The Match: Everything You Need to Maximize Your Residency Chances

by Alec Palmerton, MD in Residency

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The journey to become a practicing American physician is long. Arguably the most important leg of the journey is what residency you match at. Known as “The Match,” the National Resident Matching Program determines not only what specialty you will practice, but where you will do your residency training. In short, it determines some of the most critical aspects of your training and future as a practicing clinician.

But “The Match” is often seen as a black box. What are your chances of matching? What are the most competitive specialties? We’ve discussed before the characteristics of successful applicants. In this article, we will delve into the NRMP Match. Specifically, we will discuss:

• How “The Match” works
• Terms you need to understand to have a successful match
• How many residency programs/spots are available in each specialty
• What people’s chances were in the 2019 Match
• Which specialties were the most- and least- IMG- and DO-friendly in 2019
• Updates on the MD and DO residency merger,
• Much more

Table of Contents

Everything You Need to Know to Get Into Residency from Day 1

The Match is the culmination of a long process that begins your first day of med school. To learn how to maximize your pre-Match time, here is a sampling of some of our most popular articles:

• Get Into a Top Residency: 5 Things You Need to Know
• The Key to Success in Medical School (and Life)
• Average Step 1, Step 2 CK Scores, Research by Specialty (US Seniors, IMGs)
• Step 1 + Step 2 CK Percentiles: What’s a Good Score for Each Specialty?
• The IMG’s Guide to Obtaining Residency in the United States
• MD vs. DO vs. IMG: A Harvard Program Director’s Views
• Fail Step 1, Step 2 CK or CS? Do This
• Interviewing to Match Into a Competitive Residency

The NRMP Match: What is It?

The NRMP Match is like most things you’ve applied to your whole life. The general process is that you:

• Submit an application
• Receive interview invitations
• Go on interviews
• Make/submit a rank order list of programs you interviewed at (your “Match list”) to the NRMP
• Residencies make/submit a rank order list to the NRMP of applicants they interviewed
• A computer algorithm uses these preference lists and tries to create optimal pairings

(To read Interviewing to Match Into a Competitive Residency, click here).

The major wrinkle in the NRMP Match is that programs don’t “accept” you. Instead, the algorithm takes your preferences and tries to pair you with a single program.

The NRMP has made an explainer video on “The Match” process.

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The Match: Don’t Try to Game the System

The major takeaway? There is no benefit to trying to game the system. Instead, you should make your Match List based on your true preferences.

In other words, let’s say I want to go to MGH-Anesthesia, but I’m not sure they’ll rank me high. However, I had a great interview at Columbia, and the program director told me I was ranked to match. (“Ranked to match” essentially means you are a shoo-in if you want to go to that program). In this scenario, MGH would be my top choice, and Columbia would be my second choice.

If MGH is my first choice, I should put it first on my Match list. Even if I have no chance of going there, I lose nothing by putting MGH first. If I put MGH first, and don’t match, then the algorithm will try to match me at my next-lowest spot. I would match at Columbia regardless of whether I had ranked MGH or Columbia first.

Let’s say, though, that MGH ranked me higher than I thought. If I were ranked high enough, and I put MGH first on my list, I could still match at MGH. However, if I had put my second-choice (but shoo-in) program in the top slot, I wouldn’t have a chance to match at MGH.

What Programs Don’t Participate in the NRMP Match?

Nearly every residency program (and many fellowships) participate in the NRMP Match. This is especially true now that previously DO-only residencies participate in The Match.

With that said, there are a few exceptions to specialties that do not participate in the NRMP Match. These are:

• Ophthalmology: Part of the S.F. Match
• Plastic Surgery (for those already participating/finished specialty surgery training): S.F. Match
• Urology: an independent match administered by the American Urological Association
• Air Force, Army, and Navy: administered by The Joint Service Graduate Medical Education Selection Board (JSGMESB)

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Alphabet Soup: Applicant and Program Types

The Match contains a dizzying array of various terms for different applicants/positions. Here we discuss what the different terms mean.

IMG, U.S. Senior, US Grad, Osteo, Categorial, Advanced, and Physician (“R”)?: What Do They Mean?

