In 2021, 48,700 applicants registered with the National Resident Matching Program (NRMP), and a total of 35,194 American residency positions were offered in the Match.1 A total of 4,350 individuals participated in the Canadian Resident Matching Service (CaRMS) in 2021, and 3,272 participants successfully matched to a residency position.2 That same year, 1,078 applicants to Canadian residency programs remained unmatched after the second iteration of CaRMS,2 and 12,346 Supplemental Offer and Acceptance Program (SOAP) applicants to American residency programs remained unmatched.1 While the vast majority of these unmatched applicants were international medical graduates, 123 Canadian medical graduates and 3,060 American medical graduates remained unmatched.1,2
The increasing number of unmatched applicants has been identified as an issue in both Canada and the United States,3,4 yet the experiences of those individuals going unmatched has remained largely unexplored. Findings arising from research on this topic have suggested that unmatched applicants find themselves in limbo following significant time and financial investments in undergraduate medical education5 and that the experience of going unmatched is associated with challenges, including feelings of shame and financial distress.6 Okoniewska and colleagues write that “being unmatched may result in not only an unclear professional future and its associated stigma, but also potentially serious financial and emotional consequences; some are so distraught that they instead choose even suicide.”5 The generalizability of these findings, however, was limited by a focus on Canadian residency applicants and small sample sizes, in part due to the sensitive nature of this topic, which has limited the recruitment of participants to scholarly studies.5 Without a better understanding of such experiences, medical schools will be limited in their abilities to support unmatched graduates through these challenging times. This may in turn hamper unmatched applicants’ endeavors to successfully secure a residency position and, ultimately, their entry into the physician workforce.
This study seeks to build on the existing literature to better understand the collective experiences of unmatched medical students and medical school graduates as a necessary part of informing and enhancing supports available to unmatched applicants. In light of concerns regarding the generalizability of findings from previous studies, we sought to understand the experiences of a greater number of unmatched residency applicants, including those who did not match to American residency programs. Our research question was: What are the shared experiences of unmatched residency program applicants?
Method
To further understand the experiences of unmatched residency applicants, we turned to social media as our source of data. Qualitative research using data from social media has been increasingly used to study a wide range of topics. In addition to social media providing a source of abundant data, the “cloak of anonymity” provided by the online environment has allowed researchers to access data involving sensitive and stigmatizing topics.7 The social media platform Reddit has garnered particular attention as a source of qualitative data, with data from Reddit being used to study a range of areas that are prone to stigma, such as cannabis use,8 psychedelic microdosing,9 urinary incontinence,10 and involuntary celibacy.11
Reddit is a website that hosts online discussion forums known as subreddits, each of which is dedicated to a particular topic. Each subreddit is denoted by “r/,” followed by the title of the subreddit, and is divided into posts, which are essentially discussion threads, with each post containing one or more comments from users. To publish content (i.e., a comment or post), users are required to create a free account with a unique username. Although not required, users are provided the option of including a brief biography and/or photo. Reddit posts are publicly available, and an account is not required to view content.
We explored the shared experiences of unmatched applicants using a thematic analysis of comments posted on the subreddit r/medicalschool, which is described as “an international community for medical students.”12 At the time of this study (August 16, 2021), this subreddit had 409,194 subscribed users, who had signed up to receive daily updates.
The Research Ethics Office at the University of Alberta was consulted, and this study was deemed exempt from research ethics board approval as it relied on information in a public forum. As such, the individuals to whom this information refers would have no reasonable expectation of privacy.
Data collection
The r/medicalschool subreddit was searched for comments containing the term unmatched on August 16, 2021. This search returned a total of 175 posts. Five mega-thread posts were excluded, as these posts contained thousands of comments in which users typically shared the location and specialty of their successful residency match. Comments from these posts were returned in our search if the word unmatched was used for any reason, and comments from these mega-threads commonly contained posts about statistics of unmatched residents or posts with a user sharing that they successfully matched after going unmatched without elaboration on the experience of going unmatched. As such, these particular posts were deemed irrelevant to this particular study. The remaining 170 posts contained a total of 5,180 comments.
One researcher (M.M.) read all 5,180 comments and further filtered out comments based on whether the comments contained content involving the first-person experience of an unmatched medical student. We felt that it was important to focus on comments that communicated information about the first-person experiences of unmatched medical students, so as to avoid comments that speculated about another person’s experience. Given the open-ended, user-generated nature of the content on Reddit, it was common for discussion threads to diverge into a range of topics. For example, a post might start with an initial comment from a medical student inquiring about their odds of matching to a particular specialty, but the discussion might evolve to include comments related to studying strategies for examinations, physician income, and so forth. Of the 5,180 comments returned, 206 comments were retained for inclusion in the thematic analysis.
