Ten Years Later:
Scrambling was Definitely Not the End of the World
Finding Opportunity in Apparent Adversity
Kirsti A. Dyer, MD, MS, FAAETS
Out of every crisis
comes the chance to be reborn, to reconceive ourselves as individuals,
to choose the kind of
change that will help us to grow and to fulfill ourselves more completely.
It doesn’t seem possible, but this spring
it will be ten years since I went through the Residency Match and ended
up scrambling for my internship spot. At the time scrambling was a monumental
life crisis, but in time I have come to realize that it wasn’t the end
of the world. For the tenth year anniversary of this event, I decided to
reconsider an article that I had written about the experience, "It’s Not
the End of the World"  and see how I was affected by this unlucky life
event for me. I am also revisiting the article to provide an encouraging
resource for a new generation of medical students. While a resident I discovered
that several of my medical students had already read the original article
that was circulated by their friends or medical school. The article was
shared prior to the Match to help medical students prepare for the worst—scrambling—in
case it happen to them.
So much has happened in the ten years since I
graduated from medical school; there have been so many positive changes
in my life that this negative one—the ordeal of scrambling—is just a distant
memory. I sit here writing, nearly eight months pregnant with my second
child, while my almost two year old daughter keeps interrupting as I try
to meet the deadline for this article. Despite the interruptions, I wouldn’t
trade the experience I have had as a mother for a high prestige career.
I am living a much better and different reality than what I had originally
envisioned for my life as a fourth year medical student. (See also the
related article, "The Road
Now Taken" )
It has been enlightening to mentally return to
that place and time many years ago, when it seemed as though my entire
world had crumbled. However, scrambling was not the first professional
life-changing crisis that I endured. I have faced others—previously and
since—and survived. Each crisis has been a chance for self-assessment and
personal growth that has forced me to critically evaluate the situation
and find the opportunity frequently previously overlooked or unconsidered
prior to the life-altering circumstance.
Medical professions want to be organized and in
control of our lives, but life is unpredictable. Many times despite our
best efforts, things do not go the way we had planned. This is a difficult
lesson to learn within our professional career, and perhaps even more difficult
to learn when dealing with our patients and their medical problems. The
experience of not matching and having to scramble, although at first it
was devastating, taught me an invaluable lesson. Much as we might try,
we cannot predict or control the future—a hard lesson, but an essential
one to be learned early in one’s professional career.
Looking back on this experience has made me realize
how different my life would be if I had matched in my original specialty
choice—obstetrics and gynecology. In retrospect, not matching and having
to scramble was one of the major events that helped lay the foundation
for much of the work I am doing now—working to educate colleagues and the
public in coping with loss and life-changing events and in understanding
the grief response. Facing a series of life-changing crises forced me to
evaluate my priorities and determine what was important for me, for my
career, for my husband and for my children. It also taught me the importance
of learning what I can control and what I can’t, but most importantly to
be sure to live life. Perhaps John Lennon expressed these sentiments best:
Life is what happens to
you when you’re busy making other plans.
In the midst of all the chaos, it is important
to remember that having to scramble is not a sign of lack of competency.
Scramblers, contrary to popular belief, are
always people at
the bottom of their medical school class. Often, not matching is the result
of inadequate planning, insufficient ranking, trusting an interviewer about
a promised position, circumstances, bad luck, a poor original specialty
choice, or a restricting location or life-style choices. Frequently scrambling
is the hazard of applying in a highly competitive field with way too many
applicants for too few residency spots.
On some level, I instinctively knew that I wouldn’t
match. Prior to the match many of my classmates had received some pre-confirmation
word from their program choices that they had been ranked highly, nearly
guaranteeing them a spot. I never heard any kind of confirmation. I had
chosen a competitive specialty—obstetrics and gynecology—and restricted
my interviews to California programs. In essence I had severely handicapped
my chances of succeeding from the start. It would have been interesting
to calculate the odds of my matching, based on the number of programs I
was interviewed by and the number of applicants. In hindsight, my odds
might have been better at winning the lottery.
