Game, Set, Match: The Personal Path to Residency Success

Last month, we talked about how Match Day is a very tense time for both medical students and medical school administrations. Now that the dust has settled on the 2018 match, we're going to discuss some of what goes into the process.

We're going to dive into how it's really more about walking a personal path than any institution-driven development, and how you can make the right choices for your own future in medicine. We'll do this with a mix of data from residency directors, insight as a school, and finally, with direct input from some of our most recent graduates. Most of them agree that there's no single factor that makes the definitive difference. Instead, there are two elements that come together, a mix of quantifiable performance and personal growth.

The majority of residents secure their spots through the National Residency Match Program (NRMP) or the Canadian Residency Match Service (CaRMS), systems. These both literally "match" an applicant's top program choices with a residency program's top applicant choices for a single, binding residency offer. The outcome sets future physicians on a path that will determine the course of their career.

That's what a match is at a technical level. Our goal today, though, is to cover its association with schools, the realities as a personal path to success, and where those two ideas interact. By the end, you'll start to see a pattern: that academic performance definitely helps secure the interview, but that is ultimately half the battle. The other half comes from who you are at an authentic level, beyond the nervousness and formality of the interview process itself. In both cases, it's about personal accomplishment, but in different ways.

Before we get too deep into the weeds on this, we need to briefly discuss the concept of a match rate, why it's important, and where students can take charge.

A match rate is the percentage of applicants in a particular cohort that secured a residency placement in the match itself. What follows is a look at how that data is sliced for 2018.

• 78% of all applicants who participated, matched to a 1st year residency position
• 94% of US allopathic (MD) seniors secured a 1st year residency
• 66% of osteopathic (D.O.) applicants who participated in the AOA specific system match
• 82% of osteopathic (D.O.) applicants who participated in the NRMP matched (After the 2019 Match, the AOA and NRMP systems will be combined.)
• 57% of US Citizen IMGs, many of whom studied in the Caribbean, matched and increase from last year and the highest match rate since 1993.
• 54% of Non-US Citizen IMGs matched as well, most of whom studied in their home countries of India and Pakistan as well as Canadian citizens who studied abroad in the Caribbean and elsewhere.

So, while we can look at percentages of each cohort that Matched (graph, left), it’s a very different picture when you consider all who matched and the type of applicants they actually are. This can include both what programs they applied for (i.e. specialty) and what sort of school they graduated from (MD-US, DO-US, MD-IMG, etc.), even down to when: first time vs repeat attempts at matching. We're going to write more deeply on this topic next week, but for example, almost half (49%) of all first-year residency positions were in primary care specialties and less than half (48%) of those were filled by US seniors. Similarly, almost twice as many MD-IMGs 6,862 matched than did DOs at 3,771. It's crucial to keep all of this in mind, as well as an honest evaluation of your own goals.

Match rate is something to consider in a variety of contexts, and it's still a useful data point. However, to over-rely on the school's published numbers belies the hidden complexities of the match itself. While institutions, friends, family all offer an incalculable amount of preparation, opportunity, and support, ultimately matching is, as we've been saying, a very personal process.

‍We, the school, provide the tools, the preparation, the training, and even a few safety nets and networking opportunities, but when it's time to match, it really is about the students. A school taking credit for a residency match is like a coach taking singular credit for the home team winning a big game. The support and strategy the coach provides is the framework, and they definitely work to help the team get to their very best, but the players were out there on the court. Their work would ultimately be the deciding factor. As a result, they deserve most of the credit.

So, what does that all mean? What is the individual work these people put in that means the difference between matching or waiting a year to try again?

From the biennial survey of residency program directors, the top five factors that will get an applicant invited to interview are:

• USMLE Step 1 score
• Letters of recommendation in the specialty
• Medical Student Performance Evaluation (MSPE/Dean's Letter)
• USMLE Step 2 CK score
• Grades in required clerkships

Once through the initial gauntlet, the top criteria flip from you-amidst-the-pack to Your interpersonal skills and ability to communicate, the survey lists the most important factors in ranking as:

• Your interactions with faculty during interview and visit
• Your interpersonal skills
• Your Interactions with house staff during interview and visit
• Feedback from current residents
• USMLE Step 1 score

It’s worth noting that other factors at the top of the criteria list are more personal qualities and characteristics, not traits taught in medical school such as perceived commitment to specialty, leadership qualities, audition elective/rotations within departments, and of course, personal prior knowledge of the applicant.

Continuing onto that top criteria we mentioned earlier: The USMLE Step-1 exam is, without a doubt, the culmination of the most traditional "undergraduate" style learning a student does in the first two years of medical school. How they absorb the classroom and independent study material is evaluated by the USMLE to determine their preparedness as they move to a clinical setting. Effectively, they are being asked by the licensing authority of the United States, "do you know enough to start learning in the hospital?" It is the bedrock on which medical acumen develops.

The USMLE Step-2 exam (this test is in two parts, clinical skills and clinical knowledge), is similarly important, but also carries some overlap with letters from preceptors and clerkship grades. In many ways, it relies on a different skill set. While students are still absorbing information at increasing levels of depth and complexity, they're also learning how to apply it, hence the term "clinical." These three elements of matching come in the latter two years of medical school, when students are spending their days in the hospital observing and assisting. Ultimately though, each of these elements truly come together for students who do the work and take initiative to succeed. Their grades are their own, their scores are their own. Similarly, the relationships they build with their preceptors during clinical rotations and the sorts of letters those doctors can write for them comes from a student's ability to work with others under stress, to work hard, and make a good impression.

Making that good impression can be incredibly difficult in any setting, let alone a hospital. And it's not always the students with the best grades that make the best impression. This is one area where we discussed that complexity underlying the match process: There is a fine balance between being diligent and being over-eager. Fortunately, Trinity students have additional experience in that setting leading up to it, learning not just how to thrive in a hospital work setting, but how to interact with a variety of different patient populations, as well as doctors and staff in a culture different from their own. The baseline level of collegiate respect Trinity students develop goes a long way when it comes time to match.

Finally, we have the MSPE (dean's letter). The dean's letter is a significant summary of a student's life in medical school, as summarized by the dean. In many ways, it combines both tracks we've been following, personal development and academic success. It includes comments from faculty, grades, even comments on involvement in relevant, school-affiliated extra curricular activities. The MSPE is, effectively, the school's formal perspective on your performance. The MSPE is not written in a vacuum, it is created every day by every interaction students have with the faculty and administration, with preceptors during clinical rotations, and it is evaluated against their colleagues across the board, as dictated by the AAMC's preferred format.

While no single document, no evaluation can truly encapsulate a student's essence, the depth of the MSPE comes very, very close. Four years is too long of a time, covering too many miles, with too many different people, with too high of stakes for most people to successfully "fake it." A student's performance and professionalism not as they hope they are, but who they manage to become in medical school. And while they become that future doctor under our watchful eye and with our full support in every imaginable way, they ultimately do that work. They take the steps to look inward and decide who they need to be to become the physician their future patients need, on their good days, their bad days, and everything in between.

That's what goes into the match. That's what it takes to make that connection. It's the summation of what you've done, who you are. One gets you in the door, the other gets you the match. The school is just a part of the support structure and, in the case of Trinity, that first opportunity students need to prove to themselves and the world they have what it takes. Above all else, matching is a personal triumph.

‍