I didn't match! What should I do now?

Unfortunately, not every applicant matches into a residency program. As bad as this year's situation was with the delayed list of open programs on Scramble Day, you can't just blame the NRMP. And maybe some program directors gave you false hope during your interviews, but they never actually promised you a residency position. Think back. Did you get as many residency interviews as you had hoped for? Now is the time to assess your application and determine how to make it stronger to get those interviews you want:

1. What specialties did you apply in last time? Did you pin all of your hopes on a competitive specialty like orthopedic surgery? Or did you remember to apply in primary care fields like family and internal medicine, which often have more vacancies and are looking for qualified applicants?
2. Where did you apply last time? Did you focus your search on states like California and New York, perhaps because that's where you and your family live? Or did you apply to places like Idaho and Nebraska to increase your chances of getting interviewed, since programs there don't always fill during the Match?
3. What have you done since graduating? Have you been relying on the knowledge base and procedural skills you learned in medical school? Or have you continued to grow as a doctor through externships, medical volunteering, and relevant research?

If you're planning to apply to residency programs again in the fall, you must seriously consider what you can do over the next few months to become a stronger applicant:

1. A hands-on externship is much more impressive than a simple observership. Admittedly, these opportunities can be hard to find. But if you're serious about improving your application, talk to the doctors in your community to find out about available externship opportunities. There are even companies you can pay to place you into an externship. While it's an expensive option, the knowledge you acquire and skills you practice during that externship will be extremely valuable, should lead to a strong letter of recommendation, and will be prized by the residency directors.
2. If you graduated from a foreign medical school, and you performed poorly on USMLE Step 1 or Step 2, you should consider taking Step 3 now. Remember that taking the exam is not enough; you need to have your passing score available before you submit your applications to residency programs. Applying with the phrase "awaiting results" in your ERAS Common Application Form is not going to help you; there are plenty of people who have already passed Step 3, and why should a program director look at your incomplete application? Of course, you want to do better than simply passing Step 3; you want to get a great score, so you should strongly consider paying a professional test prep organization to help you study. Additionally, your externship will be a great way to prepare, since there's nothing like real-life experience.
3. Did you have someone help you with your residency application? A well-written personal statement and detailed Common Application Form can make a huge difference when residency directors are deciding who to invite for an interview. I am happy to provide a free consultation, assessing your old residency application and suggesting some things you can do to improve it. I have over ten years' experience advising and supporting residency applicants like you.

How the residency Scramble works

March 15, 2011 at noon (Eastern time) is the first time you will be able to access the dynamic list of Scramble programs with open positions. (it's a dynamic list because as programs fill, the NRMP is supposed to take them off the list - roughly once per hour the list will be cut down, but they don't add new programs) These are only available as PDFs, so you will need Adobe Reader or a similar program to view them.

You and your advisor (having an advisor help you is crucial!) should log into the NRMP website, look through the list of programs, and decide who to contact first. For example, maybe your advisor was a classmate of a program director and chooses to call her first on your behalf. And you might decide that there's no way you would work in Kansas or Nebraska, so you cross those programs off the list. But basically you'll start by reviewing the programs and deciding who to call. This is a long process. It's hard to get through to a program director so you (or your advisor) will be leaving a lot of messages.

If you two do get someone on the phone, there's no single "right" way to proceed. Often the advisor will speak on your behalf, briefly advocating for you, describing your skills and why you'd be a great candidate. Then hopefully you'd be able to have a short phone interview with the program director, who would encourage you to send your application via ERAS. But maybe a program coordinator will answer the phone and say that a Scramble spot has already been filled (some open positions are filled almost instantly, even though the NRMP would still show it as being open until the database was finally updated). Or you might simply be told that the program will not take any international graduates during the Scramble, and you'll never be able to get on the phone to plead your case. Or they might not want to speak to your advisor at all and only want to talk to you. In the end, you'll follow up by transmitting your official application.

According to the program directors I've spoken to over the years, they really want to get your application via ERAS, not by fax or email. That means that paying a company to fax your application is usually a waste of money. But of course you should do whatever you think is best. You will be able to apply to a maximum of forty-five new programs through ERAS (specifically 30 on the first day of the Scramble, 10 on the second day, and 5 on the third day). You cannot pay ERAS to apply to more programs.

But since ERAS limits how many new programs you can send an application to, many people do not send out their applications through ERAS during the Scramble before talking to program directors or program coordinators. If there are more than forty-five open positions in Internal Medicine, you don't want to waste one of your applications by applying somewhere that's already full or a place that doesn't want an international graduate. Forming a personal connection first is crucial. The hope is that the mini phone interview will help them get to know you and want to know more about you by reading your entire application. Remember that during the phone conversation, they basically know nothing about you, so that's why your advisor introduces you, and then you briefly describe yourself and your strengths.

While it's true that some Scramble applicants will get match offers quickly, many others will send out their applications through ERAS and then wait to hear back. Since the program directors don't need to fill the positions blindly, some do take the time to read every page of every new application and then decide who should visit for an interview. Interviews sometimes occur throughout the spring before someone is offered a residency contract.

