The form of March madness most familiar to graduating medical students, their friends and families, and those involved in medical education is Match Day. This is the day, usually in March of each year, that the National Resident Matching Program informs medical students in the United States and Canada of the residency positions they have attained. That thousands of graduating students simultaneously and publicly learn where they will be training and working for the next several years through the opening of an envelope is shocking to many observers outside of medicine. Emotions range from joy to deep disappointment. Much attention and care have been given to developing the algorithm underpinning the Match, and the process seems just: Optimization favors applicants over training programs.
As an ardent supporter of residents and medical students and a former senior associate dean of medical education, I find the annual events that play out on Match Day joyous, but the joy is tainted with concern. The source of joy is obvious. Passionate and accomplished young women and men are one step closer to realizing their dream of becoming a doctor (Let’s have the envelope, please!). Along with the excitement and pride, I feel some hesitation for reasons I outline below.
To Thine Own Self Be True
The choice of which specialty to pursue in which specific training program should reflect the needs and personalities of the medical school students themselves. Specialty, training program, and location are highly personal considerations. Above all others’, students must listen to their own voice. To thine own self be true. Predictably, graduating medical students will receive a great deal of well-meaning, but sometimes misguided, counsel. Using examination scores or class rank as the measure of intelligence, those in a position to advise may direct students away from a specific area because they are “too smart” or because they are “not smart enough.” Students may hear that they will “not have a life” if they choose a particular specialty—as if work–life balance were dictated by someone else. Students may be told that a particular area does not pay enough—as if an average salary of $223,000 for primary care doctors and $329,000 for specialists were a hardship.1 I caution students to be skeptical of faculty who claim to know which are the best residency training programs for a particular specialty. Most of us faculty members do not really know what happens in training programs (other than our own), and we certainly do not know whether individual students will thrive in specific programs.
The three greatest concerns that I have as Match Day unfolds are the process that the students undergo to “optimize” their chances in the Match, the extraordinary expenses they incur, and the metrics used to judge a “great match.” I worry whether each student’s best match is synonymous with their best fit. I raise these concerns not to dampen the excitement of the transition from undergraduate to graduate medical education training but, rather, as a call to action. This Invited Commentary represents a plea to develop strategies to help medical school students best identify the program(s) that will optimize their own growth and professional satisfaction.
Preparing for the Match
Medical students show concerns for their match outcomes early in their training—sometimes before they even matriculate into a medical school. I was shocked a few years ago when applicants to our medical school, recognizing that their standardized test scores could influence their chance to train in a certain subspecialty, asked how faculty were preparing students for the United States Medical Licensing Examination (USMLE). My concerns about the examination are not new; I have previously written about the inappropriate use and unintended consequences of using USMLE scores to screen residency applicants.2
In addition to feeling excessive pressure to ace their examinations, students applying for currently highly competitive specialties (e.g., orthopedic surgery, dermatology, ophthalmology) frequently receive advice to spend an extra year in medical school to focus on research in their specialty of choice. I strongly favor the pursuit of biomedical research during medical school if it reflects the student’s genuine passion. I think that pursuing research, or engaging in any other activity, simply because it affords checking off a box on an application is folly. In contrast, I think that seeking additional clinical experiences during medical school in areas being considered for residency training is important. This added exposure to a chosen specialty provides a good reality check for students to assess whether they have the interest and aptitude to find this training and the field rewarding.
I believe that for students to complete at least one elective at an institution outside of their own is valuable. Ideally, this rotation would be at a program the student is seriously considering for residency training. This experience will broaden the student’s perspective of the field and provide an “insider’s” view of the personality of the program. I have been surprised to hear that students often are discouraged from doing such away rotations. They are cautioned that they risk not looking as good to the program in person as they do on paper. This warning does not make sense to me; rather, I think that students and programs alike benefit from learning before matching if they are incompatible. A few weeks of a suboptimal experience during medical school seems better than three or more years of negative experiences during residency. Also, importantly, several highly competitive specialty areas, including orthopedic surgery, are much more likely to recruit students who have completed an elective in their institution than those who have not.3
An expensive process
The high costs that students incur when they participate in the match process is another concern. Here I am not referring to the substantial costs expended in USMLE preparation, an issue that I have addressed previously.2 The direct costs of the match process primarily relate to traveling around the United States and/or Canada to complete an increasing number of interviews. Because interviews are not coordinated among institutions in the same geographical area, students spend a lot of time, effort, and money crisscrossing back and forth from program site to program site. Limiting the number of programs to which graduating students can apply would go a long way toward reducing this cost. This reduction also would make the work of program directors, facing an ever-increasing number of applicants, more manageable. Finally, others have suggested that a smaller number of applications would result in less reliance on using USMLE scores as a screening strategy.4
I also have concerns about the metrics used to judge the quality of each student’s match. A statistic commonly cited by medical schools is the proportion of students who get their number-one choice for residency. Although conventional wisdom may hold that getting what you want is a good thing, recall too the adage “Be careful what you wish for.” If the program to which a student matches is not as excited as the student is, the long-term relationship may not be a happy one. Like a marriage that ends in divorce because of a poor initial match, a mismatch in training may result in a broken contract.
