The Residency Scramble: How It Works and How It Can Be Improved

By Jessica Freedman, MD
President of MedEdits: Medical Admissions

The scramble. Just these words make applicants and program directors anxious. So, what exactly is the scramble, why is it so competitive, and how is it likely to be changed?

The annual “Match Week” is March 16th – 19th 2009, and though I hope no one reading this article will ever need to put the information below to practical use, it seems an ideal time for a brief overview of the scramble — just in case.

A Little Background

jessica_freedman_md1The national residency matching program (NRMP) was established in 1952 to create uniformity and a schedule for postgraduate medical education assignments. Every March, the NRMP conducts a residency match to optimize the chances that both programs and applicants match with their most highly ranked choices.

Keep in mind that the NRMP is not an application service; applications are submitted via the electronic residency application service (ERAS). The NRMP is the mechanism for connecting programs and applicants.

After interviewing, applicants submit rank order lists (ROLs) of programs based on their preference, and programs do the same for applicants they have interviewed. Since 1998, the NRMP has used a matching algorithm designed to ensure that both applicants and programs “match” with their most desired choices.

For those applicants that did not match, the scramble is a period of time after the match when these applicants attempt to find, or “scramble”, to try and obtain one of the remaining unfilled positions.

The Numbers

Why is the scramble so competitive and stressful? The numbers tell the story.

In 2008, 4,214 programs participated in the match and a total of 25,066 positions were offered: total applicants were 35,956, 15,692 of whom were from accredited US schools and 20,264 who were independent. How’s that for fierce competition for a match? Of the almost 36,000 applicants, 28,737 submitted rank lists, of whom 20,940 matched.

What happened to the applicants who did not submit rank lists? Some applicants “pre-match” at programs and sign contracts before the match.  Others enter the match just to have a list of unfilled positions to enter the scramble. Since some applicants who pre-match do not withdraw their applications, data for the number of applicants who pre-match are not available.

The NRMP estimates that roughly 13,000 applicants, many of whom are non-US citizen international medical graduates (IMGs), registered for the sole goal of competing in the scramble. These applicants competed for only 1,388 unfilled PGY1 and PGY2 positions. Clearly, entering the scramble is not a wise gamble and should be avoided.

What is the Match Week Schedule?

March 16th: At 12 noon EST applicants find out if they matched.

March 17th (Scramble Day!): At 11:30 AM EST individual programs find out if they have filled their positions.

March 17th (Scramble Day!): The race begins. At 12 noon EST the locations of unfilled positions are released, and individuals may start contacting programs to obtain these positions.

March 19th: MATCH DAY! For those who matched, results are posted at 1 PM EST.

How Quickly Do the Unfilled Spots Fill?

The unfilled positions are filled very quickly during the scramble. By 4 PM on scramble day in 2008, more than half of the 1,388 PGY1 and PGY2 open positions were filled. By 6 PM the day after the scramble, only 179 positions remained open.

At many US schools deans are available to help students on scramble day; though this is helpful, the chances of obtaining a spot via the scramble still are slim.

While many individuals send applications to unfilled programs via ERAS, others hire for-profit commercial companies who “fax” materials and email programs on behalf of clients. Jammed fax machines and lines of communication make this process challenging. Only 8,700 individuals submitted applications via ERAS during the 2008 scramble, suggesting that all of the other applicants used commercial services. Some applicants even hire companies and send applications via ERAS.

What Changes Are Ahead?

Recognizing that applicants and programs are forced to make important decisions quickly and that the scramble is disorganized and lacks leadership, the NRMP, together with the Association of American Medical Colleges, is forming a scramble task force to propose changes. The earliest these changes would be implemented is for the 2011 match. Here are some of the major changes being proposed, based on a five-day match week.

  • NRMP releases unmatched applicant and unfilled program information simultaneously on the Monday of Match Week.
  • Programs may not make offers for 48 hours after this information is released, giving them time to review applications and conduct (phone) interviews.
  • Programs submit applicant preference lists on Wednesday (after the 48 hour period).
  • The NRMP system emails applicants with offers from Wednesday to Friday; applicants can receive multiple offers.
  • Applicants have two hours to consider an offer, after which the offer expires. Offers are sent out every two hours until 6 PM each day (valid until 8 PM).
  • Applicants are required to submit only applications via ERAS.
  • Programs are required to accept only applications via ERAS.
  • Until Friday, program directors can add candidates to their preference list until positions are filled.
  • Match Day is moved to Friday.
  • This ERAS “scramble mode” ends at 6 PM Friday and remaining unfilled positions are posted.

