By Dr. Charles Patterson, WCI Columnist
Every year, thousands of rising fourth-year medical students across the world brace themselves in hopes of landing their preferred residency. This nerve-wracking misadventure, hosted by the Association of American Medical Colleges's (AAMC’s) Electronic Residency Application Service (ERAS) and the National Resident Matching Program (NRMP), seeks to join qualified medical students with training programs through a rack-and-stack assemblage of criteria and the shared desires of the involved parties. The NRMP match, not to be confused with match.com, is software-driven and [relatively] straightforward. In an era of AI and algorithms, if marriage can be a computer-linked endeavor, then so should your career be.
For the hundreds of students obligated to military service through the Health Professions Scholarship Program (HPSP) or the Uniformed Services University of the Health Sciences (USUHS), this process is mirrored through a match system in December that occurs in parallel to its civilian cousin, which happens three months later. As many can attest, understanding this translucent process is difficult and best learned through folks who have recently completed it. In contrast to the NRMP, the military match feels analog. Navigation resources exist online, though referring to any of them as centralized and easily accessed might be overselling it. The official websites for Navy GME and the Air Force Physician Education Branch are repositories for official instruction but lack nuance.
In this article, we will try our hand at succinctly explaining the process while providing a launching point for unraveling the Rube Goldberg machine that is the military match.
Background of the Military Match
The Medical Corps needs physicians of all stripes, be they non-residency trained general medical officers, primary care doctors, or subspecialists. These needs evolve, and as such, representatives of the various specialties (senior military physicians called consultants) convene yearly and submit their recommendations for manning in a process known as the Health Professions Education Requirements Board, or HPERB. The end result is a list that contains the number of training spots allocated for each specialty, positions for which applicants will then apply.
An important note here: if your chosen specialty is not listed, then it was not approved for funding. So if you want to be a cardiothoracic surgeon and there are no integrated residencies or fellowships available, then it is very unlikely to happen in that cycle. While there are magical hidden pathways to many things in the military system, I am unaware of a mechanism by which one pursues an unavailable training pipeline.
Medical students, interns, and staff physicians seeking training begin the selection process in the summer, with online applications due by August 31. This period coincides with away rotations (called Active Duty Clerkships or ADTs), during which interviews are typically conducted. By the middle of October, all supporting documents (transcripts, letters of recommendation, etc.) must be uploaded. Finalized preference lists for specialties (yes, you may apply to more than one) and training locations are also due at this time.
In the late fall of each year, a convention of senior medical officers from the Army, Navy, and Air Force gather to form the Joint Service Graduate Medical Education Selection Board (JSGME). During this meeting, applicants are scored, ranked, and matched to programs. Following approval from the Surgeon General, funding is granted by Congress and the results are released.
How Does the JSGME Match Process Work?
Full disclosure: I have never sat on a JSGME Board. There are outdated versions of score sheets peppered across the internet which are likely “unverifiable” but similar to the most current evolution. However, we believe the generally accepted guidance for scoring is as follows: points are given based on strength of application, board scores, letters of recommendation, etc. More points are given for publications and performance in internship or residency, and even more points are awarded for operational experience and potential for successful practice as a specialist and officer. So if you have completed one or more successful tours as a staff physician and did well along the way, your points tally will likely dwarf that of a medical student.
The JSGME will grade the applications and produce a rank list—those with the highest scores at the top. The board will then divvy the selectees to the available training sites, preferentially filling the military sites first. As both the applicant and the program director will have made a rank list, the board will try to match as best as possible the wishes of both parties. Extenuating circumstances, such as special family needs, are also taken into consideration. The JSGME, with rare exceptions, can only fill the number of positions authorized by the HPERB. So, if there were 20 authorized training positions to be filled for a given specialty and 30 applicants, the top 20 would be selected, and the bottom 10 would be placed in “non-select” status.
What Are the Training Pathways in the Military?
As you might imagine, the military provides excellent training through the Accreditation Council for Graduate Medical Education (ACGME)-accredited programs. Board pass rates are high, and it has been my experience that physicians graduate well prepared for their clinical duties. However, the number of training positions authorized by the HPERB outnumber the positions offered within the military training programs. Take family medicine, for instance: in the Air Force in 2021, there were 75 positions authorized to be filled, but only 55 of them were military. Thus, 20 applicants who are selected for a categorical residency but who are not placed in a military training site are obliged to participate in the NRMP Match and train in the civilian sector. Accordingly, all family medicine applicants must also apply through the ERAS system. This cyclical shortfall tends to be well-known in the larger Graduate Medical Education (GME) sphere, with most civilian program directors aware of this unique circumstance.
For subspecialty training, a greater proportion of selectees complete their training in the civilian sector, as there are fewer ACGME-accredited fellowships in the military GME platforms. Again, many program directors are familiar and are gracious to consider out-of-cycle military applicants.
Once authorized for training, selectees are directed into a training status. Below is a breakdown of the “types” of status available:
- Active Duty: The selectee will train in an active duty status in a military training program. Time spent in an Active Duty Residency counts toward retirement but not toward any previously incurred commitment.
- Civilian Sponsored: The selectee will be authorized for training through the JSGME and will then need to seek acceptance in an accredited civilian residency or fellowship. While in training, the military will pay salary, benefits, and incurred training expenses, and it cannot receive salary support from the civilian institution. The trainee is considered on active duty, and this arrangement typically incurs an added service commitment.
