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.
Conclusion
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.]
Sir, regarding wanting to go into a specialty that is not formally available that year. It is possible, but unlikely, and I have only ever seen it with fellowships.
While you gave examples of more applicants than positions, there are also plenty of times when there are more positions than applicants. When this happens, the funding is still available for training, and can (at the discretion of various echelons above reality) be used towards different specialty training. I have only ever seen this happen with fellowships, but if say the EM ultrasound fellowship does not fill, then that position could be used to fund an EM toxicology fellow in an off year (Army typically only funds tox in alternate years).
Great tip.
There is an unwritten rule for highly competitive residencies and locations in the military for the average applicant (at least on the Army side): if you do not rotate at a training program YOU WILL NOT MATCH TO THAT PROGRAM. Each HPSP applicant should have funding for 2 away rotations their 4th year (from MS3 and MS4 year). So the highly competitive and highly desired locations will see 20-30 students rotate through their programs in a given year. Program directors give preference to known entities, ie students that rotated with their program and the residents and staff got along with. They also assume that if you didn’t rotate with their program with a funded rotation, you don’t care enough to be there. This has career implications as at least in general surgery the faculty tend to have trained at that program. It pays to talk with current residents because there are some programs (at least in General Surgery) that are more snobbish about board scores than others. My biggest advice is to find current residents in your desired specialty as 2nd and 3rd years, because setting up your 4th year rotations correctly is critical. I cannot emphasize enough how important these rotations are to success in a highly desired specialty in the military.
I went through the system 30 years ago so I am sure a lot has changed. Back then, as Army General Surgeon notes, residences wanted candidates they knew and further the selection board I sat on wanted those who they knew wanted them so they wouldn’t get turned down. I always wondered if such candidates had told multiple residencies that they were their top choice… They also (then) rebuffed my advocating for diversity, ie selecting the unrepresented minority if the candidates were otherwise equal. (Though I was probably chosen to be on the panel because I was the only female in the residency.)
I was certain then and it is probably still true now that candidates for the Os and Derm who were not quite as strong as civilian candidates for those highly sought after residencies had a better chance in the military, though usually only after serving a couple years as a GMO. I also felt, and doing the military residency did not change my mind, that the residencies offered in family medicine through the military were much stronger than the civilian ones. However, this bias against my med school area’s family medicine residencies was probably instilled by the specialists training us at the medical school. Still uncertain if it was valid or not. But in any case the Army presented a much stronger view of this specialty.
I always wondered why the military was happy to offer a second residency to those already trained, even as my spouse did just that. Probably because it was a way to keep senior officers, rather than having them leave the military, and their rank and experience gave them more value than making a fresh medical school graduate happier with their selection.
One Air Force specific addition (perhaps true in the other services) – if you are going to only do an internship, you can be either a flight surgeon or a general medical officer. You will have to pass the flight physical to be a flight surgeon, but the two paths are fairly different, so once you know you will be going down the internship only pathway, I highly recommend you explore your options quickly, as getting a flight physical completed can take a fair amount of time. IMO, talking to folks in both tracks before you make your decision is the best way to get the real scoop.
That strategy is HIGHLY recommended no matter what you want to do in military medicine. Find whoever is doing it right now and learn what it is really like and how to do it (and meet the people who control your fate.)
As a former pediatric resident in the Air Force I would emphasize the most important thing to do is a medical student rotation in your area of interest. Be the best you can be. Meet and interact with the faculty and department chair who may have some input on the decision making process. This means contributing to discussions, being interested and curious, be a positive learner and be helpful. Get to know the residents currently on rotation- talk with them about the process- there is much to be learned. If you have no previous military experience and have never even been on a base then you will definitely step out of your comfort zone. Embrace the uniform and protocols- you are in the military and do not be afraid to ask questions. I have found that the active duty residents/ nurses/ aids/ techs are more than happy to help and advise- let them. Things may have changed since I was a HPSP student and you may already have had an orientation as a scholarship student- but even this is hard to put in practice until you are doing it everyday on base. Remember you are there to contribute to the military mission- in my case as a provider to give excellent care and support to pediatric military dependents
RG-thanks for the put, and for your service.
I couldn’t agree more with the sentiment. Military programs are filled with motivated and committed folks who want to work with motivated and committed folks. Being an engaged learner and active participant in ADTs paints that picture and checks one of the most important, non-scored boxes.
I’ve participated in the last 7 GME selection boards for the Navy. Here is a post that details my tips on how to get selected for GME:
https://mccareer.org/2021/07/15/tips-to-get-selected-for-gme-a-2021-update/
Bump on Doc Schofer’s article for most specialties in the Navy.
For small community specialties with rare training opportunity, nothing is more important than a good relationship with the Specialty Leader.
The Specialty Leader is the Navy version of an Air Force Consultant. These Senior Officers are key to finding an unconventional pathway to training that works for both you and the Navy.
Great article! I’d like to point out one thing regarding the residency options: if you are dead set on a 20+ year career, favor the military residency. Your professional contacts, familiarity with how things work, ability to influence your post-residency duty assignment, time in grade, and eligibility to transfer your post9/11 GI bill benefits will be worth a lot.
If you favor serving long enough to pay off your obligation and then leaving the military (the correct choice for most) then the 3 options each have benefits and costs.
Absolutely agree! The trick is knowing that you want to stay for the career (a sentiment that may change more than annually)
I was thinking about Military Match 1 year ago while applying for Civilian Match. My circumstance is kinda odd. I am an IMG, but I have been served in the US Army for 4 years. I thought it would be my advantage. However, when I talked to a recruiter from one of the military resident programs, I was disappointed. He said there was no chance for an IMG to match in the Military match even though I wanted to be in Family Medicine, not a competitive specialty. In conclusion, he said this Match was only for those who were from military med schools.
Are you sure this was a healthcare specific recruiter? The recruiters down at the mall know just enough about medical programs to be dangerous, you need an AMEDD / healthcare specific recruiter to get the real answer. On the other hand, if it was someone from a residency program and not a recruiter, they may not have known all the possible programs available. Our residencies don’t formally have “recruiters” assigned to them, though they may at times work with /in support of various recruiting stations.
If you are a US citizen, eligible to get a medical license in the US, and eligible to match to US residencies in general, then there are military programs available to provide some funding during a civilian residency. There are also programs that will pay a fairly generous recruitment bonus if you try to join after residency. I could also see a path into the military match where you first join as a GMO with a license but no residency, then apply to the following year match.
Piling on to KFM:
The HPSP does not typically fund overseas undergraduate medical education. However, I am not familiar with any reg that prohibits IMG folks from participating in the JSGME. As always, take recruiter “guidance” with a grain of salt.
The military match is only for people already on military scholarship, not people who already graduated from medical schools but are not affiliated with the military in any way. If you are an IMG, you can match into a civilian residency and THEN, if you meet the requirements, try to join. What happens is that people who are having difficulties matching (frequently a situation for IMGs) try to use the military to secure a residency, and that doesn’t really work.
Also, if you are not already on a scholarship, you need to match in a specialty that the military wants and has a recruiting goal for in order to try and sign up. They/we won’t take any residency. If we are overmanned in a specialty, there won’t be a recruiting goal, so you won’t be able to sign up from any residency.