By Dr. James M. Dahle, WCI Founder

Both medical school positions and residency positions are increasing in number, but medical school positions are increasing at a much faster rate. Thus, simple math will demonstrate that more and more medical school graduates each year are failing to land a residency job, something a number of people will experience on March 18, 2022, during Match Day. While failing to match can happen to just about anybody at any school applying for any residency, it is more likely to happen to DOs than MDs and much more likely to happen to International Medical Graduates (IMGs) and Foreign Medical Graduates (FMGs).

Despite the large number of doctors this happens to each year, it is an incredibly lonely and anxiety-producing place to be.


Overall match rate

As you can see, there used to be more positions than applicants. That hasn't been the case since 1980, and it's been getting worse the last couple of years. If you break it down by type of applicant, you can see the difficulties that DOs and particular IMGs have in the match:


MD vs DO vs IMG Match

The first graph doesn't look too bad, for MD seniors. The second one is basically people applying for the second time. It's a 50/50 proposition at best. DO seniors do a little worse than MD seniors, although that gap has closed so much in recent years that it can almost be argued it no longer exists. Going to a Caribbean school is a pretty big gamble with 2 out of 5 people who actually make it to graduation not matching into anything.

If this happens to you and you don't match, here's what needs to happen next.


Medical Residency Scramble!

Match week occurs every March at medical schools all over the country (and even the world). On the Monday of that week, medical students find out if they matched. If they did match, they find out where on Friday, often at a ceremony planned by the school. Friday is usually a happy occasion for most students as the majority (3/4) match into their chosen specialty at one of their top-four choices.

Match in first three choices

However, that ceremony can be a sad moment for a few as they discover they matched into a program that they did not rank very highly, matched into their backup specialty, or perhaps matched into only part of their post-graduate training plan (only into an internship or only into a PGY2+ residency position without a corresponding internship).

That Monday before Match Day is a really bad day for an unfortunate few. That morning, your school finds out you didn't match (or only partially matched), and you get an email that day saying you didn't match. Programs also find out if they filled their spots or not at the same time. The list of unfilled positions is provided to the applicants. That same day, the applicants can start applying to the unfilled positions and, thus, begins the Supplemental Offer and Acceptance Program (SOAP), informally known as “The Scramble.”

The next morning, the programs can start reviewing the applications and start making their rank lists. Applicants don't make a rank list in the SOAP. They just hope for the best. On Thursday, the applicants are advised whether they matched in the SOAP. They have two hours to accept or reject any offer given to them. I suggest you accept it. It would have to be a very terrible program in a very terrible place to be worse than not matching at all. That afternoon, the process begins again with any programs that are still unfilled. Later that day, the applicants again get two hours to accept or reject any offers. Then, it's all over for the year.

If you scrambled into a position, you get an envelope on Match Day (Friday), although unlike most of your classmates, you already know what's in it. If you did not, there's a good chance you won't even want to attend the Match Day event. It'll just be too painful unless you are a saint.

Try to at least SOAP your way into an internship. You'll be a far stronger applicant with more clinical experience and new letters of recommendation. Yes, you'll then have a gap year after your internship, but that's probably easier to deal with than a gap year after graduation.


Get Over the Shock

At this point, if you are unmatched or partially matched, it's time to take a break. You probably haven't gotten much sleep this week and maybe you're feeling pretty depressed. If you're really depressed, go see a professional. Heck, it's probably not a bad idea to see a therapist even if you aren't feeling all that depressed. Call your family and friends and let them support you through this rough time. Know that your journey to being a practicing physician isn't necessarily over.


Try, Try Again

The next week you should go in and meet with your advisor or another faculty member in your desired specialty. It's time to do the post-mortem. Why didn't you match? Were you a borderline or worse applicant to start with? Did you do a poor job of applying? Was there a major red flag on your application? Was there a problem with your interviewing style? Did you try to couples match? Were you just unlucky?

Not matching once is pretty common. If you ask around, you will find that many doctors had to apply to medical school two or even three times. Same thing with the match. I know very good doctors who had to scramble or apply twice after not matching or only partially matching. The key to matching in your next attempt is a lot like the key to matching the first time—being realistic.

You have to know yourself. Know what you are good at. Know what you are bad at. Know how well you stack up against your peers—at your school and across the country. Few applicants have top-notch grades, board scores, letters of recommendation, extracurriculars, and interviews. Most of us are better at some things than others. Beg your faculty members to be brutally honest with you. You need to know where your application is weak.

