Coaching Students to Maximum Match Potential

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Medical Education Feature — September 2014

Tex Med. 2014;110(9):47-51. 

By Amy Lynn Sorrel
Associate Editor

As Jorge E. Novo, MD, prepared for last year's Match Day, The University of Texas Medical School at Houston student was "quite confident" about his prospects for securing a residency training position in his preferred specialty: otolaryngology (ENT). 

His U.S. Medical Licensing Examination (USMLE) Step 1 score was well above average, and the honors student did additional rotations at other institutions. His residency interviews went well. And while student affairs counselors at the time cautioned Dr. Novo and other students about applying to competitive specialties like ENT, advisors also told him his academic performance and top rankings made him an ideal candidate. 

"There was nothing else I could do," he said, except wait. 

When Dr. Novo received an email from the National Resident Matching Program (NRMP) saying he did not match into an ENT residency program, he was "flabbergasted with the news. It took me a while to realize it was happening. I thought, 'Is this the right message for the right person?' I was in complete emotional shock," he said, as was his mentor.

Nevertheless, Dr. Novo had to quickly collect himself to prepare for the post-match process — the SOAP, or Supplemental Offer and Acceptance Program. After the main match, he had just two hours to scan the remaining positions, decide on a new career trajectory, and submit his applications.

"At that point, the match means everything: where you're going to live, what you are going to do for the rest of your life. Then suddenly, you have no clue, and you are making decisions amid that turmoil. It's too hard to redefine your life in two hours," he said. 

After another 48 "excruciating" hours by the phone waiting for offers, Dr. Novo found out that new life would be pathology, in Chicago. 

Six months later, he's enjoying his new specialty. But at the time, "It was not my first choice. I was trying to hold back the tears and convince myself I can do other things. Then I thought, 'I guess I'm going to be a pathologist now.' I definitely felt the pressure of, 'Is this the right choice?'"

Dr. Novo's experience is becoming all too common. 

Despite the success of this year's Match Day — 94 percent of U.S. seniors matched to a first-year residency position — medical school deans in Texas and across the country remain concerned about a growing number of students who have difficulty matching. 

They say those numbers could add up to missed opportunities in the form of physicians and medical education dollars that do not immediately end up in a workforce that is hurting for doctors of every discipline, especially in Texas, which is experiencing rapid growth in population and prevalence of chronic illnesses.

To keep pace, the Texas Medical Association and organized medicine continue to advocate at the state and national levels for increased funding for additional graduate medical education (GME) training spots. (See "Reconsidering GME Funding.") 

But medical education leaders also point to an increasingly competitive match climate as part of the problem, as they search for ways to better counsel students to maximize their opportunities early and often throughout their medical education. The TMA Ad Hoc Council of Medical School Deans raised the issue at TexMed 2014.

"To have any students who don't have a place to continue to train is an issue, considering all the money we put into medical education," said Steven L. Berk, MD. The dean of the Texas Tech University Health Sciences Center (TTUHSC) School of Medicine in Lubbock chairs the TMA deans group and serves as a consultant to the association's Council on Medical Education. "Schools have always had the infrastructure for advising students. But so much has changed that what we used to tell students three or four years ago is not the same thing we should tell them now to advise well and maximize their chances for success." 

Competition Heats Up

Nationally, 16,000 U.S. medical school seniors — 94 percent — matched to a first-year residency position in 2014, according to NRMP. Half matched to their first choice, and roughly 80 percent matched to one of their top-three choices. This year's match also offered 500 more positions — mostly in primary care — than in 2013, for a total of more than 29,000 first- and second-year slots. 

Despite those gains, 2013 was the first year there were more unmatched seniors (1,097) in the post-match SOAP program than open first-year positions (850) — a trend TMA leaders warn could worsen as medical schools graduate more students. In 2014, the gap shrunk but remained with 975 unmatched seniors and 934 unfilled first-year positions. Of those, 412 did not match at all.

