For residency program directors, there’s less drama, but still plenty of excitement.
As the Medical School erupted in cheers and screams at noon on Match Day, it was business as usual at the residency program offices where students will begin their medical careers in July.
“Match Day is like any other day,” says Craig P. Eberson, MD RES’00 F’01, director of the Brown University Orthopaedic Surgery Residency Program. “There’s less drinking involved on our end.”
That’s partly due to timing. Residency program directors got the news, via email, the day before. They just couldn’t tell anyone. “It’s cool to have a secret, but then you can’t say it. So what’s the fun in that?” says John Kawaoka ’00 MD’04 RES’08, director of Brown’s dermatology residency program.
Program directors admit it’s a slightly less pivotal day for them than it is for fourth-year medical students. Though of course programs have favorites, and rank them accordingly on the list they submit to the National Resident Matching Program (NRMP), they like and want to work with every candidate they’ve listed. “I don’t put them on the list if I don’t want them in my program,” Emergency Medicine Residency Program Director Jessica Smith, MD, says.
But the match is still a thrill for program directors, no matter where they are. “Last year I was in Miami at a conference, and I was on my phone constantly checking [email],” Eberson says. “No one else could care less, and I’m in the back of the room—‘Yes! We got that guy!’”
Playing the Numbers
For residency program applicants and directors alike, the match is the culmination of an intense, months-long slog that essentially places the futures of tens of thousands of aspiring physicians at the mercy of a computer program.
In an oversimplified nutshell, the NRMP fills available hospital intern slots each year by taking graduating medical students’ ranked lists of programs and programs’ ranked lists of candidates and feeding them into an algorithm that attempts to match each applicant with their highest-possible choice. The results are binding for both parties—so stakes are high.
It’s a remarkably effective system: this year, according to the NRMP, 94.3 percent of fourth-year MD students matched to PGY-1 (first postgraduate year, or intern) programs. More than three-quarters of all applicants matched to one of their top three choices.
That success rate, however, belies the angst and uncertainty of an undertaking that residency program directors call “heartbreaking,” “out of control,” and “Game-of-Thrones-like.” “Not matching is horrendously traumatic,” says Eberson, an associate professor of orthopaedic surgery.
While the number of people seeking US residencies continues to rise, residency positions have not kept pace. This year, 35,969 candidates competed for 31,757 spots—both record highs, the NRMP reports. Though fourth-year allopathic students have consistently matched at rates between 92 percent and 95 percent over the decades, they’re applying to 50 percent more programs now than they were 10 years ago, according to research by Warren Alpert Medical School professors Phil Gruppuso, MD, and Eli Y. Adashi, MD, that was published in Academic Medicine last year. Though no data support it, they wrote, “The notion that ‘more is better’ appears to have taken hold.”
And perception is everything. “It’s just known that, really, if you want to increase your chances, you just have to apply as many places as you can,” says Kawaoka, an assistant professor of dermatology.
His field is a case in point: nationwide this year, there were 651 dermatology applicants; more than 550 of them applied to Brown. “So they’re applying to pretty much every [program],” says Karen Medici, the program coordinator. And they were vying for only 423 available PGY-2 dermatology slots nationally (four of them at Brown). In other words, about a third of aspiring dermatologists failed to match. “The joke that the people who are in derm now say is that if we had to apply now, we would never get in,” Kawaoka says.
The avalanche of applications that programs receive each fall means that, by necessity, most candidates begin as little more than words and digits on paper. Most programs have a minimum threshold for board scores, grades, and other criteria, including the Internal Medicine Residency Program at Morristown Medical Center in New Jersey, associate program director David Kuo ’89 MD’93 F’98 says. His program gets well over 5,000 applications each year, for 50 categorical and prelim slots; the cutoff “helps us separate the wheat from the chaff,” he says.
That concerns program directors and educators. Not only can reliance on quantitative metrics “further erode emphasis on students’ backgrounds and qualitative indicators of performance,” Gruppuso and Adashi wrote, it may penalize “students from disadvantaged educational backgrounds who may be at risk for underperformance on standardized examinations.”
With that in mind, even program directors who have thresholds read every application. “One of the things we like to do is recognize potential,” says Smith, a clinical associate professor of emergency medicine. “If your board scores are not at the top of the charts but you’ve done really well clinically, you’ve had great scholarly productivity, you’ve rebounded [from Step 1 to Step 2]… that is a sign that academic potential is there.”
