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" [1] 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" [2])

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:

My Experience
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 not 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 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 me.

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:

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:

• 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.)
• Quit altogether.

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 Internet Era
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) [5], 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, [6] 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. [3] 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. [7] 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. [8]

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 Situation
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:

• 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

Conclusions
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 area.

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:

References:
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 at: http://jama.ama-assn.org/issues/v283n22/ffull/jrf00014-1.html
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 at: http://www.aamc.org/eras/
6. San Francisco Matching Program. Available at: http://www.sfmatch.org.
7. Association of American Medical Colleges (AAMC). FindAResident^TM Available at: http://pnet400.aamc.org/findaresident/
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 website.

---

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.