Problems with the Current NRMP Match

Fifty years ago the medical community was faced with a worsening problem. In many specialties, the competition for the best and brightest medical students was at an all time high. Medical students were forced to commit to residency programs while still years from graduating, or risk doing residency at undesirable programs. Hospitals were forced to play the game or risk losing out on top applicants. Then the National Resident Matching Program (NRMP) arrived on the scene.

Established in 1952, the NRMP created a new process for residency programs to find medical students. Now programs and students would "rank" each other, then submit their respective lists to the NRMP (first on paper and now electronically. A computer algorithm match medical students to programs, and order was restored to the world. Or at least that is what they want you to believe. From their website:

"The National Resident Matching Program (NRMP) is a private, not-for-profit corporation established in 1952 to provide a uniform date of appointment to positions in graduate medical education (GME). It is governed by its Board of Directors. Five medical/medical education organizations, one program director organization, and three medical student organizations nominate candidates for election to the Board: the American Board of Medical Specialties (ABMS), the American Medical Association (AMA), the Association of American Medical Colleges (AAMC), the American Hospital Association (AHA), the Council of Medical Specialty Societies (CMSS), the Organization of Program Director Associations (OPDA), the AAMC Organization of Student Representatives, the American Medical Student Association (AMSA), and the AMA Medical Student Section. The Board also selects one program director, three resident physicians, and one public member from at-large nominations. Each year, the NRMP conducts a Main Residency Match that is designed to optimize the rank-ordered choices of applicants and program directors. In the third week of March, the results of the Match are announced.

The NRMP is not an application processing service; rather, it provides an impartial venue for matching applicants' and programs' preferences for each other consistently. Each year, approximately 16,000 U.S. medical school students participate in the Main Residency Match. In addition, another 20,000 "independent" applicants compete for the approximately 25,000 available residency positions. Independent applicants include former graduates of U.S. medical schools, U.S. osteopathic students and graduates, Canadian students and graduates, and students and graduates of international medical schools."

Unfortunately, things are not quite as perfect as they would like you to believe. First, the match is expensive. Both medical students and residency programs pay a significant amount of money each year to the NRMP for them to do three things: ensure that medical students are eligible to participate, maintain a website allowing for list entry, and running the lists through a basic computer algorithm. For this they collect roughly seven million dollars per year.

But more than just a financially, there are several problems that arise when one considers the actual mechanics of the match. If you are not familiar with the process, it can be found here. The most simple way of thinking about it is that medical students are guaranteed to match at their top choice if the program ranks them within as many open spots as they will have. For instance if the University of Chicago has 5 spots in their orthopedic residency, then any medical student in their top 5 ranks--who ranks them first--will match there.

As you can see from the description, the match really favors residency programs. No matter how much they try to tell medical students that they have the advantage because their list is "looked at" first by the computer, program directors really have the final say. I could want to get into a plastic surgery residency at the Mayo clinic, but unless I am ranked in their top few spots, it is not going to happen. In less competitive specialties students lists are emphasized to a greater extent, but the power still resides with the programs. I do not necessarily have a problem with programs being favored, my problem is more with the deception that medical students have the power to determine their destination.

A related problem is that "the Match" does not actually create the best possible matches. Using the same line of thought as above, a program may match a medical student that ranked them 15th, while not matching a medical student who ranked them first. Although the program may be happy that they got someone from the top of their list, in actuality they are getting a future resident that didn't really want to be there. This seems like a prescription for losing residents who drop out or refuse to sign a contract.

Those that do match did so through a program that is unlike anything else in society. When does one apply for jobs and expect to wait 4 months to find out where they matched. "Well I ranked Subway over Burger King but I'd really be happy going anywhere in my top three..." Intentionally or not, the match has created a system that restricts concrete thinking about where one would best fit in. And because of how closely guarded the data is, it is difficult to determine just how poorly the match performs.