Here are the NRMP’s definitions of each applicant type, with explanations where appropriate:

• U.S. Senior: Senior student of U.S. Allopathic Medical School. A fourth-year medical student in a U.S. allopathic school of medicine accredited by the Liaison Committee on Medical Education (LCME). U.S. Seniors have a graduation date after July 1 in the year before the Match. U.S. seniors are sponsored by their medical schools.
• U.S. Grad: Previous Graduate of U.S. Allopathic Medical School. A graduate of a U.S. allopathic school of medicine accredited by the LCME. U.S. Grads have a graduation date before July 1 in the year before the Match. Previous U.S. graduates are not sponsored by the medical school.
• Canadian: Student/Graduate of Canadian Medical School. A senior student or graduate of a Canadian school of medicine accredited by the Committee on Accreditation of Canadian Medical Schools (CACMS).
• Osteo: Student/Graduate of Osteopathic (“D.O.”) Medical School. A senior student or graduate of a medical school accredited by the Commission on Osteopathic College Accreditation (COCA).
• 5th Pathway: Graduate of Fifth Pathway Program.
• U.S. IMG: U.S. Citizen Student/Graduate of International Medical School.
• Non-U.S. IMG: Non-U.S. Citizen Student/Graduate of International Medical School.

PGY-1 vs. PGY-2 Positions: What’s the Difference?

PGY stands for “Post-Graduate Year.” The number refers to the number of years after graduation one would be when they start.

For example, PGY-1 refers to any program that starts the year after graduation. Any “intern” year program is technically a PGY-1 year position.

PGY-2 positions begin two years after graduation. These often are the same as “Advanced” positions. (See below). Examples of fields with mainly PGY-2 posts include dermatology, radiology, or radiation oncology.

In other words, most dermatology residents need to match into two separate programs. They need to match into the dermatology program itself, most of which start in PGY-2. Most prospective dermatologists also need to match into a “preliminary” year, as well. (See below). This is because dermatology training starts during the PGY-2 year.

Some programs begin specialty training during the PGY-2 year but include a PGY-1 year as well. These are known as “categorical” programs. (See below). Many surgical specialties are exclusively categorical, despite starting specialty training during year two. For example, orthopedic surgery begins the ortho training during year two. The first year is often doing a year of general surgery training.

Program Types: Advanced, Categorical, Preliminary, and Physician

Here are the definitions for Program Types:

• Advanced (A): begin in the PGY-2 year and require a year of prerequisite training. This means you need to apply for/match into a separate PGY-1 “Preliminary” program. (See below).
• Categorical (C): begin in the PGY-1 year and provide the full training required for specialty board certification.
• Primary (M): Categorical programs in primary care medicine and primary care pediatrics. These begin in the PGY-1 year and provide the full training required for specialty board certification.
• Preliminary (P): One-year programs that begin in the PGY-1 year. These provide prerequisite training for advanced programs.
• Physician (R): reserved for physicians with prior graduate medical education. Reserved programs offer PGY-2 positions that begin in the year of the Match. These are not available to senior medical students.

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How Many Residency Positions Are There? How Many Spots Fill?

One way to look at the data is to see how many spots are filled.

• The overall position fill rate for the 2019 Match was 95.0 percent.
• 1,768 of the 35,185 positions were unfilled
• 1,652 of the unfilled positions were offered during the Supplemental Offer and Acceptance Program (SOAP). (AKA “Scramble”; see more below).
• After SOAP, all but 458 positions were filled, for a post-SOAP fill rate of 98.7 percent.

Here are the total positions available in the 2019 Match, and how many were filled. Unless otherwise noted as PGY-2 or “R” (Physician), positions are PGY-1/Categorical.

M.D. vs. D.O. vs. IMG: How Each Group Fared

One way to break down The Match data is to look at the different applicant types.

(To read MD vs. DO vs. IMG: A Harvard Program Director’s Views, click here).

How Many U.S., D.O., IMG, etc. Applicants Are There?

Every year, more and more applicants apply for residency spots. Here is the list of applicants by type, from 2015-2019.

And the same data graphed:

What Are the Chances of Matching if You’re a US Grad, IMG, or D.O.?

As an applicant, you probably don’t care much about how many spots are filled. You care about your own chances of matching in any given specialty!

For example, let’s say you were a non-US IMG. If so, you’d want to see how many non-US IMGs didn’t match. Similarly, for D.O. students – what percentage of D.O. applicants matched in 2019?

Which Specialties Were the Most DO-Friendly?

As you can see above, D.O.s and IMGs match at lower rates than U.S. Seniors. There are likely a variety of reasons for this. However, some specialties indeed filled with a higher percentage of D.O.s and IMGs.

Here is a list of the most DO-friendly residency programs in the 2019 NRMP Match. Specifically, we list the % NRMP 2019 positions filled by IMG, DO, and US Seniors. Note: unless otherwise noted as PGY-2 or “R,” positions are PGY-1/Categorical.

Which Specialties Were Most IMG-Friendly?

We can also look at the Match data from the lens of which programs are most IMG-friendly. Here is a list of the programs with the highest proportion of spots filled by IMGs. Specifically we look at the percentage of NRMP 2019 positions filled by US and Non-US IMGs. Note: unless otherwise noted as PGY-2 or “R,” positions are PGY-1/Categorical.

Thinking of Switching Medical Specialties? Here Are the Most Popular.

One thing you might be wondering: what happens if you want to change specialties? If you don’t like your residency of choice, you may look to match into a different field.

As we saw above, some residencies (“Physician” tracks) even cater to this population. Here is a list of the residency positions that were most popular among U.S. Grads. (Previously graduated from a U.S. allopathic med school).

Which Specialties Were the Most Competitive?

The Match can be extremely competitive, depending on the program you are interested in. As we’ve discussed previously, applicants to the most competitive fields have pristine applications. For example, here are the median, 25%ile, and 75%ile Step 1 scores for matched 2019 US Seniors in each specialty.

Step 1 US Seniors, 25%ile, Median and 75%ile for Matched Applicants 2018 Match

(To read Step 1 + Step 2 CK Percentiles: What’s a Good Score for Each Specialty?, click here).

Because of this, many people interested in the most competitive programs apply to a “back-up.” For example, if I were interested in orthopedic surgery, I might also apply to a less-competitive specialty.

Many people, however, apply to only a single specialty. For those people, we can use the rates of matching as one measure of a specialty’s competitiveness.

Here are the Match results for U.S. Seniors and Independent Applicants who ranked each specialty as their only choice. *Note: the TOTAL row includes all positions in all specialties.

And the data for Independent Applicants (non-US Seniors)

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Will You Match At Your First Choice? Second? Third?

One closely tracked metric is how often people match at their first choice program. As you might expect, U.S. Seniors match at their first-choice programs at a higher rate.

What do you notice? The people who match at the first-choice programs has decreased over the past ten years. That said, nearly 75% of U.S. Seniors match at one of their top three choices.

Here are the same data for Independent Applicants (IMGs, DOs, etc.)

How Do So Many People Match at Their Top Choices?

You may be wondering how so many people can match at their top choices. Note that “choices” refers to the list of preferences on the Match list. So when schools advertise the number of students who match at their “top choice,” it is a bit misleading. “Top choice” refers to its spot on my Match list, NOT my pre-application preferences.

In other words, let’s say I wanted to go to the University of California-Davis. However, if I didn’t receive/attend an interview, I wouldn’t be able to add it to my Match list. Even if I desperately wanted to go to UC-Davis, it wouldn’t count as my “top choice” if I didn’t interview there. (True story: UC-Davis was the only program that didn’t offer me an interview!)
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SOAP (“Scramble”): What if You Don’t Match?

As you look through the data, you’ll see two things:

1. Not every person who applies will match to a residency spot
2. Not every residency position gets filled

So what happens to the applicants/positions that aren’t matched? Many will go on to the SOAP (Supplemental Offer and Acceptance Program). Sometimes called the “Scramble,” SOAP offers unmatched applicants a second-chance at matching. This occurs during Match Week, specifically the week leading up to Match Day.

Unmatched vs. Partially Unmatched: What is the Difference?

Before we discuss SOAP, let’s discuss the difference between being unmatched and “partially” unmatched. You’d think that they would mean the same thing. How can someone be “partially” unmatched?

The distinction matters only for those who need a PGY-1 position. Recall that for specialties like radiology, I need BOTH a PGY-1 and a PGY-2 position. In other words, I need to match into an “advanced” radiology position, but also am responsible for my intern PGY-1 year.

Sometimes, people will match into one but not the other. So if I matched into a PGY-2 radiology position, but didn’t secure a PGY-1 position, I’d be “partially” unmatched. Thus, I would need to find a PGY-1 position, unless my PGY-2 advanced position would be in jeopardy.

When might it be more common to see applicants match into a PGY-2 position, but not into a PGY-1? Often if their application was much stronger for their specialty than it was for the general PGY-1 positions. Since “preliminary” year programs are for one year, they care less about your research, and more about your ability to do the work of an intern.

For example, someone may have a ton of radiology research, but may not have strong clerkship grades/USMLEs. They may be a lock for a radiology position, but may not be as strong of an applicant for PGY-1 positions.

SOAP: How Does It Work, Exactly?

On the Monday of Match Week, at 11:00 AM ET, applicants learn if (but not where) they matched. They won’t know WHERE they matched – simply whether they matched or not.

Then, from Monday through Thursday of Match Week, partially/unmatched applicants participate in SOAP. The “Scramble” is essentially a condensed speed-dating like process between programs with unfilled positions and partially/unmatched applicants.

