Scrambling for a Career

In the weeks after Match Day, the day that fourth-year medical students learn their fates for residency training, most medical students are reflecting on their results with joy, resignation, or despair. A handful of others are still reeling in the realization that their medical careers are going to look significantly different than they had planned.

I’m talking about the “Scramble,” the little-publicized event that occurs two days before match day for those students that did not match with any of the programs they had ranked. There are a number of reasons that this occurs, but frequently it is because some specialties are so highly sought-after that there are more students applying for a position than there are positions available to train them. Diagnostic radiology, for example, offered 141 first-year training positions in the 2010 match. 663 US seniors applied, implying that 522 aspiring radiologists are possibly soon to begin training to be a completely different kind of physician.

Upon learning that they didn’t match, the student (with the aid of their medical school administration) then identifies residency programs that still have positions available through the National Resident Matching Program (NRMP). If they’re extraordinarily lucky, a spot in their desired field will be open. If not, some hard choices need to be made in a short period of time. Should I be a surgeon instead? How about family medicine? Or maybe I’ll just do a transitional year while I mull things over? The process differs slightly from program to program, but within the next 48 hours the student and the program make contact, often through the Electronic Residency Application Service (ERAS), usually visit over the phone, and the remaining open slots are filled. Often the student and the program don’t even meet face-to-face. The assignment is sent through the NRMP, and the scrambled student then has an envelope to open with his or her colleagues on Match Day. And on that fateful day, while most students are discovering the where of their training, the scrambled students may still be coming to terms with the what, and perhaps the why.

Editor’s Note

The scramble is a chaotic process on several levels. The NRMP says it best, “Trust exists in the Match but not in the Scramble.” From a 2009 meeting, the NRMP outlines the downfalls of the current paradigm:

  • No consistent, orderly process for applications
  • For-profits clog programs’ email, phones, & faxes
  • No communication between applicants & programs
  • No separation between application & appointment
  • Applicants must make career decisions too quickly
  • No rules govern applicant & program behavior
  • No organization has stewardship of the Scramble

In an effort to sanitize the process, the NRMP recently voted to implement a Managed Scramble for the 2012 Residency Match. Under this new plan, all unfilled positions must be offered and accepted through the NRMP online system during Match week. With the Managed Scramble, “the NRMP assumes stewardship of the Scramble.”


NRMP. Advance Data Tables 2010 Main Residency Match, 2010.

NRMP. The Managed Scramble, 2010.

T. A. McNamee, MD

T. A. McNamee, MD, is an associate professor and internal medicine residency program director at Sanford School of Medicine of the University of South Dakota.
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