Data analysis
Thematic analysis was used to analyze this sample of comments, as described by Braun and Clarke.13 We opted to use thematic analysis as it is not bound to a prescribed epistemological approach and allowed us to approach this analysis within a social constructivist paradigm. We understood that the subjective meanings of the unmatched applicants’ experiences, and our interpretations of these experiences, would have been formed through social interactions within a cultural and historical context. It was important for us to recognize that our previous experiences had the potential to influence our interpretation of the data; for example, one author had a previous experience as an unmatched applicant and one did not, which allowed us to together reflect on the impact of these prior experiences, openly discuss our personal reactions, and check our prior assumptions throughout the course of this study. We often found that our emotional reactions to the data differed, which stimulated curiosity about these reactions and facilitated in-depth discussions that helped us to more richly interpret the data.
Using an inductive approach, each researcher independently examined 50 comments to generate initial codes. These initial codes were then discussed. Areas of strong overlap were identified, and an initial set of codes was agreed on. The full set of comments was then independently examined by each researcher and coded according to this agreed-on code set, with each researcher keeping detailed notes about our respective assumptions. Each researcher also made note of verbatim quotes that we felt were representative of the respective codes. During this process, new codes and modifications to the existing codes were proposed, and when consensus was reached regarding proposed changes, the set of codes was modified in an iterative process.
We employed visual thematic mapping to display these codes, which allowed us to visually group and identify relationships between codes with overlapping ideas. Through this mapping process, higher-order themes and subthemes emerged from these groups in an iterative process over the course of multiple meetings and discussions until consensus was reached. Once codes were collapsed into themes and subthemes, we revisited our lists of prospective representative quotes. We selected several quotes by consensus with the intention of promoting a deeper understanding of these themes and subthemes among readers.
Results
The 206 comments included in the thematic analysis were authored by 124 unique usernames between the years of 2012 and 2021, with an average of 220 words per comment. One hundred twenty-two (59.2%) of these comments included content related to first-person experiences of being currently unmatched, 52 (25.2%) had content related to previous first-person experiences of being unmatched from users who later matched, and 32 (15.5%) were unclear as to whether they were made with respect to being previously or currently unmatched. Only 1 (0.5%) comment was made concerning going unmatched to Canadian residency programs through CaRMS, and the remainder (205 [99.5%] comments) were made regarding going unmatched to U.S. residency programs through the Match and/or SOAP.
Two primary themes emerged in the analysis of these comments: (1) perceptions of insufficient return for investments made in medical education and (2) concern about the possibility of going unmatched again in the future. Within each of these themes, several subthemes were identified.
Perceptions of insufficient return for investments made in medical education
Numerous comments were made expressing a perceived lack of return, with respect to both career development and finances, from the investments—including investments of money, time, and effort—made in medical education. As one user wrote, referring to unmatched medical school graduates: “We’re basically useless without a residency, and the [MD or DO] degree has no value.” Multiple users commented on the financial debt that they had accrued over the course of medical school. For example, another user wrote: “Right now I’m 400K in debt and can practice as a medical assistant at best. [Expletive] Was anything I did the last 10 years worth [it] now?” Describing their experience of learning that they had not matched to a residency position, another user wrote: “All at one moment the weight of hundreds of thousands of dollars of debt and years of work felt suffocating.” Within this theme, 3 subthemes were identified and are discussed below.
Regret for pursuing medical school.
Themes of regret about undertaking medical education took different forms. Some users indicated that when they started medical school, they were unaware of the possibility of completing medical school but being unable to secure a residency position. In the words of one such user: “I never would have gone to medical school if I realized this could happen.” On a related note, as described above, there were multiple comments related to the financial burden that is commonly experienced by medical students. Others discussed forgoing certain life events in the pursuit of medicine. For example:
I failed despite missing major life events due to medical school. It wasn’t worth it for me. For some, they obtained their dream, I’m truly happy for you. If you want to ask me if I would do it again, no.
Perceptions of failure.
Multiple users wrote about a sense of failure after going unmatched. For example, one such individual wrote:
The feeling of failure is immense…. Some days I wish I could get in my car and just keep driving. Other days I just wish I wouldn’t have woken up at all. I cried the morning of graduation and almost didn’t attend because I didn’t want to face my peers because I felt like such a failure.
In other cases, users wrote more direct comments about suicidal ideation in relation to such perceptions of failure. For example, one user wrote:
Really felt like killing myself. My problem was, and this happened before, was that my identity was getting wrapped up in to what I was applying [to]. So, it’s existentially shattering when something like this happens. You better believe suicide is a serious possibility when that happens.
Considering an alternative career.