For some candidates, cost can be a further disadvantage. “It’s a huge financial strain on students to have to travel to 30 programs to interview, when the reality is they probably don’t even need to interview at 30 programs,” Smith says.
Students are “taking nearly two months off from medical school to engage in what is a nonstop, travel-across-the-country process,” says Simone Thavaseelan, MD RES’10 F’11, director of Brown’s Urology Residency Training Program and a clinical assistant professor. The average urology candidate does 14 interviews, she says, and “that cost is many thousands of dollars to them to travel, to visit, to lodge, to crisscross the country.”
That doesn’t even include several month-long away rotations during fourth year, which increasingly have become the norm for competitive residencies. Also called audition rotations, they’re opportunities for both sides to make a good impression and see if they’ll be a good fit. According to a study Eberson coauthored in January in the Journal of the American Academy of Orthopaedic Surgeons, the average orthopedics aspirant completes 2.4 away rotations and spends $2,799 to do them. Furthermore, he and his coauthors wrote, the rotations may not align “with the mission of undergraduate medical education.”
Yet again, Gruppuso and Adashi found no data to support the belief that away rotations improve the odds of a match. But they’re part of the culture in certain specialties, including urology, Thavaseelan says: “I’m convinced that my away rotation at Brown was critical to my successful match.”
If the Program Fits
Fit is a top concern of program directors as they sift through mountains of applications. Kuo says as he reads them, “I try to ferret out if they’re a good fit for this program, which for me, it’s finding out if they have good team spirit, a strong work ethic, if they’ll fit in with our culture here.”
But the electronic application lets students effortlessly play the odds, and apply to dozens of programs they may know little about—which worries program directors. “It’s just click, click, click,” Thavaseelan says. “It’s very difficult to discern who might actually be interested in Brown Urology.”
Program directors “agonize” over interviewee selection, Smith says, because they know, inevitably, they will give some of their precious few interview slots to candidates who really have no interest in their program—and pass over others who would thrive there. “It’s really heartbreaking to say, oh, god, we have to reject someone because they’re average,” she says. “That person could come here and do amazing things.”
“You’re reading through [the applications]and you’re saying, yes, no, yes, no,” Kawaoka says. But “every single one of them is amazing. … It’s a skewed viewpoint of the world.” He adds: “These are real people. This is not Monopoly money. This is real. Real chances, real opportunities.”
Interview days are as long and exhausting for program staff and faculty as they are for candidates, with everyone trying to impress. They conduct dozens of interviews each day; depending on the size of the program, directors meet with most or all of the interviewees. Kuo says it’s one of his favorite things. “It gives us an opportunity to meet these fresh and enthusiastic faces. We only meet for 30 minutes at a time, but it’s a lot of fun to interview them,” he says. “We’re interviewing them as much as they’re interviewing us.”
“We hope it’s not a lot of pressure,” Smith says. “We really want to get to know the students. The hard part is getting the interview.” She tells candidates, “By virtue of the fact that you are in these seats, we like you. We want you.”
With their focus on fit, many interviewers don’t ask candidates about medicine. “We take into account interesting stories about their childhood, their background,” Eberson says. “Those intangibles are important; otherwise why invite them to interview?” Thavaseelan says her go-to questions include “what do you think makes a good resident? … What are those qualities that you want to emulate?”
Naturally, programs want—and need—team players. “Some [orthopedics]programs don’t have an ER. Here the ER is slamming,” Eberson says. “It’s an enormous team atmosphere.” But directors want their residents to gain from the programs they join, too: fit is as important for their well-being as for the team’s.
“You’ve got to be in a place where you’re going to feel as supported as you can with a network of friends that’s going to carry you through the tough years of residency,” Smith says. “They might be a great applicant, but who are their friends going to be here? And that is a legitimate question that we ask ourselves because we don’t want someone to feel isolated or alone.”
It’s a lot to assess in only a few minutes, and Kawaoka finds it stressful. “They try to figure out what we’re like, we try to figure out what they’re like,” he says. “That’s just bound to not work out sometimes.”
Leap of Faith
To finalize the rank order lists for the match, most departments hold several meetings, attended by program directors, faculty, senior residents, and others, where they compare notes about interviewees and arrange and tweak (and rearrange and retweak) the list in order of favorites.
“We have a number of people who interview, and then a lot of opinions,” Kawaoka says. “There’s definitely some heated discussions at times, but no one’s thrown a punch yet.”
