Using “SOAP” to Clean Up the Scramble

By Michelle A. Finkel, MD
Founder, Insider Medical Admissions

In response to persistent concerns about the “Scramble,” the two-day process when unmatched residency applicants vie for unfilled residency positions, the National Residency Match Program (NRMP) and the Association of American Medical Colleges (AAMC) have announced significant Match Week changes to start in 2012, thus affecting next year’s residency applicants. The new system, called the Supplemental Offer and Acceptance Program (SOAP), is an attempt to improve the Scramble after repeated complaints about disorganization and lack of transparency. SOAP will overhaul the Match Week calendar, so all applicants – both unmatched and, indirectly, matched candidates – will be affected by the reforms.

Why Change?

Two issues prompted SOAP: First, the increasingly competitive nature of getting a residency position has made the Scramble a bad method of handling a worsening problem. Second, applicants and residency administrators have had considerable concerns about the Scramble’s integrity, organization and professionalism.

Escalating Competition

The competition to obtain a residency slot has amplified. According to the NRMP, last year was the largest Match in history: 30,543 applicants participated, vying for one of 22,809 first-year and 2,711 second-year residency positions. The competition is more intense for unmatched applicants: In the past nine years, the number of unfilled PGY-1 residency positions has declined from 2288 in 2001 to 1060 in 2010. Yet, in 2010, nearly 13,000 applicants participated in the Scramble. These numbers and the subsequent competition involved in matching applicants to unfilled positions mandated a streamlined system, which the current Scramble is not.

Criticisms of the Scramble’s Process

The Scramble has been fraught with problems based on the system’s lack of stewardship – leaving little applicant or residency program accountability – and its dizzying schedule. Currently, the Scramble works as follows:

On Day 1 applicant matched and unmatched information is posted to the NRMP web site at noon EST.

On Day 2 the NRMP’s Dynamic List of Unfilled Programs, an index of all residencies that have unfilled slots, is released at noon EST. After looking at the list, unmatched candidates start to submit applications. Many unfilled programs accept applications through both ERAS, the official system, as well as through external means, including direct faxes and phone calls. This dual system leads to a chaotic process: Many applicants submit through ERAS, while simultaneously, frenetically faxing and calling programs.

On Day 4 the Scramble ends. Match results are available at 1pm.

Although the Scramble is technically a two-day process, the NRMP has documented that the majority of unfilled residency slots are taken within the first few hours on Day 2. If an unmatched applicant is fortunate enough to be offered a slot, she or he doesn’t have a lot of time to consider it, forcing candidates to make career-changing decisions rapidly, often within a matter of minutes.

What Precisely are the SOAP Changes?

SOAP would launch several changes in the current system: First, the NRMP will take stewardship of the process. Previously, no organization was responsible for filling unmatched positions, causing confusion and a lack of accountability.

Next, unmatched applicant and unfilled residency program information will be released simultaneously. Previously, candidates found out they were unmatched a day before the NRMP’s Dynamic List of Unfilled Programs was released. Candidates might spend Day 1 collecting friends or finding companies to help send massive numbers of faxes the next day to unfilled programs. With SOAP, that planning day will be eliminated, alleviating some pre-process anxiety.

Third, all participating applicants will be required to use ERAS, obviating the outside, unofficial means that heightened the Scramble’s chaos. All residencies will be forbidden from accepting applications through means other than SOAP: No phone, fax, email or personal contacts will be permitted.

Fourth, the NRMP’s web-based system, often called R3 – for registration, ranking and results – will now allow unfilled programs to submit a preference list for their empty slots. (Although residencies cannot fill their slots outside of this system during Match Week, they can opt to leave their slots unfilled.) A residency’s unfilled slots will be offered to applicants in order of preference until all positions are filled or the list is exhausted – rather than the seemingly haphazard approach used now. Applicants will have to accept or reject an offer within a specific time frame or lose the offer. When an applicant accepts, the R3 program will automatically establish an electronic commitment between the applicant and the program, and the unfilled slot will be removed from the Dynamic List of Unfilled Programs.

Fifth, to ensure more integrity is afforded to SOAP compared to the Scramble, SOAP will be covered by the Match Participation Agreement, and applicant and program participants will be penalized for infractions.

