Saturday, January 2, 2010

Decoding MD/PhD match lists

Every year the National Residency Matching Program (NRMP) publishes a "Charting Outcomes in the Match" summary on their website about matching trends. Here is the 2009 version:

Comparing MD/PhD match outcomes from 2007 to 2009 gives the following information.

Charting outcomes 2007:
Total # of MD/PhD students: 563
Total # of unmatched MD/PhD students: 32

Charting outcomes 2009:
Total # of MD/PhD students: 624
Total # of unmatched MD/PhD students: 51

In just two years the number of unmatched MD/PhD students increased more than 50%. How would anyone know this is the case? How would anyone know that MD/PhD students fail to match at all? Certainly, there has been a culture within the MD/PhD world that MD/PhD students have no difficulty matching with matching. This is completely incorrect in my experience as a student, but nobody is talking about it. I want to tell you about how programs hide their non-matchers in various ways. So here's a quick guide to:

MD/PhDs don't match?! Decoding MD/PhD match lists.

"From my own experience (and others at my MSTP program), "Post-doc" is code for "did not match" in most cases." -- calvinNhobbes

This has been true from what I've seen as well. Post-doc seems to mean all kinds of things, including the one "post-doc" on the match list who went straight into industry. In my sixth year, four graduating MD/PhDs failed to match, but nobody outside the senior student circle and the program adminstration would ever know.

Besides the all meaning "post-doc", be suspicious of any preliminary (internship) year only matches. Preliminary only matches can be due to a few legitimate reasons such as deciding on a specialty too late or a student changing their mind about specialty during the application process. These situations are very rare. Typically, any MD/PhD in a preliminary year only did not get a spot in a categorical residency.

Similarly, be highly suspicious of medicine or surgery matches to no-name community places. It might be a preliminary match, and some programs don't want to admit their student didn't match to a categorical program. So the student is listed as a medicine or surgery match to make it look like a categorical spot. When a categorical match was not achieved, an honest program will simply list their prelim match with a clear preliminary denotation.

For example:
Let's say I apply in radiology, which requires a standalone internship year. Let's say I apply separately for transitional years. Now what might happen to me:

I may ONLY get the transitional internship but not radiology. How will a program list me on the match list? Transitional Year if at all. Maybe with a "planning to apply in radiology" caveat.

I may ONLY get radiology position and not an internship. In this case I would likely scramble into a nightmarish surgical prelim. The prelim may not even be listed.

I may get NEITHER. In this case, I may elect to scramble into a nightmarish surgical prelim and reapply. This will likely be listed on the match list as surgery or surgery (prelim). Or perhaps I take a year off and decide to reevaluate life. This might be listed as post-doc. Or I might be left off the match list for that year entirely.

Here is another example:
Let's say I apply in radiation oncology, which requires an additional, typically separate, internship year.

Now radiation oncology is extremely competitive. Many will say to apply to medicine programs as a backup specialty since it is much less competitive. If I fail to match radiation oncology, my match will be listed as medicine, and you will never know I applied to radiation oncology at all. The difference in competition is so great, one could easily match a strong academic medicine program and not match into radiation oncology at all.

So maybe I am confident or can not come up with a backup plan, so I apply only to radiation oncology categorical programs and preliminary medicine internships. Then I only match to a preliminary medicine program. Some programs would list me on the match list as: internal medicine. Others would list me as Medicine (prelim) with nothing else specified. Analysis of match lists by one SDN expert has indicated that the number of internal medicine matches to community programs with easy preliminary year programs is increasing. It is assumed that these scenarios are driving this increase.

Unfortunately you would never know if a student had to take a less competitive specialty choice, go far down their rank list, not get interviews where they wanted to be at all, or just outright scramble. All of these issues are all far more common than I was led to believe when I began the MD/PhD program. It has been quite a surprise for me. The standard excuses I've heard from those who only peripherally know the person who didn't match have been:

1) "That student WANTED that residency at lower-tier academic program". Reality: usually far down rank list. Also possible: strong location preference if the location is not a big city.

