Wednesday, April 2, 2014

A match-day lament: "We will rank you very highly"

A medical student and I were discussing his experience with this year's resident matching process. He told me he had interviewed at 18 programs and ranked 17 of them. He matched to a categorical five-year general surgery position at his sixth choice hospital and was satisfied.

His assessment of the situation was that his somewhat below average USMLE Step 1 score might have affected his chances at his first five choices. [See my previous post on how residents are selected here.]

Then he said, "I was a little surprised as I had some really positive correspondence with programs at the top of the list with one even telling me they were ranking me very highly."

Even though he had been warned that this type of thing might happen, he said, "It is so hard to not fall into the trap. It feels so good to hear 'you're ranked highly.'"

He was disappointed that a program would tell him this and not follow through. He planned to tell future applicants to beware.

"I almost wish there was a 'no contact' policy," he said.

Other than hurt feelings, no real harm was done. The match algorithm favors the student. The fact that a program director would tell an applicant that he was ranked highly and then not do so does not affect the way the match process works.

The applicant's rank order list is queried sequentially by the computer until the first unfilled program that ranked him is identified, and that's where he will end up.

Having been out of the program director business for a few years, I'm sorry to see that this sort of thing still goes on.

It works both ways. On numerous occasions, applicants would call or email me to say they were ranking my program highly, only to go elsewhere come match day. I assume that these applicants thought their chances would be improved and I might rank them higher if they expressed greater interest. After being burned a few times, I learned to disregard any such statements.

I agree with my young friend. There should be no contact after the interview including the obligatory waste of time "BS" thank you email from both sides. If there is contact, both parties should take whatever is said with a grain or two of salt.


artiger said...

Kind of like college football recruiting, it's a sometimes dirty business. To be Clintonian about it, it depends on the definition of "highly" as to whether or not the truth is being told.

I would have been thrilled to have gotten my sixth choice 22 years ago. I seem to remember getting one letter that did not say that I was being ranked highly (although it could be implied), but that if I matched there I would be a good fit for the program and would be well trained. I would hope that would have been the case for anyone who matched there.

Skeptical Scalpel said...

The problem is what is being said is easy to misinterpret. It borders on unethical. Med school seniors are naive.

The NRMP match process favors the student. The applicant should rank programs according to her preference. There's no penalty for aiming high.

Anonymous said...

I was an applicant this year and the post-interview courtship was the part of the process I disliked the most. One program I interviewed at specifically stated that they did not consider post-interview correspondence in their ranking decisions, and I appreciated this a great deal. I wish it was disallowed across all programs. The other part of interviews I disliked was the 'second look', which some programs seem to encourage. I wondered if by not going for a second look, would I be at a disadvantage by appearing uninterested in the program.
As applicants, the algorithm favours us ranking programs based on our true preferences, and I would imagine the same is true of programs. So is it a myth that by expressing interest, or telling a program you will rank them 'highly' or number 1, they in turn will rank you higher?
The NRMP algorithm takes care of matching applicants to programs according the preferences of each. The courtship ritual as you mentioned is a waste of time, may increase costs in the case of second-looks, and should be addressed.

artiger said...

Understood, Scalpel. Programs should aim high as well, right? Is there some (un)official ranking out there somewhere, that lets everyone know which programs got their first choices? Or is it all just a quiet ego thing?

Skeptical Scalpel said...

Anon, i appreciate your comments and that you agree with me and my friend. That second look stuff is also nonsense. I don't know if PDs put any stock in it or not. I discouraged the practice. I believe it is a myth that telling a program you will rank them higher will get you moved up on the list and the same goes for the applicant list. In fact if I were an applicant and a PD told me he was ranking me #1, I'd put that program farther down the list because I'd figure that program is a lock for me (possibly wrongly since it might not be true).

Artiger, I do not think there are any published data on who got their first choices and how far down the list a program had to go to fill. I do know that lots of PDs say they filled with 3 of their first 4 on the list. This is about as believable as "the check is in the mail," "it was dry when we closed," or "we will rank you highly."

Anonymous said...

For many would-be doctors, match day is the most important day of their young lives.

SS has talked about thinking long and hard before attending an offshore school. Here is an instructive story, with a happy ending:

Anonymous said...

I think the perfunctory "I will rank you highly" is just a polite sign-off for both candidate and program. It doesn't affect the eventual match.

Both parties know their attractiveness. A few years ago a friend of mine at the local med school thought it was disappointing they had to get down to number 12 to fill their 8 or so surgery spots.

Skeptical Scalpel said...

First anon, thanks for the link. Everyone should read it. It's a happy ending but how many others are there whose stories don't end so well?

Second anon, I agree it doesn't affect the match, but it can cause confusion and consternation.

Sarah L said...