On the day before the match I still had not heard
anything by 11:00 a.m. I thought I’d made it past the appointed hour and
was in the clear. I was ready to breathe a sigh of relief, but an inner
voice was eating at me, urging me to call. Wanting to be absolutely sure,
I phoned my medical school:
"I didn’t match…didn’t match…." The words echoed
in my head. That unspoken fear about the residency application process,
a subject so unpleasant that no one ever discusses the option of not matching
for a residency spot was my reality. Scrambling was only supposed to happen
to those at the bottom of the class. I was stunned, numb. I could barely
register the instructions given to me for what to expect on the following
"I was just calling to check…
Ah, You’re glad that I called. You were getting
ready to call me? Why?…
You needed to let me know that I didn’t match."
When I hung up the phone the anger surfaced. It
wasn’t supposed to happen this way. I’d worked too hard, sacrificed too
much for too many years. I was supposed to be rewarded, not punished for
all of the sacrifices. I’d spent so much time, money and effort applying
and interviewing for everything to end like this. Then the doubts emerged.
How would I restore my shattered self-esteem to make it through the scramble,
the following day? I would need several days to get over the shock of this
news. This could be the sign that I had been waiting for since being accepted
into medical school—that I wasn’t meant to be a physician, confirming what
I secretly had suspected all along that getting into medical school was
an accident, a fluke. Now despite all of the hard work in the last nearly
four years of medical school, I feared it was going to be taken away from
The afternoon passed in a blur calling family
and a few friends to tell them the news and get some support and needed
encouragement. Somehow in the midst of this turmoil, on a fundamental level
I remembered an inspirational quote by Eleanor Roosevelt:
The future belongs to
those who believe in the beauty of their dreams.
Now all I needed to do was to find some new dreams
and settle on a strategy. It was time to devise the best alternative "Plan
B." Fortunately, I have always been good at coming up with "Plan B’s" after
having experienced so many failed "Plan A’s." Taking a few deep breaths
to steady my nerves and regain my composure, I spent the night mulling
over my various options:
Next I started weighing my options. First, I had
to decide if I wanted to finish medical school. Deciding to finish was
relatively easy. Between my loans, my parents and my patients, I had no
choice—I had to finish. I couldn’t see a way to easily pay off my school
loans if I did not finish the medical degree. Postponing graduating would
give me another year to take other acting internships at other institutions,
research, or explore other specialties. This option would add another year
of tuition and living expenses that would have to be repaid. Plus every
additional acting internship at another institution would add extra expenses.
Even if I took the extra year, I wondered if the stigma of not matching
would continue to haunt me and impair my chances of strengthening a future
application. The financial setbacks that would have been accrued from an
additional year plus the unknown social stigma did not outweigh the extra
experience, so I could not see any real benefit to postponing graduating.
Although the "Michael Crichton" option had a certain appeal, I knew it
was pretty risky and required talent and a lot of luck to succeed. I also
knew that in order to get licensed in California, that I needed to at least
complete an internship even if all I wanted to do was to become a general
Postpone Graduating and reapply the following year.
This would give me time to:
Take additional acting internships at different programs
to strengthen my chances of applying.
Spend the year conducting research. ( I had a Master’s
degree that would enable this option)
Consider other specialty options.
Take a one-year transition or preliminary year position.
Finish medical school and see what job options existed
with just a medical degree. (Michael Crichton seemed to have done pretty
well without going through a residency program.)
Preparing for the scramble and deciding on a game
plan was difficult. Without a doubt the hardest part was remaining calm
and restoring my self-confidence. I knew I could not let the nagging doubts
undermine the belief in myself and faith in my ability to become a caring
and competent physician. First, I considered my original field, obstetrics
and gynecology. After looking at the odds from the previous year—30 open
spots and 200+ scramblers—I was willing to try a few obstetrics programs,
but realistically accepted the fact that I would probably not match in
any of them. Next I considered the alternatives—family practice, transitional
year, or a preliminary year in internal medicine. For me, the choice was
medicine since I had considered it initially during third year and I was
not sure I could handle the pediatric portion of family practice. The best
option seemed to be to take a one-year transition or preliminary position
and hope that as an intern, I would have enough free time to decide what
to do to complete a residency program. I selected back-up programs in internal
medicine from the list of unfilled spots.
Scrambling in the "Good ol’ Days" vs. in the
Things were very different at the time I went
through the match and scrambled in 1992. Scramblers and unfilled residency
programs relied on busy telephones for contacting programs and fax machines
for sending information and applications. (I heard of one person who bought
a FAX machine so he wouldn’t have to wait to use the medical school’s machine.)