2) "That student couldn't decide on a specialty." Reality: Didn't match categorical. Other possibilities: couldn't decide because they realized too late there's no way they'd get the competitive specialty they wanted, or couldn't decide because their curriculum gave them no time for fourth year electives.

3) "That student had personality issues." As much as I hear this one you'd think we're all demented freaks. Reality: Under 220 step I score and not AOA.

4) "That student didn't apply to enough programs/were overly cocky in programs applied to." The last student I heard this about applied to 30 programs and got interviewed at 3. See the *reality* for excuse #3.

The MD/PhD Trap

Caveat: The MD/PhD trap section is merely a guideline/thought process and should not be taken as gospel.

Academic programs in competitive specialties often have Step I cutoff scores for interview. Even if not a strict cutoff, step I scores, clinical grades, and LORs are examined closely. These factors are almost always far more important to programs than the research you have done. Thus even with a merely average medical school performance, you may not get the specialty you want.

It goes without saying that many programs will automatically cut students who have serious academic issues ranging from failing a course to failing a year to a bad LOR. I am not talking about these students with serious "red flags". What I mean is that to match to strong academic programs, you need to be a strong medical student in addition to having a solid PhD.

So MD/PhDs need to be strong medical students to match to competitive academic residency programs that have the research opportunities we need to persue academic careers. Conversely, MD/PhDs are essentially excluded from categorical community programs. These are the programs that usually match MD-only students with lower step scores and grades than the average for a specialty. These are your standard "backup" programs. But these programs know they don't have research to offer and assume an MD/PhD is going to go elsewhere. Even if an MD/PhD student tries to spin otherwise by downplaying their research experience, they will likely not be interviewed or match there. I've heard some stories of antagonistic interviewers along these lines--"What are you doing here? We don't have research!"--"Where else did you apply? You'd never come here." I've seen several applicants get burned either by thinking community would be a backup, or by applying to mostly community programs in some specific geographic region for family/relationship reasons.

Thus it is possible to be caught in the middle. If you have a merely average medical school performance, you will often be shut out of research heavy academic training programs for lack of competitive statistics such as step scores and AOA. Yet if you are an MD/PhD, the community programs don't want you. This is the trap which can lead to you not matching. If one wasn't so research-heavy there would be a chance to match community where your MD-only classmate with similar stats matched. But you can't match at those community programs. In these situations lower-tier academic is the best bet, but still risky.

Overall point

MD/PhD! Your ticket into top residencies anywhere!***

***Offer valid only in certain residency specialties. Offer not valid at community programs. Offer may only be used in conjunction with above average to excellent medical school performance. May not apply to residencies in competitive locations.

Anyone who tells you other than what I have told you here is lying to you. This may either be for recruiting purposes, or simply because that person is too junior to know the reality. They may have had an extremely strong application overall and assumed their PhD counted for more than it really did.

I am always amazed at how out of touch senior faculty are with this reality I am presenting to you. In general, your best source of information for applying to a specialty is the PD at a program that would seriously consider you or junior MD/PhD residents. The PDs at big name academic programs will set you up nicely for this trap. Since there isn't a lot of communication between programs, the PD at a top program will tell you to apply community and then come back there for fellowship. The PD at the community program will tell you that there's no way you should be at their program. Try it yourself.


When I look at my school's matchlist I can see examples of almost everything I talked about in this post. Four students failed to match recently and another student failed to match the following year. Though you wouldn't necessarily know it because one was left off the matchlist entirely and one scrambled into a prelim spot that was not listed as a prelim.

I don't know if what I've seen reflects an aberration or a rapidly progressing problem. I tend to think it's not an aberration given the posts here by this expert in MD/PhD residency outcomes:

Should I apply to community programs?