Sixth, because the R3 program will now create a binding commitment between applicants and unfilled programs, the NRMP will ensure applicants using SOAP are eligible: The week prior to Match Week, medical school deans and the ECFMG will be required to re-certify the status of their students through the R3 system. Ineligible students will be notified the week prior to Match Week and will not have access to the Dynamic List of Unfilled Programs.

The table below offers a comparison of the current and proposed Match Week schedule:

Day Current Schedule Proposed Schedule
Monday Before Match Week NRMP sends re-certification requests to Deans.
Wednesday Before Match Week 12 pm: ECFMG and Dean’s re-certification information complete.
Friday Before Match Week 12 pm: NRMP informs all applicants, regardless of matched status, if they are SOAP eligible.
Match Week: Monday 12 pm: Applicants find out if they matched. 12 pm: Applicants find out if they matched and programs find out if they filled; Dynamic List of Unfilled Positions posts; ERAS opens for SOAP.

Unmatched applicants begin using ERAS to submit to unfilled programs. Programs begin interviewing but cannot offer slots yet.

Match Week: Tuesday 11:30am: Programs find out if they filled.

12 pm: Dynamic List of Unfilled Positions posts.

Unmatched applicants submit to unfilled programs using ERAS and outside methods.

Programs continue to interview unmatched candidates and start creating their preference list in R3.
Match Week: Wednesday 2 pm: Programs receive a roster of their match applicants. 11:30 am: Deadline for unmatched programs’ preference lists.

12 pm: Offers to unmatched applicants begin through R3.

Offers are made every 3 hours. Programs may continue interviewing and adding names to the bottom of their preference list.

Match Week: Thursday 1 pm: Applicants find out where they matched (Match Day). 2 pm: Programs receive a roster of their match applicants.

Offers to unmatched applicants continue to be made every 3 hours.

Match Week: Friday 1 pm: Applicants find out where they matched (Match Day).

5 pm: ERAS SOAP mode ends.

Offers to unmatched applicants continue to be made every 3 hours until 5p. Dynamic List of Unfilled Positions posted thru May 1.

How and Whom Does SOAP Help?

SOAP eliminates many of the problems that plagued the Scramble. Because of the NRMP’s leadership and the inclusion of the Match Participation Agreement, the process should be more explicit and professional. Furthermore, the use of ERAS exclusively should avoid the chaos and inequalities that the Scramble posed.

Those who traditionally have more difficulty matching to U.S. allopathic residency slots – IMGs and osteopathic medical students – are likely beneficiaries of these improvements. However, unmatched U.S. allopathic medical graduates should, of course, also be positively affected. Even matched applicants will see changes because of the new schedule: Previously, Match Day fell on Day 4, and it will now fall on Day 5 of the Match Week.

Taking suggestions

SOAP was initiated in 2008 by a task force consisting of medical school student affairs deans, program directors, and recent U.S and international medical school graduates. From now through April 1, 2011 the task force will solicit comments from NRMP and AAMC constituents regarding SOAP:  The NRMP Executive Director will accept suggestions at [email protected]. In May, the NRMP is slated to adopt SOAP at its May 2011 meeting.

For those applicants and residency administrators who have been through the Scramble or those who may need to go through it in the future, SOAP is viewed with optimistic anticipation. As with most new processes, especially those based on technology, there may be some glitches, but the changes will likely be an improvement over the current very broken system.

Dr. Finkel, formerly an Assistant Residency Director and faculty member at Harvard Medical School, founded Insider Medical Admissions to level the admissions playing field by offering elite advising services for applicants to residency, medical school, fellowship, post-baccalaureate programs and dental schools. Check out Dr. Finkel’s latest entries at the Insider blog.

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22 Responses to “Using “SOAP” to Clean Up the Scramble”

  1. Justin says:

    I think this change is definitely needed in light of the increasing competitiveness of residencies. I would prefer if there were simply more residency positions and this extra complication would not be necessary. It is unfortunate that every US senior who is adequate for post graduate training is not guaranteed a residency position somewhere.

  2. HQ2000 says:

    I agree with Justin. The number of residency spots must increase but in recent years this number has only slightly increased relative to the demand (i.e. Med School grads and IMGs) who are all qualified to become physicians. This along with the size number of med school classes, it only makes sense to increase residency spots!

    At a time when nurses are trying to increase their presence and independence and yet physicians can’t find jobs…what does that tell us about the state of affairs of our contemporary healthcare system?!