The specific insights that might have been helpful ten years ago now are
obsolete, as the technology has advanced so that matching and scrambling
are done via the Internet. At the time I went through the Match, it is
now known that the algorithm used to rank and match for residency spots
favored the hospitals not the applicants. In 1998, the Match algorithm
was changed to favor the preferences of the applicants over those of the
programs. Previously it had favored the programs. [3,4]
Under the current system, medical student and
resident applicants must apply directly to residency and/or fellowship
programs. In addition applicants must register with both NRMP for the Match
and ERAS for the Internet technology. Most programs now participate in
the Electronic Residency Application Service (ERAS) , which transmits
residency applications to program directors via the Internet. In addition
to matching for internship positions, the NRMP's Specialty Matching Services
(SMS) conducts matches for advanced residency or fellowship positions.
Other sites, www.sfmatch.org,  exist to provide support services to
applicants and programs to facilitate the application and selection process
for specific residency and fellowship positions e.g. neurology, ophthalmology,
and many of the surgical subspecialties.
In 2000, the NRMP took the Match to the Internet,
making it an Internet-based process for both applicants and residency programs.
 Recently, the NRMP collaborated with the Association of American Medical
Colleges' Electronic Residency Application Services (ERAS) to create an
online service that assists unfilled programs and unmatched applicants
in the post match process of finding one another. This new program, FindAResident™
helps residency programs and applicants alike locate available programs
and applicants, both immediately following the Match and whenever positions
become available during the year.  This service would have been invaluable
to me in subsequent years when I was looking for a second year position
and had to "cold call" residency programs to determine if they had any
vacancies in their program.
The scramble is a bit different now in the Internet
era. Beginning at noon Tuesday of Match week, there is still a period of
time set aside for the applicants who did not match, to give them an opportunity
to contact unfilled programs to try to secure a position before Match Day.
The Internet has helped in facilitating this process and making more information
available sooner to unmatched applicants. The NRMP prepares the list of
unfilled programs by specialty. This list is then posted on the NRMP website
at 12 noon EST on Tuesday of Match week and sent via e-mail to unmatched
applicants on the same day to assist them in identifying unfilled positions
for the scramble the following day. 
In my situation, I was unwilling to risk a bird
in hand by waiting several hours for one obstetrics program to possibly
respond. I accepted a preliminary year position in a California internal
medicine program, little more than two hours away from my parents. By 11
a.m., two hours after the scramble had started for me it was all over.
My decision was made easier, since several of my scrambling classmates
had also accepted preliminary year positions at the same program.
Finding the Positive in an Apparent Negative
It may be difficult for many people to believe
that something positive can emerge from a potentially negative experience
such as scrambling, but it can:
Scrambling forced me to reevaluate my original specialty
choice and examine my motivation for choosing the field. Within a less
than 24 hours, I had to decide if I wanted to study obstetrics and gynecology
above all else or if I could be content in another field. I had to determine
whether I was willing to go anywhere—to sacrifice life-style, to leave
my family, friends, and home state—for my original choice. Did I even have
a realistic view of what practicing on a day-to-day basis in Ob/Gyn or
any other specialty would involve? I had come into medical school with
interested in obstetrics—in particular reproductive immunology, birth control
and women’s health issues. I had chosen obstetrics halfway through my third
year as the reconciliation of my medical and surgical leanings thinking
I might pursue Gynecology Oncology (an even more competitive subspecialty).
I’d never given any other specialty much consideration. But by the spring
of my fourth year, with interviews completed and match lists submitted,
I was having doubts about my specialty choice, questioning the stress level,
the professional liability and the obstetrics life-style. The night before
the scramble, I was able to find 20 reasons for changing to internal medicine
and few for staying with obstetrics. I was starting to create new dreams.
Programs that did not consider an applicant initially
may select him/her during the scramble. Every year, some prestigious programs
do not initially fill. The applicant may get a better spot than ones he/she
initially had chosen.
Scrambling can help the applicant to seriously consider
other options. Another specialty may be the ultimate career choice, but
the alternative option may not have been originally obvious.
