties has coincided with declining student interest in primary care.

The programs also receive a “Dean’s Letter” from each applicant’s school. It summarizes the student’s performance over the preceding three years, along with extracurricular and leadership activities. While the Dean’s Letter generally tries to put the student in the best possible light, the final sentence often contains a code that conveys class rank. “This student performed outstandingly compared to the rest of the class,” for instance, implies a ranking in the top 10 percent. Says David Crandall, a physician at Detroit’s Henry Ford Hospital, “If more people from your school are applying to the same program and they all are ‘outstanding’ candidates, and you’re just an ‘excellent’ candidate, then you could be in trouble.”

Once the residency programs sort through the paperwork, they invite top contenders for interviews. To increase their chances, students visit as many programs as they can — it’s not uncommon for applicants to shell out $6,000 or more in the process.

The interviewees frequently fret that their applications are not taken seriously if they lack connections to the regions where they are interviewing. Residency program directors are wary about wasting their top rankings on a long-shot, and consequently will try to ferret out any hint of reluctance on the students’ part.

UCSF, according to Warren, has been able to fill its slots from among its top-ranked applicants ever since it began to pay closer attention to whether interviewees had any strong reason to live in San Francisco. “Before, a lot of the people who were ranked had no intention of coming to California,” he says. “Now [UCSF officials] scrutinize applications for any indication that the person isn’t serious about the location.” Smart applicants play this game to their advantage. One emergency-medicine resident in Seattle initially got the cold shoulder from her program when she applied as a medical student, so she called the program and mentioned that her fianc√© worked in the area. “I got an interview right away,” she recalls.

After the interviews were over, Warren and his rivals ranked the programs they’d visited according to preference — UCSF was his dream, even though he knew at least four hundred people were applying for six spots. The residency programs, meanwhile, submitted their own rankings of interviewees. Then, as happens each year, everyone’s preferences were plugged into the complex computer algorithm central to the Match.

The fates of Warren and thousands of his fellow students were now in the hands of a machine.


Backroom Deals

Harrowing and subjective as it may be, the Match might indeed be the fairest way to place medical students were it not for one thing: Parties on both ends sometimes lie and cheat to fulfill their goals.

Residency programs are highly motivated to recruit their top-ranked applicants. It’s embarrassing to a program when a desirable student ranks other ones higher, forcing the program director to look further down the rank list to find a match. That’s a big part of why programs favor applicants with local connections, or who show exceptional interest in that program.

Crandall recalls how, during his interview at Oklahoma State University, administrators made a point of telling him they “never go past eight or nine on their rank list.” This type of remark compels many a medical student to write three or more adoring post-interview letters to program directors, each emphasizing: “Your program is my No. 1 choice.”

It’s strictly against Match rules for programs to cut advance deals with students, but many do it anyway. Some will assure top candidates that they’ve been ranked highly in order to ensure the applicant will in turn rank the program highly. But sometimes it’s just talk. Warren recalls how two of his student friends were guaranteed to be ranked “high enough to match” by certain programs, and then ended up elsewhere on Match Day. “They’re still bitter,” he says.

Unfortunately, he adds, such backroom deals happen all the time, and his friends’ experience with dishonesty is not unusual. Crandall has heard of similar behavior by residency directors. One program, he recalls, told four of his medical school classmates that they were ranked No. 1 when there were only three open spots to begin with.

Crandall also points out that the depersonalized, computer-based system can lead to tragic glitches. He recalls a classmate who was ranked first by her own No. 1 pediatrics program, but ended up elsewhere because the secretary typing up the hospital’s rank list accidentally transposed two digits in her application number. The error could not be undone.

Things get even trickier when people apply to two specialties at once. Some applicants choose a competitive specialty and a “backup,” while others are in such a quandary over what kind of medicine to practice that they interview in two fields and let the Match decide. But that’s risky. Programs that learn an applicant has interviewed in another specialty may well yank that person from their rankings.


Black Monday

Perhaps what medical students most fear is what they call Black Monday, the day would-be doctors receive that fateful pager call. When Warren found himself empty-handed, he contacted the UCSF orthopedic surgery department to find out why he hadn’t been chosen. He simply couldn’t believe it, especially when he had been in constant contact with the program director.

Some unmatched students will spend a year doing research and try again. Warren, who had applied for a backup fellowship at the National Institutes of Health, went back to the lab for two. But students truly desperate for a residency put themselves at the mercy of a brutal yearly ritual called the Scramble.

The day after Black Monday, the unmatched students gather in their deans’ offices. The night before, they may have hammered out two or three additional personal statements for alternate specialties, trying to sound passionate about pediatrics or pathology at a moment’s notice. The dean gives them a list of programs with positions still open, usually because they didn’t rank all the candidates they interviewed. Then, at exactly 9:00 a.m. Pacific Daylight Time, chaos erupts as the students feverishly call programs around the country seeking to apply for those precious spots.

Hospital fax machines spit out pages and pages of applications, while program secretaries are swamped with desperate phone and e-mail entreaties from all over the world, each would-be resident hoping to be the first. Jackie Sternberg, the dermatology coordinator at Cornell’s medical school, recounts the “fluke” that left Cornell with an open position last year. “Trust me, it won’t happen again,” she says. “My phone was ringing off the hook.”

