Friday, March 13, 2015

So you did not match...

This is an update of our advice for the student who finds themself in the unfortunate position of having NOT matched in Emergency Medicine. There are some changes from last years post on the same topic. As always the advice that follows is based on the experiences of applicants who did not match in recent years and the compilation of recommendations from the members of the Clerkship Directors in Emergency Medicine (CDEM) and Council of Residency Directors in EM (CORD EM). 

First step: take a breath, your life is not over. Your goal of training in Emergency Medicine is still alive. While it is difficult to see now, the hurdles, trips, and falls teach us more than our successes. You will grow and learn from this and become a better care giver for having struggled through this. 

You are now faced with a huge decision:  Do you SOAP (scramble) into something else with the plan to train in that specialty? Or are you still intent on EM even if it is not this year?

The advice that follows will be useful to those not willing to give up on EM.  One key thing to remember when deciding which group you are in: not matching this year does not mean you would not be an outstanding Emergency Physician. There are many great unmatched candidates out there who would have a spot if it were not for late applications, poor advising, a bad test score, or just bad luck.   

So what are your options if you are still intent on EM?
Most people come up with one or more of the following plans:

  1. SOAP into an open EM spot at a program they had not previously applied to.
  2. Take a year off and do research or pursue a graduate degree like an MPH to improve your CV.
  3. Extend your med school training to a fifth year and improve your application for next year.
  4. SOAP into another discipline with the intention of reapplying next year.

Let's address each of these options:

1.  Using the SOAP to get into an open categorical PG1 EM spot is almost impossible.  There were just 2 spots in 2013, with 686 US seniors without a match in EM. The chance of getting one of those 2 spots is 0.2%.  To put it another way 99.8% of US seniors who did not match in EM did not get a SOAP spot in EM. In 2014 there were 14 unfilled positions in the match, which is still not very many (family med had 142 and surgery prelim had 449). There is no reason that you cannot try to SOAP into EM but you need a back-up plan in place.

2.  There is near universal agreement that taking a year off for research will hurt you more than it helps you. Program Directors just do not care that much, especially about the kind of research you can set up and complete in one year (just not rigorous/impressive enough).  Many Program Directors are happy to interview re-applicants who have gained some clinical experience, but often do not bother if an applicant did research for the year.  There is significantly less agreement about what a degree like an MPH would do for you - which means that some people will be interested and others will not. 

3.  Extending medical school may be the best option for some students, if your school will allow you to do that. The clear downside is cost, which is likely huge. If the price or rules of your school (ask your dean) are not deal-breakers you can build an extra-year of experiences that will make you a better qualified candidate for next years match. This is a particularly good option for solid candidates whose applications suffered from being late to EM or being complete late in the application cycle. If more opportunities to interview were all you needed to get your 10 to 12 interviews, then extending will let you do that. This option also leaves you available to fill a last minute opening that comes up after the match (though you cannot count on that kind of luck). 

4.  Lastly, is the most common back-up plan: doing a year of something else. The clinical experience will certainly better prepare you for your EM training and can make you a stronger candidate. Putting yourself through the application process again can only enhance the perception of your commitment to EM. Many applicants have been successful using this pathway to eventually match to EM. If you choose this option there are two primary considerations in this decision:  What kind of year to do?  Where to do it?

If I want to reapply to EM, what specialty should I SOAP into?

There is significant disagreement among CDEM and CORD about what kind of prelim PG1 year is best, or if you should go for a categorical program (contract for full course of training) instead.  Here are the options and some explanation:

Transitional prelim year - thought of by the majority of Program Directors to be the best option for a re-applicant. You split the year between surgery and medicine and get to do many of the things you would be doing as an EM1. It is more rigorous and impressive than a year of IM and your future EM program may be able to give you credit for some of the months. The downside is finding a suitable one that fits your other needs (see below).  There is also possible lack of flexibility for doing EM months and interviewing, and at the end of it you are left without a job if you do not match into something else. In recent years these have become increasingly difficult to find in the SOAP as less are available. The best way to have a Transitional year as back-up is to apply and interview for it, not to scramble (too late).

Surgery prelim year - students choose to do this but few Program Directors think it is necessary, or even more helpful than a Transition or IM year. That being said, there are some who think the more rigorous/abusive Surgery year is more impressive. Again, you are left without a job after one year.

Medicine prelim year - often provides greater flexibility for getting EM elective time early (when you can get a new letter) and for interviewing. And you will usually be treated better. Some Program Directors are less impressed because it is not as rigorous, AND at the end you don’t have a job. However, finding a categorical IM program that will let you start as a PG2 should be an option if matching into EM does not work.  