  3. Nate says:

    The Scramble sounds like a mess. Are any of you guys med students, and actually experienced this?

  4. Jake says:

    Physicians do not have or maybe do not care to lobby for their own like the Nurses. Nurses are now pushing for independent practice while the lazy fellas at AAMC sit and do nothing for the medical students.

    They could easily push congress for more residency slots but they only look out for their own self interests rather than for the whole profession.

    Shame on them.

  5. N K says:

    “IMGs and osteopathic medical students – are likely beneficiaries of these improvements.”

    How exactly are they to benefit from this change?

    Also, how are the interviews for the applicants in the SOAP going to be held in those 4 – 5 days?

    • Michael says:

      Well said, N K. Those were the 2 questions running through my head.

      1st question – “How are IMGs & Osteopathic medical students likely to benefit from this change?”

      I researched and thought hard about this. I actually think this will hurt IMGs much more versus the traditional Scramble. The Scramble was a mess, true; however, it was 1st come 1st serve. It was messy, but this gave IMGs a chance, at least. In regards to SOAP, think about it for a second from a director’s point of view. Let’s say you’re a director of a Family Medicine program and you saw an unmatched US med grad that was originally applying for Dermatology vs an unmatched IMG applying for whatever, chances are the US med grad would be given the offer every time. In short, priority will be given to all unmatched US med grads. Whether or not this applies to DOs, this will undoubtedly hurt IMGs in my honest opinion.

      2nd question – “Interviews under SOAP”

      I’d like to know if anyone has thoughts on this, also. I’m guessing they’d be phone interviews.

  6. Michael says:

    The NRMP system failed miserably in the 2011 Scramble. The NRMP system crashed on us for 4 hours and I had to rely on myself and my friends to fax and email my application. Few phone calls but no luck. I see that they still think there will be glitches so here we go again except now we are not allowed to use the fax and email and phone routes. Dr. Finkel since you are so in love with NRMP and their useless system how can you help me if the NRMP fails and crashes again? I got 2 interviews only so far and I am not hopeful for a match. I do not have any trust in the official systems anymore. No creativity what so ever. I hope no one messes up my chances again this year.

  7. Michael says:

    By the way I am not the same Michael as the one above in which I agree with that the new useless so called SOAP would help IMGs more, its a lie. It will only serve the US grads. I have 2 of my 4 close medical school colleges who got a position in the 2011 Scramble, they used a service when NRMP failed me.

    • NA says:

      I agree that it will favor US grads more than it favors us IMGs.But comeon friends, US grads should get preference in Matching in any case.where else will they go ?

      i think this system is smart because personal factors are out and technical and calculable factors are in. that would be very helpful for qualified people who are otherwise unlucky in their calls and applications

      • DrB says:

        well, US grads will match anyway, how about US citizens who went to a school outisde the US but did us Clinicals, should they not have the same consideration?

        I have no where else to go myself since I’m a Natural US citizen.
        The US grad with the lowest USMLE scores will still match
        The FMG like me with better scores will still have a tougher time.

        Sorry its not fair

  8. AJ says:

    ^Go to a US school. You knew what you got yourself into when you went foreign. I think making you equal to US grads is what’s unfair.

    • Luda says:

      This is a bunch of nonsense. This type of thinking is prejudicial, biased, and ignorant. The current system in the US is a “good ole boy” system. It is racist, discriminatory, and predicated upon ignorance and institutional racism. The Program Directors should be asshamed of themselves. Acquiring a medical education does not have anything to do with where you went to school. The people who make the statements like the one the posted above are just hiding behind a system that enforces racism and is attempting to prevent the “other man” from entering the US system and making a decent living while practicing medicine. Just because you go to school in the Caribbean does not mean that you are incompetent or pose a risk to any given patient population. We use the same books, are taught the same information and have to pass the same USMLE exams…period. It never ceases to amaze me how racism and discrimination can be masked. That is all this IMG/FMG nonsense is about. Stopping the “other man”, even at the expense of US nationals who went to school in the Caribbean. So go ahead and admit it, and stop trying to hide behind there being a “quality” issue. I rotated with many incompetent gamers who were US students. Likewise, some of the most “brilliant” physicians I have met have been foreign trained. So take off the mask…or shall I say “hoods”!!!

