Rank List in!

Last night Eric and I finalized my residency rank list, and I stayed up late to submit it. It's in! It's done! The final deadline is Feb. 25 at 9 pm, but I'm not going to open the list back up before then. First of all, I'm going to be gone Friday-Tuesday, leaving me just Wednesday to play around with it, and second of all, word on the street is that people who make changes or submit close to the deadline have an increased frequency of 1) having computer malfunctions screw with their ability to submit and 2) having regret about last-minute changes. So that's it, I'm done.

What comes next? Between Feb. 25 and March 16, a computer program runs The Match and produces the results. On March 16, if you have not matched anywhere, you receive an email and start to cry. On March 17, you get to see the list of unfilled spots in the country and participate in The Scramble, in which you scramble to contact programs with unfilled spots and beg for acceptance. If you have matched somewhere as of March 16, you just breathe a sigh of relief that you don't have to scramble, and you continue to squirm until March 19.

On March 19 at noon, every graduating medical student across the country gets to open an envelope that contains the name of the program they have matched into. Most schools have a Match Day ceremony of some sort that involves some pomp and circumstance, food, anxiety, and alcohol. At noon, everyone opens their envelopes, everyone cries either happy or sad tears, and then the drinking continues. Whew! I get nervous just thinking about it. Oh, who am I kidding; I've BEEN nervous for months now!

So how exactly does the program match everyone up? Well, the basic tenet is that the match favors the student, not the program. That is, it will try to put each student in the highest possible program from his or her list, rather than filling a program's spots with the program's highest ranking members. Here's an article that appeared in JAMA describing the history of the match, why it was implemented, and how it has changed over the years.*

And here's a really good explanation of the matching algorithm courtesy of NRMP, the National Resident Matching Program, the body that runs the match. Here's a personalized example:

I create my rank list, with 3 programs. We'll call them Program A, B, and C. Each of those 5 programs has 5 spots to fill, each interviewed 50 applicants this year, and each program ranks its 50 applicants from most desirable to least desirable.

So say Program A, my #1 choice, ranks me as its 6th choice. Program B, my 2nd choice, ranks me as its 2nd choice. And Program C, my 3rd choice, ranks me as its 10th choice.

The computer first looks at my list, and sees that I ranked Program A first. At that moment, at the beginning of the algorithm, Program A has all 5 of its spots open, so I get put into one of them. I have tentatively matched. Then the computer moves on to the rest of the applicants in the pool. If 5 other applicants all ranked Program A as their #1 choice as well, and those 5 applicants are higher on Program A's list than I am (at #6), then the computer would bump me out of Program A and fill Program A with Program A's #1-5 applicants, since those applicants also chose Program A as their #1.

So now I'm unmatched again. Now the computer considers it impossible for me to match at my #1 choice, and moves on to my #2 choice, which is Program B. If Program B is already tentatively full, I will bump the lowest ranking applicant out, because I am Program B's 2nd choice. I think at this point it would be nearly impossible for me to not match at Program B and match anywhere else, so I should be all set.

But how could it be possible for me to match at Program A, if I'm Program A's 6th choice and they have 5 spots? Well, if Program A's top 5 applicants don't all choose Program A as their first choice, I have a window of opportunity. For instance, if Program A's top choice (we'll call him John) hated Program A when he went to interview and decided he would never in a million years want to go there, then he wouldn't rank it at all. So even though Program A really wants John, John absolutely does not want to go to Program A, and it is therefore impossible for that match to be made (see, this is where the match "favors the applicant's desires, not the program's."

So if John is out of the running, then I would become Program A's #5 choice, instead of its 6th, and I should get in.

Stressed out yet? Yeah, me too. Now multiply that until you reach reality, in which there were 3,475 programs with 22,240 available spots for 44,598 applicants (U.S. seniors, foreign medical grads, people who delayed entering residency for a variety of reasons, etc), and 20,940 matches last year. (Data and charts here.) Eek! Thank goodness computers are so fast and powerful these days!