Medicine or Family categorical spot - same benefits and downsides as a one year Medicine spot but with the advantage that you still have a training position should you be unable to jump to EM. There is an additional downside of needing to break a contract should you match in EM. This rarely is a problem so long as you are open and upfront with your IM Program Director. Re-application is hard, and they know they have a good chance of keeping you, so being supportive of your plans keeps you happy with them.  After a Transition year this is the second most recommended option by EM Program Directors because you have a fallback position if you do not match in EM.

Where you do your year is MORE important than what kind of year you do.

The ideal position is one where you will have the opportunity to do an EM elective early (August, September) in an ED that has a residency program you are interested in joining.  This gives you access to new letters from people in an EM residency. Most EM Program Directors agree that these letters will be the most important part of your re-application. You are better off doing a conditional Medicine year at a hospital with an EM residency than doing a Transitional year at a hospital without an EM residency. You need access to EM faculty who teach EM residents, and the EM Program Director at your hospital can be your best advisor in getting a spot in their program, or another.  

What do you do if you find out at noon on Monday, March 16th, that you did not match?

  1. Call your dean and find out what your options are.
  2. Call your EM advisor for a personalized recommendation on what you should do. You can also contact us by email or in the comments.
  3. Schedule as many clinical EM rotations as you can for the rest of the year. Get SLOE's from all of these rotations so that you can include better letters than you had this year and so that you can meet as many people within EM who can advise and advocate for you. 
Best of luck!

Adam Kellogg is an Associate Residency Director and formerly an Emergency Medicine Clerkship Director.  He is a member of the CORD EM Student Advising Task Force and of the SAEM Resident and Student Advisory Committee. Some of his favorite Emergency Physicians did not match on their first try.  


  1. Thanks so much for your helpful post. I was reading it now because I'm concerned about having only a couple EM interviews right now and am looking into applying to TY and prelim programs. I have 1 question about the medicine prelim option: will I have trouble getting into an EM residency due to GME funding if I do a medicine prelim?

  2. That is a great question. Some programs can only take residents who still have full funding (3 years) attached. However, many hospitals are already "over the cap" and self-fund a significant number of their residency spots. While the year of training will cut the number of interested programs, the added experience makes a huge difference to those that can train you.

  3. Hi Adam! I'm confused about the timeline of re-applying if you didn't match and are doing the traditional internship route. Do you re-apply after a year of traditional internship? That means you have 1 gap year with no job? Or do you re-apply for EM as soon as you start you traditional internship so there's no gap year?

    1. You are better off not having interruptions in your clinical training so you want to reapply during the internship. The hard part is that you need to get both the time free to go interview AND some way to improve your application during July - September. Rotating in the ED and getting new letters is your best bet if the reason you did not match was a problem in your application.

      If the problem was with your application strategy (too limited or not well matched to your competitiveness) then you are not in as great a need of new letters. Ideally you would still have someone writing positively about what you are gaining from your extra-clinical training.

    2. Hi Adam!

      1. When should you re-apply to EM during your traditional internship year? ERAS opens July but that's when many interns start so I'm assuming you should wait until after you've finished an ER elective and get a letter? But you also don't want to wait too long in the process. Which month (sep/oct/nov) would you say is the cut-off for re-application as a traditional intern?

      2. Some programs directly state "This program will grant residency credit for the 1st postdoctoral year of training. Students will "Match" directly into this residency and the 1st postdoctoral year will be considered the first year of residency training." Does this mean that we do not need to worry about funding with these programs if you match into their program during an traditional internship year?

    3. ERAS may open in July but your application won't go to programs until 9/15 - so that is the real deadline. An October rotation is the absolute cut-off for a letter in most cases. That letter won't arrive until november when all of the interview spots will already be offered. Better to have a letter from a september rotation arrive in early october before application review really heats up.

      Question 2 is probably going to depend on the program and on what your intern year experiences were. Often internship is repeated as there are big differences in the curriculum.

  4. Hi Adam!

    I appreciate your article and the advice you provided.

    Do you have any advice for my particular situation?

    I did not match to ER residency in 2007 and scrambled into an FP program. I completed the intern year which was very OB oriented. I then then switched and successfully completed a 3 year IM residency at my original institution.

    I have worked the last 7 years as a hospitalist, locums physician, and most recently made it into a solid full time ER job which I have always wanted and really enjoy. I am a single provider in a 30 bed ER that handles level 4 trauma and have excelled over the last year. I am 36 years old and truly want to go back for ER residency to open up my future employment opportunities to continue working in the ER field. As you know, they are extremely limited with an IM/FP degree.

    I would appreciate any insight or advice you can provide.

    Thanks in advance!