Managing the Scramble

In an ideal world, avoiding the scramble is the best strategy. But if this is impossible, try to have a leader at your school who can advocate for you and help you through this stressful day.

Every year holds “surprises,” with some great programs not filling that must enter the scramble. Some applicants who thought they didn’t have a shot for a spot at a competitive program or within a competitive specialty may therefore end up with a really desirable position through the scramble. Such good luck is the exception, however.

Match Day

Match Day is not only a rite of passage but a tremendous accomplishment for everyone in medicine. Every Match Day is accompanied by some tears but more often by happy screams. If your school has a Match Day ceremony, I encourage you to participate.

In my day, we received the news in an envelope and didn’t have the option of finding out our “match” alone, via the internet. Even if you don’t get your number one match, this is a momentous day in which you should participate as a member of your class. Good luck and match well!

For more information on the match and the scramble visit the NRMP website.

Jessica Freedman, MD, a former medical admissions officer, is president of MedEdits Medical Admissions (www.MedEdits.com), a medical school, residency and fellowship admissions consulting firm. If you want to decrease your chances of having to enter the scramble next year, visit: www.MedEdits.com. Dr. Freedman is also the author of the MedEdits blog, a useful resource for applicants: (www.MedEdits.blogspot.com).

Meet Dr. Freedman at the American Medical Student’s Association Meeting in Arlington, Virginia, March 12th- 14th, 2009. Visit us at booth #3 and pick up a free SDN lapel pin and pen.

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47 Responses to “The Residency Scramble: How It Works and How It Can Be Improved”

  1. Terpskins99 says:

    As someone who is anxiously awaiting the results of this year’s match, I was wondering why they only tell you if you match on the 16th, but won’t reveal the actual location until the 19th. What is the rationale for that? That always struck me as a little fishy.

  2. Mazen says:

    I would like to ask, if someone has all the Steps exams done, is it possible to obtain a preliminary position during scramble period without having applied to the initial match? if so, how is that possible?

  3. Terpskins99 says:

    Mazen, I’m pretty sure you can. I’ve met residents that completed all 3 steps prior to internship (they were usually international medical grads). They successfully matched though, but I doubt it would be any different for someone attempting to scramble.

  4. EOB says:

    An applicant is not eligible for the scramble unless that person has applied to at least one program in one specialty and ranked at least one program on a certified ROL.

  5. Terpskins99: Since programs find out if they filled on the 17th, students cannot find out prior to programs where they have matched. Since students must be prepared to scramble, they know if they matched prior to the 17th.

    Mazen: If you have completed your steps (and you are ECFMG certified if you are an IMG), you can apply to programs during the scramble. You must obtain lists of unfilled programs, however, if you didn’t register through the NRMP. Also, if you haven’t submitted an application via ERAS, you must send your application materials directly to programs.

    EOB: As stated by the NRMP, if an applicant has registered through the NRMP, they can obtain a list of unfilled programs. Many IMGs register with the NRMP solely for this reason and do not submit rank order lists. Applicants can send application materials directly to programs or via ERAS during the scramble. In 2008, only 8,700 of roughly 13,000 applicants participating in the scramble sent applications via ERAS suggesting that the others contacted programs directly or used commercial services.

  6. Joseph Kim, MD, MPH says:

    Good luck to all those in the match (and to those who find themselves in the scramble).

  7. lmfish says:

    So I did not match into OB/Gyn and there are still a few slots open that I will try to scramble for, but the reality is that I will likely have to do preliminary surgery or medicine. How can my personal statement that talks about wanting to be an OB/Gyn be altered to be “heart-fealt” and sincere about pursuing another type of program. Im not a liar and I dont want to say something I dont mean, but I want to do SOMETHING with the next year of my life.

  8. Imfish: If you are applying via the scramble, it is assumed that you did not match in your desired specialty. So, an “OB-GYN focused” personal statement would not be perceived negatively by preliminary programs. A solid foundation is surgery or medicine would prepare you well for an OB-GYN residency.

