EMRA and CORD Student Advising Guide, 2023

Ch. 12 - What If I Don't Match

So, you didn’t match?

First, we are very sorry. While you reflect and start to prepare for your next steps, know that you are not alone — others have been in your shoes and gone forward to succeed. We hope our words offer a source of comfort and assist you in achieving success, whatever that may mean to you at this stage.

As you reflect, it is key that you understand why you didn’t match. Only with an honest appraisal of what may have contributed to you going unmatched can you plan your best approach to the Supplemental Offer and Acceptance Program (SOAP), reapplication, or alternative career trajectory.

If you are reading this as someone who thinks you may be at-risk of not matching, then you are one step ahead! Meet with an academic EM advisor now to discuss proactive strategies.

Why Are You Here?

Before you can form a plan to move forward, you need to know why you didn’t match. External evaluation should be an essential portion of your application review. Any faculty member who told you that not matching would be a possibility is likely a good source. Your dean of student affairs is another good resource, and a sympathetic program director can be a wonderful additional source of information.

Be wary of information from sources such as Reddit, Discord, and other online community groups. While the threads may be helpful, anyone can post anything, so the information may not be 100% sound or truthful. At the same time, they may give you a source of solace, some creative ideas for application modification, and information on new programs or open spots. Thus, take the information from online groups with a grain of salt and follow typical internet best practices.

Assessing Your Candidacy

Begin by asking yourself, “Did I get at least 11-12 interviews and rank at least 11- 12 programs?” If you did not get a reasonable number of interviews, either you did not apply to enough of the right programs, or something in your application was limiting you.

Evaluate the six elements of your application to find weak spots that may have caused you to not match (revisit Chapter 8: Understanding Your Competitiveness: Apply Smarter, Not Harder.)

• Step Scores: With Step 1/Level 1 now transitioned to pass/fail, there will probably be an increased emphasis on USMLE Step 2. If you did not take Step 2 or did not take Step 2 by mid-September, your application may not have been reviewed at all. The average Step 2 score for matched U.S. MD graduates was 247 in the 2022 Match.¹ Substantially lower scores are likely a barrier to getting interviews. Unfortunately, it is difficult to overcome this hurdle — the one method that can prove clinical acumen is to do well on additional rotations. Meet with your medical school dean early to decide whether you can modify your schedule to get more EM rotations in before you graduate to assist with reapplication efforts. You may also consider delaying medical school graduation to do more rotations (and thus get more SLOEs for a reapplication).
• ERAS Application: Red flags on the ERAS application include felony convictions, a lack of involvement in any activities, misleading statements about activities, or leaves of absence without explanations.²
• Personal Statement: This rarely makes a substantial difference, but grammatical errors, a statement shorter than three-quarters of a page, or inappropriate comments in your personal statement all can serve as barriers to getting an interview. Additionally, if you have a known red flag in your application, the personal statement should address this and explain why it will not interfere with your career as an EM physician.
• LoRs (including SLOEs): This could be a blindside reason for not matching. SLOEs with comments such as “disinterested” or “confrontational” are barriers to matching. However, students are not able to see their SLOEs, so how can you know if a LoR or a SLOE is what caused you to not match? SLOEs are reflective of grades and comments received during a rotation, so low scores or less than enthusiastic comments are indications that a specific SLOE might include red flags.³ Consider whether you need to obtain an additional, stronger letter so programs are not influenced by that letter’s impression of you.
• MSPE: Most medical schools allow you to see your MSPE. The significant red flags within an MSPE are either professionalism concerns, taking time off, negative comments from clinical rotations, or low quartile ranking. Professionalism issues must be addressed in a personal statement, as they remain the largest red flag in an application. As MSPEs are finalized and follow you, other elements of the application must address any MSPE deficiencies.
• Program Signals and Geographic Preferences: If you did not submit program signals and/or geographic preferences, you may have put yourself at a disadvantage. If you sent program signals, the programs you chose may not have been the right tier of programs for your academic profile. Going forward you should use EMRA Match, T-STAR (only available through your dean of student affairs), and the AAMC’s Residency Explorer™ Tool to assure you do not signal to programs that might not match your level of competitiveness.