Several users shared that they were considering a career path that would not involve a medical residency. Some users discussed contemplating a career change, and others explicitly noted that they were intending to pursue or had already pursued a different career. While some of these comments did not specify a particular occupation, some users wrote that they were pursuing a career as a registered nurse or physician assistant or a career in the pharmaceutical industry. For example, one user wrote that after going unmatched 3 times, they were “ditching [another Match cycle] and going straight for pharma career. Trial management in clinical operations pay approaches that of an internist, without the hellish lifestyle.”
Concern about the possibility of going unmatched again in the future
Many comments communicated concern regarding the prospect of not matching to a residency program again with future applications. For example, one user wrote: “I am worried now … that if I am unable to find meaningful clinical experiences over the next year that it will be frowned upon [in subsequent applications].” Even some who had secured clinical or research experiences after going unmatched expressed fear about possibly going unmatched again. One user noted a sense of relief from making arrangements after going unmatched and also indicated: “I’m simultaneously terrified that I won’t match again next year.” Within this theme, 2 subthemes were identified and are discussed below.
Perceived lack of transparency and fairness in the match process.
A common theme in the comments was the perception of the match process being unfair, flawed, and lacking transparency. In many cases, unmatched applicants discussed being unclear about the reasons for not matching to a residency program. In some of these instances, they described having been given assurance that they would successfully match, with one user sharing that they felt “sour about [program directors’] false reassurances.” While some spoke of their ability to obtain feedback on potential reasons for going unmatched, this was by no means a universal experience. For example, one user wrote: “My medical school really has been not helpful at all, and I am reaching my wit’s end trying to figure all this out on my own.” In light of this lack of clarity, it appeared that some users were motivated to use social media as a means to improve future applications as discussed below.
Desire to improve future applications.
Users frequently sought advice from fellow users about how to improve applications to residency programs for future iterations of the match process. One user wrote: “How many programs should I apply to? What would be a good way to explain what happened during the previous Match or why my graduation was extended? Any advice you have would be helpful.” Others shared the strategies that they were employing in efforts to improve their odds of matching in the future. Such strategies included pursuing additional clinical or research experiences. Some discussed plans to delay or defer graduation from medical school to facilitate such experiences. Commonly, unmatched applicants shared their intention to apply to residency programs of other specialties in the future, with these other specialties often being used as backup options.
Discussion
The results of our study suggest that unmatched applicants are prone to a range of negative cognitive and emotional reactions, including regret about pursuing medical school (in part owing to financial distress), personalizing a sense of failure, and in some cases, suicidal ideation. The findings from our analysis of a sample of narrative comments from unmatched applicants to almost exclusively American residency programs, are in keeping with previous literature regarding unmatched applicants to Canadian residency programs.5,6 The experiences of unmatched applicants are compounded by the high levels of psychological distress due to factors including academic pressures, financial concerns, and exposure to the suffering and death of patients that medical students commonly experience even without the experience of going unmatched.14 Among medical students, self-actualization and a sense of fulfillment may be protective against psychological distress,14 and it is reasonable to infer that this protection would be lessened by the perceptions of shame and failure that are often experienced by unmatched applicants. Therefore, unmatched applicants are likely to be doubly adversely affected by way of exacerbating vulnerabilities pertaining to baseline distress among medical students and diminishing factors protective against psychological distress among medical students.
Accreditation standards for medical schools in Canada and the United States mandate the provision of “effective financial aid and debt management counseling” for medical students as well as “programs to promote their well-being and to facilitate their adjustment to the physical and emotional demands of medical education.”15,16 Many unmatched applicants have not yet graduated from medical school and therefore would remain entitled to such programs and support. Furthermore, multiple comments from unmatched applicants expressed perceptions of being inadequately supported by their medical schools in addressing their distress and in providing guidance to improve future applications. This mirrors a comment by Fellows and colleagues about fellow applicants seeking guidance after going unmatched: “There is uncertainty around going unmatched. Rather than seeking information from their universities, many students reached out to us to learn about going unmatched.”6
In light of our findings indicating that unmatched applicants are vulnerable to experiencing the aforementioned range of negative emotional and cognitive reactions, medical schools should ensure that effective supports are being offered to unmatched applicants in a timely and nonjudgmental manner. Given the many comments expressing uncertainty about the reasons for going unmatched, unmatched applicants may benefit from honest, critical, and objective feedback about their applications, with the goal of improving the likelihood of success of subsequent applications. Medical schools should also endeavor to destigmatize the experience of going unmatched, which may lessen the propensity of unmatched applicants interpreting the news of going unmatched as a judgment on their competence or personal characteristics. Such efforts to destigmatize this experience are especially salient since, as previously noted, the experience of going unmatched is underrecognized and receives insufficient attention.17
We are aware of some existing supports available for unmatched residency applicants. The American Medical Association published an online article in March 2022 outlining recommendations for unmatched applicants.18 These recommendations include maintaining contact with their medical school, pursuing research projects, finding a job in a clinical setting, and taking additional licensing examinations. In Canada, the Peer Support Network, supported by the Canadian Federation of Medical Students, provides an online forum for users to seek guidance and mentorship from a previously unmatched applicant.19 Additionally, the Canadian Federation of Medical Students has offered Safe Spaces peer support discussions,20 in collaboration with the Canadian Medical Association, to enhance connections between medical students experiencing stress related to the residency matching process in a confidential setting. We do not know of any similar programs for American residency applicants, and a review of the American Medical Student Association and Association of American Medical Colleges websites did not yield any information about such programs. The development of peer support programs in the United States may benefit unmatched applicants, and an evaluation of the aforementioned Canadian programs could inform this development.
