Making a Doctor 101: How the residency match works (for laypeople)

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All I do is try to make it simple, the ones that make it complicated never get congratulated – Kid Cudi





Yes, you. The one who isn’t  in the medical profession. It’sa me, Mario! More specifically, I’m a student in my fourth and final year of medical school. You’re here because you’ve got someone in your life who is training to be a physician. Maybe they’re a friend, roommate, significant other, cousin, daughter, son, niece, nephew, local heartthrob, or that annoying person who won’t shut up about how they’re in medical school (see: every medical student). For one reason or another, you’re wondering about how exactly someone becomes a doctor. What the heck is this “residency” process? When are they actually a real doctor? Is the moon landing a hoax?! There’s an endless amount of questions.

This is an article that medical students can link to when they get asked, “So, how does residency work?” or any number of things dealing with becoming a doctor. Not that I don’t love explaining it (I do love educating people!), but this is going to be a simple breakdown of how one goes from primordial ooze to frog, or in this case, high school student to fully fledged physician. I am going to focus on the residency match process, but will also include all steps in the training process for completeness sake. And I’m going to do my best to make it short.

Here are the steps to becoming a doctor:

  1. College (undergraduate education)
  2. Medical  school (undergraduate medical education)
  3. Residency (graduate medical education)
  4. Fellowship (optional)
  5. Doctoring

Step 1: College

Every medical student must go to college in one way or another, because it is required to get into medical school in the first place. This is your typical, Animal House-esque university experience with or without the togas. For me, it was at Indiana University in Bloomington, Indiana. This can be done at any university inside or outside of the country, and the student can major in anything they want. This includes music, ballet, engineering, or if you’re weird like me: math.

However, they have to do a required set of premedical coursework, which now includes biology, inorganic chemistry, organic chemistry, physics, and social sciences. This is to prepare them to take the MCAT: the Medical College Admission Test. This is akin to the SAT or ACT, but for admission to medical school instead of admission to college. Oh, and it’s also took some super-roids. It also includes verbal reasoning.

It is the MCAT, undergraduate grades, activities, and so on, that go into the application for medical school, along with a personal statement, letters of recommendation, interviews, and so on.* It is after becoming accepted that they move on to the second step.

*As long as someone has done the premedical coursework and has a college degree, they can apply to medical school. This includes those who go back to do their requirements later than directly after undergrad. There are plenty of people in their 30’s and 40’s who start medical school instead of going straight from undergrad.

Step 2: Medical school

So, our primordial ooze has made it to the “hardest part” of being a doctor: getting into medical school! Surprise, that’s not true at all!

Medical school is where you learn all the nuts and bolts of being a doctor, generally including 2 years of “book work” on anatomy, physiology, immunology, genetics, pathology (the study of disease), pharmacology (the study of medications), and more. This is the knowledge base upon which students go into their 3rd and 4th years of medical school, which are the “clinical years”. During these two years, students rotate through most medical specialties and learn the basics of real medicine beyond the textbooks.During the most expensive 12 month vacation ever 4th year, a medical student becomes a professional interviewee filthy slob even more adept at their clinical skills, honing their abilities and taking more electives in their chosen specialty.

Medical students pay A LOT of money to go to school, and most subsist off of federal loans. I currently owe the government in the neighborhood of $250,000….ladies ;).

At the end of medical school, the students become doctors. They earn their M.D. or D.O. degree and have the power to prescribe and take care of patients. However, they are not able to practice on their own! That’s where residency comes in.

Step 2.5: Applying for Residency

Fooled you! There are 5 and half steps to becoming a doctor! This is what I wanted to concentrate on in this post.

During the final (4th) year of medical school (where I currently am), a large majority of the student’s time is dedicated to applying for (and hopefully securing) a residency spot. Residency is a job. Residents get paid. Residents are doctors. Residents, however, are not “boarded” and thus are unable to practice on their own. Your primary care doctor, your orthopedic surgeon, your OB/GYN, these are physicians who have graduated residency. Some of you might see resident physicians if you go to an academic center, but they all have a faculty physician overseeing them.

This is basically like applying for a job…if everything you knew about the job application process was flipped upside-down. Here are the basics of attaining a residency spot, in a numbered list for ease of reading.