Assessing Your Match List

Once you have assessed your application, the next area to explore as a reason for not matching is your actual list of programs. Sit down with your program application list and carefully evaluate program type and number. Did you apply to programs that you are competitive for and an appropriate number? Did you apply to a good mix of reach and safety programs? If you had red flags, did you apply to places that will focus on your positive attributes?

Applications such as EMRA Match, T-STAR (only available through your Student Affairs Dean), and the AAMC’s Residency Explorer™ Tool can help you organize the programs you applied to and assess the appropriateness of your status as an applicant. Reach out to an experienced EM advisor for additional support. Ideally, this should be done before your application is completed, but it can be helpful retrospectively as well, particularly if you reapply to EM.

For your rank list, the primary question is if you ranked enough programs (see Chapter 11: Preparing and Submitting Your Rank List for details). Ranking at least 11-12 programs as a U.S. senior medical student gives you a > 95% chance of matching.

What Are My Options?

There are several paths you can take from this point. The most immediately available is participating in the SOAP, which is done the same week as Match Day. Historically, matching into EM via SOAP was extremely unlikely. In 2017, 99.7% of the 2,047 spots were filled; this left six spots open. In 2016, there was one spot open.² However, in 2022, there were 219 positions available in the SOAP,¹ and that number doubled in 2023. It is too early to know if an increased number of open EM positions will be an ongoing trend, but if any EM spots are open, you should pursue them through the SOAP. If EM positions in the SOAP are scarce, then the decision you’ll need to make is whether to try to SOAP into a one-year preliminary (“prelim”) position and then reapply to EM, choose another specialty to SOAP into, or do a non-clinical year and reapply to EM. Read more about the SOAP below, or skip ahead to other options.

SOAP

The SOAP occurs during Match Week to match unfilled spots with unmatched applicants. This is facilitated via ERAS and is a binding contract, just like the standard Match.

You find out on Monday of Match Week at 10 a.m. ET whether you matched. An electronic list of unfilled programs that are participating in the SOAP is also available at that time. If you did not match, then at 11 a.m. ET Monday you can begin applying to programs in any unfilled specialty. Typically, programs offer video interviews to applicants they are considering. Programs can begin seeing applications on Tuesday at 8 a.m. ET, so you need to be available for potential interviews starting Tuesday morning. It is against NRMP rules for you (or any advisors acting on your behalf) to contact program directors of unfilled spots until the program has contacted you first.

Four rounds of offers are made — starting in 2023, all of the rounds occur on Thursday, starting at 9 a.m. ET. Because all offer rounds occur on the same day, the likelihood of programs offering additional interviews between rounds is almost zero, so you should use all your program spots in the initial SOAP application on Monday. If you receive an offer, you have two hours to accept or reject it. Once the SOAP rounds are completed, all remaining open spots will be listed. At that point, students can contact programs directly.

Other Options?

Occasionally there may be a new residency in EM that receives approval after the NRMP process, and students who have not matched at first or through SOAP are eligible to contact those sites directly. An EM advisor actively involved in the application process should know if they exist and can direct you to them. Also, scour the web and community groups for more information (Twitter, CORD, EMRA, etc.).

If you decide to do a prelim year of post-graduate training in another specialty, make sure you go to an academic institution with an EM residency program. Secure an early rotation in the ED so they can advocate for you and write a LoR/eSLOE for your reapplication. If you are open and honest with the program leadership about your situation, you’ll find many people willing to help guide you to success. A 2018 survey of program leaders showed most believe the best use of time is to SOAP into a prelim year (if no categorical EM positions are available) and reapply the following year.⁴ Further, they preferred the applicant perform the prelim year in a surgical or medicine department.

Non-clinical choices include obtaining an MPH or MBA, performing a research year, extending medical school to a 5th year, or obtaining some other type of graduate degree. These are all reasonable options, but be ready to explain how this better prepared you when you reapply to EM. Choosing one of these paths does allow you to apply for positions that become available after the Match (assuming you have not chosen an option with a binding contract). If you choose to do research, do so with an emergency physician if possible. If you choose another non-clinical route, find ways to stay involved with the EM program in your facility. To get another eSLOE prior to graduation, you can consider completing another EM rotation in the months just before graduation.

In the past, applicants have decided on a different specialty, such as internal medicine or family medicine, and then worked in the ED after graduation. These positions are sometimes available in more rural areas and may be an option for those who want to work in a less acute urgent care setting, but they are typically not an effective pathway to the independent practice of EM.