Which brings up another problem. The match is trying to do all things for all people. As mentioned before, the match seems to work best for specialties that are not very competitive such as family medicine. When a program has to rank 300 applicants to fill 20 spots, there is a greater emphasis on where a medical student would like to end up. As described above, this works less well for competitive specialties. Because of this and the lack of information provided by the NRMP, several specialties have formed their own matches.

Those that do not match must either wait another year or take part in something called "the Scramble." During this time, medical students that did not match contact programs that did not fill all of their spots. It is impossible to describe the chaos of trying to contact the a dozen programs that have hundreds of medical students calling at the same time. Because of this many programs that have spots open are filled through back room deals via channels of communication within the specialty.

Having just gone through the match process I can say unequivocally that the system is flawed and in dire need of modernizing. It is expensive and stressful and often does perform its one task well, to best match medical students to programs.

As always, feel free to put any thoughts on the Match in the comments.

The Medical School Forum is Here

We now have a forum up for asking and answering questions related to medical school and medicine in general. It can be found here. It's like other forums just more intuitive and better looking. Also humble.

A Tongue in Cheek Look at Sites Like Orthogate

Orthogate is a site where people post "advice" for medical students applying for orthopedic residencies (among other things). In general the posts are mostly self-serving opportunities to tell everyone how great you are, and the advice is usually generic and/or meaningless. This was a lighthearted, wholly made up post that I put together on a page for people to discuss how "the Match" went for them. I've copied this mostly for posterity as it isn't as funny without the context.

"I'm not going to put any of my grades here, because needless to say they are awesome, as is everything else about me. Here are my thoughts on programs broken down into needlessly confusing tiers. By the way, I second what the last guy said about big name programs being overrated, I just liked them the best.

Tier AAA:
HSS: Awesome. Fellows. Awesome. Program director is competent in orthopedics.
Mayo: Awesome. Middle of nowhere. Awesome. Chairman had firm handshake. Mentorship.
HJD: Also in New York. Awesome. Expensive. Nice brunch.
Harvard: Fellows I met told me that they added to the experience. Boston. Awesome.
Iowa/Utah/UCSD/Carolinas: Awesome place that isn't in a huge city. Less awesome when more people find out about it. Great for hipsters.
Pitt : You want second opinion? You ask Freddy Foo twice.  

Tier A1AA:
Campbell Clinic : Not affiliated with the soup manufacturers. Beautiful new orthopedic hospital: The Bruce Pearl Center for Orthopedics.
Duke : Had one or more trauma attendings if I remember correctly. Anti-Arizona bias noted.
Colorado : Create your own unsubstantiated rumors here (especially if you are an MS1 and you heard this from your friend who is an Ob/Gyn).
Washington : Harborview ER. Rainy. Historically, many residents find fellowships.
Grand Rapids : Rotate through trauma and sports during residency.
Tier 1AA (Residency Championship Subdivision)
UCSF : Residents smiled frequently on interview day.
Yale : Cumbersome application requirements. Maine is beautiful in summer.
Beaumont : Family and dog friendly, but not both.
WashU : Best free weights of any program south of Wisconsin.
Miami/LSU : Receptive to sexual favors.
Dartmouth/Hopkins/Columbia/Brown : Patients will have no idea that your training was no better than at Henry Ford.
U of South Alabama : Guaranteed to catch a whiff of James Andrews cologne at least once during residency.
Minnesota : In alternate years prefer either non-rotators or rotators, please consult website to determine value of doing rotation.
Med Coll of Wisc : Those lacking ovaries need not apply.
Wisconsin: Those with ovaries need not apply.
USC : Those lacking ethnic diversity need not apply.
Detroit Medical Center : Will interview anyone.

I'm losing focus here as I only did a 4 hour workout today. Maybe I'll add to this after hanging with the brahs. Oh and I matched at a SUPER PRESTIGIOUS SECRET PLACE that is not EVEN ON THIS LIST. Hope this is helpful!!!"

