What Happens to Medical Students Who Don’t Match?

Even for the top medical school students in the country, an otolaryngology residency is one of the most difficult specialties to land, and nearly 40% of applicants don’t match. Last year, 574 highly qualified applicants competed for one of 341 openings. That left 233 aspiring otolaryngologists without a residency in their chosen field. After four years of hard work and big student loans for many, what happens to these students?

“It’s an extremely challenging situation to work through, partly because there are so many more unmatched applicants in recent years,” said Steven Pletcher, MD, residency program director at the University of California, San Francisco.

While in the past it may have been somewhat taboo to talk about not matching, now there’s more of a general acceptance that a high number of highly qualified otolaryngology applicants each year will go unmatched. As medical schools have increased the number of students they accept, residency programs—funded largely by Medicare and Medicaid—have not kept pace.

Supplemental Offer and Acceptance Program

Medical students who don’t match receive notification on the Monday before Match Day. They then have the option of applying to a program in a different specialty that has unfilled spots through a process called the Supplemental Offer and Acceptance Program (SOAP).

“This obviously means a major change of plans for a future career,” said Marilene B. Wang, MD, a head and neck surgeon and professor in the department of head and neck surgery at the David Geffen School of Medicine at the University of California, Los Angeles.

Under these circumstances, students will look at specialties that hadn’t necessarily been on their radar. They may plan to apply again to otolaryngology while doing a transitional program, such as a year of surgical residency, or otolaryngology-related research. Or they may end up really enjoying the other specialty they match into through SOAP and choose to continue to pursue it.

Dana Crosby, MD, MPH

Medical students put more pressure on themselves than most groups. When they hear from those close to them that they are loved and supported regardless, it’s one of the first and most important steps of moving forward. —Dana Crosby, MD, MPH

Osama Hamdi, MD, a current otolaryngology resident at the University of Colorado in Aurora (CU), went unmatched the first time he applied to otolaryngology programs; he applied to the SOAP but had second thoughts and quickly withdrew his application. “I was still passionate about otolaryngology and wanted to give it one more shot so that I didn’t live with regrets,” he said.

Dr. Hamdi spent the following year doing otolaryngology-related research and reapplied to otolaryngology residencies in the next match with backup applications to general surgery programs. (He had not applied to backup programs in his first round.) Having spent the year doing a research fellowship in otolaryngology, he felt that if he did not get in this year, he had exhausted his options to become an otolaryngologist. Becoming a surgeon, however, was a nonnegotiable, he said, so he would be content if that were his only choice. Dr. Hamdi was delighted this time, however, when he matched at CU, his first choice.

Dr. Wang added that it’s important to maintain a healthy perspective about residency and career choices. “Sometimes a specialty choice doesn’t work out, but that doesn’t mean another one isn’t just as good of an option,” she said. “I’ve seen students not match into their choice of specialty and eventually find another one that’s equally rewarding. There are so many different ways to apply your skills, passion, and energy into helping patients improve their health and well-being.”

Well-qualified otolaryngology hopefuls who don’t match but are open from the start to considering other specialties often have much better luck through the SOAP process, according to Dr. Pletcher. “Oftentimes, they’re very desirable in the SOAP positions or for preliminary surgery positions because they’re such great candidates,” he said.

Transitional Year(s)

Students who apply to transitional years in research before attempting to match again generally opt for institutions that have strong otolaryngology programs, offering exposure to new mentors and high-powered research institutions for otolaryngology topics to help bolster CVs, according to Jonathan Bock, MD, a laryngologist and director of medical student education for otolaryngology at the Medical College of Wisconsin in Milwaukee. Getting a research position at an institution where an applicant wants to do an otolaryngology residency could be ideal, as they may become more of a known quantity by those who will ultimately evaluate their otolaryngology residency application.

“The problem is that these aren’t guaranteed positions, and the pay for research isn’t that good—an issue if student loans are coming due,” Dr. Bock said. Additionally, there’s no way to guarantee that during the week of Match Day these students will be able to land a transitional surgery year or a research position that late in the process.

Dr. Bock and his colleagues have discussed whether students should have a backup plan on how to approach otolaryngology applications, and for couples hoping to match at the same institution. This could include reaching out to some of the research fellowship programs in advance of the match or even interviewing for surgery positions in general surgery. “Then, of course, the question becomes whether they need to reveal during interviews that they’re applying to different specialties.” Dr. Bock said. “There are no clear guidelines about that.”

Evaluation Without Step 1

Evaluating medical students for residency is always challenging, but the next match will be the first with no Step 1 scores—and Step 2 scores can’t be far behind. How will programs evaluate medical students without this information?

“I don’t think our algorithm is going to change that much, except we’re probably going to have a slight preference for people who took Step 2 early and use that as a proxy,” says Cristina Cabrera-Muffly, MD, an otolaryngologist and residency program director at CU, adding that as her program does not have a cut-off score for the Step 1, its loss doesn’t change much.

I was still passionate about otolaryngology and wanted to give it one more shot so that I didn’t live with regrets. —Osama Hamdi, MD

What most frustrates Dr. Cabrera-Muffly, however, is the inability to compare medical school grades to one another because some have a pass/fail curriculum, whereas others have very clear grading scales that range from honors to non-satisfactory. “You also want to ensure that you have a statistical breakdown, because if 80% of students received ‘honors,’ then honors don’t mean much.” When she reviews applications, Dr. Cabrera-Muffly finds it easiest to batch them by institution to see how the school grades. She can then evaluate all of the school’s students at the same time.

Step scores and grades aside, when finding herself with 100 to 200 additional applicants each year who are great candidates, Dr. Cabrera-Muffly finds that there are a couple of things that make a difference. One is the use of preference signaling, the process instituted in 2020 that allows medical students to let up to five residency programs know that they are in their Top 5. The other is a geographic tie, such as family, a partner, or another loved one living near the residency location.

Emotional Well-Being and the Unmatched

In the immediate aftermath of not matching, experts recommend that medical students reach out to those who love and support them unconditionally, including friends, family, and very close mentors. Unmatched medical students may not only feel that they’re disappointed in themselves, but also that they have let down their families.

“Medical students put more pressure on themselves than most groups,” said Dana Crosby, MD, MPH, residency director and chair of otolaryngology at the Southern Illinois University School of Medicine in Springfield. “When they hear from those close to them that they are loved and supported regardless, it’s one of the first and most important steps of moving forward.”

Dr. Crosby likes to connect students who have not matched with those currently going through matching to help them get a sense of what the future might look like and how to move forward successfully. She also recommends that students reach out to counselors or a psychiatrist, especially those associated with medical schools. “It can be challenging as you’re simultaneously asked to make very difficult and important decisions,” she said.

Dr. Wang has counseled medical students about the chance of not matching, and that the preparation for residency must begin early in medical school— getting to know the specialty, working with faculty members and residents on research projects, writing papers, and gaining experience in research or even obtaining another advanced degree. Because of the number of people interested in the specialty, it’s vital that every otolaryngology applicant create a Plan B.

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Renée Bacher is a freelance medical writer based in Louisiana.