The National Resident Matching Program (NRMP) process, also known as “the Match,” is competitive and stressful for most students,1 but it is especially so for those who finish Match Week without a graduate medical education (GME) position. The 2016 Match was considered highly successful, with 30,750 positions offered and 29,572 positions filled during the primary Match, the highest numbers on record for both metrics.2 Of seniors graduating from MD-granting medical schools in 2016, 17,057 (93.8%) acquired a GME position during the primary Match.

Since 2012, students who do not obtain a position during the primary Match can be eligible to participate in the Supplemental Offer and Acceptance Program (SOAP). The SOAP offers students a way to rapidly apply to and be considered for the GME positions that went unfilled in the primary Match.3 In 2016, 975 postgraduate year 1 (PGY1) positions were available through the SOAP for 13,920 applicants, of whom 1,130 were unmatched seniors from MD-granting medical schools in the United States.2,4 At the conclusion of Match Week in 2016 (post-SOAP), 615 of these seniors still did not have a PGY1 position.2 This number of unmatched seniors is expected to increase as medical school enrollment and new medical school growth continue to exceed the number of PGY1 positions. Currently, 27,655 first-year students attend MD-granting and DO-granting medical schools in the United States, which is 362 more students than the current number of PGY1 positions available in the Match.5 The NRMP process has become increasingly competitive as U.S. medical school graduates (comprising active seniors and reapplicants) compete for GME positions with both U.S. citizens who have attended international medical schools and international medical graduates, many of whom are highly qualified.

Unmatched students often turn to their medical schools for guidance, yet no data-driven guidelines, consensus recommendations, or accepted best practices are available to help medical schools in this situation. Only a few specialty-specific studies have explored the factors that might help reapplicants successfully complete the Match.6–10 The Liaison Committee on Medical Education (LCME) requires schools to report their Match rates as part of the accreditation process.11 However, the LCME does not mandate what responsibilities schools have to unmatched students or how long schools should continue to support students who have not obtained a GME position.

Several environmental factors relate to the issue of unmatched students, including undergraduate medical education class size expansions and the development of new medical schools in the United States,12 undergraduate medical education expansion outpacing GME expansion, and projections of shortages in the number of physicians available to adequately care for our aging population and to replace current physicians who are expected to retire in the next 10 years.13 Although full consideration of these factors is beyond the scope of this Perspective, there is little debate that these factors will influence the Match landscape, and questions remain regarding how best to align the needs of the population with the supply of trained physicians.

We were unable to find an accurate and organized informational resource related to unmatched students. In this Perspective, we discuss a number of issues related to unmatched MD students and offer a variety of options that students, advisors, and medical schools can consider while navigating this difficult and often stressful time.

Considerations Regarding Unmatched Students

Medical schools’ obligation to students and to society

Because students invest large amounts of time, effort, and money in their medical degrees, conventional wisdom and our culture have held that medical schools owe students a tangible outcome in the form of a career as a practicing physician, which almost universally requires at least one year of GME training. Students’ indebtedness plays a major part in this relationship. In 2015, the median educational debt for MD graduates was $183,000.14 The expectation that all medical students will become medical professionals appears to be unique to physician training, as other professional degree programs (e.g., dental, law) in no way guarantee trainees job placement after graduation, despite similar levels of indebtedness relative to future salary.15–18

Alternatively, if a medical school’s primary obligation is to produce physicians with the knowledge, skills, and attitudes necessary to safely serve society, then the school’s duty to society trumps that to individual students. From this perspective, it is society and the public—not the student—who is the medical school’s customer, and paying tuition merely offers the student “the opportunity to progress toward a degree.”19 Students may not have matched because they may not be ideally suited for a career as a practicing physician as a result of academic problems or lapses in professionalism that became apparent during training.20,21

Beyond this philosophical debate about medical schools’ primary obligation, we describe several issues below that all medical schools and advisors should consider when working with unmatched students.

Delaying versus not delaying graduation

There is no consensus among medical schools about whether students are allowed to delay graduation after failing to match. At our school, once students have met their graduation requirements—and matching is not one of them—they graduate. We do not want to increase indebtedness (which occurs even if tuition is waived because of fees and/or interest accumulation) without the guarantee of future success. High levels of student indebtedness, in turn, can place schools at an increased risk for LCME scrutiny. Delaying graduation also may create a “double jeopardy” situation for students if they previously met graduation requirements but then later have an academic or professionalism incident that jeopardizes their ability to graduate. Finally, graduation delays may strain institutional resources, such as clinical site capacity, or place the student and school at risk for federal financial aid fraud if the student is taking out loans for a program she or he has essentially completed.

Alternatively, policies at other schools that allow students to delay graduation might be influenced by the school’s mission or by a relatively low number of students needing this option. Students may benefit in the short term from delaying graduation because it affords them the opportunity to gain additional clinical skills by pursuing elective opportunities in alternative clinical disciplines from their original chosen field. Students can make connections and seek new letters of recommendation. All things considered, students and advisors should be aware of the policies in place at their medical school regarding this important issue.

The Medical Student Performance Evaluation

Questions arise regarding the Medical Student Performance Evaluation (MSPE), also known as the Dean’s Letter, for unmatched students. If a student reapplies to the Match, should her or his MSPE be updated to include information about any final coursework that was not included in the original MSPE? Should subsequent MSPEs indicate that the student has been unsuccessful in a previous Match? The Association of American Medical Colleges’ (AAMC’s) 2016 Recommendations for Revising the MSPE do not suggest a best practice for this situation.22 We recommend adding a one-time addendum to the original MSPE for any student reapplying to the Match that includes a narrative summary of her or his coursework, including grades earned for all clinical experiences taken in the fourth year of medical school, starting where the previous MSPE left off. We do not know if including this information will affect the success of reapplicants in subsequent Match cycles. However, it does allow reapplicants to show more about their advanced clinical rotations than their transcript, because these rotations can be an important influence for program directors looking for additional clinical performance evaluations from sub-internship-level clerkships.

Pathways to Securing a PGY1 Position Following an Unsuccessful SOAP

Unmatched students have three pathways to pursue a GME position.

Secure an open PGY1 position immediately after the SOAP but prior to the start of the GME program

These opportunities often come through specialty-specific Web sites or listservs. In addition, there are a few positions that are left unfilled after the SOAP. These positions are posted in the dynamic list of unfilled programs in the NRMP Registration, Ranking, and Results system.

Secure an open PGY1 position during the year following graduation through a residency vacancy

Some disciplines maintain a residency vacancy catalog on their specialty Web sites23 or send alerts about openings on their listservs. The AAMC sponsors an open positions report called FindAResident,24 which is available for a small fee that is further discounted for active Electronic Residency Application Service users. Unfortunately, no “one-stop shop” or clearinghouse includes all open positions. More recently, for-profit Web sites have emerged claiming to specialize in matching residency vacancies with applicants, but we do not know how effective these services are in assisting unmatched applicants.25

Reenter the Match in the same or a different specialty in a subsequent year

Many unmatched students reenter the Match the following year and receive assistance from their schools, which provide Electronic Residency Application Service Tokens and upload MSPEs and transcripts. The rates of success for reapplicants vary by specialty and are influenced by many factors including the reasons a student failed to match initially and the specialty’s competitiveness, among others. In the 2015 Match, the top five specialties that reapplicants from U.S. MD-granting medical schools successfully matched into were (1) family medicine (139 students), (2) anesthesiology (101 students), (3) internal medicine (101 students), (4) surgery (86 students), and (5) diagnostic radiology (64 students).26

Other Pathways for Unmatched Students to Pursue After Graduation

Finding opportunities to use a medical degree can be a challenge that will often be dictated by the graduate’s case-specific variables. Pursuing activities to strengthen one’s application should be the primary focus for students who intend to reapply to the Match. The 2014 NRMP Program Director Survey asked respondents to rank 33 variables according to their importance for selecting applicants to interview and then match.27 A previously unmatched reapplicant can improve on only 10 of these variables in subsequent Match applications. As such, in reviewing postgraduation opportunities, students should consider whether the opportunity allows them to (1) obtain letters of recommendation in their specialty, (2) enhance their personal statement, (3) demonstrate commitment to the specialty, (4) gain personal knowledge of faculty, (5) demonstrate leadership qualities, (6) demonstrate interest in a program, (7) gain volunteer experiences, (8) demonstrate involvement in research, (9) gain fluency in another language, or (10) take Step 3 of the United States Medical Licensing Exam (USMLE) (if allowed in that state).