The applicant can play a more active role in determining
where to spend his/her intern year. (Not all of my classmates were as happy
with their matched choice I was with my scrambled one.)
Scramblers get into good residency programs and become
capable, competent physicians
In hindsight, I do wish I had considered more
specialties while I was in medical school and had a bit more time to explore,
rather than going through school fairly focused on one specialty. Several
of the specialties that I might have had a better "fit"—namely family practice
and psychiatry—had problems within the departments at my medical school;
these specialties were not portrayed in the best light as I went through
the rotations. However, I don’t know if it would have made much difference.
Since finishing medical school I have had several opportunities to consider
other fields. During my intern year, after experiencing another professional
setback, I was able to reconsider applying to psychiatry and family practice.
But neither of these specialties felt as though it would be any better
for me than internal medicine. Once out in practice, I worked for a time
as an emergency room physician in several rural communities, enough to
recognize that I preferred ambulatory and primary care to emergency care.
I now realize that I was ahead of the trends.
I had difficulty "matching" because I didn’t "match well" with any of the
available specialties at the time. Many of the areas I was interested in
did not yet exist as specialties and have become fields of study since
I completed my training in 1996. These areas include integrative or complementary
medicine, women’s health, primary care/ambulatory medicine, palliative
care, thanatology (death education), medical informatics or Internet, and
the psychology of loss. Unfortunately, I also completed my training at
a time when funding quickly dried up for resident physicians to pursue
a second residency programs. There are so many more different training
and specialty options today than when I was scrambling in 1992. Plus with
the migration of the information to the Internet, it appears that today’s
scrambler has more informed options.
In 1998 I applied to start a Preventive Medicine/Public
Health program, one that I was unaware of during medical school, in the
fall of 1999. I was accepted into a preventive medicine program, but because
the public health program did not accept me I had to pass on the spot.
Life has a funny way of working out, because by the fall of 1999 I was
pregnant with my first daughter, which has been a better and more rewarding
experience for me than trying to complete a second residency program. Instead
since completing my residency training I have developed and pursued my
own post-graduate Fellowship training in the areas of grief, loss, bereavement
and trauma. I have obtained what limited credentialling exists in this
emerging, but overlooked field of medicine. I have completed half of a
distance learning degree in medical informatics—exploring uses of the medical
Internet for patient and physician education. My current career goals are
to educate colleagues and the public by writing, teaching and maintaining
a website, Journey of Hearts,TMwww.journeyofhearts.org,
on grief, loss and bereavement in medicine. Without the perspective of
having experienced several major personal and professional losses, I would
not have the insight, or the background to explore this important, emerging
The experience of not matching and scrambling,
although at first may appear devastating, it should be viewed as a challenge
and an opportunity for growth. As with many of my life-changing crises,
I view crisis as a wake-up call and try to turn my adversities into opportunities.
These initially negative experiences forced me to re-evaluate and reassess
my life’s priorities and find out who I am professionally and personally.
I have been able to fulfill myself more completely than I ever would have
if I had not endured the ordeal and confronted critical issues in my life.
Stephen Covey expressed the importance of wake-up calls:
In the absence of wake-up
many of us never really
confront the critical issues of life.
1. Dyer KA. It’s Not the End of
the World. JAMA 1993;269(9):1184.
2. Dyer KA. The Road Now Taken.
MomMD, 2001 Available at: http://www.mommd.com/road.html
3. Phillips R. Recent Changes to
the National Residency Matching Program. JAMA 2000;283:2997. Available
4. National Residency Match Program
(NRMP). Available at: http://www.nrmp.org
5. Association of American Medical
Colleges (AAMC), Electronic Residency Application Service (ERAS). Available
6. San Francisco Matching Program.
Available at: http://www.sfmatch.org.
7. Association of American Medical
Colleges (AAMC). FindAResidentTM
8. National Residency Match Program
(NRMP). Announcement of Results. Available at: http://www.nrmp.org//res_match/special_part/us_seniors/match_results.html
This article is scheduled to
be featured in the March MomMD Newsletter & appear on the MomMD.com
crisis has been a chance for self-assessment and personal growth
that has forced me to
critically evaluate the situation and find the opportunity
overlooked or unconsidered prior to the life-altering circumstance.
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911 Page for links to immediate resources
if you are feeling helpless,
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