Another common metric used by many schools to judge the success of their students’ matches is the proportion of students heading to institutions highly ranked by U.S. News & World Report (USNWR). Many academic institutions, including those at the top of the list, believe that some of the criteria used in generating the USNWR rankings (e.g., Medical College Admission Test [MCAT] scores and grade point averages of matriculants) are suspect. The mathematical computations are arbitrary, and how well they reflect the quality of undergraduate and postgraduate training experiences is not known.
Match vs. Fit
My greatest concern about the match process is that a great match is not synonymous with a great fit. A great fit is one in which the strengths, passions, and personalities of the trainee align well with the strengths, passions, and personalities of the training program. Using a single factor, or even a small number of factors, to determine match lists will not work well unless the factor(s) selected happen to be what both the student and program most care about. If a program cares primarily about recruiting residents who will excel at standardized tests, then choosing those with the top MCAT scores and USMLE scores may be a good strategy. If a program cares a great deal about the future academic achievements of its graduates, selecting candidates who have explored scholarly projects during medical school and engaged in the process of discovery and innovation may result in a better fit. Just as standardized test scores predict future test performance, experience in research, along with a record of scientific presentations and peer-reviewed publications, is predictive of continued scholarly engagement.
What do future physicians and programs really care about during trainees’ final period of professional development prior to beginning practice? I doubt that the answer is the attainment of high scores on in-service and certification examinations. Achieving certification certainly is an important outcome for the trainees and their programs, but in the end, I believe no one particularly cares about the percentile scores attained on the examinations. From my informal review of the literature, I have found a slight positive correlation between absolute scores on USMLE examinations and specialty certification examinations; however, importantly, the USMLE scores that predict passing certification examinations, across all specialty fields evaluated, is not high. Specifically, in five studies (of pediatrics, obstetrics–gynecology, orthopedics, anesthesia, and internal medicine) published between 2007 and 2015, 90%–100% of residents passed their certification examination on the first attempt if their USMLE Step 1 examination score was greater than 200–220.5–9
Many training programs may care about the proportion of their residents who choose to subspecialize and explore academic careers; such programs may select incoming residents who have already distinguished themselves in scholarly work through PhD training or dedicated research experiences and who have already accumulated a record of publications. Other programs may be seeking trainees who dedicate themselves to primary care or public health; these programs may invite for interviews candidates who have participated in community service and/or advocacy programs of some sort. Programs that emphasize patient care may seek candidates whose passion for taking care of patients in the clinic is reflected in exemplary patient-centered activities during clinical rotations and, perhaps, election to the Gold Humanism Honor Society or a similar organization. The Match will have the best outcomes if each program prioritizes the attributes of candidates that align best with its mission.
Success During Training
The greatest consideration should be given to what trainees and programs want in the short term: success over the next few years while the resident is working and learning in the training program. This gets back to fit. All parties want to be able to work together productively and happily. The worst outcome of a match is that it falls apart—that the resident and program are incompatible and they separate. No one wins. Such dissolutions are not a small problem. For example, according to a 2015 survey conducted by the American Orthopaedic Association’s Council of Orthopedic Residency Directors, in the six years preceding the survey, 77% (75 of 98) of programs placed a resident on remediation or probation, and 40% of the programs had to terminate a resident.10 The percentage of residents who choose to drop out of training also is disturbingly high. Investigators conducting a systematic review of the literature (published in 2017) estimated that the pooled attrition across general surgery training programs, predominantly in the United States, was 18%.11
What can be done to optimize compatibility and ensure the most satisfying and successful training experience? Some forward-thinking programs include assessment of applicants’ inherent personality traits in their selection process.12,13 These traits are assessed by considering applicants’ prior accomplishments; by requiring candidates to complete structured questionnaires and interviews designed to quantify motivation, curiosity, and determination; and by observing candidates during visiting clerkships. Not surprisingly, past accomplishments are predictive of future success in nonacademic arenas just as they are in scholarship and testing. Personality factors that have been shown to forecast success in residency include a sustained desire for knowledge acquisition, a commitment to serving others, and insight.14 In longitudinal studies of medical students, factors predictive of early academic success include conscientiousness, having high aspirations, and an absence of self-indulgence.15 Being able to work well with others is an important attribute of a successful resident. Metrics indicating that candidates have strength in getting along are likely more important than those linked to getting ahead!
In summary, my hope for medical students entering the Match is that they listen to their own voices. Students should know that their examination scores are not indicative of what specialties they should (or should not) pursue, nor of the programs to which they should (or should not) apply. I hope that students are not convinced that well-meaning faculty, friends, or family members know what they are best suited for. And I hope that students do not worry if they do not get their first choice. I think all of us involved in the Match would do well to remember the words of Nobel Laureate Bob Dylan: “Well I try my best / To be just like I am / But everybody wants you / To be just like them.”16 That is, I encourage students to look for programs (and for programs to seek students) whose goals, interests, and priorities align with their own. The best fit is achieved when two parties share a mutual attraction based on shared passions and values that becomes the foundation for a mutually fulfilling, tenable, long-term relationship. I encourage us to seek and celebrate the best fit, not the best match.
The author wishes to acknowledge the support and guidance of Laura K. Bachrach, MD, for her thoughtful reflections and review of this Invited Commentary.
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