One of the fun parts of this space is getting communications and questions from readers, social media followers, experts, colleagues, and people who just stumble upon things I've written on Google.
Many of the questions I get are unique, but there are a few others that I get asked often enough that I've slowly started posting video answers as a permanent resource for everyone. (If you missed this, subscribe to theSheriff of Sodium YouTube-Kanal.)
And this time of year I don't get a question more often than a version of this:
What if I don't agree?
This is a difficult question to answer. In part, that's because it can be difficult to talk about. Many unsurpassed applicants suffer from intense feelings of shame and failure, and it can be difficult to have an open conversation about strategies and options when dealing with that grief.
But it's also a difficult question to answer because every situation is different and the optimal strategy is situation-specific. Still, there are some general themes and advice that apply to all unsurpassed applicants, and I'll lay that out here. In doing so, I'll try to highlight some of the big areas where the best strategy might differ. Note that your mileage may vary.
1. Take care of yourself.
For better or worse, we live in a society where being a doctor is not like other jobs. It's not yoursAgain- it's something youAre. So when you put in the effort and tears to make it to the last hurdle in medical school—and then procrastinate—it's a punch in the gut.
So, my first piece of advice, superseding any decision-making or strategy advice, is to take care of yourself.
Surround yourself with people who genuinely care about you and filter out everyone else. Receivereal helpif you need it Take a deep breath and remember this is not the end.
It can be helpful to remind yourself that you are not alone. Actually,manyof people are unmatched.
If applicants match their first choice, you will hear about it. You will see her post on Instagram,#blessed. If people pass, they go and tell the story on the mountain. When people don't match, they tend to suffer in silence. You don't hear from them.
So just know they're out there - thousands of people out there, just like you. And perhaps more importantly, there are thousands and thousands of physicians in current medical practice who were initially unmatched.
But regardless of whether you were shocked to be unmatched or just plain disappointed, it still sucks. It's fair to acknowledge that, and you should feel entitled to mourn. But try not to let your grief paralyze you, because you have work to do.
2. Diagnose the problem.
There are many reasons why applicants are not a good match. And applicants often know exactly what the problem is in their case.
But sometimes they don't.
And even if youthinkYou know, my urgent advice to you is that you take at least a moment to carefully consider whether you have the right diagnosis - because the reason you haven't been found can influence your strategy and decisions.
From my point of view there are three general reasons why applicants do not match.
Please note that these reasons are not mutually exclusive. In fact, they often overlap heavily, and many unmatched suitors have a little of each reason. But it's still instructive to imagine these three broad axes, and you should think about which phenotype best suits you.
The first phenotype is a competitive applicant who has applied in a field that has just been littletocompetitive.
Last year, thehit ratefor MD seniors trying to match in dermatology was 72%. For ear, nose and throat medicine 69%. For orthopedic surgery 66%. For plastics 63%.
I promise you won't find many mistakes in the resumes of the 30% of applicants who excel in these highly competitive fields. There is simply a significant excess of people with very elaborate resumes relative to the number of positions available.
This phenotype also applies to most unmatched DO senior applicants who have applied in anesthesiology or OBGYN or PM&R, specialties for which thematch rateswere all 65% last year. Again, these are usually strong applicants who probably wouldn't have had any trouble fitting into, say, pediatric or family medicine. There is nothing with their application; You only applied in one competition area.
The next category of unsurpassed applicants are those with what I call “known weaknesses”. That doesn't mean they will be bad doctors. It just means that their application has some weaknesses, and as my terminology suggests, the applicant knows exactly what they are.
Maybe you failed USMLE. Or you were in the academic probationary period or felt like you were on leave. Or maybe you attended a lesser-known Caribbean medical school, or you were unmatched in previous cycles. The point is, there issomethingin your application, which you cannot change, but which many programs perceive as a weakness (and move on to the next applicant without giving you a chance to explain or redeem yourself).
Applicants in this category are usually theat leastsurprised when they don't match. That's because they typically haven't received very many interview offers. Their well-known weaknesses meant that their application was sorted out at the beginning (often by automated filters).