Someone told me that this matching algorithm was originally designed for some sort of dating match-making, and I found another article that confirms this (from the Society for Industrial and Applied Mathematics). Another tenet of the match, aside from favoring the applicant's desires over the program, is to create a situation in which no applicant-program pairing prefers swapping with another applicant-program after the match is done. In other words, say I end up at my #2 and John ends up at his #2. If I ranked his program as my #1 and the program ranked me as its #1, but John ended up there; and at the same time, John ranked my program as #1 and it ranked him higher than it did me, then my program, John's program, John, and I would all prefer to switch around. This would be disastrous if it happened to multiple pairings, because then the match would not have worked as well as possible, and you'd have people switching around afterward. A logistical nightmare!

And yes, when I signed up for the residency application process this fall, when I registered with NRMP a few months ago, and when I submitted my rank list last night on NRMP, I agreed over and over again to adhere to the match results I am given. If I match somewhere on my list, I can not pull out completely, or approach other programs to try to switch. It's binding. I don't know what legal action might be taken, but you can bet I would never match anywhere next year if I tried to reapply. I'm sure I'd be blacklisted.

So what makes a successful rank list? Essentially, a longer list is better (especially if you're applying to something really competitive), because it gives you more options. If I only rank only one or two programs, there's a higher chance the computer can't stick me anywhere that works, so I might have to scramble. In order to rank a program, you have to have interviewed there. Then, you have to decide whether you want to rank it. The litmus test is to say, "Would I rather learn [my chosen specialty] at [Program X] or would I rather learn [my chosen specialty] in somewhere completely random (like Alaska, Alabama, Maine, insert random middle-of-nowhere place of your choice)?" A stricter litmus test is to ask, "Would I rather learn [my chosen specialty] at [Program X] or would I rather learn something completely different somewhere completely random?" (I often say, "psychiatry in North Dakota".) If that's your choice, you're likely to decide to rank Program X after all.

However, I interviewed at 16 programs, and have only ranked 13. The last three were just too horrible. Well, two were horrible and one I decided would be a big blow to my ego. And yes, I fully believe that I would rather become a surgeon or internist at some random middle-tier program (for one year, anyway, then reapply) than to learn Ob/Gyn at those three programs. They were that horrible. I think this is safe; 13 is a pretty long list, so I should be OK.

And finally, why the long wait between the ranking deadline of Feb. 25 and the results starting March 16? According to NRMP, they say that in those three weeks they take :

"a number of major steps to assure the accuracy of both the Match and the subsequent release of Match information. Those steps include:

• Checking the integrity and completeness of the data.
• Transferring the data to the algorithm module, checking it again, and running the Match.
• Verifying the results of the Match and transferring the data into the NRMP databases.
• Creating more than 60,000 individual reports for applicants, programs, and schools, and assuring confidentiality of the information. The reports are then posted to the Web in accordance with the Match Results schedule.
• In addition, time is allotted for unmatched applicants and unfilled programs to make decisions before Match Day." [ie, the Scramble]

I guess that sounds fair. You might also be interested to know that almost every year, someone tries to sue NRMP on anti-trust grounds. I have to admit, the whole matching concept is rather weird. But objectively, it is a fair and orderly way to evaluate programs, to have programs evaluate applicants, and to try to make everyone happy. If things were the way they used to be, in which I might get a telegram offer during my second year and have to reply in a matter of hours (well, it would be via email nowadays), that would be MUCH more stressful. You might agree to accept a position and never know if that's truly the best you could have done with yourself. Decisions would be made based on first- and second-year grades, which, while important, aren't necessarily good predictors of becoming a good physician. I can't even imagine the insanity. Yet somehow, lawyers, dentists, pharmacists, and a number of other professional students manage to find jobs without using a match. Who knows.

In any case, now it's just a waiting game. Twenty-six days until March 16, when I found out IF I've matched, and 29 days until March 19, when I find out WHERE.



*Subscription may be necessary to access the full article, but just comment if you want the pdf and I'll send it you. The citation is JAMA. 2003;289:909-912.