- Civilian Deferred: The selectee will be authorized for training through the JSGME and will then need to seek acceptance in an accredited civilian residency or fellowship. In contrast to civilian sponsored status, however, the selectee effectively becomes a civilian just prior to starting the pipeline (technically, enters the Individual Ready Reserves similar to HPSP students). Accordingly, no salary or benefits are furnished by the military, and at the completion of training, the newly trained specialist will re-enter active duty.
For most medical students applying to residency or fellowship hopefuls who know that no military training program exists, participation in the AAMC ERAS process is typically mandatory, and it occurs in parallel with the JSGME program. This ensures that if authorized for civilian training, all of the requisite documentation and interviews are complete. There are exceptions to this rule, such as pre-selects or out-of-cycle applicants. Unlike ERAS, there are no (direct) fees when applying through the military system.
What Goes into My GME Application?
Application materials closely resemble that which goes into the ERAS application:
- Form Submission with Demographic Information
- Curriculum Vitae (CV)
- Medical School Transcripts
- United States Medical Licensing Examination (USMLE)/Comprehensive Osteopathic Medical Licensing Examination (COMLEX) Transcript
- Personal Statement
- Letters of Recommendation
- Program Director Interview/Evaluation Sheet
- Documentation of Physical Fitness
- Non-Selection (PGY1) Worksheet
This data is uploaded into a utilitarian, Army-managed online portal called the Medical Operational Data System, or MODS. Trust your instincts if they are telling you that there are too many acronyms but also prepare for more.
Here, we should highlight that medical students are not the only folks vying for training positions. Previously unsuccessful applicants, having completed a PGY1 year or General Medical Officer (GMO) tour are also competing for residencies and fellowships. Further, it is not uncommon for residency-trained medical officers to pursue a second primary residency. Applications from these latter pools require the above documentation, in addition to endorsements from Commanders and Consultants and Officer Performance Reports (OPRs).
How to Match Successfully in the Military
“Successful match” here might mean that both applicant and program are satisfied with the selection, and that after an illustrious medical career, one looks back and sees that it all worked out. The match rate in the military for most specialties tends to be fairly similar to the civilian sector, though outliers abound. As is to be expected, competition among the highly-sought-after fields, such as dermatology and ophthalmology, is far greater than for primary care. Expectation management is of utility in this process, but you can be confident that a strong application, Sub-Internship (ADT), and interview will give you the best chance in the JSGME.
First things: be an exceptional medical student, seeking knowledge and the betterment of your patients and peers. Do better than your best in pre-clinical years and in rotations. Crush the USMLE/COMLEX. Maximize relationships, seeking mentors from whom you can grow personally and professionally. Research experience is desirable but do so from a position of curiosity. From there, affability is priceless. Remember that a large part of vetting a potential colleague is answering the question: “Would I want to work with this person at 3 a.m.?” Along this vein, make every effort to present yourself as an outstanding military officer. Program directors have a wealth of military experience and have a vested interest in cultivating professionals who are going to serve admirably. Observing customs and courtesies, tending your uniform, and standing in the presence of superiors are all simple gestures that communicate your competence.
Make your wishes and needs known to program directors! If you have life circumstances that dictate geographic or work-related restrictions, make them clear. The goal for everyone involved in this process is to produce strong officer-physicians capable of leading a ready medical force. And to that end, they realize that a thriving home and family life is imperative.
If you are a medical student wanting to go into a highly competitive field, don’t be dissuaded by the above-described points calculus. You can't control nor predict who is applying in a given year, and there is overwhelming anecdotal evidence supporting medical students directly entering selective categorical residencies. It's true that at the end of it all, you may fall short in points. But it’s a small community, and leaders remember those who have made a strong impression.
What Happens If I Don’t Match?
The road following a non-selection depends on your status during the application.
For medical students, the application process requires you to fill out a PGY1 Only Form, which is a preference sheet for non-selection. Applicants who are not selected for categorical training are required to complete a PGY1 year in internal medicine, general surgery, or a transitional year. This year is typically done at a military training site, but these too are limited in size. As a result, some interns complete the year at a civilian institution.
Those applicants completing a PGY1 year who are non-selected for training will be assigned as a General Medical Officer and may re-enter the JSGME after two years of service. Alternatively, they may finish their service obligation (typically 3-4 years for HPSP) and enter civilian practice.
Finally, staff physicians applying for GME who are non-selected simply continue their service and may re-apply in subsequent years.
The JSMGE process doesn’t look or feel particularly approachable, but having gone through this wringer four times, I can say that the folks conducting it want the best for you and the Mission. And there it is: the Mission. It’s why the military exists, why we and our families sacrifice, why we signed up. Conducting it sometimes (or in my case, multiple times) means that, while qualified, we may not be deemed the most qualified. I truly hope that your match dreams come true, but know that even if they don’t this time, you are still going to have the opportunity to treat America’s best.
How have you approached the Military Match? What other pieces of advice do you have for somebody going through it right now? Comment below!
[The views expressed in this article are those of the author and do not reflect any official position of the Department of Defense or the U.S. government. These writings are not authorized, approved, or endorsed by any of the above entities.]