    If you would like, you can always enter a new personal statement via ERAS to send to preliminary programs that clearly explains your situation.

    During the scramble period you can apply to a maximum of 45 programs (30 new programs and 15 programs to which you have already applied). At 12 noon on Thursday, March 19th, the scramble period ends and you can start applying to more programs that still have open positions.

  9. dma89 says:

    Above it said if we did not apply through nrmp but we have submitted application through eras, we must obtain list of unfilled positions to scramble. But I thought the only way to obtain list of unfilled position is through nrmp. How would you get the list if you cannot get access to nrmp site?

    If you are still img student that graduates in may but passed Steps 1 & 2 and have eras forms/docs submitted, can you participate in scramble tomorrow if you’re not registered with nrmp?

  10. meh85 says:

    I did not match radiology but I did match into an internship position. I am curious if I do not get a position in the scramble how does re-applying for radiology as an intern work next year. Do I repeat internship or do some programs save slots for incoming interns? Does anyone have any suggestions or advice? Thank you!

  11. dma90: You must register with the NRMP to obtain the list of unfilled programs. Although, this information can be found pretty readily on the internet once it is released at noon. If you have not registered with the NRMP you can apply to programs individually but you need to get this list of programs. If you are an IMG, you need to be ECFMG certified.

    meh85: I suggest you first see if any radiology spots are available today and try to scramble. Next year (2009/2010) you could try to get a PGY1 – PGY4 spot or, if you matched into a PGY2 – PGY4/5 position, you have a gap year.

  12. bruins512 says:

    My wife did not match for OB/gyn this year and we are absolutely devastated. Since slots are so limited this year, she has really has no choice but to scramble for a prelim year and try again next year. My concern is that her chances of matching next year may be even slimmer. Won’t programs look unfavorably on a candidate that failed to match previously?

  13. Bruins512: Just because your wife did not match this year does not mean she will be unsuccessful next year. She needs to evaluate the quality of her written documents, her selection of letter writers and the depth of the programs to which she applied. For example, did she limit herself geographically or did she have too few letters from OB-GYN faculty? She also needs to make the rest of her fourth year “count.” She should try to do some OB-GYN rotations this year for additional letters and get involved in a research project, if possible.

  14. Kierra says:

    how soon do programs begin contacting applicants after the scramble has begun and have re-applied through ERAS?

  15. Programs begin contacting applicants immediately after the scramble begins. In 2008, fewer than 50% of unfilled positions remained at 4PM on scramble day.

  16. Kierra says:

    so with 44 positions remaining currently in Family medicine…the fact that i have not heard back from any of them via email/phone means i am pretty much out of the running huh?

  17. Alis says:

    Did anyone out there get any success through scrambling, any tips…

  18. Kierra: It doesn’t mean you are “out of the running” but, obviously, the chances are slimmer…

  19. raph says:

    Dr. Freedman: Thank you for all your previous advice. I completed a PGY1 residency year in obgyn and wish to transfer to internal medicine. Will any of my obgyn rotations count toward IM? If so, would I be better off seeking a PGY1 position and then advancing early, or should I look for a PGY2 position knowing that I will have to do some catch up rotations before I actually become a PGY2?

    Does it hurt me that I completed PGY1 and now I am looking to transfer because of the decreased federal medicare funding programs may receive?

    Lastly, are there PGY2 positions in the match and scramble other than the ones that require an internship year, i.e., path, rads, pmr?

    Thank you.

  20. hbyha says:

    path doesn’t require an internship anymore, and it hasn’t for SEVERAL years now…

  21. Leon says:

    Dear Dr. Freedman: I got 7 interviews on IM,FM,Pd and Ps. Unfortunately I dit not match any program. Do you know is any program or courses can help to improve interviw skill and write personal statement?

    Thank you much!

    Lean

  22. Leon: MedEdits offers comprehensive residency admissions and advising services.
    Visit: http://www.MedEdits.com

  23. Raph: It is very program dependent if they give you credit for your OB-GYN rotations and whether or not the program will support you financially depending on federal funding restrictions.

