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We talked to young physicians about the stress of the match.
The Ides of March and its treachery were upon us once again, this time in the form of the 2021 medical student National Residency Match Program (NRMP), also known as “The Match.”
Match Day is the final hurdle towards becoming a fully-fledged physician, marking the culmination of seven-plus years of effort (four years of college and more than three of medical school) and hundreds of thousands of dollars of student loans for most medical students. This day is particularly stressful because, without acceptance into an accredited residency program, graduates have no hope to gain a license to practice medicine, rendering their medical degree nothing more than an expensive piece of paper.
For most, Match Day is a day of relief and rejoicing as future physicians learn where they will be spending the next three-plus years of their lives—ideally in their specialty of choice, but for some graduates, at any program that will take them. But with more applicants than available residency positions, Match Day often brings disappointment and despair.
This year’s match was no different. Although the NRMP joyously announced that 2021 marked “the largest match on record” with the highest number of matched United States MD and DO seniors, over 2,200 medical students graduating from accredited U.S. medical schools failed to match into a residency position. Another 2,143 internationally trained U.S. citizens and 5,730 non-U.S. citizens tried and failed to gain a residency position, putting a halt to their medical careers. What will happen to these thousands of medical school graduates?
Supplemental Offer and Acceptance Program (SOAP)
Some lucky applicants will be fortunate enough to “scramble” into a slot during the “Supplemental Offer and Acceptance Program” (SOAP), a process during which students compete for any unfilled spots at programs across the country. According to the NRMP, there were 1,927 such positions available after the match—still not enough slots to accommodate all graduating seniors.
Joshua Umland, a fourth-year DO candidate at Western University of Health Sciences, described the stress of going through the SOAP process. “I found out on Monday that I hadn’t matched,” said Umland, who hopes to become a pediatric emergency physician. “I was shocked. I had no red flags on my record, had put in 90 applications, and ranked a total of 17 different programs between emergency medicine and pediatrics.”
After learning that he hadn’t matched, Umland had only hours to re-apply to open positions, using the Electronic Residency Application Service (ERAS). But with thousands of other applicants also attempting to upload applications, the system was unable to keep up with demand. “I was trying to get my information uploaded, but the site kept crashing, which also caused delays in programs scheduling screening interviews,” says Umland, who spent the next few days constantly checking his email and refreshing his computer screen in the hope of receiving an interview. Umland was fortunate to find a position when a slot happened to open up at one of the programs he had initially ranked. “It was amazing to get the call and be offered a position,” said Umland. “It was the best possible outcome for me.”
Other unmatched graduates weren’t quite as lucky. It took several years for Nadezhda Ibragimova, DO, an internal medicine physician in Bronx, NY, to find a residency position. “I was the only medical student that did not match in my graduating class. The level of embarrassment I felt was so overwhelming; I was numb.” Ibragimova had to work outside of medicine for several years until an opportunity arose for her to complete a residency. “Many don’t understand that just because you have finished medical school doesn’t mean that you can now work as a physician,” said Ibragimova, who notes that her student loans piled up during her time between graduation and finding a residency. Fortunately, an opportunity arose “in a program I had never heard of, in a location I had zero desire to be in.” Ibragimova says that although she “cried like a baby” when she matched, she “wouldn’t change anything about my training—it was awesome!”
Alethea Poste, MD, was also unable to find a residency slot for several years. Although she attended medical school in Mexico, Poste transferred into New York Medical College’s “5th Pathway Program,” an additional fifth-year of medical school for international medical students, where she excelled in all her rotations and received very strong letters of recommendation.
Despite applying for 20 Family Medicine and Internal Medicine programs, Poste was only invited to interview at three. She did not match, nor was she able to gain a slot during the SOAP period. “I tried to scramble—I called all over the country, looking for any place that would take me to work doing anything in the medical field, but no one would take me. I was devastated. Five years of medical school, five years of undergraduate studies, and over $200,000 in debt.”
On top of everything, Poste learned that she was pregnant with her first child. “I had no health insurance and no income. I felt like a failure. If it were not for my husband, my faith, and the joy of having my son, I don’t think I would have made it through that year.” Poste got a job working minimum wage at a research lab at New York Medical College. Her husband was a PhD student working at two Universities. “We lived off of $20,000 that year and were on welfare,” says Poste, who remembers feeling “embarrassed by my failure, depressed, and helpless.”
The next year, she reapplied for residency positions, but once again failed to match, even after being asked back for a “second look” at her preferred program. “I cried for days. I told myself if I didn’t match again, I would start a new career path.” Fortunately, her tenacity paid off. On her third attempt, Poste matched at a Family Medicine program, where she was ultimately awarded “Resident of the Year” all three years—an unprecedented achievement at her program. “Today, I am a successful Family medicine physician. I’ll never forget how difficult it was for me to get where I am today, and I am grateful every day,” says Poste.
A “system” problem
Medical students should remember that not matching does not mean that they are a failure. “This isn’t about you as a person. It’s about a broken system,” says Joshua Umland. “While it sounds good that 90% of DO graduates matched, this means that 10% of graduates did not. If there are 100 students in your class, ten won’t match. That’s still significant.”
Even though the lack of available slots means that a certain number of students simply will not match, no matter how qualified they are, most medical students report feeling embarrassed and ashamed when they do not match.Sonia Millan, MD, a sports medicine and family physician in Florida, is sharing her experience openly for the first time because she wants others to know that they are not alone. “Even though it has been years since I graduated, I was so humiliated that still tears well up when I consider it.” Millan also notes that these feelings followed her into her residency. “I struggled with the feeling that I wasn’t meant to be a doctor, and that I wasn’t good enough. It affected my confidence—I never felt adequate as a resident.” Millan believes that it is important for physicians to share their feelings and get help during this difficult time. “Don’t give up—talk to others and seek mental health help if you need it.”
Medical student Joshua Umland also decided to share his story publicly because he wanted other unmatched students not to feel isolated.He says that not matching can be extremely tough for medical students, many of whom have “Type A, extremely competitive” personalities. “But failure is a part of this. We have all failed, and failure is inevitable at some point. We need to talk to others and get moral support.”
Umland says that talking about our failures allows us to gain support and helps to destigmatize not matching. For this reason, he decided to share experiences on social media. “I was surprised by the outpouring of support from my Twitter posts. I don’t have a big following, but thousands of people shared my posts about not matching. I was blown away.” Ultimately, Umland hopes that his story will help others who have had the same experience.
Even more importantly, Umland and others hope that steps are taken to provide opportunities to the thousands of unmatched physician graduates every year, especially considering an anticipated physician shortage that has led to an increase in the production of non-physician practitioners like nurse practitioners and physician assistants. While medical schools have increased, Medicare-funded residency training program funding was frozen in 1997, creating a bottleneck for licensed physicians. The Resident Physician Shortage Act of 2021, reintroduced in the Senate this month, would increase residency slots by 14,000 over seven years. Alternate proposals for solving the bottleneck include requiring that medical schools provide a minimum one-year internship program for all of their graduates to obtain a medical license as a general practitioner, an assistant physician program like that offered in Missouri, or granting a provisional license similar to that a nurse practitioner or physician assistant that would allow medical school graduates to practice under a licensed physician or as a general practitioner.
Rebekah Bernard MD is a family physician in Fort Myers, FL, and the author of Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare.