Interviews, Rank Order Lists, and the “Match”
The last stage of your 4th and final year as a medical student. Once interviews are over and you’ve finalized your ranked list of programs, you anxiously play the waiting game to find out if and where you Matched. I’ll first describe what the Rank Order List (ROL) is and how the “Match” process works. Then we’ll get into specifics for your interviews.
The “Match” refers to an algorithm run by the NRMP that places applicants (both U.S. and foreign graduates) into Residency programs based off mutual Rank Order Lists (ROLs). The best way to explain this is via an example: let’s assume applicant “Badass” receives 15 interview offers. He decides to go on 12, and ultimately realizes that he hates 2 of those programs and would rather not Match than end up at those. Badass then takes the 10 programs he likes and ranks them from 1 – 10 on his ROL, in order of his preference. Similarly, Residency programs rank Badass and all their other interviewees from 1 – whatever (depending on how many students the program interviewed that year). The NRMP algorithm then sifts through the ROLs of all applicants and programs of that specialty, trying to place applicants into their highest choice. The algorithm was changed several years ago to a style called “applicant-proposing”, meaning that the algorithm uses the applicant’s ROL as a baseline and tries to place them into their highest ranked program and working down the list from there. This slightly favors applicants over the programs in terms of granting them their highest preference.
Pictured here: a badass
An important thing to remember: DON’T TRY TO GAME THE SYSTEM. Rank the programs in the true order of your preference. If you really liked Program A the best, but you think you have a better chance of matching at Program B because they liked you more…still put Program A higher. If you are not ranked to match by Program A, then the algorithm will automatically move to your next program on the list, Program B. If you were indeed ranked to match by Program B, then you’ll end up there. But by putting Program A higher on your list, there’s a chance that the applicants that Program A ranked above you may Match elsewhere and you could still end up there. Basically…be true to yourself and make your ROL with your real preferences.
As an aside for the nerds out there (be honest – that’s most of you), the NRMP algorithm derives from a famous Game Theory problem known as the “stable marriage problem”. It has been validated and modified to favor applicants over programs (albeit only slightly). It even won Lloyd Shapley the 2012 Nobel Prize in Economics for stable allocations. The algorithm was originally implemented in the 1950s because of a very competitive environment between hospitals vying for a limited supply of medical students. Hospitals were giving out offers to students as early as their 2nd or 3rd year, demanding responses within 12-24 hours, and even pushing for verbal commitments over the phone as soon as a student was told of the offer. The Match was created to rectify this craziness. The algorithm originally favored hospitals over applicants, but in 1998 the current applicant-proposing model was enacted.
Interviews culminate at the end of January or early February (depending on the specialty), and applicants and programs finalize their ROLs by end of February. Then you have the distinct privilege to joyously await the 3rd week of March. On that Monday, applicants find out whether or not they Matched, but don’t know to which program. That Friday is the official “Match Day”, where medical students across the U.S. receive envelopes revealing which program they Matched into. The reason for this delay is because of the SOAP (Supplemental Offer & Acceptance Program). If on that Monday you do not Match, you are eligible for the SOAP. You basically go back into ERAS and can view the list of all programs with unfilled positions. You must quickly act to contact any and all available programs (unlikely to be in the specialty of your choice) to see if you can somehow garner acceptance in one of their unfilled positions. Despite the fact that medical students on the whole are very qualified, every year there are many people that don’t Match. It’s simply the reality of having less Residency positions than applicants. But don’t get nervous and start pondering doom and gloom scenarios. If you work hard and do well, the odds are in your favor.
Now let’s talk about interview specifics.
After submitting your application, interview offers begin rolling in around October and November. Interview offers are sent through ERAS, and you’ll receive email notifications when they come. It’s imperative that you respond ASAP. There are only a limited number of interview dates for each program, each with limited numbers of interviewee slots. Some programs may only offer two date options. And you’ll likely have conflicts between programs because many have interviews on the same date. Additionally, most of your communication regarding interview scheduling will be through the Residency program coordinator. It is very important to be polite and prompt with your replies, because scheduling proper dates and times for interviews is crucial.