Re-application

Reapplying for residency is a red flag for many programs. The fact you are reapplying cannot be hidden, and you have very little time before the next application cycle begins. Be honest about your deficiencies, and address the ones that are possible to alter. You cannot change your Step 1/Level 1 or Step 2 scores or grades on your transcript. You cannot change any possible felonies or other red flags. You can, however, prove your work ethic, add a stronger eSLOE, show your dedication to the field, gain additional clinical experience and skills, and make more contacts through conferences, social media, presenting research, etc.

If you think an eSLOE from your previous year may have prevented you from matching, choose which letters to resubmit with your new application. Even if you do ask that an eSLOE be resubmitted, sit down with the letter writer, try to show what you have done to improve yourself, and they might revise the eSLOE accordingly. Consider completing additional EM rotations before you graduate to obtain new eSLOEs that are more supportive. If these new eSLOEs are supportive they will help your application more than one or more less supportive original eSLOE(s).

If your interview skills are not strong, practice. Find friends and advisors to give you frank commentary on those skills.

If you have matched into a categorical residency, you need your PD’s permission and LoR for reapplication. Also, if you are in a non-EM categorical residency position and then decide to reapply, some places will not be able to interview you because of funding issues. The government assigns funding based on your first categorical match in a particular specialty for a certain number of years, which can often create a shortfall because of the difference in lengths of residencies. For example, if you matched into a 3-year non-EM categorical residency position, there will be a lack of funding if you switch to a categorical EM residency position, as you will only have two (or less) years of funding left. However, if you initially match into a 4- or 5-year categorical in a different specialty and are reapplying, the government will provide funding for the number of categorical years you would have had remaining. Of note, prelim years do not count against this funding.

The LoR from your PD if you are in a clinical year (eg, preliminary surgery or medicine) can address changes in your clinical abilities and work ethic. It is important to note that you will have only worked with them for a couple of months by this point, so their LoR may not be as influential as EM PDs’ letters. If in a categorical program, talk to your PD and see if you can schedule an EM rotation early to get a strong, EM-focused letter.

If you decide to reapply, you need to understand your chances are certainly not universally better. You may improve your chances at a few places that now know you better or are willing to meet you, but statistically, your chances of matching into EM are diminished. In the 2020 NRMP PD survey, 56% of program directors indicated they never interview or rank prior medical school graduates, and approximately 41% responded they seldom do.⁴ Even interviewing itself is more challenging if you are in a clinical year and need to find creative ways to get time off. A broad application strategy and a backup plan are even more crucial because a second reapplication to EM is even less likely to be successful.

Step 3/Level 3

One other thing to consider is using the time between the next application cycle to take your USMLE Step 3 or COMLEX Level 3 exam. This will not only make your first year as a resident easier but will show PDs you are committed to the field and remove a potential barrier to succeeding in the future.

• The most important step to take if you don’t match is to find an advisor wellversed in EM application/reapplication. Sit and talk through your application to identify what likely contributed to you not matching and to construct a personalized strategy to move forward.
• The SOAP allows you to apply for open spots within EM for this Match (if available). You can also choose to apply to another specialty or for a preliminary position during the SOAP.
• There are multiple approaches to reapplication in EM, including extending medical school, pursuing a year of clinical training in another specialty (prelim or categorical), and completing an additional degree. Each of these has advantages and disadvantages.

References

1. Charting Outcomes in the Match: Senior Students of U.S. MD Medical Schools Characteristics of U.S. MD Seniors Who Matched to Their Preferred Specialty in the 2022 Main Residency Match SAP Crystal Reports. https://www.nrmp.org/wp-content/uploads/2022/07/Charting-Outcomes-MD-Seniors-2022_Final.pdf Accessed january 20, 2023.
2. Liang M, Curtin LS, Signer MM, Savoia MC. Unmatched U.S. Allopathic Seniors in the 2015 Main Residency Match: A Study of Applicant Behavior, Interview Selection, and Match Outcome. Acad Med. 2017;92(7):991-997.
3. Negaard M, Assimacopoulos E, Harland K, Van Heukelom J. Emergency Medicine Residency Selection Criteria: An Update and Comparison. AEM Educ Train. 2018;2(2):146-153.
4. Results of the 2020 NRMP Program Director Survey SAP Crystal Reports - (nrmp.org).