    The only PGY2 positions that are offered in the scramble are those that require an intern year. For “open” PGY2 positions at programs, you should utilize the AAMC find a resident service: http://www.aamc.org/students/findaresident/.

  24. Eric says:

    Dr. Freedman, thank you for some great advices. I have been trying to match into program last three years, graduate of 2006. I am sure many out there going through difficult time as I have. My question is, despite having sent in 150-200 applications a year costing upward of 5000 a year along for interview and application fee, I am wondering at this point if medicine is really for me. I am running out of resource and time. What advise would you give to someone like me in this situations. My scores are low 205,203 Have had few interviews each season but no luck . both steps( multiple attmepts) planning to pass the step 3 next month. I am one of FMGs. How do admission committe really view FMGs? I need some desperate counseling or advices to pickup and go again. its really a emotionally draining process.
    Thank you

  25. Eric: I am sorry to hear that you are having a difficult time matching. IMGs are viewed differently by individual programs; as you know, some programs are “IMG friendly” while others are not. Since you received interview invitations,you should consider calling program directors at the residencies where you interviewed and ask them, specifically, if they have any advice about how to improve your candidacy. You should also ask if there was a problem with the way you interviewed and request they provide honest feedback.

  26. Erik says:

    Hello,
    I applied to Emergency Medicine rather late this year, at the end of November, after changing my mind about which specialty I wanted to do. As a result, I only obtained 5 interviews and ranked all 5; however, I did not match. I spent all day trying to scramble into something, and was lucky to obtain an internal medicine spot at the last minute. However, this is a categorical position. My Program Director made me promise that I would not try to re-apply for Emergency Medicine. I have to go sign my official contract within the next few weeks, and I’m scared as to what it says. If I do decide to try for Emergency Medicine again, when would I apply? I know that it is typical to apply in early fall for a fourth year student. How would I get time off for interviews? I would also need to get letters of rec from the internists, but I wouldn’t want my PD to find out I’m leaving too early. I also would not want to re-apply, not get matched again, and have my PD hating me for the next 3 years!

  27. meh85 says:

    Dr. Freedman,
    I just wanted to thank you for this resource. I did not find a spot in the scramble, but I am going to reapply next year after my internship. If you have any advice I would appreciate it, but mainly I just wanted to thank you.

  28. Erik: If you told the PD at the internal medicine program into which you scrambled that you would not try to reapply to emergency medicine next year, then it would be unethical to do so. Also, the emergency medicine programs would want a letter from your PD and, if you did not have this, it might be seen as a red flag. The application timing is the same every year.

    meh85: I am happy to help.

  29. Confused says:

    Hello Dr. Freedman. Perhaps you’re the only one who can help me. Apologize in advance for the length as it’s complex: I’m a 4th year DO student interested in Ob/GYN since I was 16 & would eventually like to specialize in REI. I had many interview offers but made it to 16 and ranked 12 in the allopathic match only because I had more options to stay local. I did not match. Now I am facing an option of doing a general traditional DO rotating internship at a well-reputed program or a “ob/gyn focused” rotating internship at a not so well-known or reputed program, (who cannot guarantee, but will put me in their Ob/gyn residency in the event that someone drops out-(statistics at this program show that people usually do leave in their 2nd or third yr which would make them take more students at the bottom) So I am torn between doing an internship at the reputed program versus not so reputed program, but where I would do what I want to do & save a yr by doing the ob-gyn specialty track and have the possibility of being a ob/gyn pgy-2 next yr. Considering I want to do a fellowship, should I take the more reputed school? What would you advice?

    Also, is it true that as an osteopathic student, the governement will pay for me for 5 years if I do an osteopathic residency and only 4 years if I do allopathic? If I do the traditional DO internship at the reputed school and re-apply for the allopathic match next yr, will I only have three years left for the governement to pay for me? –thus making an allopathic program reluctant to hire me as they would lose money on me in my final year of residency training?

    Am I putting myself at a disadvantage by doing a DO internship?

    Since it’s an MD world for REI and if I applied allopathic again next year, would the PGY-2 status from the not-so reputed program even count towards allopathic programs? Would there even be any openings at that level?

  30. Confused: Your situation is, indeed, complex. I would need to have a full understanding of your situation to provide any solid advice. You will not be able to specialize in OB/GYN regardless of how “OB focused” the internship.