I wish you the best of luck during the Scramble. If you have trouble matching and need to reapply next year, please let me know if I can help.

Preparing for the NRMP Residency Match

Every year, the residency application and interview process culminates in the Match. Though you used ERAS to transmit your application materials to residency programs, the NRMP is the organization that administers the Match. In this process, you prepare a list of the programs you interviewed at, putting them in the precise order that you would prefer to go to them for residency training. Here are a few points that explain this confusing process:

1) You should rank every single program you interviewed at, unless you would rather be unmatched than go to a specific program.

2) You should rank the programs in the order that you hope to match to each one. The NRMP algorithm is skewed in the applicant's favor; it will not hurt you to list your favorite program first, even if you think you have no chance of matching there.

3) The rank list you certify with the NRMP is a legally binding commitment. If you match to a program on your list, that's where you will be going.

4) The deadline for certifying your rank list with the NRMP is 9:00 PM Eastern time on February 23, 2011. However, I strongly suggest that you certify your list well in advance of that deadline. I've heard horror stories in the past about power failures and bad Internet connections, and if you don't meet that deadline there is nothing that anyone can do for you.

Additionally, it can be difficult to decide what criteria to use when ranking these programs. Here is an incomplete list of factors to consider when preparing your rank order list:

• salary and benefit options
• geographical location (which part of the United States, as well as urban versus rural areas)
• population dynamics of the community
• the program's accreditation standing
• the PGY-3 pass rate
• support for professional development (such as attending conferences)
• the program's academic strengths
• long-term connections with that program (do you see yourself doing a fellowship there? how many residents become attendings?)
• opposed/unopposed programs
• the number of rotations done away from the hospital (which might separate you from your family for lengths of time)
• the program's individual values
• your prior contacts within the program (such as medical school alumni)
• how this move would affect your family

Of course, you need to decide how important each factor is for you. Some might not be important at all, and there might be other considerations specific to your situation that aren't listed here.

I wish you the best of luck during the Match! Please contact me if you don't match successfully, and I will give you a free consultation to help you prepare for next year.

Join a committee

One great way to strengthen your candidacy for residency is to join a medical school committee. Typically, there are a variety of committees chaired by a dean or faculty member that meet regularly to discuss campus issues, such as ways to improve the curriculum, improve student life, adjudicate legal matters, or prepare for an upcoming re-accreditation process.

There are strong potential benefits to joining a campus committee. You'll learn a lot about how your medical school works, making you better informed and more well-rounded during your interviews. Also, many residency directors assess both the short-term and long-term benefits of your ERAS application. Short term, of course they want to know that you have the knowledge base and patient skills to be a great resident. But long-term, they might hope that you would stay at the hospital after your training and help guide the next version of the residency curriculum. Your committee experience could be an important factor in the residency director's decision.

Committee involvement could help your application in other ways. Your dean would include it in your MSPE, hopefully praising you for your dedication to the medical school community. Additionally, the chair of the committee could be the source of a strong letter of recommendation, especially if you two also worked together in a clinical or research capacity.

However, your academic transcript and USMLE scores need to be a priority! Don't join a committee if you can't balance your life. Many student committee members join in the pre-clerkship years, and leave when they start clinical rotations, and that might be the right plan for you too. There are also certain committees that would greatly benefit from the perspective of a third-year or fourth-year student. So if you're interested in getting more involved, talk to your dean at any time about opportunities.

I'm here to help you

Are you applying to residency programs? Maybe you feel like you're not getting the personal attention you want from your medical school dean, or you've already failed to match on your own and realize that you need more help this year? Perhaps you were trained abroad and now want to practice medicine in the United States, but the process of applying as a foreign graduate seems incredibly complicated? Or you're an osteopath who doesn't know how to present your training to an allopathic residency program? I'm here to help all of you.

In January 2001, I started supporting medical students at the University of California, San Francisco. It was a privilege to develop my advising skills and knowledge of the residency application process while ghostwriting the Medical Student Performance Evaluations ("dean's letters"), organizing workshops on personal statements and using ERAS, and helping to develop a new component of the medical school curriculum. After earning the respect of my colleagues and a major award from the students, I left UCSF in 2007, and since then I've been sharing my skills with people from all over the world.

It's been ten years since I started helping medical students. In that time, I've learned a great deal and have helped a number of people successfully write personal statements, edit Common Application Forms, solicit the right letters of recommendation, share documents with the ECFMG, prepare for interviews, and use the NRMP to match into great programs. Now, I want to help you answer the question, "How do I get into residency?" I plan to use this blog to explore a variety of topics, sharing some of what you need to know to improve your chances of matching.

Of course, this isn't just my passion, but it's also my career. I run http://www.residencysupport.com/ - currently, my clients and advisees are medical students and graduates from all over the world (plus a handful of undergrads getting a head start on their futures who want to know "How do I get into medical school?"). I've helped people from all over the United States, as well as graduates from medical schools in locales including Mexico, South Korea, Iran, and throughout the Caribbean. This year my clients were trained in many of the same locations, plus Canada, India, Egypt, China, Armenia, and more! If you want a personal consultation at any time, please visit my website for more information; I look forward to hearing from you.