The final category of unsurpassed applicants are those who have weaknesses or red flags in their application... but unlike a step failure or a leave of absence, the applicant does not know they are there. Often these applicants are themostshocked to learn they aren't a good match because they've done a reasonable amount of interviews and everything seemed to be going well.
Most of the time, these are applicants who had a bad interview. If you got a lot of interviews, it means you had the basic qualifications for those programs—but for some reason you didn't shine that bright on your interview days.
If that's you, don't feel bad.
Again, it doesn't mean you will be a bad doctor. But it's a truism in life that the way you see yourself isn't necessarily the way others see you, and you should think honestly and critically about the way you interview in order to see if there are ways to present yourself better.
The other thing to consider is if there is something in your application that you cannot see that is preventing you from being ranked highly. Here the most common culprit is something in your letters of recommendation. (This is especially true if your subject uses standardized letters of recommendation, where a teacher who thought you did well but didn't rate you as highly as the average letter writer rates you as "average" and this is taken as a red flag, If this is the case, the program will carefully review your application for ranking.)
The reason it's helpful to consider which phenotype of the Prime Applicant best describes you is because the optimal strategy is different for everyone.
For a highly qualified applicant trying to compete in a highly competitive field, it takes figuring out how to do yourselfeven morecompetitive. Completing a research year might get you where you want to be sooner than panicking and throwing yourself into a PGY-1-only-tentative year in SOAP.
If, on the other hand, your application shows known weaknesses, a temporary position may be just the right thing for you. Sometimes program directors worry that applicants whose resumes aren't spotless won't be able to handle the rigors of the residency. And there is no better way to prove that you can be successful with residency than with a successful residency.
3. Consider your options.
Option 1 – Das Supplemental Offer and Acceptance Program (SOAP).
If you consider all comers, this is the best option for the most unsurpassed applicants, as it gives the opportunity to start specialist training in July. But there are still some things you need to know.
First, you should understand that SOAP isn't exactly a buyer's market. There areAwaymore applicants participate in SOAP than there are positions left after the match run.
Second, the type of position available in SOAP is probably not what you were looking for. While you won't know the individual programs with positions up until Match Week, the general distribution of those positions is fairly constant from year to year - and knowing the number and type of positions likely to be available may influence your decision to participate in SOAP (and if so, which positions you aim for).
If you've excelled when attempting to break into a highly competitive field, there will likely be few, if any, vacancies in SOAP.
However, there are likely to be several hundred categorical positions in family medicine and internal medicine. Last year there were also 217 emergency medicine positions (and I betwe will see significantly more EM positions in SOAP this year).
Nevertheless, around half of the positions available in SOAP are temporary positions in medicine or surgery or positions in the transition year. These are PGY-1 positions only. That is, if you are offered any of these positions and accept them, you must develop a plan to receive a categorical residency after a year, either through the match or outside of it.
There are potential issues to consider for certain applicants that may arise if they accept a provisional position or a categorical position in a specialty other than your "dream" specialty.
Suppose you dream of general surgery but accept an interim position in internal medicine or a categorical FM position with the aim of applying again next year. First, these experiences may not improve your standing in the eyes of a surgical program director. But even worse, they are “starting the clock” on the funding the program will receive from the federal government – limiting it to the three years it would take to qualify for a board position in IM or FM to reach. This will potentially make it even more difficult - if not impossible - to obtain a general surgery position later, as the program will not receive CMS funding for the additional years of surgical training.
The point is, if you decide to use SOAP, here's what you need to do firstclearly define victory. Given your situation and career goals, what would winning SOAP look like?
Some mismatched psychiatric applicants may be just as fortunate to counsel patients in the family medicine clinic. Some wouldn't.
Some applicants who did not qualify in anesthesiology might be happy to do internal medicine and move into critical care. Others might be better off completing a prep year for surgery and competing for a categorical anesthesia position next year.
For applicants with weaker applications, any residency position is better than none.Many applicants who struggle to qualify for multiple cycles eventually get a foot in the door by taking an interim position. Then they take that opportunity, blow the program director's socks off by being hard working and reliable, and use that to get a categorical position on that program or a strong endorsement to go elsewhere.