On Scramble day, simply getting through to programs can be a huge challenge. The slots fill quickly, and participants can see their opportunities dwindle in real time as positions vanish from a Web version of the list the deans hand out. The key is to score a phone interview at a sympathetic program, which might take a few minutes or all day, depending on luck. The luckiest of the unlucky have well-connected senior faculty members to make phone calls on their behalf. Such calls, especially between program chairs, are the most crucial factor in landing a position during Match and Scramble alike, Warren says. If a scrambler can make the proper connections, the appointment letters are faxed, signed, and faxed back, and the exhausted student is hired.

Thierman, who will be out of the country on Match Day, says she has Dermatology faculty members ready to make calls for her if she doesn’t match.

But beggars can’t be choosers. Scramblers often must settle for programs in faraway small towns or poorly compensated specialties. Others sign up for a far more demanding life than they’d anticipated, with night after night on call. Kimberli Cox, a surgeon who moderates an online medical forum, recalls a gay male friend who put only desirable locations on his rank list and didn’t match in psychiatry. He entered a harrowing scramble, which ended in a telephone offer from UCSF-Fresno’s residency program. The student thought, “‘Great, UCSF,'” she recalls.

Fresno, the student promptly discovered, is a world apart from San Francisco.

Yet there are worse things than geographic shock. After years of preparation, the scrambler must be ready to switch fields on a dime. “You get to feel like the most worthless pile of crap as you beg for positions and get pushed by your dean’s office to try for specialties you don’t even like,” says Denise Portugal, a resident working in Los Angeles.

A 42-year-old physician-blogger who calls himself Panda Bear MD recounts how he left his structural engineering career to follow his dream to work as an emergency room doctor. With a wife and children, he didn’t have the option of not working after medical school. So when he didn’t match, he entered the Scramble and doggedly pursued the few open spots in emergency medicine. But no program would take him that year. “The Scramble,” he concluded in an online posting, “is like having four or five rabid badgers shoved up your rectum.”

Applicants who don’t find a residency through the Scramble still have a few options. The urology match and SFMatch each provide program vacancy lists. But finding a vacant position in any of the NRMP-match specialties is significantly harder. The organization’s Web site maintains no such vacancy list, but rather directs applicants to FindaResident, a Web site run by the Association of American Medical Colleges. Here, vacancies are listed by region and specialty, but don’t specify the program. A $75 fee is required to view them, and according to some residents, most programs don’t advertise their open positions in any case.

One New York dermatology resident, posting on an online message board for medical professionals, writes, “It’s true there are a few Derm spots that go unfilled or suddenly open up most years for various reasons. They are virtually all filled by those with connections … either they are top level applicants who didn’t match and got their department chairman to go to bat for them, or research fellows who have been waiting patiently for a spot to open.”

Indeed, a common strategy is for applicants to do research for a year, preferably at their top-choice institution, and then reapply, even though programs usually prefer first-time applicants. Mike Javaheri, a current ophthalmology resident in USC’s prestigious program, opted for this strategy, making his future uncertain. “I felt like an outcast at my medical school graduation,” he said. A year of toiling in a USC research lab finally got him noticed.

But the research year is no guarantee, and often ends in disappointment. One mistake can make an applicant history in the eyes of the program director, and even productive lab time can prove worthless if it doesn’t lead to publication. Given that medical papers often spend three months or more in the editing process, that crucial publication often appears too late to improve a student’s application.

Problems with the Match sometimes thwart even the best of students. Just a few years ago, for example, a glitch in the urology match left six highly competitive programs without any residents at all. Johns Hopkins and other top hospitals refused to accept the scramblers, so the algorithm had to be run again. This left one applicant, who had initially matched at Harvard, completely unmatched in a matter of days.

This year, applicants using SFMatch experienced mishaps due to a new electronic distribution system. One scored an interview at the well-regarded Kresge Eye Institute in Detroit. Trouble was, he hadn’t even applied. The mixup infuriated students who had spent precious student loan cash to apply at Kresge, but never got a callback.


Struggle Pays Off

Adam Warren had to work his tail off for it, but he finally got his elusive dream. After two years of research post-medical school, he returned to UCSF for a one-year surgical internship. He was working in the ICU last March when he got the life-changing news: He had matched in orthopedic surgery, and would continue at UCSF as a resident. “It was somewhat surreal,” he remembers, “but the excitement came from friends and family realizing I had finally made it.”

Now Warren is taking extra time to continue his research and obtain a master’s degree in public health from UC Berkeley while completing his residency. “I think things happened this way for good reason,” he says. “I definitely cherish my job a lot more, having struggled to get it. It makes a difference when I am tired and I have to take care of sick and injured people. I’m confident they are still getting my best.”

Of the Match, Warren says he has no regrets. “I think it works for the most part,” he says. “It is not entirely fair, but neither is getting into med school for that matter. If you have desire, it forces you to become savvy at the process and do your best. It should not be done away with; it should be improved. I think the advising of medical students and their guidance are the areas that need the most work.”

Warren now supervises medical students vying for a position similar to the one he now holds. His advice to them is less about scores and grades than about networking. “Internal medicine is different, because there are so many spots. But in orthopedic surgery, if you don’t have someone advocating for you at that residency committee meeting, you won’t get in. Because six other people will have someone advocating,” the young doctor says emphatically. “It’s the intangibles like that that are really important.”

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