A TMA survey of Texas' nine medical schools shows that out of 100 fourth-year Texas medical students who did not match to a residency program during the 2014 main match, 68 found a position during the post-match process. Thirty-two did not match at all — 2 percent of this year’s roughly 1,600 medical school graduates. 

The most competitive specialties for Texas students were orthopedic surgery, surgery, otolaryngology, dermatology, obstetrics-gynecology, and ophthalmology, according to TMA's survey. National data show similar results. 

A handful of Texas students who did not match right away chose not to participate in SOAP and instead pursued other options, such as a master's degree, according to TMA's survey. Dr. Novo says he considered taking a transitional year to do research or clinical work to strengthen his application. 

The longer students wait, however, the lower their chances of matching, Association of American Medical Colleges (AAMC) data show. (See "Missed Opportunities.")

Fewer available SOAP slots are a big factor contributing to the nonmatch numbers, but not the only one, educators say. The problem can compound when students who don't match jump into the following year's pool of residency candidates. 

Even so, "if 100 students don't match in Texas, additional GME slots sounds like a fantastic thing. But it depends on the [specialty] distribution," of those added slots, said Dr. Berk, an internist who specializes in geriatrics and infectious diseases. "Lots of things happen in four years of medical school that influence students' interests. They develop competitive records, and suddenly they never thought about dermatology until they get a 270 on the USMLE." 

Dr. Novo adds that market and lifestyle factors, such as practice location, ability to pay off student loans, and demand for certain specialties, also influenced his decisionmaking.

Fewer open positions in the supplemental match make for a more competitive environment, with more students applying to more programs across a broad range of specialties to better their chances. 

And the match process itself has changed, Dr. Berk adds, with some benefits and drawbacks. 

As of 2012, SOAP replaced the previously unmanaged "post-match scramble," which left students and schools on their own scrambling to line up interviews and applications for as many unfilled spots as possible. That also put pressure on residency programs flooded with requests. Now, NRMP simultaneously releases information on unmatched applicants and programs, and it's up to residency programs to reach out to students with offers. 

But students have just two hours to accept or reject those offers between rounds — usually with no interviews — giving what educators described in TMA's survey as a woefully short amount of time for students to process the news about not matching and for faculty to help assess their potential for and interest in alternate programs. 

SOAP rules also prohibit schools and students from contacting residency programs unless asked by the program, making it nearly impossible for faculty members to advocate on behalf of their students, Dr. Berk says. 

Call in the Coach

Like most medical schools, UT Southwestern Medical School in Dallas has a four-year career advising program with workshops to help students explore various specialties and align those interests with their own goals, values, strengths, and skills, Associate Dean for Student Affairs Angela Mihalic, MD, says. Advisors also offer self-assessment tools to help students with their career search and the application process. (See "Tools for Success.") 

Each clinical department appoints a faculty advisor who generally serves as the central resource for information regarding that specialty, and in their third year, students are assigned an individual specialty advisor. The associate deans for student affairs also meet with the classes annually to review data from the annual match and provide advice and insight on the application process. 

Despite those efforts, Dr. Mihalic points to AAMC surveys of student affairs deans showing nonmatchers typically do not follow the guidance from an advisor or dean's office, have an appropriate backup plan, or rank enough programs. They also tend to receive low or failing USMLE scores, have poor interviewing or interpersonal skills, and not be competitive for their first-choice specialty. 

That may mean schools have a tough job ahead of them. But Dr. Mihalic and fellow medical education leaders agree: More personalized coaching is imperative for students' success. "Generic advice to student groups is no longer feasible or successful." 

Members of TMA's Ad Hoc Council of Medical School Deans also firmly assented that given the competitive match environment, such counseling must encourage students to have a second choice of specialty at the ready. 

With little to no published data on the competitiveness of individual residency programs, however, Dr. Mihalic says the task of advising students on the number and types of programs they should apply to is a difficult one.