Paid employment

Working in a research, clinical, or teaching environment can allow unmatched students to gain related experience in their desired field. These positions can be difficult to secure, and when available, they may not provide the necessary income for students to support themselves and begin to repay their loans. Gaining employment near a GME program in a desired field may allow students to strategically network.

Volunteer work

Volunteering in a clinical setting could be valuable, but such opportunities may be limited because students lack a medical license and/or liability coverage. Nonmedical volunteering, or opportunities with limited stipends such as those through AmeriCorps, Teach for America, or other nonprofits, also can have a powerful effect on a student’s reapplication, showing her or his grit in overcoming adversity.

An additional degree or certification

Pursuing an additional degree can be done either to strengthen a student’s reapplication credentials or in planning for a new professional focus. Examples include master’s degrees (e.g., MPH, MBA, MHA), doctorates (e.g., PhD, EdD, JD), or degrees in other health professions. These advanced degrees may be useful, but they can be costly. Some schools offer fellowships to medical graduates without GME training (e.g., informatics, biomedical engineering/technology, ethics). This option is initially appealing to unmatched students, despite the cost, as it provides the comfort of remaining in an academic environment. However, admissions cycles for these programs may have closed by Match Week in March. Some medical schools do have special agreements with their own school’s master’s programs and may allow for a special exception to application deadlines for unmatched students.

A nonclinical career

Some students may decide that it is not in their best interest to pursue a GME training position, so they turn to nonclinical careers after graduation. The AAMC-sponsored Careers in Medicine Web site includes information about pursuing nonclinical careers, including in public health and service, public policy and government, communications and journalism, informatics, pharmaceutical research, and consulting.28

A growing number of medical students are entering careers in the technology sector following graduation.29 As the number of stressors on practicing physicians increases, so too does the number of online networks30,31 and print resources32 supporting alternative career choices for physicians. Advisors should be aware of these options, as some of the academic or professionalism hurdles that may have prevented a student from securing a GME position are possible indicators of that student’s ambivalence about medicine or red flags that the student may not be suited for the academic rigor and stress of GME training.

Assistant physician jobs

Intriguing yet controversial legislation that has been passed in a handful of states allows students with an MD degree but no GME training or licensure to practice in underserved areas as assistant physicians.33 Significant concerns have been raised by the American Medical Association34 and the CEO of the Accreditation Council for Graduate Medical Education,35 with the principal argument being that medical school graduates who have not successfully completed a GME program are not ready to safely practice medicine. In the future, such programs may provide opportunities for unmatched students to practice clinical medicine with supervision.

Unmatched students often pursue a number of these options simultaneously. A 2015 AAMC survey examined strategies taken by those who did not immediately secure a PGY1 position.36 Strategies that led to success in subsequent Match cycles included obtaining research experience (25%), reentering the Match in a different specialty (14%), seeking clinical work experience (13%), and pursuing an additional degree (4%).

No one pathway forward exists for unmatched students, and the issues they encounter are complex. As such, we offer the following practical guidelines for advising unmatched students.

Guidelines for Advising Unmatched Students

Immediate post-“no match” period (1 to 4 weeks)

Counseling students in this period is challenging and highly individualized, as students are often grieving, which can impede their ability to absorb advice, create plans, and function well on their remaining clinical rotations.