Additionally, in 2018, the Association of Faculties of Medicine of Canada released a series of recommendations to reduce the number of unmatched Canadian medical graduates.21 Their recommendations included “that faculties take responsibility for creating appropriate structures, policies and procedures to enable them to support their unmatched Canadian medical graduates, including but not limited to, access to electives and to extensive Student Affairs Office guidance.”21 Balon and colleagues22 lay out several suggestions for actions that can be taken by unmatched medical students and their medical schools, such as students obtaining feedback from the residency programs to which they applied, strengthening their applications with the assistance of medical school advisors, and seeking debt management and mental health services. These authors acknowledge, however, that when applicants “suddenly face the overwhelming and distressing reality of not matching, they are under considerable stress and lack information while they must decide what to do next.”22 For this reason, we would advocate for medical schools to take a proactive approach in advising their students about the prospect of not matching to residency, as well as allowing students the option of opting-in to have medical school staff reach out to them in the event that they do not match. This process would remove the onus from the student to reach out for support during a time of distress and uncertainty, potentially allowing for more timely intervention.
Our use of qualitative data from Reddit came with advantages and disadvantages. As previously described, the anonymity afforded by social media allows users to discuss and explore content that they may otherwise keep silent about. In this sense, “researchers can identity voices that may not otherwise be heard through more traditional approaches.”23 Furthermore, social media users may demonstrate unconstrained behavior that may not be observed in artificial contexts,23 such as a focus group or individual interviews, allowing for more authentic expressions of personal experiences. By examining posts that were made at various times over the past several years, we were able to capture comments from users who were in the midst of going unmatched at that particular point in time. Since these comments were largely made temporally proximal to the unmatched experience, recall bias may have been mitigated in our study, compared with the recall bias that might occur in a cross-sectional study conducted at a later point in time. Disadvantages of relying on social media data include that we were not able to observe nonverbal communication that may have added to the richness of data collected in other formats, such as a face-to-face interview. Researchers using social media data may also be unable to follow up with anonymous users to confirm or verify their interpretation of data. While acknowledging these disadvantages, we felt that our use of data from Reddit was justified, as we were able to analyze data about a stigmatizing topic from individuals whose voices might not otherwise have been heard.
There are limitations to our study. While recognizing previous literature suggesting that anonymity may facilitate the sharing of sensitive and potentially stigmatizing information in online forums,7 this anonymity precluded the gathering of demographic characteristics of Reddit users. Our study was not designed to determine whether the experiences of Reddit users differed from those of non-Reddit users, so the possibility of selection bias cannot be ruled out. The initial screening was carried out by a single researcher, raising the possibility of researcher bias. Some of the analyzed comments referred to personal experiences of going unmatched in the past, thus, some of our data may therefore be subject to recall bias. There may have been other comments authored on Reddit that did not use the term unmatched, and so would not have been captured in our search but would have nonetheless contained content related to the experience of going unmatched. In addition, nearly all comments analyzed referred to institutions and application processes in the United States (e.g., American medical schools, NRMP, SOAP). This is not surprising since the number of unmatched residency applicants in the United States far surpasses the number of unmatched applicants in Canada. Nonetheless, this may limit the generalizability of our findings.
In conclusion, the findings of this study suggest that applicants who do not successfully match to an American residency training program may feel that they have derived limited benefit from their investments in pursuing medical education, face financial strain, perceive themselves to have failed, face uncertainty related to the prospect of not successfully matching with future applications, and may even experience suicidal ideation. Supports for unmatched residency applicants are limited at present, and our findings highlight the need for medical schools to ensure that necessary supports are offered to unmatched applicants to preserve their well-being and that their skills can be used to develop the physician workforce. Our use of social media data allowed us to circumvent issues with stigma, which have served as a barrier to research in this area. Nonetheless, further study is warranted to better understand the experiences of individuals who go unmatched, as research findings to date may not be representative of all unmatched applicants. Future work should also focus on investigating the outcomes of interventions intended to support unmatched applicants.
References
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