The original  thread is found here.

Match Day

Match Day is fast approaching! Only 10 days until everyone knows where they will be spending the next 3-7 years!

On the road to Dartmouth for the 4th interview this week and 5th overall. Very tiring. Trying to write down thoughts on programs before I forget.

Lots of questions asking "why did you apply here." Never answered "rather be here than Witchita" which would've been closer to the truth.

Kicked off the interview season today. What an awkward/interesting process. 5 interviews in 5 hours, with 60 students for 4 positions. Good to have one done.

Orthopedic Pimp Questions

Here is a list of questions that I'll add to from time to time of ortho pimp questions I have been asked/heard people asked.

What is the innervation of the three muscles that insert as the pes anseurinus?

What are all the muscles that insert on the scapula?

What is the muscle belly of the iliotibial band?

What is worse regarding ROM lost, a subtalar or talonavicular fusion? (TN)

What composes the nucleus pulposis and annulus fibrosis--in detail?

In the OR:

What nerve is in danger with this incision?

What is the innervation of this muscle? As mentioned before, much more rarely are questions re: origin and insertion asked-- don't waste your time knowing the 3 main arteries to the knee if you don't know the innervation of the tensor fascia lata.

What muscle is this?

Why can't I use the cautery on the Mayo stand? (Only patient is grounded)

What are the layers that I will be cutting through? More commonly asked in gen surg than ortho

As always, feel free to add other questions you have been asked in the comments.

Secrets to Orthopedic Away Rotations

Here is a quick rundown of what I've learned and been told about how to thrive while on an orthopedic away rotation.

First and foremost, as I'm sure you already know this is a tryout. It's a chance for you to try a program on for size, but moreso it is a chance for them to see what kind of resident you might be in their program. It's easy to slip into the mindset that just because you graced them with your presence for a month that they are going to think better of you. Not so. In fact that is why on average it is a lot easier to hurt your chances of getting into a program by doing an away than it is to help your chances. The all encompassing first rule of away rotations is: always work hard.

What are some of the ways you can shine? You can prepare the notes before the resident's arrive in the morning. Perhaps it is just where I am at, but unlike general surgery, it seems that the residents do not care (and may even prefer otherwise) if you see a patient in the morning before they get there. They seem more concerned that the actual rounding process is streamlined. Regarding the OR and pimping, the most important thing to know is anatomy. Most commonly you'll be asked questions such as "What nerve is in danger with this incision," "What muscle is this," etc. Expect more nerve-muscle questions than insertion, origin and action questions.

When in the operating room, assume that once you are given a role once, they expect you to fill it from that time onward. For instance, some common tasks are adjusting the lights, sponging up blood in the field, and using the suction. Additionally, one should be familiar with deep tissue, subcutaneous, and skin closure so that when the attending asks if you are comfortable doing so you don't respond by saying something like "we'll I only saw it once..." Another thing to mention: when the resident or attending moves towards where you are standing, you should move to the other side of the table, they won't always take time to say "Hey can you switch positions with me."

Another OR tip: when retracting don't worry about them repositioning the retractor frequently. It is likely nothing but them wanting it in a specific place and not a commentary on how you are doing. You'll likely notice them doing the same thing with the residents.

The biggest thing that programs are looking for is hardworking, teachable medical students that appear to be engaged in the case or lecture, with whom they can get along with on a day-to-day basis. Most of the time they would rather have the above student as a resident than one that is just the best at answering all of their pimping questions.

Hiking Mt. Olympus

After hiking Mt. Olympus (Utah) today and nearly requiring LifeFlight to get me off of the mountain, I thought I might share a few thoughts that you will not easily find on SummitPost or other similar sites that dramatically oversimplify some of the challenges that you will face. But before I get ahead of myself, here is the rundown of what happened and the mistakes I made.