Here’s the breakdown of interviews. Most involve a social event the night before, allowing you to meet current residents and faculty. Many of these are low-key and professionally done, with light snacks and drinks served at a fancy restaurant in town. Others can get notoriously wild. I’ll refrain from mentioning any specific programs, but copious consumption of libations, chugging contests, bar hopping, and even the occasional “Gentleman’s Club” visit are not unheard of. It’s very important to realize that EVERYTHING YOU DO IS SCRUTINIZED. It’s fine (and likely beneficial) to have fun and be relaxed. But keep your wits about you. Don’t do or say anything controversial. Don’t get excessively drunk. Don't flirt or act inappropriately with anyone. Use this as an opportunity to learn about the program and city in a casual setting directly from the residents. And go home at a reasonable time so you’re well rested for the next day’s interview. Even though these socials are a great way to get to know the program and meet people, they’re NOT MANDATORY. It’s definitely to your benefit to go. But if you have conflicts (multiple interviews in consecutive days) and have to miss a social – no problem. I actually missed the social at University of South Florida…and I still matched there. So don’t sweat it. The most important thing is going on multiple interviews. That’s the priority.
Poor decision before an interview
The interview day itself is usually split into a morning and afternoon group. One group finishes all their interviews in the morning and spends the afternoon taking tours of the facility and shooting small talk with the residents. The other group will do the reverse, interviewing in the afternoon. Personally, I found it far better to interview in the morning. You get done early, are no longer on edge, and probably most significant: you don’t have to stick around any longer. This is super important if you’re on a string of back-to-back interviews. At one point in January, I had a stretch of five interviews in six consecutive days. I literally had to fly from Texas to Florida, then back to Texas, then to Massachusetts, then back to Florida, then back to Texas. It sucked. Like really sucked. I also had to miss almost every one of those socials because I was flying back and forth. And this is where corresponding with the program coordinator comes in. For all my interviews, I always requested to be placed in the morning group. Even if I didn’t have another interview the next day, you never know if an invite will come late (some programs sent interview invitations even into January). So prepare in advance and try to get in the morning group!
For the interviews themselves, there’s a ton of variation. Some programs do Multiple Mini Interviews (MMIs), where you have short 10-15 minute interviews with up to ten faculty and residents. Some do panel interviews, with 3-5 people interviewing you simultaneously. Other places will do traditional 1-on-1 interviews. And still others employ silly and funny tricks to throw you off (one of my interviewers literally made me play the children’s game Operation while I answered his questions). The interview style and questions themselves also vary greatly. Some are very formal question/answer sessions. Others are casual conversations interspersed with jokes.
Regardless of the interview style, you should prepare the same way. Know your ERAS application cold. Read it the night before every interview. Be able to speak intelligently about anything on it. Also have a list of questions to ask. At the end of every interview you will be asked, “what questions do you have for us?”. Never say that you have nothing to ask. Always ask something. And don’t simply ask for the sake of asking. This is your future after all. Really try to figure out the type of program, training environment, program culture, etc. If you have specific research interests, ask if there’s infrastructure in place to assist residents in securing grant funding, writing IRBs, editing manuscripts for publication, time off for conference presentations, etc. If you’re interested in Global Health and outreach, ask if there are opportunities for international electives.
Even though individual interview questions and scenarios vary by specialty and program, be able to adequately address the following (in no particular order):
Why do you want to do XYZ specialty?
What are your biggest strengths and/or weaknesses?
Why should we take you in our program?
What do you like about our program?
What do you like to do for fun?
Tell me about a time you overcame adversity.
Tell me about a time you failed.
Tell me about ____ (something specific from your application)
Imagine that you are a junior resident; what would you do if ____ (insert ethical dilemma; for instance, you disagree with a certain action taken by a senior resident or attending…how do you tackle it?)
There’s no right or wrong answers to these questions. Just be honest, confident, and balanced in your responses. When addressing questions that may potentially cast you in a negative light (like if asked about your weaknesses), give an honest response but also highlight actions you’ve taken to improve upon it. Show that you recognize it and have endeavored to better yourself.
Cowering in fetal position will not help you
Furthermore, you may encounter potentially controversial topics during the interview trail. Interviewers are traditionally not supposed to engage in religious or political discussions. But every so often they do arise. For example, I was asked what I thought about “Black Lives Matter” (while I was interviewing, this was a popular social media hashtag referring to perceived racial motivations behind use of force by police). I was also asked about my opinion on the civil war in Syria and the mounting refugee crisis at the time. You can of course simply refuse to engage in these conversations stating that you don’t think it’s appropriate subject matter for a Residency interview. However, that can be perceived as awkward and possibly make you seem rude regardless of how much tact you employ. You can also feign ignorance, stating that you simply don't know enough about XYZ or haven’t kept up with it. Personally, I think you can safely address these via a balanced midline view, not grossly favoring any one stance on the topic. You can additionally qualify your stance, by stating pros and cons on both sides of the issue. This will show that you have an understanding of both sides of the argument and are willing to entertain disparate viewpoints. But again, these are not very common.
