Featured topic and speakers
Reapplying for Match and wondering where to start? Family medicine resident Thomas Irwin, MD, MBA, and his advisor Carla Keirns, MD, PhD, associate professor of medical ethics and medicine at University of Kansas Medical Center talk about strategies to do just that.
Speakers
- Carla Keirns, MD, PhD, associate professor of medical ethics and associate professor of medicine, University of Kansas Medical Center
- Thomas Irwin, MD, MBA, family medicine resident, HCA Healthcare
- Brendan Murphy, senior news writer, American Medical Association
Host
- Todd Unger, chief experience officer, American Medical Association
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Transcript
Dr. Irwin: And so you, my unmatched friends, I've been there. And it hurts, let it hurt. But let it motivate you. Because there is a way out. Now it's a question of hanging in there, doing the things you know you need to do to get ahead and being honest about what got you here, why we're here, making the changes necessary, but go get it. You've earned the right to be here, it's yours, go take it.
Unger: That’s Dr. Thomas Irwin, family medicine resident at HCA Healthcare. On this episode of Making the Rounds, Dr. Irwin is joined by his advisor, Dr. Carla Keirns, associate professor of medical ethics and medicine at University of Kansas Medical Center. Together, they share strategies for reapplying to Match. Here’s AMA senior news writer, Brendan Murphy
Murphy: Hello and welcome to Making the Rounds. I'm Brendan Murphy, senior news writer at the AMA. Today, I'm talking with Dr. Carla Kearns and Dr. Thomas Erwin about their research on strategies to recover after an unsuccessful residency application cycle.
Dr. Carla Kearns is associate professor of medical ethics and associate professor of medicine at the University of Kansas Medical Center in Kansas City, Kansas. Dr. Thomas Erwin is a family medicine resident at HCA Research Medical Center in Kansas City, Missouri. Thank you both for joining us today. How are you?
Dr. Keirns: Excellent. Thank you.
Dr. Irwin: Doing well.
Murphy: This is a salient topic at this time as we are just coming off the Match. Can you give us some background on your work in this space and how your experience as former applicants and in your case, Dr. Keirns, as a faculty member, informed this research?
Dr. Keirns: Sure. So, I'm a professor at the University of Kansas and I'm a historian sociologist of health care as well. So, I graduated from medical school about 20 years ago, but I studied the process of medical education before I actually entered it myself. So, I've been watching the changes in this process for decades.
As a faculty member, I noticed about 10 years ago, along with my peers, that the process of matching was really changing. And in particular, who doesn't match was changing. And then in the last five years, I've had several students who I thought were excellent, who had trouble, or in fact, who did not match. And so that drove us to try to understand the process better and what could be done to improve it.
Murphy: Dr. Irwin, could you tell us a little bit about yourself?
Dr. Irwin: So, I am Dr. Keirn's advisee. I'm a graduate of the University of Kansas School of Medicine, now working for Research Medical Center with HCA. And what happened with me was I had a hard time matching. And one of the things that we did to make sure that some lessons were learned from this was we went back and systematically deconstructed everything we did. What worked? What didn't work?
And particularly in today's shifting landscape of trying to match in a much larger pool with a fairly stable number of residency slots out there, what does the applicant have to do to make sure that one is competitive, to make sure that one is able to match because as most folks know, doing, listen to this podcast know you have to have a residency to work. Many folks in the in the rest of the world don't know that if you don't have a residency position, you cannot work as a physician in the United States.
Murphy: In your answer to that last question, Dr. Keirns, you mentioned the profile of candidates who don't match is shifting.
Dr. Keirns: Yeah.
Murphy: How is that so?
Dr. Keirns: So up until about 1980, from the 60s to the 80s, there were more positions than there were applicants. And then from the 1980s to about 2000, there was an uneasy balance. About 16,000 U.S. MD graduates and about 8,000 DO graduates, international graduates and foreign graduates competed for about 24,000 spots. And then in 2000, we started opening new medical schools. We have opened 29 new medical schools in the last 25 years and increased the total number of graduates between MD and DO schools by about 50%. So that 16,000 U.S. graduate applicants for 24,000 spots is now closer to 24 for 24. And we still have a pool that includes international graduates, both U.S. citizens and non-U.S. citizens. That has dramatically increased competition, and it has changed. There's also been a recent merger of the DO and MD matches, which is great for both applicants and programs, but again has changed who is applying where.