The point is that you must decide whether participating in the SOAP makes sense in your situation, and if so, what types of positions would represent an asset.
This is a situation-specific question and depends in part on what other options are available to you. But if you choose SOAP...
I. Clear your calendar.
If you're a student doing a rotation, you have to apologize. If you're a temporary resident, you need to be as covered as possible. Because things will move fast and you must be prepared to seize any opportunity that presents itself.
Almost all applicants use the same ERAS application they used for the regular season. But if you're worried that you might have a hidden red flag, that's itpossibleupload new LORs or a new personal statement - but this has to be done very quickly.
If you are a student at a reputable school, preparing for SOAP is automatic. Your deans can come over and help you, and you'll essentially move into a student affairs conference room until SOAP is over. But for other schools, or for applicants who aren't in school (or worse, working as provisional year residents), you'll have to campaign yourself.
ii. Know the traffic rules.
Because things move so quickly and because there are so many applicants and so few positions at SOAP, the NRMP has a fewtraffic rulesthat you don't want to resist.
The most important thing is thatYou cannot contact programs– You have to wait for them to contact you. This rule also applies to mentors and advisors and anyone else acting on your behalf – they are also not allowed to contact programs. (In the spirit of honesty, I must note that this rule is not always universally followed, and that back-channel communication - particularly among more connected and privileged applicants - does occur. But you should know that this is a gaming violation and can be reported to the NRMP, and if you are the applicant, you will be disqualified from the match the following year.)
You are toonot authorized to share the list of vacant programs. There have been instances in the past where the NRMP has done thissuedEntities that shared the program listing online.
Another difference between SOAP and the regular application process is thatApplications are limited. Although there may be 2000 positions available, you can only apply for these45from them.
This means that the decision on where to submit applications is up to youDiemost important decision you'll make during SOAP week—and you won't have to think long about it.
For stronger applicants—like most MD and DO seniors in the US—make sure any programs you apply to meet your definition of victory. For applicants with known red flags who are ready to take on any position, don't waste applications on oversubscribed programs that will only weed out your application again. For example, if you are a non-citizen IMG trying to beat the 3% SOAP odds, you must at least google every single program you apply to and be sure there are non-citizen IMG residents before you submit one of your valuable applications.
iii. Go all out.
This year SOAP will consist of 4 separate rounds. You don't necessarily have to submit all applications at the beginning... but if your goal is to get a position in SOAP, mystarkThe advice is that you submit at least 43 or 44 of your applications (if not all 45) to begin with.
To understand why, put yourself in the shoes of the program. You just recruited applicants for four months – and got nothing. They want these positions to be filledas quickly as possible. When they find someone capable and enthusiastic, they will snap them up and not hope that someone better will turn up later. Not surprisingly, the overwhelming majority of SOAP positions are filled in the first round.
However, some positions may fall through the cracks and if you have any leftover applications you can submit them before the fourth and final round of SOAP. So if you want to keep a SOAP application or two to use at the last minute for an understaffed program in Round 4, I'm not mad at you. But most applicants should do whatever they can to maximize their chance in the first round, and if you hold on to more than 1-2 applications you are almost certainly reducing your chance of getting a job (especially a highly sought after one). .
If you're getting an interview, or if you've been offered a job, my "all in" advice applies even more. Again, the average program and applicant wants to get SOAP over with as quickly as possible. If you get a chance and that chance fits your definition of victory, jump at it. If you get a bird that lands in your hand, don't let it fly away while you're rooting in the bush.
Option 2 - The research year.
This can be a good option for competitive applicants who have applied in competitive fields. In fact, more and more incoming physicians in highly competitive fields like dermatology or ear, nose and throat medicine are completing a research year - sometimes after initially failing to keep up.
If you already have a shiny resume but need to make it even shinier, this might be an option — and for some people might be a better choice than taking a random position on the SOAP.
Some research positions are just research positions. They are posted by the mentor or lab and can be completed by anyone. But there are more and more "research fellowships" funded by residency programs in competitive fields, often at very prestigious institutions. They offer research mentoring and some clinical exposure or residency program integration, and are marketed to unmatched applicants with the suggestion that participation in their program will lead to success in next year's match cycle.
Again, there are some traffic rules to be observed.
Each year, during Match Week, some institutions will advertise their research grant positions when they shouldn't. Because if you are a SOAP eligible applicant, you may not accept the position if it is part of a residency program that participated in the match. So before you sign on the dotted line, you should make sure you are not in conflict with the NRMPsPolitics.
Option 3 - Delay Completion.
Of course, this is only an option if you have not completed medical school. But it is becoming more common for schools to offer an extra year to mismatched students.
This helps the school in two ways.
For one, while not usually paying full price, the student still has to pay some tuition to hang around for the fifth year.
Second, it allows the school to create the books through their match numbers.
See, most medical schools report their match statistics based on students who areDiploma– So if a non-matching student is reassigned to the next grade, it is removed from the denominator of the match calculation and the school must report a higher match rate.
Of course, an extra year can also help many students. For one, it can prevent the student from being screened out by automated ERAS filters in subsequent game cycles.
A filter that is often used to check initial applications in ERAS is the "Year of completion" filter. Many programs choose to limit their screening to applicants graduating this year or within the past few years. The thought here is that if one has not matched in previous cycles,There's a reason. Therefore, PD can either spend the time themselves going through the application and figure out what that reason is...or they can just assume that the other people who reviewed the application in years past knew what they were doing, by discarding them or not ranking them highly.
I'm not saying that's fair or right, but it happens. Observant viewers may have noticed a few minutes ago that the agreement rates for MD and DO graduate students ranged from 92-93%, but the agreement rates for past MD and DO graduates didlowerthan the agreement rates for international medical graduates. The reasons for this are multifactorial, but staying in school keeps the applicant in a preferred category, at least as far as ERAS filters are concerned.
The other potential benefit of staying in school is for students who decide to change majors. Some mismatched applicants in plastic surgery or orthopedics can be very competitive applicants, for example in anesthesiology or radiology. Someone who mismatches in OBGYN could be in high demand in family medicine. But it may be that there are zero (or at least zero desirable) positions available in the SOAP, taking those applicants a year to recalibrate and move into another field.
And that idea of recalibration – well, that leads to the last avenue that some unmatched contenders want to consider.
Option 4 - Other options.
I call this "other options" - because the specific option can be many things.
It might be someone who is starting to wonder if they have the fire in their stomach to do clinical medicine. Maybe their interviewers somehow caught on. Maybe that's why they didn't fit together. So maybe now the candidate is taking the opportunity to do their MD and follow their heart and move on to another field. You cannot practice medicine without completing at least one internship, but many physicians have the skills and background to thrive in areas bordering on clinical medicine, such as technology or pharmaceuticals, or even administrative or business aspects of medicine.
Or it could be someone who is dying to practice medicine in the United States but had a low USMLE Step 1 score 7-8 years ago when they took the test and despite applying and applying year after year, that is It's never happened to them before, and now they're getting fewer interview calls each cycle because they're being sifted out by the Stage 1 or senior year filters. But perhaps they have the opportunity to study or practice in another country, and perhaps if they are second to none it is a sign to change course in that direction.
The point here is this: It's your life.
Many unreached contenders want to do nothing but doggedly pursue their dream in future match cycles. But for others, I want you to know that it's okay to dream new dreams.
It's fair to compare the opportunity cost of trying again next year with all the alternatives available to you. Ultimately, you don't have to answer anyone but yourself, and I honestly believe deep in my soul there isn't oneonly true wayfor almost everyone in this world. The goals we set and the paths we take are the result of so many random things that happened before and doctors could have taken a different path and been happy and successful and in other ways real contributions to the world can afford. You shouldn't be afraid to embark on a different path and pursue it with as much passion as you did for the path you walked. You have to do what is right for you.
And that brings me to my final piece of advice, which is this. Once you have your plan in place, work on it. Do not look back.
Mismatch sucks and I wish it hadn't happened to you. But that's not the end of your story. All the obstacles you overcame to get here, it all really happened. It was you. All the people who believed in you and saw promises and gave you opportunities, they weren't wrong. Keep your head high and embrace whatever comes next with grace and dignity.
And remember I'll be here to cheer you on.
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