You now have one year to address that weakness. Assuming you passed your boards, you can't retake those. Repeating medical school classes probably isn't an option either, although you probably have time to squeeze in another sub-internship. But you can certainly strengthen an application by getting more clinical experience and doing some research. You can get different and hopefully better letters of recommendation. You can get involved in other activities (paid or volunteer) that make you a more interesting person and a more compassionate and competent doctor. You can get an MBA or an MPH. You can do more practice or take a course on interviewing or public speaking. There are plenty of ways to improve your application.

As you apply again, you need to lower your expectations dramatically. Spend some money. A lot of money. Both on applications and on interviews if you can get them. Apply to twice as many places as you think you need. Maybe apply to every program in your specialty. Go to every interview you get. Leave it all out on the court, so if it doesn't work out, you can at least know you did everything you could. Remember your odds of matching the second time are just less than 50/50. But you have to ask yourself if you're a glass-half-full kind of person or a glass-half-empty kind of person.


Specialty Decisions

Obviously, some specialties are more competitive to match into than others. If your desired specialty is particularly competitive, or even moderately competitive, you should also pick a backup specialty the second time around. Maybe the backup specialty is just completing an internship. Sure, maybe your first love is ophthalmology, but wouldn't you rather be an internist than not practice at all? Look at all of the options you have available to you after completing an IM residency.

Need a backup specialty? Don't pick one on the top half of this list. Think Neurology, FM, IM, Peds, or Path.


Career Decisions

OK, now, let's say, you've applied two and maybe even three times and still haven't matched. You can't strengthen your application any more. You're never going to be a practicing physician. It's time to reconsider your options. What are you going to do for the rest of your life? How are you going to put food on the table? How are you ever going to pay off those student loans?


Jobs for MD Without Residency

You have two major options. The first is to leverage your medical degree into a job. While a doctor who has completed residency and practiced for a few years is very attractive for jobs in many industries, one who has never practiced can also be quite useful—especially with some additional training, such as an MBA, some financial training, an MPH, an MPA, or an MHA. You may also find jobs in pharma, insurance, or other related fields. You can coach pre-meds on how to get into medical school. Lots of options.

Alternatively, you can simply go do something else. Open a business. Start a real estate empire. Go into sales. Be a therapist or a coach. There is a whole world full of careers you don't even know about. You will probably like some of them.

medical match day


Financial Decisions

The elephant in the room, of course, is the student loan situation. If you were fortunate enough to get through medical school with no debt or minimal debt, you can basically have a fresh start from zero. If you have a contract (HPSP, NHSC, MD/Ph.D.), you'll need to read the contract and talk to the appropriate authorities. With the military contract, you'll likely still have a service obligation. That's not so bad. You'll have a job, and that job likely qualifies for PSLF! If your contract was an MD/Ph.D., you likely have no further obligation as you completed the Ph.D. long before the match. You can simply go into the research side.

If, like most students, you have substantial student loans, you've got a bigger problem. If your loans are mostly federal, enroll in an IDR program and give serious consideration to any job that qualifies for PSLF. You might actually be earning more money in forgiven student loans than in salary! You might also consider IDR forgiveness, although unlike PSLF, that comes with a big tax bomb and requires an additional 10-15 years of payments. It does have the advantage of not requiring you to work for a nonprofit; you don't have to work full-time or even work at all.

Alternatively, and especially if you have a lot of private loans, you're going to have to find something that will earn enough money to pay them off. That can be tricky, but if you're smart enough to graduate from medical school, you're smart enough to figure something out there. In the meantime, remember the big advantage of student loans: they can ruin your credit but they can't foreclose on your brain. Student loans don't go away in bankruptcy, but they are also unsecured loans. The worst-case scenario is ruined credit, forfeited tax refunds (easy to arrange minimal refunds), and rarely, having 15% of your wages garnished. It's not the end of the world.


Student Loans and the many programs and options are challenging to navigate.
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Failing to match is a major career and financial catastrophe. Do all you can to avoid it. If it happens to you, attempt to SOAP out of it and apply again. If you still cannot match, consider your other options, both within and without the medical field, paying special attention to your student loan burden as you do so.

Yes, all of this is a major career and financial setback, but you are one of the most resilient people on the planet. Lots of people overcome it; why not you?

What do you think? What advice do you have for those who don't match? Comment below!