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The Road Less Traveled

HOW SOME MEDICAL SCHOOL GRADUATES GET A RESIDENCY OUTSIDE OF THE MATCH.

The New Physician May-June 2001
Death, taxes and the Match—for medical students, these are inevitabilities of life. Aren’t they? Not necessarily.


Each year approximately 31,000 applicants—16,000 fourth-years from U.S. allopathic medical schools and 15,000 others, including graduates from U.S. osteopathic schools, international medical graduates and “independents” who previously completed medical school—put their lists of favorite programs into the “magical” Match process, hoping the National Resident Matching Program (NRMP) sets them up with one of the 23,000 openings for first-year residency positions starting in July. While some specialty programs—thoracic, plastic and reconstructive surgeries, pediatric cardiology and others—use separate matching programs, the far majority of positions go through the NRMP.


So, with only 0.74 positions available per applicant, Match Day—the third Thursday of March when the NRMP announces placements—is a suspenseful and often stressful experience for students. Will they land their dream residencies, be forced to settle with their third or fourth choices or have to scramble for any acceptable vacant position? To many future residents, it seems life would be a lot more enjoyable without Match Day.


For graduates who find their residencies outside of the NRMP process, Match Day is nothing more than a series of second-hand anecdotes from their tortured comrades. Don’t let this make you think it’s easy to find a position outside of the Match, though, because it’s not. But before we get to how they do this, let’s take a closer look at the Match.


THE BIRTH OF THE MATCH


The first Match was implemented in 1952 to end widespread abuse by both residency programs and medical students. “At that time, there were so many more positions than medical students,” NRMP Director Liz Lostumbo says. “So programs were trying to sign up students as early as their second year of medical school. And on the other side, students were accepting an offer and then reneging on it when a better offer came along.” Ninety-eight percent of U.S. residency programs and 97 percent of fourth-year U.S. medical students participated in that first match, which was organized by the National Student Internship Committee. As a result, 6,000 U.S. medical school seniors were easily matched into the 10,500 available intern positions. With this success, a permanent program—then called the National Internship Matching Program—was established to direct this annual event.


Since then, the program has evolved into the NRMP, an independent organization sponsored by the Association of American Medical Colleges (AAMC), the American Medical Association (AMA), the American Board of Medical Specialties, the American Hospital Association and the Council of Medical Specialty Societies. In addition, four student organizations—the American Medical Student Association, the AAMC Organization of Student Representatives, the AMA Medical Student Section and the Consortium of Medical Student Organizations—sit on the board of directors. However, only two of these student organizations are provided with voting privileges, as determined among the four groups at the beginning of each year.


Under this leadership, the NRMP enforces a two-sided ranking system with a variety of rules attempting to ensure confidentiality as well as ethical and professional conduct by all involved parties.


Here’s how the current process works: After exchanging information with programs and interviewing with them, students submit a ranking of their top program choices to the NRMP, while at the same time residency program directors submit a list ranking their top applicants to fill their July openings. It costs medical students $40 to rank up to 15 programs with a $30 fee for each additional program.


For example, student A ranks hospital X as his top choice; however, hospital X fails to list the student. Therefore, the Match process goes on to student A’s second choice, hospital Y, which ranks student A fourth. At this point, the student would be tentatively placed at hospital Y, as long as it has an unfilled position. However, nothing is written in stone yet. If any of the students hospital Y ranked above student A select hospital Y as their top choice, then student A gets bumped. In that case, the NRMP would then take a look at student A’s third and fourth choices until a match is found. In some instances, student A might not match with any of his choices, in which case he is left to scramble for an opening.


As you can see, the process can be confusing. The NRMP says it continues to tinker with the Match to make it more applicant-friendly. For example, in 1998, following a series of critical articles in Academic Medicine, the NRMP adjusted its matching algorithm to change the process from favoring programs’ interests to being more responsive to students’ rankings. However, the “student-optimal” system has seemed to have little impact. In 1999, 57 percent of students were placed at their top choices, while 15 percent were placed at their second. Nine percent of the applicants were matched with a program they ranked fifth or lower. That was hardly an improvement over a couple years before when 55 percent of applicants ended up with their top choices and 14 percent at their second.