For the merely average MD/PhD student applying in a competitive specialty the question is: should I apply to community programs or risk not matching? Despite having an above average residency application and a very strong graduate school portfolio in the department, I was advised to apply to many community programs so I could match. This is advice received from several members of the department who do significant amounts of research. The reason being? "We only interview AOA or close to it." "You need a 99 step 1 score. Your 98 (240/98) will hurt you."

There are fine rationales for this. For example, residency is a clinical training time, not a research training time. One can then hopefully obtain an academic fellowship, though this is specialty dependent and the big name residency helps you do that. Still, advisors in highly academic programs don't realize the MD/PhD trap exists. MD/PhD faculty often don't review residency applications, and when they do they have often already been heavily filtered for clinical grades and step scores before they hit their desk.

Why should I care if you are cashing in your PhD for a shot at a lucrative clinical career?

This question bothers me on many levels. It assumes there is no research in competitive subspecialties. I did my PhD in a subspecialty department with a multi-R01 funded investigator. There are many examples of this across subspecialties where I trained. A member of my thesis committee was an anesthesiologist who performed 90% research. Conversely, many senior MD/PhD students do not plan on a research-based career for various reasons. In my experience they are just as likely to apply to traditional MD/PhD specialties such as internal medicine with the goal of subspecializing. In this case, the extra "suffering" of a fast-track residency seems appealing compared to an extra year of wards in a general medicine residency. But you won't meet these senior students when you interview at an MD/PhD program. I think the attitudes for the 6th year students were along a spectrum of "I don't know if I want to keep doing research" (most optimistic group, including myself) to "There's no way I want to keep doing research." Why would any of us come tell you bright eyed bushy tailed juniors about this? It just reflects badly on you. Everyone will assume there is something wrong with you personally, and the program will be unhappy with you.

In the end I think anyone who insists one should go only into particular specialties to do academics is extremely narrow minded. I know in the department where I did my PhD, there was an incredibly difficult process recruiting attendings. You could easily get an academic subspecialty faculty position as an attending. The problem is that nobody wanted to stay in academics, and instead went to private practice for drastically increased (3-fold) pay and vacation time.

The sad thing is that the MD/PhDs are most likely to continue in academics regardless. The vast majority of the MDs who claim to love academics based on their few months of research in fourth year will go right off into private practice. But, program directors in general don't care. As long as they get the residents who will produce the most clinically and get a little bit of clinical research out of them, everyone stays happy. It's bad for these fields in general to focus so much on step I scores and third year clinical grades, but nobody seems to care. 

What else can you tell me about how to get a good residency?

The advice at my program was consistently that one shouldn't worry about residency choice before the PhD. We were told that MD/PhDs all match extremely well and this wasn't an issue. The important things we were told was the mentor and the project in graduate school, and not to try to tailor your research to your residency. We were also told not to worry about step 1 score. This was BAD ADVICE.

My opinion is that you should tailor your PhD to your future residency. This helps not only to sell yourself later to residency programs, it also helps you to make connections in your field. In the long run, you come into residency already fairly well versed in some area of research within that specialty for which to launch your own research based career.

I wrote this entry because I want applicants and junior students to know about these things. The MD/PhD isn't a ticket into whatever specialty or residency program you want. Ignore advice to "pace yourself", "keep balance", and that you will "get whatever you want since you're MD/PhD, just don't fail." Yes, you need to maintain some work-life balance, but this is a topic for another day.

Fortunately, I realized fairly early that something was amiss in the usual MD/PhD advising. This is because I was drawn to a PhD in a competitive subspecialty department, and I realized that the clinical faculty who controlled the residency didn't care about my research. So this is not sour grapes on my part. Junior students will find out quickly that negative feedback comes back to you in bad ways. But I don't mind irking the senior community to help junior students.

In the end, for those looking for a rule of thumb on how best to get a strong residency: look at what your MD classmates are doing to match into your specialty of choice, especially at the big name academic programs. This includes everything from grades to LORs to step scores to electives and away rotations. Set yourself up to match to the top academic programs even if you didn't have that PhD.

Finally, one last story from SDN to drive home my point.