The last thing to mention about Interviews is post-interview communication (in the form of “thank you” emails and “letters of intent”). This is by no means required. In fact, some programs will actively discourage it to avoid any possible breaches in what’s allowed (NRMP bylaws). Programs are also not allowed to solicit how you plan to rank them. You may volunteer this information, and programs as well may volunteer that they really like you as an applicant. Yet despite the “rules”, back-channel communication definitely occurs, more in some specialties than others. Some programs will specifically tell you to keep in touch and send them an email about what you think of their program. Ultimately it’s a game and you need to decide how you’re going to play it. During a couple of my interviews, I was specifically told by several Program Directors and Chairmen to “keep in touch”, “send me a note”, “let me know what you think about our program”, etc. Of the 11 interviews I went on, I only kept correspondence with the three programs I was highly interested in. I didn’t send “thank you” letters or communicate with any of the other programs after interview day.
Regarding Letters of Intent (LOIs): this is basically just an email you send to the Residency Program Director and/or Chairman at the programs that you are very interested in. Applicants often correspond with several programs that they really liked. The key phrase to use when telling a program that you liked them is “I plan to rank your program very highly”. Don’t lie and tell multiple places that you are “ranking them #1”. Only tell a program that if it’s actually true. If you falsely tell a program you’re ranking them #1 and they also rank you to Match, and you end up somewhere else, they automatically know you lied. And people have long memories. You don’t want to create a negative reputation early on, especially if it can potentially hurt you down the road for Fellowships, job prospects, etc.
I personally think the best way to send an LOI is to combine it with an application update. For instance, I had a manuscript accepted for publication during interview season, so it was not on my ERAS application. I sent an email to the programs I was interested in, informing them of this addition to my application. In the same email I also told them how much I liked XYZ about their program and that I am “ranking you very highly”. I also made sure to “cc” the residency coordinator on all correspondence emails. He/she is the one who makes sure that updates actually get into your applicant file for review by the Residency Admissions Committee before they finalize their rank list. An update can be anything, such as taking Step 2 CK or CS, getting a score back, something research related, receiving an award, etc. Even if you truly have no updates, still go ahead and send LOIs. It can be very helpful to your cause if programs know you’re interested. After all, they want people who actually want to be there.
Phone calls are the final point to mention in post-interview communication. These are not common, but every now and then Program Directors may call you if they particularly liked you. I will not mention any names, but one Program Director called my cell phone a couple days before rank lists were finalized and told me that their committee thought I was an outstanding applicant and they’d be delighted to have me in their program. Driving back from Chick-fil-A, I was naturally caught off guard...the only thing on my mind was devouring some waffle fries. But I made sure to remain calm and professional, and just like in my LOI email, I reiterated that I thought their program was excellent, that I’m ranking them very highly, and I’d be very happy to match there. I was actually ecstatic, because I was highly interested in this program. And this was a solid indication that this program was ranking me to Match. But I did not change my ROL because of it.
Me post phone call (minus the sand eating)
You can also ask people to make phone calls on your behalf. These carry weight only in certain situations. For instance: they personally know someone at a program you’re interested in, trained at that program for Residency or Fellowship, are famous enough in that field to have name recognition, etc. If there’s a program you’d really like to go to and you know someone that’s amenable to calling on your behalf, definitely avail that opportunity.
Once interviews finish, all that’s left is to finalize your ROL by the end of February as discussed above. Then you simply wait…and wait…and wait…until later in March to uncover the hopefully joyous results of Match Day! I’ll be honest, even though I was pretty confident that I would Match, hearing the good news that Monday was a huge relief. Regardless of which program I Matched into that Friday, now at least I knew I’d become an Orthopaedic Surgeon. The Friday of Match Day was truly fantastic. Tearing open that envelope was equally nerve-racking and relieving. My parents and brother came in town, sharing the experience as we found out where I’d be for the next five years. I was elated to discover that Tampa would be my new home as I trained at The University of South Florida – Morsani College of Medicine. Residency is a completely new phase of life, just like medical school and college before it. Seeing where your friends and classmates will be over the next several years is awesome, because we are all embarking on this new journey together.
But enough sentimental reminiscence. Match was happily over. Luckily, I had already completed all my medical school requirements before Match Day. I knew I’d be starting a very demanding five-year Orthopaedic Surgery training program in July. So I could think of no better way to spend the months before graduation than exploring the world. Peace out and best of luck y’all, I’m off to Europe!
To read about specifics for Matching into Orthopaedic Surgery, click here!