Most programs discuss and rank every interviewee, save one or two who may have taken themselves out of the running voluntarily—or behaved unprofessionally on interview day. “If on the one day you need to put your best face forward, if you cannot get through an interview without profanity, that’s a red flag,” Smith says.
“Anyone who goes on the list, we want to be very, very sure that we want to have them in the program,” Thavaseelan says. Disagreements are inevitable, and reputations may be on the line. “Everyone remembers when you really advocate for someone, so when they match, god forbid they’re not perfect,” Eberson says.
Despite the hours upon hours of application review and interviews and deliberations and debates, there’s simply no way to know what a candidate will be like until they report for duty, as a resident. “It’s like if the NBA draft got numbers from the weight room and a speed test but they have never seen [the player]shoot a basketball,” Eberson says.
“We’re doing our best to make the list full of people who we think are going to work well together and contribute. And it’s hard,” Kawaoka says. “It’s hard.”
There probably is no way to make the ultimate task of residency program directors—annually creating the best possible class of new physicians for their departments—any easier. But some reforms, if widely adopted, could ease the stress and burden for everyone involved.
In their Academic Medicine article, Gruppuso and Adashi suggest that “capping the number of interviews per student would go a long way towards stemming the time and resource drain on both applicants and GME [graduate medical education]programs.”
Thavaseelan would go even further. “If you consider application caps, perhaps it limits free choice, but it would increase, on the program side, the percentage of people that we review who are truly interested in our program,” she says. Her program received 270 applications this year for just two positions. “We’re flying by the seat of our pants trying to get all our work done and all these applications reviewed in a meaningful way.”
But, she acknowledges, the intense competition for urology’s limited spots—it has only a 75 percent acceptance rate nationwide—prevents “wholesale change.” “It’s hard to counsel a candidate against them trying to increase their odds,” she says.
Advisers help, Smith says—as long as they’re “honest and realistic with [students]about their competitiveness as an applicant so that way they can target an appropriate number of programs to apply to.” This might mean counseling them to consider a different specialty. “Sometimes it feels like you’re crushing someone’s hope or dream,” Thavaseelan says.
There’s more that programs could do: for example, conducting a first round of interviews online via Skype or another platform is a potential money- and timesaver, Gruppuso and Adashi wrote. They also advocate coordinating the timing of interviews, across all disciplines. Thavaseelan says New England urology programs already do this, so interviewees can schedule one visit to the region. Brown’s dermatology program is one of only a handful nationwide that hold their interviews on Saturdays, instead of weekdays, which Medici says reduces conflicts for candidates.
But it’s unlikely any changes can ever alleviate the anxiety of the residency placement process. Because once the matches are finalized, everyone’s fates are sealed.
“What the match is, is it’s a contract,” Eberson says. “On the surface everyone knows the contract says: you agree to train, you agree to come. What it really means is, if you show up here and you have an issue—a personality problem, you’re stressed out, you don’t work well under pressure, you’re not a good surgeon—we have no test for dexterity—we agree we will do everything in our power to help you graduate a confident and competent surgeon.”
The Big Day
After the lists are submitted, it’s a waiting game until the third week of March—Match Week. The big day, for most program directors, is Thursday: at 2 p.m. Eastern, they receive, via email, their uber-confidential match list. And at 2:01, they start getting phone calls and texts and personal visits from colleagues: “How did we do? Who’s on the list? Who did we get?” Smith says. “It is a wild secret. I can’t even tell the chair who is on that list.” Only associate program directors and program coordinators can know; she avoids everyone else. “I do not have a very good poker face,” she says.
But on Friday, at 1 p.m., the list is public, and the celebrations can begin—muted though they may be. “Is there champagne? No, not usually. … I’ll be at the clinic,” Kuo says. But “generally there’s a lot of happiness.” Faculty are especially thrilled about the people they vouched for, he says: “If we know someone will be really good and we have them accepted to the program, it is a great accomplishment all around.”
Program directors and other interviewers usually call the new interns Friday afternoon to congratulate and welcome them. But that’s just a short break from an otherwise regular day. “We’re pretty much back to work 10 minutes after we find out,” Thavaseelan says.
But maybe with a smile on their face, or a little skip to their step. “These are people we spend a tremendous amount of time working with, and they’re really part of our family,” Eberson says. “It’s a big deal to us.”
Want more Match Day coverage? Read the feature.