So, what we started to see about 10 years ago was students who should have matched who didn't. When I graduated in 2003, the folks who were U.S. MD graduates who didn't match typically had applied to programs they were not competitive for. Their board scores or their grades were just not ever going to get them a spot in ophthalmology, dermatology, some of those highly competitive specialties.
And there was a guy in my class who applied three times to ophthalmology. I hope he finally decided to do something else. But about 10 years ago, we started to see students who were applying in medicine and family medicine with, you know, decent grades and decent scores start to not match. And that really showed us that what we have now is a much more noisy process, a much … a little bit more chaotic process, and we are having some folks fall through the cracks who would never have done so before.
Murphy: We are fresh off a match in which about 6%, 6-7% of U.S. MD and DO applicants went unmatched. Dr. Irwin, can you draw from your experiences what you did when you went unmatched? And how would you tell these applicants to change their approach based on your experiences and also based on this research you guys conducted?
Dr. Irwin: Sure. The first thing is you're going to have a week of absolute desolation and panic because you are now on the hook for those student loans you took out to go to medical school. That's not fun. The first thing is that you have to make sure you contact your school and be in touch with advisors who can begin to help you reintegrate into the process of looking for the other reapplication the next year, finding empty slots in the current year, and also a trusted advisor who's going go back over your application and figure out why didn't you match? And that takes a certain level of introspection harsh evaluation of what did and didn't happen. That can be very tough. And again, finding that right trusted advisor to do that who's plugged into the system is the most critical thing. The second thing, and I think this is the part that gets lost a lot in translation, is you have to keep advancing your resume. So, if you're sitting out for a year, the first thing that everybody worries about is, are your clinical skills going to wither?
That is the single most critical point, through research, that people have said matters to them on reapplicants. We don't want someone who's been sitting out a very long because we have a fresh crop of new medical students coming in the next year who are fresh out of their clinical work. And so, they're going to know how to do what they need to do. You can, if you can find your way into an empty slot in one of the preliminary positions either in medicine or in surgery, that is better than not doing anything. Second thing as well as you can also look into research positions—paid research positions, preferably, that give you some clinical exposure, but also give you a chance to advance your resume by publishing research, anything that will demonstrate to programs you're going to apply to the following year, that you're continuing to work within the field.
And the third point about it is, especially for someone who's got, for whom board scores may have been a question, is you go ahead and take Step Three in that intervening year. You make sure that that's out of the way on two fronts. One, nobody wants to chase another board exam. But two, another solid score will go a long way to alleviating people's fears about whether you can pass your boards because program directors care about two things in particular. One, are you going to take good care of their patients? That matters a lot. The second part is, and another part that they're very heavily judged on is, are you going to pass your boards? If you have Step Three taken care of, they know that you can pass their boards. And if you have clinical experience going forward, they know you can take care of their patients.
If I have a problem with either, I'm not taking you, especially when there is a fresh crop of kids coming in who have already demonstrated that they can pass the boards and do good clinical care.
Murphy: You do have to have some changes to your applicant profile and what you're looking for, I imagine. How does specialty choice play a role in going unmatched and how might applicants reconsider their specialty choice on that second go around, Dr. Irwin?
Dr. Irwin: So first of all, certainly with me, I applied to a competitive specialty and was not able to match into it, and it wasn't for lack of try. Both in the here and now and also for the reapplicant, the question becomes, if you know what you want, how many different ways can you think of to get there? If you want a surgical specialty, can you figure out a way to get into at least a general surgery preliminary year and do your intern year in surgery? If not, is there another way that you can get to something close to what you want going through medicine, going through the medicine, family medicine side of things. And thirdly, it also requires some introspection. Is your score on Step Two, in particular, which is the only metric with which we have to go right now—is your step score, on Step Two going to be enough to put you in that competitive category? If the answer is no, you do need to consider, do I need to look at another specialty to apply to? And also, can I make a convincing argument that I'm serious about going to that specialty in order to match into it?