Starting out around noon (aka the "Hottest Time of the Day"), I parked just down the street from the trailhead, along Wasatch Blvd. I had read on a few pieces on climbing Olympus that there were more cars broken into in the parking lot that there were windows shattered along the street--a rumor that was denied by several people that I met on the trail. But going back to the start time, if you are from a humid state such as the southeast or midwest you will be unpleasantly surprised at how hot it is. The temperatures were in the mid-90s, but because it is so dry here it felt like high-70s and I thought nothing of it.

After starting out at a decent grade out of the parking lot, you enter a series of open switchbacks with low vegetation and great views of the valley. There are a few spots with minimal exposure, but for the most part the trail is extremely safe. In my mind the trail has four segments: the first segment contains mostly scrub brush and grasses.

In the second segment, you enter an area of low trees mixed with increasing amounts of rock that you have to navigate as you climb. In the middle of the summer, this segment also contains your only source of water on the hike in the form of a small stream. Many other sites talk about how it is a steep hike that is only 3ish miles each way, but you would be surprised how fast you go through water, especially if you have not fully acclimated to the altitude.

The third segment of the trail has higher trees, steep grades and significant amounts of rocks in the trail that will slow you down. Many times you are walking in a tunnel of foliage with increased humidity.

The final segment is what I found to be the most grossly underdescribed in other websites. This is the segment of the hike above "the Saddle," a flat segment of ridge that gives great views to the east.

First of all, if this is grade 3 climbing then it's 3.9. The last 45mins or so of the climb is a lot closer to grade 4 climbing than it is grade 3. When I think of grade three climbing, I think of the kind of climbing that is necessary near the summit of many Colorado peaks where you are going up and over some low boulders but would not fall/roll more than 20ft in a worst case scenario. The last bit of climbing on Olympus has significant exposure in several spots and requires at least minimal vertical climbing skill, more than your average mountain hiker may be comfortable with, especially considering many hikers on Olympus are lugging decent sized packs up, which significantly alters one's center of gravity. Never mind my biggest pet peeve about this segment.

Utah. I get it. You are all about the "go for it, and if something goes wrong, maybe we'll be able to help you before it is too late." I also understand the massive amount of wilderness in Utah. But this is probably the second most popular hike in the SLC area! This is a trail that has 12 year olds and 70 year olds on it. And yet there are zero markings as to the trail above the saddle! Not only is this incredibly dangerous, but it also means that you waste large amounts of energy coming back down as nearly everyone takes different paths and has to double back when they hit a 10 foot drop off. In other words it's manageable on the way up but can be disastrous on the way down.

I got in a situation where I was so low on energy that I had to continue down despite the fact that it was much much more dangerous and exposed than the path that I went up on. There were times where a slip backwards would have almost certainly meant broken bones and likely worse. Not only is the trail marked at all, but there is a grand total of two cairns to help one navigate down, and one of them is next to the mailbox at the summit! It's no surprise that in the past few years a number of people have died.

To wrap up my meandering story, although I brought plenty of water I quickly dried up the available calories in my body and became so nauseated that I could not get a dry granola bar to go down--so I called for help. Luckily as the trail is mostly on the valley side, you should be able to get help if needed. I had become so weak that I was afraid of falling down the trail, even though I was back in the 3rd and slightly less steep stage. I had to just sit and wait until my friends could help me by bringing some zofran (anti-nausea) and some liquid energy.

Was much of this my fault for leaving on a hot day at the hottest time of day? Yes. Should I have brought more calories with me? Yes. Are there dangers inherent to climbing Mt. Olympus that are not described on other sites? Yes. I hope that if you are like me and searching out info about the climb that you be sure to start early, budget extra time, and take extreme caution above the Saddle area if you plan on summiting. Multiple people die here every year, if you are like me you may underestimate how difficult the grade is, especially if you are used to the typical Colorado 14er which rises a mile in 7 or more miles walked. Feel free to share your Olympus stories in the comments section.

PS these images are my own, please do not copy them onto other websites without permission as they are protected.