  31. Confused says:

    There are many programs that claim to give you enough ob/gyn electives during your general internship that classify you as a pgy-2 the following year so that you do not have to repeat a year. I know someone who has done this for Surgery as well. Just don’t know how many allopathic programs are open to this?

  32. Confused: I cannot say how many programs would give you credit. It would depend on the individual program to which you were applying.

  33. Rave says:

    I did not match anywhere after nine interviews and concrete promises from program directers, who I feel now mislead me into a confort position. i did not match anywhere in scramble as well. fairly reasonable scores. what wshould i do now. what Ai want is PM&R. should I do research or still keep looking for any residency for one year and re-apply- Very frustrated with the process.

  34. Dear Rave: I understand your concerns. In the past, when people have approached me with similar concerns, I have analyzed, in depth, their application and backgrounds to understand if there are any flaws or issues. Oftentimes there are nuances in the way applicants present themselves that “make or break” their candidacy. I cannot offer any specific advice here.

  35. Guy Kakin says:

    I did not match and am still waiting for some programs to sift through Eras. If I don’t get anything I probably will have to get a job and try again next year. Does anyone know what types of jobs I can get as an MD (besides research)

  36. aleks says:

    I’m IMG. I’ve recently completed all requiremnts to apply via ERAS. I’m not sure if any unfilled position in pediatrics has left after the scramble. Does it make any sense to register me now to know this and try to get into a program? I thought that my only option at this time was to apply on July for the 2010 Match but honestly, after reading comments in this forum, I get confused. Thanks in advance

  37. Jennifer says:

    I HATE NOT MATCHING!

  38. Gina says:

    Hello Dr Feedman,
    In recent years, OB/GYN has become a much more competitive field. I have desired to become an OB/GYN for the last fourteen years, and I have really focused much of my life on achieving this goal. I am currently a second year medical student, with average grades, and I will be taking the boards in a little over a month. All I keep hearing is to do great on the boards, and I should not have a problem matching. Of course, I am going to do my very best on the boards, as I am sure is the case for everyone who takes them. However, I cannot help but worrying…”what if I don’t pass, or barely pass?” this scares me more than anything right about now. I know in the First AID book there is a range of about 200-220 for people who get OB/GYN positions, which to me says if you are below that range, you will not get a position in OB/GYN. So since I only plan to apply to OB/GYN programs, without much interest in going into Internal medicine or something of that sort and then focus on womens health, what are the other options if someone is also unsuccessful in the scramble. Is it better to earn an MPH, do research, go into a residency that you are not interested in and then transfer as a PGY-2, or maybe other options that I have not considered? I just have no clue what people end up doing if they are unsuccessful in become the type of physician they have worked so hard to become, then cannot match in that area for some given reason. thanks you for considering my concerns, I look forward to your response.

  39. David DO says:

    Yes I am an Osteopath, and I am in the middle of my intership. I have officially taken all 3 steps of my boards, but not the USMLE. I currently haven’t heard much on the front of interviews, but I continually hear positive comments from attendings as well as have had great repoire with residents I am on service with. I am desperately looking for a spot in Ortho and as I have struggled to find an opportunity I have thought about alternatives. I thought about Path (specifically forensics) and anesthesia, but I wonder if my lack of success is more from what I want to do combined with me being a DO. What are your thoughts? I too feel trapped and cornered without support…

  40. nkoki says:

    Hi Dr Freedman,
    I am an Img with low score 83/76/pass all first attempt.failed step 3 in july so could not get any interview. I am 2008 graduate with greencard. so no other problem. I am doing externship for 3 months and have excellent LOR. can I try in scramble? My husband is an AMG and he says collages and programs know about unfilled positions 3 days before the real date and so it’s hard for img to get it. I am scared. please advise me. I am ready to work any specialty any program. please help

  41. bbfan88 says:

    I’m so panicked about match. I’ve never gotten accepted to a school of my preference. What would make things different this time around?

  42. Adam says:

    Hello Dr. Freedman,
    I am an IMG, I got an 88 on step 1 and 76 on step 2. All first attempt. I graduate in May of 2011. I didnt get any interviews, what are my chances in scramble. Also can you go through scramble if your not ecfmg certified yet.