The residency couples match

Are you applying as a couple through the residency match? Do you feel confused about how to combine your rank lists? The NRMP algorithm works very smoothly for a couples match, although it is a bit complicated, so I've put together a sample list with some useful details. In this version, the letters of the alphabet each stand for programs, and "partner" is the other half of your couple (it could be a spouse, fiancé, domestic partner, or even a friend; you do not need to have a legal relationship in order to participate in the couples match). You'll also note that I haven't mentioned specialty choices; that's because for the purposes of the NMRP algorithm in this situation, it doesn't matter. So here's a quick look at a potential rank list:

You Partner
A        A
B        B
A        B
B        A
C        A
C        B
A        D
B        D
A      none
B      none
none    A
none    B

In this sample list, you were both interviewed by programs A and B (again, whether it was in the same specialty or in different specialties does not matter here). Only you were interviewed at C, and only your partner was interviewed at D. If you both successfully match into A, then you've matched, and if you didn't *both* match there, the algorithm looks at the next combination, which is this case is both of you at program B. But if that doesn't happen either, you've instructed the algorithm to check if you matched into A and your partner at B, then check if you matched into B and your partner to A, and so on. At the bottom of the list are situations where one of you matched into one of your two favorite programs, deliberately choosing to leave the other one unmatched.

I could have added several more combinations (such as C-D, none-D, and C-none) to the list, but in short, the couples match only works in pairs. You both need to match at a pre-determined combination of your choosing, even if that combination includes one of you not matching anywhere. The match algorithm doesn't care about specialty or location. (Hypothetically, you could design a couples match to deliberately be in different programs on different sides of the country!)

It can be harder to match as a couple in the sense that one of you could drag the other down. Let's say that you only submitted my sample list above with no additions. If you could have matched at C and your partner could have matched at D, but you didn't include that combination (maybe because they were in different cities), you would both end up unmatched. Or if you could have matched at C solo but your partner was never going to match no matter what, there's no combination listed that allows that to happen, so you would both end up unmatched. So to avoid risking anything due to the couples match, if you put every possible combination including each potential where one of you goes unmatched, then if one of you wasn't going to match no matter what, the other will still be able to match.

Going deeper into detail about that, it's worth noting that neither of your lists gets priority; you both need to fit a particular combination for the couples match to work. For a solo match, the algorithm only looks at the top program on your list without risking anything below. Either the condition is met that you match there, or the program filled with other candidates and only then would the algorithm look at the second position on your list, and so on and so on. But for a couples match, *both* of you need to meet the condition that you match to the combination in your top joint match, and either you both succeed or else the algorithm proceeds to the second combination, and so on and so on. 

Also, there's a potential that one of you might "drag the other down" in the sense that one of you might have matched into a better program applying solo. Looking back to the first three lines of my original sample list:

You Partner
A        A
B        B
A        B

If you truly wanted to train at A more than anyplace else in the world, but your partner doesn't match at A, the algorithm would then look at B-B. If you both match there, you'll both be happy in the sense that you'll be training at the same place. But you might be wondering if you would have matched at A on your own, and you might secretly feel like you just were dragged down...but you will never know it for sure. Hopefully that will not become a source of tension for the two of you. That's the only significant downside to a couples match.

Finally, I don't claim that this blog post is an exhaustive list of details about the couples match, merely a helpful perspective on what actually happens. For the official information, please visit the NRMP website.

Switching programs or specialties

What happens if you matched at one of your least-favorite programs? What happens if you matched into your second-choice specialty? Is it possible to transfer?

Matching anywhere isn't easy, so congratulations to everyone who received good news on Match Day! But maybe it's not the result that you dreamed of. For example, you interviewed at a dozen family medicine programs, but matched into your last choice. Or you really wanted to train in anesthesiology, but matched into your backup specialty of internal medicine instead. Or you were chosen for a position after using SOAP, but it's not what you were hoping for at all.

I want to strongly caution you: reapplying might hurt you more than it helps, unless you are very careful. Remember, if you leave, that will create a vacancy in your current program, and if your program director wants to fill it starting next summer, that means he/she has to interview people this year -- at the same time you're applying and interviewing. And if you don't match into a new program, but your program director finds someone, how does that get resolved? It might mean that your contract doesn't get renewed. That's why you and your director need to work this out together before you start applying (or you decide not to reapply, which is usually the best option). In short, would you prefer to complete your training where you already matched, or risk getting discharged after your first year and then not have anywhere new to train?

If you're absolutely determined to reapply, it's incredibly important to have the support of your new program director, and you should get most (perhaps all) of your LORs from your new attendings. After all, you didn't match into the particular program/specialty you desired with your old LORs, so you need to upgrade them to have a better chance. Plus, applying without the backing of your current program would look suspicious. If you don't use any LORs from your current program, you'll still need to include your current program's contact information in ERAS, and if I were a residency committee reviewing your application, that would be my first email or phone call. I can't imagine most applicants successfully transferring to a new residency program without the support of their current training program.

If you can't tell by now, I think that trying to switch is usually not worth the risk. But if you are completely convinced that you need a change, you should sit down with your program director to talk about the situation before you apply or even work on any documents. You would need a very flexible schedule so you can travel for interviews; the other residents will need to pick up the slack when you're not there, and that might cause some tension. If you take too much time off for interviews and second look visits, you might even be violating the terms of your residency contract! Being honest and upfront about this now will help you and your program director develop a good plan. But it also might convince you to stay where you matched and make the best of it, instead of trying to switch before ever giving your program a real chance.

If you need more information, please contact me for a free consultation.