Murphy: Your research found that on average 60% of applicants are making the holistic review. How would you define that, what that is and how do we ensure that if you're a re-applicant, you get to that 60%, Dr. Keirns?
Dr. Keirns: So that data is publicly available from the National Resident Matching Program. It comes from the Program Director's Survey. They receive your application electronically, just as you submitted it, and they use electronic filters to identify who they are going to interview and who they aren't. And so, things like board scores are important there whether you went to medical school in the region or not, because they're looking at who is going to come here. So if you are from the Midwest and you're applying in the East Coast, you're from the East Coast and you're applying in the West Coast, one of the things that can really be important is reaching out to program directors and say, “Hey, I want to come to California because my family's there, because there's a good job for my partner there,” because there's some other reason that you want to be there, because that can get the program director to actively look for your application as somebody who they might have filtered out just based on state or zip code. There isn't a lot you can do if you're being filtered out based on either board failures or board scores, unless you are really interested in that program, again, for a specific reason.
Think about this like applying for any other job. Do your homework about the people that you're applying to. And if you have a compelling reason why you think you would be a great fit for a program, you can reach out or you can have an advisor reach out. Now, you need to be cautious about that. There are Match guidelines that both applicants and programs have to adhere to.
And so, you want to make sure that you're not asking them to violate those rules. But expressing interest in a program for a specific reason is one of those things that can get your application pulled to at least a review. Now, some programs review every U.S. graduate who applies or review every graduate from nearby schools. I've talked to program directors who use a variety of tools, but those most common filters that get people just screened completely out are either scores, board failures or geographic.
Murphy: Does program signaling help with that sort of geographic screening problem?
Dr. Keirns: It does. So, when signaling is a really interesting story, it actually started in the market for economics professors, which is in some ways not dissimilar to the Match. The applicants kind of all look the same to the programs. And so, they started experimenting with signaling some time ago. We started in medicine in the last decade and initially applicants were given three to five signals for different specialties for programs, and that did not seem to move the needle. But in the last cycle when applicants were given 30 signals, that really did. Because what happened, and we saw this last year in the data, is that if you're applying in orthopedics and you didn't signal a program, they're not going to read your application.
But if you did signal a program, then you are more likely to have your application reviewed carefully even if you are on the lower side of the metrics for orthopedics or for whatever your specialty is. So being strategic about your signals and making sure that you're using them well is really important for those competitive specialties where, where they're becoming a de facto application cap almost.
Murphy: Dr. Irwin, we spoke generally about what applicants can do in between their application cycles to strengthen their candidacy. I would like to learn what did you do in between application cycles to strengthen your application?
Dr. Irwin: So first and foremost is I stayed in on top of looking for any program that had an opening that was even remotely interesting, and it didn't matter, I was doing this from Kansas City. I didn't care if it was in the Aleutian Islands. I didn't care if it was in Miami, you know, I didn't care if it was in the middle of Wyoming, if it looked interesting, I applied to it in the middle of what I was doing. I also got on with a research program at the University of Kansas. Thank you Dr. Gary Doolittle, my mentor on that front, and stayed clinically active, put out as many research papers as I possibly could, and I sat for Step Three at the end of my first research year. What I didn't do, it took me two tries after not matching to finally match. The first time I tried only surgical specialties on reapplication, that was a mistake.
That set me back a year. Now the thing is, everything worked out beautifully. That was not a bad thing for me personally, but in terms of the absolute, hey, I need to match. I did not include the medicine specialties until my second reapplication cycle. Once I was able to see what I wanted to do and a path to it from internal medicine, from family medicine, a lot of doors began to open.
And at that point, the other thing that this may have been the most crucial part was my trustee advisor—accompanying me on this podcast—reached out to a number of programs on my behalf that might not otherwise have spoken to me. Up to and including winding up sitting next to a program director on the plane to a conference elsewhere or calling across town to the program that ultimately took me.
As a sidebar to that, when we talk about signaling, there was a question, does signaling matter? For me, strangely enough, it did not. I matched right here in Kansas City, and I'm really glad I did. But I had signaled two places, I'm originally from Louisiana, I had signaled down there. I have friends and family in Florida, I signaled down there. And we stayed here. And my kids are happier for it.