Schools do have access to AAMC data on the average number of residency program applications in the various disciplines. "And over the past several years, the average number of applications has gone up significantly, likely due to the increasingly competitive match" and the trouble students tend to have determining which programs they are actually competitive for, she said. That also means, however, "students often err on the side of applying to more and more programs, some of which would not typically consider them based on screening criteria, such as USMLE Step 1 score."

Schools are hoping more directed coaching can help students wade through the process. 

For starters, UT Southwestern developed what Dr. Mihalic describes as "homegrown surveys" to track which of the school's students received interviews in the various disciplines they applied for and to compare the information with national data.

"We also provide multiyear data on which programs our students have matched to based on Step 1 score and quartile rank. This information is critical to support our students' success and assist them in making wise decisions regarding number and types of programs for which they should apply," said Dr. Mihalic, associate professor of pediatrics. "Ideally, this data would be made available on a state or national level." 

Educators also agree it's their job to better identify problem students early on who may not be ready to graduate versus those who simply need better preparation for the match.

Schools can take a look at how their own programs influence students' interests, too, says David P. Wright, MD, immediate past chair of TMA's Council on Medical Education. At a time when primary care specialists are in high demand, for example, schools could generate more interest in the field by giving students earlier hands-on training beyond hospital walls.

Dr. Wright is a family physician and assistant professor of family and community medicine who supervises residents and directs the UT Southwestern Medical Center's family medicine clerkship program at Austin's University Medical Center Brackenridge Hospital. "Students are amazed when they come to my clinic and see all that we do,” he says. “It's our obligation to expose students to primary care and give them a chance to explore, but we have to get them out of the tertiary care setting to do that."

Walking a Fine Line

At the same time, residency program leaders caution against the pitfall of pushing students into the wrong field for the wrong reasons and say school advisors should be attuned to ferreting out those students who are not sincere about pursuing a particular field. 

"I hope that students will be inspired to want to be family physicians when they work with me, but it's not my job to turn all students into family medicine doctors," said Rodney B. Young, MD, chair of the Department of Family and Community Medicine at TTUHSC in Amarillo. "As educators, it's our role to help them find their passion within medicine, where they can have the greatest impact for their patients."

Dr. Berk also acknowledges schools must walk a fine line between maximizing students' potential for a particular career in medicine and squashing their dreams. 

Having walked that tightrope, Dr. Novo says he would have rather had a safety net. "Schools are doing what they can," he said, but students also have to prepare themselves.

When a former classmate called him for advice about not matching right away, "I told him the conclusion I arrived at myself: 'You are not a failure. It's a failure of the system.' Too many medical schools and not enough GME spots does not mean you are a failure. But there are always spots left open," Dr. Novo said. "If you make it, fantastic. But just in case the worst happens, have a plan B ready that you came up with when you were in a normal mental and emotional state. And be realistic."

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.


Missed Opportunities 

The longer medical students wait to match to a residency position, the lower their chances. Texas medical education leaders want to make sure those numbers don't translate into missed opportunities in the form of physicians who don't immediately end up in a workforce in need of more doctors.

Year(s) Out of          MD Match Rate     
Medical School

1 year 76 percent
2 years 60 percent
3 years 55 percent
4+ years 39 percent

Source: 2014 Association of American Medical Colleges Group on Student Affairs survey of National Resident Matching Program results

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Tools for Success

Medical schools are adding to their toolboxes to help students maximize their potential for the annual Match Day. Here are some recommended resources (see all the live links on the TMA website):

Explore: The Association of American Medical Colleges (AAMC) Careers in Medicine provides self-assessment tools and a wealth of information about each specialty to assist students in career exploration and later in the application process, says The University of Texas Southwestern Medical School Associate Dean for Student Affairs Angela Mihalic, MD. 

Assess: Once students select a specialty, they can assess their competitiveness for that field using available data from:  

Investigate: Students can learn about the various residency programs through their specialty advisors, as well as through the American Medical Association Fellowship and Residency Electronic Interactive Database (FREIDA Online). Dr. Mihalic says the resource is searchable and allows applicants to explore various program features. 

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