The Match, Part 2 - The Ranklist

In the last entry we discussed the initial steps of the residency matching process, whereby U.S. senior medical students like myself apply to and interview at residency programs in their field of choice. And it was pretty simple, albeit very expensive and time-consuming. In this, the second part of our muli-act mini-blogoseries, we shall discuss the next step in the process: Making your Ranklist.

Each graduating medical student who has hopes of going on to practice medicine must decide which residency programs they might like to end up in. This decision must be made in rank order and submitted to the National Residency Match Program. So lets say you interviewed at 10 programs that you halfway liked. You submit a first choice, second choice, third choice... down to numero ten.

Meanwhile, each residency program must make a rank list of its own. All accross the country, in windowless hospital board rooms, around long tables strewn with pizza boxes and empty 16 oz latte cups, groups of medical faculty, program directors, attendings, and residents met for hour upon hour to make a list of their favorite medical students. Keep in mind, they are making their list from the hundreds of students who they interviewed over the course of the season. I've been told that in some programs they print out big copies of each of our application photos and post them on the wall, moving the photos up and down as each student rises or falls in the rank of hundreds. For all I know they also use a dart board, or pin-the-tail-on-the-donkey, or a collection of voodoo dolls to make the list. Perhaps it involves a seance. Perhaps an elaborate drinking game based on Star Wars. Or 52 card pickup. But somehow they too come up with a list of people, #1 through whatever. This list is then submitted to the National Residency Match Program.

And then a computer calcuates everyone's ranklist from all over the country, and matches each student up to a residency program. Hence, The Match. Then the computer tells you where you are going to go, and every medical student in the country finds out the results at the exact same time. More on this later.

Now, you might be thinking: Fiona, this doesn't sound that complicated. The computer program is likely based on a simple algorithm that weighs each rank list and calculates a reasonable result. What's all the fuss about? I'll tell you.

Yes, the match system is based on a simple algorithm. "This algorithm assumes that offers made to applicants for by various programs are determined by the applicants' preferred order lists (rank order lists). Applicants match into the programs listed highest on their lists that also ranked the applicant and had not filled all of available positions with applicants the program preferred as determined by the program's rank order list." That DOES sound simple!

What this enlightening and easy-to-understand statement from the NRMP does not encompass is the one cardinal rule that the Match is based on. (I love being involved in something that has one and only one cardinal rule!) "There is one cardinal rule for both programs and applicants: neither must ask the other prior to the Match to make a commitment as to how each will be ranked. Each party may express a high level of interest in the other; however, references to how each will rank the other should be avoided and should definitely not be solicited." (bold text is actually from the source).

This is important because the whole process is screwed up if someone guarantees you a spot, or if you guarantee that you are ranking them as #1. The hitch, though, is that residency programs want to have good stats. They want to be able to say that all of their slots filled from the top of their list, that they have never had to go past #20 on their ranklist, stuff like that. It makes them seem like a more competitive program that always gets the top applicants, which will then theoretically attract a higher caliber of applicant in the future. It thus becomes a weird strategy game where students try to give every program the impression that each is their number one choice, even if its not, hopefully then allowing them to be ranked higher. For some this involves emails and cards to program directors, stating their high level of interest. For some it involves lying, or stretching the truth, which violates the cardinal rule not only of the match system, but of several major religions.

I didn't want to play the game. I tried to be as honest as possible, which meant using generic phrases like "its a very hard decision for me." This, I came to learn, is universally taken as a phrase of rejection, which may have in fact hurt my chances of acheiving my ideal Match.

But the truth of the matter is that making my ranklist was the hardest decision I have ever had to make in my entire life. Having to weigh career choices, living situation, family, friends, boyfriend, aspirations, dreams, future, past, sense of adventure, sense of comfort... and having all of these forces play out into a single numerical list... it was agonizing. Honestly agonizing. It feels like you are being asked to decide the course of your life, knowing that whatever decision you make will change everything forever, but also not knowing what the result of the decision will mean. And with the match system, even a decision is no garauntee of a result, as you then have to leave it up to some computer (or as some like to call it, "fate") to decide.

For the days leading up to the ranklist due date I would get nauseous whenever I thought about it. I cried whenever I talked about it, and I talked about it a lot. I was scared of any possible outcome, my fear of making a decision outweighing the excitement that I should have been feeling about entering this new phase of my life and of my medical training. I was faced with only good options, but any option seemed to distance myself from someone that I loved.

In the end, I made a decision. I ranked one potential future higher than another potential future, and I left it that way. Although, to be honest, I did move things around a few times, and I spent a couple hours staring at my online list the day that ranklist was due. However, at the time that the list was officially certified online (February 21, 2007 at 9pm EST), I was out in Forest Park. For the 15 minutes leading up to that arbitrary decision cutoff time I walked into the forest along the creek, the soft grey of the trees closing around me, the moss hanging brightly from their branches. When 9pm EST hit, I stopped for a moment and stood still in the forest, listening to the slow, neutral trickling of the creek, smelling the damp beautiful rot of wet leaves and dirt, feeling the air cool on my cheeks. Then I turned around and walked back out of the forest, back along that same creek, ready to face my future.

Oh, that important email that I got earlier this morning from the NRMP... it said "Congratulations! You have matched."