Murphy: Dr. Keirns, do you have any other thoughts on how applicants can strengthen that application on the second or even third time through?
Dr. Keirns: So, the other critical thing that we did is review every single piece of the application. Every letter, every personal statement. We customized them as much as we could to every program. And we made sure that what was changeable, what could be improved had been addressed. The things that you can't change, you're not going to be able to change the board scores you already have. But the things that we could change, we made sure that they were as optimized as they could be.
Murphy: That audit of the application packet, that requires an objective informed mentor. And it seems as though at least part of the problem for unmatched applicants is that they might not have been given the right guidance. If you're going through it the second time, who should you turn to for that guidance?
Dr. Keirns: So, this is a little tricky because you have to identify what you want to do and you also have to identify who do you know or who are your resources. I graduated from medical school 20 years ago and applied in medicine and it was almost unheard of in my medical class to apply to more than 10 or 12 programs for medicine or family medicine.
In recent years, applying to 30 or 40 or many more is not at all unusual, even in those less competitive specialties. And so, having an advisor who has been involved in the process recently or who has kept up with the changes in the process are really important.
Reaching out to your Dean of Students office and working with them about, what went wrong? Or finding other mentors who you worked with in school and helping and having them help you analyze and identify that. And the hardest thing about that is of course that no one likes breaking bad news. But I am a palliative care specialist by training and practice. And so, figuring out what we do in my clinical world.
If you can't have what you want, can I help you to want something you can have? Can I help you, again, as Dr. Irwin was saying, identify a different path to get to where you want to be?
Some applicants are going to feel completely isolated at this stage, and there are commercial services that provide advising services. They're really aimed at international medical graduates, and I'm sure they do an excellent job. But I think the key thing is making sure that you're talking to someone who will be honest with you, who is aware of what has changed since their own Match, and who will help guide you to what you could do differently.
Murphy: Do you have any other thoughts on this topic? For students who are considering another round of applying? Dr. Keirns, we can start with you.
Dr. Keirns: Yeah, so the first thing to recognize is that U.S. medical graduates match. So maybe it didn't go the first time for you. And that is brutally hard. But the Match statistics show that 80% or more will match the second time around. And the data is even better for folks who were applying in competitive surgical specialties and are reapplying in those areas. It's more like 85% of folks will match in either in the specialty they applied in or in a related specialty. So having a little bit broader view, but also knowing that more than 95-97% of U.S. graduates will go on to the clinical fields they want to.
And a handful don't, but I went to the University of Pennsylvania and some of our MD, MBA candidates decided to go work for McKinsey instead. Or I knew folks who decided to go into public health or other areas. So, the thing that I think is most important for students to know right now is it may feel like the world is over, but it's not. You're going to do okay. Dr. Irwin, what am I missing?
Dr. Irwin: The first thing that I would tell everybody who doesn't match is... It's okay to hurt. It's okay to mourn. Because the world just changed. You're still a doctor. And now it's a question of persistence. And yes, you may have to make some decisions that take you in a different direction than what you originally wanted. And that can be tough as well, but some great wisdom from an NHL defenseman playing for the New York Rangers in 1994. They had just been scored on to go to overtime in game seven of the Eastern Conference Finals against the New Jersey Devils. And one of the veteran defensemen, Kevin Lowe, who had won several Stanley Cups with the Edmondson Oilers, walked into this desolated locker room and said, “Don't worry, if it was easy, it wouldn't be so much fun when we pull it off. We know what to do. Go and do it.”
And so you, my unmatched friends, I've been there. And it hurts, let it hurt. But let it motivate you. Because there is a way out. Now it's a question of hanging in there, doing the things you know you need to do to get ahead and being honest about what got you here, why we're here, making the changes necessary, but go get it. You've earned the right to be here, it's yours, go take it.
Murphy: That's a nice little inspiring nugget to end on. Thank you both so much for joining me today. I'm sure our listeners will value the advice you offered.
Dr. Keirns: Thank you so much.
Dr. Irwin: Thanks for having us.
Murphy: I'm AMA Senior News Writer, Brendan Murphy. Thanks for listening to Making the Rounds.
Unger: The AMA is here to help you master the process to secure a residency match. Learn more at ama-assn.org/meetyourmatch. Thanks for listening.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
