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The Match Alphabet Soup

The term "the Match" may have led you to believe that there is but one residency matching program, when in actuality there are several. However, the National Residency Matching Program (NRMP®) is the program used by the vast majority of medical school seniors, so "the Match" refers to it unless otherwise specified. In brief, the other matching systems include the Military Match, the SF Match (San Francisco Matching Program), the Urology Match, and the American Osteopathic Association (AOA) Match. The SF Match (www.SFmatch.org) is specifically for Ophthalmology, Neurotology, and some Plastic Surgery programs. However, all of these specialties require completion of some preliminary residency training that is likely arranged through participation in the traditional NRMP. Of note, while Child Neurology and Neurotology allow completion of both matching processes simultaneously, those Plastic Surgery programs utilizing the SF Match require completion of 3-4 years of general surgical residency before applying to Plastic Surgery. Urology also has a separate matching program (Urology Residency Matching Program (URMP); www.auanet.org). The URMP has an earlier timeline (January) than the NRMP (March), an important fact when considering backup specialty applications. The URMP may still receive its applications through the Electronic Residency Application Services (ERAS®), or via universal applications, or by applications created by the programs themselves. Finally, there is a separate AOA-sponsored match (www.osteopathic.org) called the National Matching Service (NMS) for graduates of osteopathic medical schools (DOs as opposed to allopathic medical school graduates, MDs) which occurs in February. Note that DOs may apply to American College of Graduate Medical Education (ACGME)-approved residency and fellowship programs via the NRMP, though not vice versa. However, given (perceived) differences in medical training, as well as separate board examinations (DOs take the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA®), while MDs take the United States Medical Licensing Examination® (USMLE®)), DO graduates have traditionally had difficulty in successfully matching to ACGME programs, particularly in Surgery (see Chapter 4: Path to the Match and Chapter 5: The Selection Process - Theirs). Be mindful that an applicant who receives a spot through the earlier AOA-NMS Match is automatically withdrawn from the NRMP.

A confusing factor in the application process is the relationship between NRMP and ERAS (and why you will need to register and pay fees to both organizations). The NRMP's Main Residency Match® is a private, non-profit, non-governmental organization created in 1952 to help match medical school students with residency programs. It is sponsored in part by the American Board of Medical Specialties (ABMS), the American Medical Association (AMA), and the Association of American Medical Colleges (AAMC). The NRMP was born in response to a shortage of residency program graduates, resulting in severe competition among hospitals to hire new interns [1, 2]. In the hope of enticing desirable candidates, hospitals began to make offers as early as 2 years before graduation. Conversely, students stalled acceptance as long as possible while waiting for a better offer. As you can imagine, it was an incredibly dysfunctional process, and both parties cried out for a more transparent and efficient system.

The Main Residency Match is managed through the NRMP's Registration, Ranking, and Results (R3®) system, which provides a consistent and objective path by which all participants, both residency programs and applicants, must abide. The system prevents programs from offering residency positions with the attached threat of an expiration date, thus eliminating the pressure students feel to accept their first offer rather than their first choice. It is essentially a computer following a programmed algorithm that maximizes the preferences of both applicants and residency programs by "matching" the two based on their rank order lists (ROLs). Secondarily, an applicant may acquire an unfilled position as part of the Match Week Supplemental Offer and Acceptance Program (SOAP®). All participants in the Match are expected to proceed in an ethical and professional manner, so that medical students can consider all prospective programs without external pressure. As an applicant, you will electronically sign a participation agreement saying that you will abide by the standards and results of the Match. This process has taken another step in the direction of protecting the rights of the applicant with the 2013 implementation of the NRMP's "All In Policy," which requires participating programs to include "all" or "none" of their positions in the match [3]. Prior to this change, programs could offer "pre-matches" to independent applicants - a group which includes all applicants except US senior allopathic medical students. International Medical Graduates (IMGs) (both US citizens and not) receiving a pre-match offer considered it a safe bet and never participated in the match, which may have limited their potential for the ideal fit. An interesting side-effect of this new policy is that there appears to be many more residency positions offered in 2013 than in the past. However, a majority of these are due to residency spots previously filled by pre-match offers.

It is important to remember that the NRMP is not an application service. It is purely a matching service, to which you must register and pay separately ($65 for the first 20 programs and $30 for each additional program as of 2014). Candidates must apply directly to the residency programs. However, the majority of programs (including AOA programs) have standardized this process by requiring that students submit applications to them via ERAS, which electronically (via the internet-based "PostOffice") transmits your application to these programs. ERAS is basically a digital manila folder with your photograph, personal statement, Medical School Performance Evaluation (MSPE, the former "Dean's letter"), letters of recommendation (LoRs), medical school transcripts, board scores (USMLE or COMLEX), and extracurricular activities. While ERAS has centralized all the components of the application, the applicant is still responsible for knowing the deadlines and providing any additional material requested by individual programs. This information is usually readily available on a residency program's website. As an alternative, the information can be quickly obtained by contacting the residency program coordinator. The ERAS fee schedule is based on the number of programs to which you apply. The ERAS fee breakdown in 2014 was:

• First 10 programs: $95
• Programs 11-20: $10 each
• Programs 21-30: $16 each
• Programs = 31: $26 each

Depending on the competitiveness of the specialty, you may have to apply to a few dozen programs. In 2013, the average number of programs to which a successfully matched applicant applied reached a whopping 29 programs, whereas those who failed to match applied to an average of 50 programs [4].

Let us do the math:

• Total fees:
• NRMP fees ($65 + $30 per program if >20 programs ranked) + ERAS fees + boards transcript release fee (COMLEX/USMLE; cost $70)
•  
• 20 programs:
• ERAS fees: $95 + (10 programs × $10) = $195
• NRMP fees: $65
• Board transcript release fee = $70
• Total fees = $330
•  
• 30 programs:
• ERAS fees: $95 + (10 programs × $10) + (10 programs × $16) = $355
• NRMP fees: $65 + (10 additional programs × $30 per program) = $365
• Board transcript release fee = $70
• Total fees = $790

Of course, this does not include the cost associated with interviews, primarily travel expenses. Therefore, although casting a wider net obviously increases your chances of matching, for most people the cost (and allowed time off for interviews) is prohibitive. This is one of the many reasons it is important to understand how competitive a candidate you are in the eyes of Program Directors.

Insider Tip: Budget your time and application expenses wisely. Residencies can begin to download applications on September 15 as soon as you pay the registration fees. Many offer interviews before your application is even complete, which technically is not until your designated Dean's Office uploads your MSPE (on or after October 1).

If you are feeling a little lost in the alphabet soup of the application process, Figure 1.1 is a general overview that includes the more common abbreviations.

Figure 1.1 Residency application alphabet soup.

The Match Algorithm and the Secrets to Stable Marriage

The NRMP is essentially a clearinghouse of residency MD positions:

• Categorical (C): Entering during your first postgraduate year (PGY-1) and continuing there until completing your training for specialty certification, generally 3-5 years.
• Preliminary (P): 1 (or 2)...