To participate in SOAP, applicants must be:

1. Registered for the Main Residency Match,
2. Eligible to enter graduation medical education (GME) on July 1 in the year of the Match, as verified by their medical school or ECFMG, and
3. Partially matched or fully unmatched on Monday of Match Week.

Here is a video the NRMP put together, explaining the SOAP process:

It is a stressful and trying time for programs and applicants alike. People who were dead-set on a given specialty may end up changing/deferring their dreams.

Rates of “Scrambling” Vary Based on Applicant Type

As you might imagine, the rates of successfully “scrambling” into a spot vary widely.

You can see in the above table that U.S. seniors have a much higher chance at SOAP. Of eligible U.S. Senior applicants, roughly 1/3 ultimately accepted a SOAP position.

On the other end of the spectrum, IMGs have a dismal rate of acceptance via SOAP. In 2019, only 3.1% and 2.4% of U.S. and Non-US IMG SOAP applicants accepted positions.

Some SOAP Positions Fill More Than Others

As you might imagine, some SOAP positions are more attractive than others. Traditionally, preliminary spots (especially prelim surgery positions) fill at low rates.

Here is the list of SOAP positions in the 2019 NRMP Match.

Next, we’ll discuss interesting trends/observations from the 2019 Match data.
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NRMP Match 2019: Two Observations

Here are a couple further observations about “The Match” from 2019.

The D.O. and M.D. Residency Merge: What Is It? How Does It Affect You?

886 DO students matched in the final D.O. match, in 2019. Starting in the 2020 NRMP Match, there will no longer be a separate D.O. Match.

For non-DO students, this likely will have a minimal immediate impact. For comparison, 35,185 residency spots were available in the NRMP Match in 2019. The 886 DO residency spots filled in 2019 represents just 2.5% of the NRMP total.

For D.O. students, the impact is less clear. In 2019, more than 50% of D.O. matches were in family medicine or internal medicine. For D.O. students interested in primary care, my hunch is the odds of matching change minimally.

Here are the 2019 D.O. Match results:

What about for D.O. students interested in competitive specialties? There may be a more significant change in the odds of matching. For example, in the D.O. Match, USMLE scores would have been of minimal importance. If I wanted to match into a D.O. dermatology spot, COMLEX scores would have been more important. However, now, with the combined DO/NRMP Match, USMLE scores will likely have greater importance. Plus, D.O. students now have to contend with competitive applicants who otherwise wouldn’t have matched into competitive NRMP positions.

Are you interested in orthopedic surgery? There were 107 matches into D.O. orthopedic surgery programs in 2019. If these ortho residency spots are available in the 2020 NRMP Match, it will represent a 14% increase. In 2019, for example, 95 U.S. seniors applied only to orthopedic surgery and didn’t match. And these unmatched applicants are typically very competitive. For instance, in 2018, unmatched U.S. seniors into orthopedic surgery had a 240 average on Step 1.

What’s Up with Radiation Oncology?

One final thing that stood out was that the number of unfilled rad onc positions spiked in 2019. Typically thought of as one of the most competitive specialties, rad onc stood out. Specifically, only 85% of the 2019 PGY-2 radiation oncology spots filled. This contrasts with more than 96% filled in the four preceding years.

While the number of PGY-2 spots spiked in 2019, the % filled dropped. It will be interesting to see if this is a one-year phenomenon or the start of a larger trend.
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Concluding Thoughts

Ask any patient, and most would likely guess that what medical school you went to would have the largest effect on your future practice as a doctor. Most doctors, though, would disagree. While most patients like to ask, “what medical school did you go to?” most health care professionals often ask what residency/fellowship you attended.

And for good reason. Unlike the med school you attend, your residency determines what specialty you enter. Where your residency is located has a huge impact on where you’ll live in the future, and what kind of practice you’ll have.

As such, knowing as much as you can about “The Match” is critical. It’s equally important, however, to understand that a successful application begins long before you go on your first interview. To read more about the characteristics of successful Match applicants, see these articles:

• Average Step 1, Step 2 CK Scores, Research by Specialty (US Seniors, IMGs)
• Step 1 + Step 2 CK Percentiles: What’s a Good Score for Each Specialty?
• I Scored 258 on Step 1 in 6 Weeks. Here’s How You Can Do Better.
• How this Caribbean IMG Got Her Top Choice “ROAD” Residency
• How This Dermatology-Bound D.O. Student Crushed COMLEX

What did you think about the NRMP Match statistics? Did anything surprise you? Stand out? Let us know in the comments!