Numerous factors can contribute to a student not matching, including low or nonpassing USMLE scores; not being competitive in her or his first-choice specialty; poor interviewing or interpersonal skills; lack of a backup plan; not applying to, interviewing for, or ranking enough programs; concerns raised in the MSPE, especially professionalism concerns; unexplained educational gaps; medical school reputation; or poor strategy in the SOAP.36,37 In our experience, unmatched students usually have more than one of these risk factors. Following an unsuccessful Match and SOAP, advisors are in an ideal position to help students gain insight and identify opportunities for improvement.

Following the SOAP, a final vacancy list is released by the NRMP, and students may contact programs directly. Based on 2015 data from the AAMC, this practice is fruitful for many, with nearly 50% finding some position in the first two weeks after the Match.36 This practice does require significant work on the part of the student as well as faculty advocacy to engage with programs inundated with similar communications.

Students should be encouraged to use their school’s support services, including behavioral and physical health, as well as debt management assistance. These services typically are included in the fees students pay and end upon graduation. The risk of failing a clinical rotation because of distraction, depression, self-doubts, and other post-“no match” issues can be high. If an unmatched student is scheduled to be on a clinical rotation during this period, we recommend that she or he consider taking a leave of absence.

Some students may decide to complete additional coursework in a specialty to which they had not previously applied but may wish to the following year.

Short-term post-“no match” period (1 month to 1 year)

Students and advisors should continue to explore the underlying issues that prevented the student from matching, discussing the student’s desire to practice clinical medicine and brainstorming about alternative fields (in medicine or elsewhere) that may be a better fit.

Many students will have months between when they graduate and when they can reapply in the next Match cycle. During this period, they will need to improve their application or create an application in a new specialty, earn an income, and stay motivated, tasks that often conflict. Although medical schools typically continue to manage the administrative aspects of reapplication, graduates may find that the support and advice that was available to them as students is harder to come by now. Additionally, they will have lost liability coverage for clinical experiences.

Valuable information can be gleaned from program directors of residencies where an interview, but not a match, was obtained. When financially feasible, students should prioritize the experiences that potential GME program directors will value most. Unfortunately, such experiences are only minimally defined in the literature.6–10

Sudden residency vacancies can create opportunities for graduates to pursue a GME position midyear, so they should be diligent in checking the various residency vacancy repositories. Graduates also should stay in contact with advisors in their desired field as they may be the first to hear of openings.

Long-term post-“no match” period(> 1 year)

Data on the success of reapplicants are limited. In 2015, the AAMC surveyed 108 alumni who graduated between 2009 and 2014 and who participated in the 2015 Match.36 The results indicated that 63% were successful in obtaining a PGY1 position in the 2015 Match, with those who were only 1 year out from graduation having the highest success rate (~78%). For other groups, the success rate dropped precipitously (below 50% for those 2–3 years out from graduation, and below 25% for those 4–5 years out from graduation). Additionally, these results may overrepresent success, as they reflect only unmatched graduates who were continuing to pursue medicine and responded to the survey, not those who decided that a clinical career was not right for them. Advisors should present these odds to any student who is considering reapplying for a GME position after 1 year to help manage expectations.

In addition, students should seek new letters of recommendation that can help delineate the progression of their skills and achievements, indicate their ongoing connections with faculty in their field, and show that they sought to improve their application.9

Conclusion

Unmatched students are a small but growing group who present significant challenges to their medical schools and advisors. Both unmatched students and their schools must consider many factors and make some decisions quickly. In advising students, no single pathway ensures success. Students who fail to match each have unique contributing factors, but common themes do emerge. We recommend that medical schools develop clear policies regarding whether students are allowed to delay graduation if they do not match, as well as whether and how to addend the MSPE for those students who reapply in subsequent years. After assisting students in analyzing the barriers to their success, advisors should use specific strategies to help those students achieve their desired outcome or have an honest discussion about why this outcome may not be possible.

In this Perspective, we have provided guidelines for discussions between unmatched students and their advisors. Future studies should explore how best to advise students to achieve optimal outcomes, as well as the need for accurate, organized, and readily available information for the growing number of medical students who are unable to secure GME training positions. We hope that this Perspective prompts further study of the myriad issues surrounding unmatched students so that best practices may emerge.