  9. doc says:

    Its not fair that someone who worked hard to matriculate into a more competitive US school will lose a residency spot to someone who went the easier “Carribean” school route. I know that people dick around while in the US schools and are not strong applicants, but the average US student should always supersede any FMG. The US residencies are in the USA right…

    • JIm says:

      Doc and AJ…those who are in Caribbean schools are US citizens who could not secure a position NOT because you are smarter than them but because there is not enough positions for them. So dont be so cocky in thinking you are smarter than those FMGs…actually FMGs are doing much better clinically than US grads. Now if you meant those NON-US citizens who are FMGs then I may agree with you just because the priority should go to US citizens since the positions are limited. Have a good day.

    • Luda says:

      Hogwash. The US medical schools have a precedent of making discriminatory decisions…especially as it relates to people of color. This practice of discriminating against US citizens who go to Caribbean schools is an example of discrimination. These medical residency programs are supposed to pride themselves on equal opportunity employment act statements and such but what we see in practice with the Match and SOAP is the polar opposite, and on a very large scale. And the saddest part of it all is that the Program Directors try to justify their intentionally discriminatory practice by hiding behind this pro-US student dogma, which in itself, is racist. Shame on you all!!!

  10. Mook says:

    I feel that NRMP has a lot of work to do before the ERAS system can be refined enough to be actually referred to as ‘transparent’. Implementing SOAP is definitely a move in the right direction because it shows effort, but only time will tell if this idea really works. I also graduated from a caribbean med school and hold US citizenship from birth, but that does not mean that we should all bark at each other and get salty.

    This is truly a system failure as classmates that I know with attempts matched via scramble for some unknown reason (maybe connections/nepotism,etc) while others with much better board scores got left for the following year. The truth is that we do need more residency spots. These politicians keep mentioning the aging baby boomers and logic dictates increasing at least 10% spots to cover the deficit, but instead the number of residency spots is going DOWN. Whatever the resons maybe (PAs and Nurses flooding the market and receiving additional training to practice independantly, etc), the fact remains that the US population needs physicians and the underserved areas are not receiving any benefit from the way this matching system works. Its MUCH worse for MDs not schooled in the USA (like myself) since ECFMG makes every effort to milk us for every dollar by suggesting that more applications = more chances to match. This suggestion by ECFMG has led to apllication chaos amongst foreign-trained physicians (US Citizens and foreign nationals, alike) where each applicant is applying to over 60 positions and a good number of applicants applying to apprx 100 position!! Then, foreign-trained medical grads are running into additional money-making scams that make false claims for helping with securing residency spots when this is not the case.

    One thing that definitely should happened is the seizure of J1 and H1 visas. Why are we issuing visas when there are a huge number of US citizen medical grads looking for spots (absolutely rediculous)? Also, if the residency spots are so limited, then the US Federal Student Loan Program needs to STOP offerring stafford subsidized and unsubsidized loans to US citizens choosing to go to carribean medical schools. The rule should be if you can’t get into a US medical school, go at your own risk AND with your own money (no Stafford Loans). I personally am over 200K in student loan debt, have passed all the steps on 1st attempt and cannot secure a residency position. It maybe that I carry the stigma of being a carribeamn med school grad but I chose this opportunity (like many of my former classmates) because these schools receive US federal student loans. It’s becuase of the student loan debt that US citizens going to carribeam med schools get frusterated as I much rather would have preferred to not have the funds to fo so I can pursue something else rather than be provided stafford loans only to panhandle for a residency position later on while J1 visas are being welsomed with open arms. The true issue for US Citizens trained in the Carribean v. US med grads, but is rather US citizen grads of Carribean Schools sitting on the sidelines while visas are being issued to foreign nationals and is you look at the residency programs in inner cities, you will see MANY programs being filled by 90% same nationality foreign grads. The nepotism does not get any more apparent and no one seems to look into this problem. There is no end to this mehem for foreign-trained grads.

    P.S. I am actually surprised to hear that US grads sometimes don’t match as I always thought they matched 100%.

  11. Michel says:

    1. We should stop importing those IMG using Visa entry for residency training program since we have limited training program positions each year.

    2. We should only accept IMG residents with green card or citizenship into our residency training program.

    3. We should create more residency training program positions for US medical students, proportionally.