Not surprisingly, the Match still has its critics and remains fraught with distrust on both sides. Research published in the American Journal of Surgery in 1999 said applicants of various specialties believe residency programs engage in questionable behavior, with more than half of all surveyed respondents wanting to see the process improved, and 8 percent believing the process should undergo a major overhaul or be completely eliminated. As for residency program directors, in Family Medicine in 2000, 94 percent reported they received commitments of being ranked highly by an applicant, but 84 percent of those directors said they were skeptical of such promises. In addition, 94 percent of those surveyed said they felt the Match pressures them to mislead applicants about their ranks in order to end up with the best matches possible.


Despite these concerns, allopathic medical graduates who want to practice medicine and start their residencies in July have little choice but to go through the Match or a specialty match. Besides specialty matches, osteopathic graduates can either be placed in a residency through the American Osteopathic Association’s (AOA) match or the NRMP. However, if entered in both, the osteopathic graduate is automatically dropped from the NRMP if matched with a position in AOA’s service, which is announced in February. Either way, they are going through a match.


Yet, for a few intrepid souls, there is still another way.


OUT OF THE MATCH


So what separates these Match-free residents from their colleagues? Well, it can be several things. Sometimes these applicants take advantage of opportunities afforded by a new program, which is not yet contracted with the NRMP to fill its July openings. Meanwhile, other applicants choose not to live by the same schedule as their contemporaries, and instead of beginning their programs in July, they look for those rare gems that materialize in October, December, January or even February. These positions usually become available when a resident is unable to complete the year, either for personal reasons or because the program director determines he’s not adequately qualified to fulfill his responsibilities. When this happens, the vacancy often leaves a void in the health-care facility’s staffing that can’t remain empty until the following July. A replacement must be found.


So the programs look to nontraditional applicants, interviewing graduates who completed medical school in August or December and who don’t feel like waiting until July to continue their education. They also come across graduates who have taken time off from training after earning their degrees (see “Time Out,” p. 18). These applicants interview directly with residency programs and can skip the Match.


In fact, Dr. Kenneth Iserson, author of Getting Into A Residency and a professor of emergency medicine at the University of Arizona, says as many as one-fifth of residency openings are filled outside of the NRMP process. And while it is unclear how many of these were filled through specialty matches or without a match program, he says that, for the assertive and well-informed applicant, there are positions available that allow you to steer clear of the NRMP. “I think there are a lot more people out there in the position to do it than actually take advantage of it,” he says. “I think most people don’t read that part of [the Match rules] and realize, ‘yes, it’s legal.’”


Dr. P. Travis Harker was able to take advantage of such an opportunity. Last August, the 2001 graduate of Ohio State University College of Medicine accepted a Dartmouth family practice and preventive medicine residency that begins this July at Concord Hospital in New Hampshire. While many of his classmates were trying to find their perfect residency during their senior year at medical school, Harker chose to wait and spend a year in a research fellowship at the U.S. Department of Health and Human Services’ Office of Disease Prevention and Health Promotion. And while honing his health-policy skills, Harker heard about a couple of openings in Dartmouth’s new preventive medicine element of its residency program and decided to give the hospital a call. “It was just an opportunity that came along,” he says. “I feel pretty lucky they had a good program and that it was a pretty good fit for me.”


The future resident acknowledges there are risks involved with accepting a position before conducting extensive research of and interviewing with programs. In fact, Harker had taken the initial steps to enter the Match when suddenly the Dartmouth opportunity came along, and he took that position instead. He says it was the right decision for him. “It saved me a lot of money, because I didn’t have to fly around from place to place looking at something that might not be a good fit for me,” he says. “On the other hand, there may be [another residency program] out there that is better…. I won’t be able to find out.”


It seems that traveling expenses are a common reason some medical school graduates avoid the Match. That was certainly true for a first-year resident at Bethesda Hospital in Cincinnati, Ohio. The 35-year-old obstetrician–gynecologist, who asked not to be identified, received her medical degree in China in 1988 and came to the United States six years ago. After taking some time to adjust to American culture, she was ready to begin her residency but couldn’t afford to spend a great deal of money traveling from one interview to the next. So when a position opened up at Bethesda in October, she jumped at it. “I was applying to the Match, but I looked on the computer and found this spot,” she says. “It was a program that fit me. So I chucked all the others and came here.”


GOOD SPOTS VS. QUALIFIED APPLICANTS


It’s not always that easy to get a residency outside of the Match. Unpredictability can make this Match-free process incredibly nerve-wracking. Residency program directors say they usually receive a lot of interest, but the quality of candidates varies. Meanwhile, graduates may find it just as difficult to find a quality program with an opening. “[Program directors] know there are only a few good people out there, but there are few spots too…. It can be pretty intense,” says Iserson, who obtained his residency outside of the Match.