  1. Medical students select their chosen specialty during the end of their 3rd year/beginning of their 4th year
  2. They fill out a gigantic application
  3. They apply to programs
  4. Programs select candidates they want to interview
  5. All the interviews occur
  6. Programs rank every candidate they interview from 1 to x (x generally being the number of total people they interview)
  7. Medical students rank programs from their top choice to their bottom choice
  8. A Nobel Prize winning algorithm matches students with programs, in a way that favors the students.

All right, it’s time to dive into the specifics. Applying for residency is much the same as applying for college or medical school. We have our entire medical school transcript put on our application, which includes our grades (generally pass/fail, sometimes with honors or high pass as options) and comments by our instructors, residents, and faculty physicians about our performance on that rotation or in that class. The grades of all of our board exams* are in there. We also seek out letters of recommendation from doctors in our chosen field, write a personal statement, do extracurricular activities, and do cartwheels through all of the hoops laid out before us.

*In order to become a doctor, there are countless exams. However, the “board” exams actually refer to two different things. The exams taken in medical school are dubbed USMLE (United States Medical Licensing Exam) STEP exams. There are 3 STEP exams, and part 2 has both a clinical and written part, so there are technically 4. STEP 1 is basically the SAT/MCAT for the residency application, except it injects steroids into its butt and works out 8 days a week. It is the single most important number in the residency application. There are then specialty specific board exams at the end of residency which certify us to practice in that field.

We then apply to as many residency programs as we want (or need) to. The average number applied to is around 40, and some people apply to as few as 20 or as many as over 100. These programs select who they want to interview out of the applicant pool. To give an example, general surgery programs with 6 spots interview between 60-80 applicants out of 600+ people who apply to their program. From what I’ve seen, programs generally interview 10% of applicants, and about 10% of interviewees end up matching at that program.

Then, we interview. Medical students, on their own dime (see: government student loans with ever-increasing interest rates for some absurd reason) book flights, drive long distances, and become a professional “tell-me-about-yourself-er”. Some people interview at as few as 5 programs, others interview at 20 or more. Most people fall somewhere in the teens as far as number of interviews attended. The interview season lasts from October to January, and is incredibly disruptive to any kind of learning or rotation going on during that time. For example, I had to take an entire vacation month to interview, as I had 9 interviews within the first 3 weeks of December.

When the dust settles, it is time to put together our rank list, putting our top choice at #1 and our bottom choice at #14 or 15 or whatever the final number is. Residency programs go through the painstaking process of ranking applicants the same way, from #1 to #60, or perhaps larger numbers such as to #300. At a certain point, the difference between applicant #144 and #145 must be pretty arbitrary, if any difference exists at all. I’m not quite sure how they do it, but it might involve flipping coins, rolling dice, or going alphabetically by astrological sign.

Then, a big computer algorithm matches the rank lists of medical students with those of the residency programs, with a bias towards the best outcomes for the applicants. It is in fact a Nobel Prize winning process, but it is quite simple. I’m going to do my best to explain it in a few bullet points:

  1. The algorithm tries to place every applicant at their #1 choice
  2. If the #1 choice of an applicant is full, it then puts them at their #2, #3, etc., until there is a spot at that program.
  3. Ties (where there are more applicants than spots) are decided by the program’s ranking of applicants, see #4 for an example.
  4. Let’s say Jeremy ranks Indiana University #1 and gets placed there, and Kelly ends up there as her #2 choice because her #1 was full. Let’s say at this point there is only a spot for one of them. If Kelly is above Jeremy on Indiana’s rank list, she gets the spot before Jeremy, even though it is her #2 choice and his #1.
  5. In this way, a student that gets matched with a program will always get a spot at that institution before a student who is lower ranked by that institution.
  6. This means that the program rank lists only come into play when there are “ties” between applicants for limited positions.
  7. If all top 6 applicants on Indiana’s rank list rank Indiana as #1, they get the spots and that’s that.
  8. Rinse and repeat with repeatedly “bumping applicants down” until all spots are filled.
  9. These are then the final match results.