    1. It is always hard to get an EM spot to re-train in. Part of this is financial as there won't be government funding for your training, but this only matters at some programs (not all spots are funded at all programs). The bigger issue is usually that the issues that prevented the match in the first place usually still hurt the re-applicant. That being said, you have changed a lot as an applicant since 2007! Your experience is an asset but can also raise concerns about teachability. Your dedication to complete more training should help mitigate that. You certainly could match and I would encourage you to give it a try.
      Good luck!

  5. I am an IMG who went unmatched this past season and still wants to pursue EM.

    Step 1: 233
    Step 2 CK: 222 :-(
    Step 2 CS: Pass (2nd attempt)
    Step 3: Work in progress

    I was shocked when I didn't pass STEP 2 CS on the first attempt. The resulting sadness and fear associated with my failure was hard to overcome, and lead to an underwhelming STEP 2 CK performance. I have completed 2 academic EM rotations in the states with 2 SLOE's.

    1.) Would doing a Categorical IM/FM or Prelim Surgery/IM Residency improve my competitiveness?
    2.)What score should I be aiming towards on Step 3? I have been told I should aim for a score higher than my Step 1.
    3.) Do I need a Step 3 to match into preliminary or categorical IM/FM programs?

    1. Getting clinical experience as a resident in the US in either IM/FM/surgery is your best pathway to eventually matching in EM. A high step 3 score should be reassuring to programs, as is that you passed CS. You do not need a step 3 to match into an internship. Given how difficult it is to get into EM as an IMG I do recommend that you pursue categorical IM or FP as that will leave you with a path to further training if jumping to EM is unsuccessful..

  6. I am a US student who didn't match to a different specialty (dermatology), and would like to try for EM which was originally my go-to specialty. I haven't really been focusing on EM at all, and so I don't have any LOR. I would like to apply again for a spot to EM.

    Would you recommend extending medical school graduation? This would make it much easier to get the needed letters and experience.


    1. Extending medical school may be the right option, especially given how much you need to do to get your application focussed on EM. The "pages" on the right hand side of this blog will take you through specifics of the EM application. The most recent post: also links to a more detailed breakdown of the decision making around what to do with this coming year. Good luck!

    2. Thank you for the reply! I guess my current issue is this...
      Is delaying graduation or taking a surgery prelim in SOAP better.

      I feel that getting SLOEs will be more difficult with a surgery prelim, however, I will graduate on time and have some income.

      I appreciate your help!

    3. That really depends on your circumstances. No one-size-fits-all answer. Best PRO/CON for each, as I see it:
      Surgery - PRO: gain clinical experience and stop accumulating student loan debt. CON: going to be hard to build up a compelling case for EM while a surgical intern. May only get a shot at the EM program located there.
      Extending - PRO: can do all the stuff you would have done this year to prep for and succeed in the EM match. CON - $$$.
      This comes down to how set you are on EM and what risks are more tolerable for you.

  7. Hi Dr. Kellogg, Thanks for answering these questions!
    I have two of my own. 4th year US MD student didn't match EM (I had 12 interviews). No course failures nor remediation, low step 1 (<210), dead average step 2. I failed CS in December and didn't have a passing score in time for rank lists. I took CS a week after I got my first score and passed without any issue. I followed up with a few PDs and was told that I was on their lists but my low step 1 pushed me down their ranking, no other red flags (I did not release my CS). At least half of the programs I interviewed at specifically stated they required CS for ranking; I did not follow up with these.
    I did not SOAP and have nothing lined up for this year. I plan to find some clinical volunteering, do some projects with EMRA, and take step 3. I will apply very broadly to all of the new programs and others in less desirable areas(most likely >100 programs).
    Am I dead-in-the-water here? Is there something else I should do?
    Thanks again for doing what you do on here!

    1. When you don't match the first step is to figure out "why?" Your why is likely due to a low step 1 putting a "ceiling" on how high programs could put you on their list combined with being left off for not having a CS score.
      Taking step 3 and being able to report a CS pass should help with any test-taking concerns programs have.
      What your re-application is going to be missing is clinical experience. If you SLOE's were consistent with a good EM performance you should be fine. If they were shakier, then clinical experience is the only reliable reassurance for programs.
      You don't need >100 applications. There are not >100 programs that don't already know you and will consider you. Skip programs that ranked you this year as they are not going to move you up and add programs you didn't apply to before that list not using a step 1 filter on EMRA Match.
      It may not be too late to seek a clinical experience. There are openings post-SOAP. There is even a program that is filling their whole first EM class post-SOAP: St. Joseph's in Stockton, CA (details in post from April 10th). Keep an eye out for unexpected intern openings at EM programs as well - often advertised on SAEM's "Residency Vacancy Service" - Lincoln is recruiting for 2 additional PGY1's right now.