For the Canadian match it is forbidden to ask or discuss rankings - I've heard of it being done but it's considered against the rules and reportable to the Canadian Resident Matching Service. There is no post-interview courting allowed, which can be scary because you often have little idea of whether a program wants you, but it does save this angst. The general advice I give people is to rank the programs you want highest, regardless of how you think the interview went.

Anonymous said...

As a Canadian (seems to be a lot of us here) I only applied to 6 (internal medicine) programs in 2 cities and interviewed at all 6. It took me 3 days of travel.

It sounds like American medical seniors apply to up to 100(!) programs and get interviews in the double-digits all over the country. That's got to be expensive. Maybe current students and residents can advise how much to save for the match process.

Skeptical Scalpel said...

Sarah, that Canadian match policy is a good one. Your suggestion about ranking the programs you want highest works in the US match too.

Anon, the process in the US is very expensive and time consuming too. I don't see how a student could interview at even 15 programs. They used to tell me that they were exhausted by the time the last view interviews rolled around.

Anonymous said...

The Canadian match is the same as the American one except for a few things:

1. There are only 11 or so programs in any specialty, which makes the odds far worse for any one field.

2. You can NEVER apply in the first round EVER AGAIN if you have even ONE day of post-graduate training. Had an epiphany for ENT at the end of 4th year but matched to family instead, because your school had no ENT rotations? TOO BAD LOSER! GO DO A WELLBABY CHECK AND STFU!

3. There are spots in competitive specialties dedicated to IMGs that are OFF LIMITS to Canadian graduates. This boggles the mind! I guess some rich-ass politico's kids went offshore and want to come back to be dermatologists. It's frustrating because I would love to get the hell out of my specialty into one that I actually want to practice but can't because the IMGs have to be able to apply ahead of me. WTF?

The match is a total farce. I hate it, and I hate medical education.

Skeptical Scalpel said...

Anon, thanks for that insight into the Canadian system. I agree that it doesn't seem fair that you can't change your mind and go into another field. What if a spot opened up in ENT? Could you apply for it outside of the match? I also agree that a specific policy to reserve spots for IMGs is hard to understand. Does every graduate of a Canadian school get matched or are some graduates unable to find a residency in any specialty? If it's the latter, then the policy is inexplicable.

Anonymous said...

No, there is no way to do it. There are no outside the match spots.

If you want to go into another field, you need to find someone to transfer with, or you need to find some magical cache of government funding to pay for your extra years of training. People very rarely switch to high-level specialties because spots just never open up. The most switches are to things like family medicine, which the government wants because it saves it money (2 year residency vs the 5 the residency came from).

It is against policy to obtain an outside the match spot. It is also against policy to obtain external funding to pay for a spot, say from a community that severely needs a particular type of specialist. If you're wealthy, you can't pay for your own spot. BUT it is apparently A-OK to accept money from Saudi nationals to train in whatever specialty so they can go high-tail it back to Riyadh after they finish.

If you really want to do another field, first you have to finish your first residency, then you have to practice for one year, and then you have to apply to a re-entry position (which are available in only some specialties that the all-powerful government deems are "in need"). Then, once you're finished training, you have to plunk down in a community of the government's choosing for five years. I guess after that you celebrate your diamond anniversary.

There have always been one or two students per class in the past that didn't get a position - people just brushed it off and attributed it to them being unfit freaks (even if they were considered totally normal before their run of bad luck). Recently, however, things have been hitting a bottleneck and the problem is starting to reach severe levels. I can't remember the exact number but the number of medical students who can't find positions in both rounds of the match, even after applying to something low like family med in SK, is higher than it should be. IMGs are certainly getting a good deal here. It's not fair, but IMGs come from privileged families who pull a lot of strings for them.

And yes, there are always spots in things like psychiatry and pathology that are available, but these are very unique specialties and most doctors don't want anything to do with them. Expecting students to just take these spots because they're the only ones available is ridiculous.

Skeptical Scalpel said...

It's a good thing that Amy Ho [] is not Canadian. If she thinks the US matching system is bad, she really would hate the Canadian way.

I guess a Canadian med student had better be damn sure what she wants to specialize in before entering the match.

I had no idea that it was so restrictive.

Unknown Google User said...

I have a question regarding a non traditional "match" procedure. My family situation is very unique and I've spent the past 10 years away from home where I pretty much raised my younger siblings and have watch them grow up while I'm in school. I'm ready to go home, and work at home, its where my heart is and where I want to live my life out. I don't want to put the fate of my happiness in the hands of an algorithm and am considering doing a year or two of research at my number one institution before applying for residency there, and only there. I know it sounds stupid but what are some thoughts?

Skeptical Scalpel said...

I don't understand your situation. Can you provide more details? Are you still in med school or have you graduated? If so, when? Did you attend a US med school? Have you taken USMLE Step 1? Approximate score?

A year or two of research would put you that far away from clinical medicine depending on when you graduated. This is usually not a plus.

What assurances do you have that the program would consider you for a categorical position?

You can answer here or email me SkepticalScalpel at hotmail dot com

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