For the opening at Bethesda Hospital, residency program coordinator Kathy Thacker says she received many applications but had to sift through them to find a good candidate. “We got a really good response; I would say more than 100,” she says. “But for [an off-season opening], you see anybody and everybody.”


In some cases, a program director may be a little wary of off-cycle candidates. One program coordinator, who asked not to be identified, says she is skeptical of many of the off-cycle applications her program receives. “A lot of [the candidates] have been out of medical school for 25 years…. You get lots of interest from people who aren’t really qualified,” she says.


But this skepticism can run both ways. Dr. Carol McLaren, the assistant dean of student affairs at the University of Washington School of Medicine, says more and more students are graduating during the summer or winter and are considering off-cycle positions, but she usually advises them to approach these residency openings with caution. “What I may suggest to them is to send out a few applications to a few really good programs, but [unless the students receive one of those positions] just to enter a residency through the Match,” she says.


Many college advisers warn students that sometimes these vacancies occur because of problems within the program. “[The off-cycle graduates] have limitations when it comes to finding a residency,” says Dr. Brian Zink, the assistant dean for medical student career development at the University of Michigan Medical School. “For programs that have a lot of unfilled residencies, it is usually for a reason.” And like McLaren, unless an ideal situation comes along, Zink advises his nontraditional graduates to wait and obtain their residencies through a match.


Still many medical school graduates are uncomfortable with the concept of putting their education on hold, particularly with mountains of debt piling up around them.


TIPS FOR BEING MATCH-FREE


Perhaps you’re sensing that you may be a candidate for getting a residency outside of the Match. So how should you start? The biggest step may be simply learning that an off-cycle residency position exists. In many cases, programs don’t advertise them; they simply “spread the word” among their residents and collegiate contacts hoping to avoid a flood of unqualified applicants. So, it helps if you know the right people. However, Iserson suggests that you do what he did: Contact appealing programs and inquire about unexpected vacancies, either at the moment or in the near future. “Who can tell if one of the residents gets sick or drops out?… [Programs] still need someone to fill that spot,” he says. “You just have to find out by cold calling or by word-of-mouth.”


Some programs have begun to advertise these first-year positions, usually through industry-related Web sites, such as the AMA’s page dedicated to residency vacancies or the AAMC’s “FindAResident,” which requires a fee. “That is one kind of a more organized way to do it other than just keeping your ear to the ground,” Zink says.


But Iserson warns that these sites only advertise a few recent openings and suggests that graduates and students anticipating entering a program off-cycle should be working well in advance. “You really need to plan early and get your act together and start contacting programs that interest you,” he says. To aid this endeavor, refer to the Graduate Medical Education Directory—Supplement, which lists programs offering start dates other than July. This listing is not necessarily complete, though. In the end, the best method to find a program that has an opening or an alternate start date is simple—just ask.


In terms of new residency programs, many directors try to find applicants by spreading the word. So having the right contacts help. New programs also place advertisements in industry-related magazines—such as The New England Journal of Medicine, The Journal of the American Medical Association and The New Physician—or post notices on Internet sites.


To aid your out-of-Match search, Iserson suggests focusing only on the positions that are really attractive to you. “Be assertive, but don’t go applying to places you don’t really want to go. [Programs] are being selective, so you need to be selective,” he says.


It can also be difficult, though, to even decipher when a position is being offered. Unlike the Match process, most programs do not have a rigid structure for interviewing and negotiating with applicants for off-cycle positions. “We try to do everything we would do during the Match process on a smaller scale, but it can be difficult,” says Geri Kelly, assistant to the residency program director at Temple University Hospital. While in some cases this leads to an intimate, professional and informative interview, Iserson warns it can also mean a disorganized and confusing selection process.


He suggests that if you’re interested in a program, particularly a new program, be sure to get all available information about the faculty’s experience and the program’s expectations of its residents. Without senior residents on staff, the burden of responsibilities will frequently fall on first-year residents. But for some interns, this more intense training may be preferred.


That’s why the out-of-Match applicant needs to be more aggressive than his Match counterpart, Iserson says. So if you decide to go for a residency position without the Match, make sure you’re well informed and make sure the residency program is being completely truthful with you. “You have to [research it] just like a job, try to get all the information you can and use all your contacts,” Iserson says.
Scott T. Shepherd is associate editor with The New Physician.