Authors: Linda Katirji MD, PGY-3 at University of Kentucky, and Adam Kellogg MD, Associate Program Director at UMMS-Baystate, on behalf of the CORD EM Student Advising Task Force (SATF)

Match Day 2018 is March 16th. This is an incredibly stressful time for applicants to residency training, and those who advise them can also be nervous.  No one wants to hear that a student ended up unmatched after they coached them through this grueling process.  A recent article by Tracy Bumsted, Benjamin Schneider, and Nicole Deorio, published in Academic Medicine, explained what unmatched students are up against (1).  This post will highlight some key points from that article and summarize the most important steps for the unmatched applicant.  For further advice about the unmatched emergency medicine applicant, please refer to SATF’s Emergency Medicine Re-applicant Applying Guide.

While match day is a time of excitement and celebration for many, for medical students who do not successfully match, what follows is the emotionally and mentally taxing task of finding a PGY-1 position. Although going through the Supplemental Offer and Acceptance Program (SOAP) is something many medical students find difficult to think about, students who are at risk of not matching should be aware of the process just in case.

Unfortunately, due to the increasing number of graduating medical students, yet  stagnant number of GME positions, there will be more students who do not have a position after the match. According to Bumsted et al., the most common reasons are due to academic problems, professional lapses, low or failing USMLE scores, poor interviewing or interpersonal skills, unexplained gaps, poor fit between applicants and their first choice specialty, compounded by the lack of a backup plan. Those who remain unmatched typically have more than 1 of these risk factors.

According to Results and Data from the NRMP 2016 Main Residency Match, in 2016 there were 975 PGY-1 positions available for 13,920 unmatched applicants. 1,130 of these were unmatched US allopathic seniors. After going through the SOAP process, 54% (615) of these US allopathic seniors still had not secured a residency spot. In 2017, 99.7% of EM positions were filled in the match, leaving only 0.3% of the spots open for the SOAP process.  As difficult as it is to think about, students should think about a plan should they end up in this position.

There are essentially 3 pathways to secure a spot after an unsuccessful match as well as an unsuccessful SOAP.

1. Secure a PGY-1 position after the SOAP but before the start of the academic year
2. Secure an open PGY-1 position sometime during the year through a residency vacancy
3. Re-enter the match the next year, in the same or different specialty

If a student does not obtain a PGY-1 spot, it is important to spend time improving his or her application with the mentorship and guidance of an advisor who knows the details of the students application. Identifying the cause of the failure to match is the first priority. The goal then is to determine the best personal strategy for mitigating those flaws in their application. For emergency medicine in particular, the most common way that a re-applicant seeks to improve their application is by obtaining graduate clinical experience. Delaying graduation / extending medical school may be an option for some (especially those who decided to go into EM late in their 4th year), however this is at a huge cost for the student. Choosing that path would give the student the opportunity to complete research or obtain an additional degree (MPH, MBA, etc). The pathway for best spending the re-applying year is an individual choice and depends on the specific circumstances of that applicant.

There is some debate on what sort of graduate training position is the most beneficial for a student who plans on re-applying to EM (transitional year, surgical versus medical preliminary year, a categorical position, etc). SATF’s Emergency Medicine Reapplicant Applying Guide explains some of the benefits and potential drawbacks of each position. The bottom line essentially is where you obtain a spot, rather than in what. If possible, try to obtain any position that has an EM residency, and hopefully rotate through the emergency department early in the year. The EM program director at that institution can act as your best advocate during this time.

For advisors, Bumsted, et al. lay out guidelines for advising students in all specialties after they have not matched. They break their recommendations into three categories by time since the student has not match:

Immediate post “no match” period (1-4 weeks)

• During this time, students are grieving and have difficulty absorbing advice or making plans which is unfortunate since this is likely the most crucial time
  • Encourage good behavioral and physical health
  • Risk of failing a clinical rotation during this time is high
• After the SOAP, the final vacancy list is released by the NRMP and students can contact the programs directly
  • “This practice does require significant work on the part of the student as well as faculty advocacy to engage with programs inundated with similar communications”
  • 50% of unmatched students will find a position this way

Short term “no match” period (1 month – 1 year)

• Continue to explore underlying issues and brainstorm alternative fields
• Students must improve application or create one in a new specialty, earn an income, and stay motivated – tasks which can conflict with each other
• Students should diligently check for sudden residency vacancies

Long term “no match” period (>1 year)

• There is limited data on outcomes of students during this time
• Studies show that probability of matching greatly decreases each year without a successful match
• Students should continue utilizing advisors and obtaining new letters of recommendation

Students who do not successfully match must act quickly and make life-changing decisions in a stressful and hectic climate. Students who at risk of not matching should work closely with an advisor to maximize their chances of obtaining a GME position in their desired field, and be familiar with the next steps should they find themselves unmatched.

If you advise students in the EM match, or you are an applicant at risk of not matching  you should read:

1. Considerations for Medical Students and Advisors After an Unsuccessful Match
2. CORD Student Advising Task Force Re-Applicant Guide