Then, in March (for most specialties, except those that go outside of the main NRMP match, like urology and ophthalmology), every medical student finds out on a Monday if they match, and then on Friday find out where they match. Medical schools host big parties where they hand envelopes to each student; these envelopes contain where that student will match. They are opened, to tears of joy or tears, disappointment, and varying desires to consume large amounts of alcohol. We have no idea, up until that point, of where we will spend those very crucial years of our lives. That day will occur on March 17, 2017, which conveniently falls on St. Patrick’s day.

And so, that is that. We then go on to graduate in May, where we officially become doctors, maybe go on a final vacation or two, move to our new programs, go through orientation, and start as newly minted residents on July 1st. This cycle then repeats itself the following year for the next class of residents.

Step 3: Residency

Then comes residency. It is through these formative years that we are transformed from scatterbrained interns, who can barely find the cafeteria, let alone room 7061, into adept attending physicians. These are the trial by fire, the sink or swim, the thrown into the shark tank, the juggling knives years of our lives. Making a doctor is like making a crock pot meal, it should be simmered slowly over many years. Instead, we pretty much unplug the crock pot, throw it into a fire pit, dump some mountain dew and lighter fluid over it, and set that ablaze while doing the dance from Michael Jackson’s “Thriller”. By that, I mean there had to be rules made to cap resident work hours at 80 hours/week because residents work their lives away. I actually will argue the duty hours are capped a little low for surgeons, as time = training, but I digress.

In this way, we condense this process to somewhere between 3-7 years, depending on the specialty. Surgery residencies take 5 years at the least, while medicine residencies generally go 3 years, and generally no longer than 4. Residents receive greater and greater responsibility over the years until they become a fully independent doctor. Faculty physicians mentor and sculpt these residents, turning out a finished doctor.

To give some insight to this graded responsibility, let’s use general surgery as an example (bet you didn’t see THAT one coming!).  Lower level residents (years 1 and 2) generally learn how to take care of patients on the floor, solve medical problems like bowel obstructions or seizures, treat ICU patients, and more. They tend to not operate as much, and they are first in line for 4am phone calls and fiascoes that happen in hospitals overnight. Years 3 and 4 find a resident becoming the leader of their team, increasing their autonomy and their ability to make decisions. They mentor the junior residents and keep them in check, and also learn how to do  complex cases in the operating room. They are given more autonomy in the operating room to do more of the case and make more decisions when it comes to patient management. By year 5, the “chief residents” work with nearly complete autonomy, honing their final surgical skills. They take younger residents through operations, are the leaders of the surgery teams, and transition to practicing by themselves. They operate their faces off so that they are ready for the world beyond residency.

Step 4: Fellowship (optional)

It is at this point the residents take their final board examinations, both written and oral, and become certified into their specialty of choice. A lot of residents decide to pursue additional subspecialty training. For example, cardiologists undergo 3 years of internal medicine residency and then 3 years of cardiology fellowship. As far as surgeons go, some go on to pursue fellowships in surgical oncology (cancer surgery), breast surgery, vascular surgery, trauma surgery/critical care, pediatric surgery, and more. This allows residents to further expand their skill set and make themselves more marketable, as well as practice exactly in the area they want. These fellowships run between 1-3 years, so in theory a surgery resident can spend anywhere from 6-10 years (if they did a 7 year residency) in training before they move on to the final step.

Step 5: Doctoring

It is at this point, after residency (or residency and fellowship) that new doctors go out to practice on their own. They go to rural areas to practice community medicine, to cities to practice specialty surgery, or to academic centers to both treat patients and do research. The world is their oyster, and after what amounts to 13 years of learning through high school, 4 years of college, 4 years of medical school, and anywhere between 3-10 years of residency and fellowship, they are ready to practice. That makes between 24 to 31 years of training to create a fully-fledged doctor.

That, my friends, is a looooooooooooong time. It is a gargantuan investment of time, money, effort, and hours spent wondering how you’re possibly going to finish it all. It is a profession unlike any other, and I am honored to be joining this esteemed, though imperfect, way of life. Because we never really stop being doctors, even when the white coat is hung up, the pager is turned off, and we walk out of the hospital doors. I have both worked hard and gotten very lucky to be here, and it will be an honor to serve you. I hope that you now have a better understanding of how this crazy process works and how it relates to your medical person of choice. If you got referred here by a student in your life, I’d like to thank you for reading.

With that, I end with “Human” By Jon Bellion, a great song about being human.


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