And the Emmy goes to….
Today is the most exciting day of the medical year. Something is happening today that’s pretty much unlike anything that happens in any other field. The closest thing I can think of that compares to it is the NFL Draft. But just imagine that instead of three days, the draft took one second and instead of 250 players drafted, there were over 40,000. Even my high school classmate, Mel Kiper, couldn’t keep up with that.
Interested? Read on.
My wife has a childhood friend who’s a Hollywood producer. She’s had success in film and television with projects that you would probably be familiar with. Not long after my first son was born (1997) she visited New York and offered to take me to a premiere where she promised to introduce me to Halle Berry. Unfortunately, I was on call, an emergency came up, and I couldn’t go. Another small sacrifice to a career in medicine. So, she’s legit Hollywood, and I’ll always appreciate the fantasy that she left me with.
As far back as the early 1990’s I suggested to her an idea for a movie that I believed - and still believe - would be a sure-fire hit. It would have human drama. Some comedy. Pathos. A thrilling emotional climax. It would have an ensemble cast of actors in their mid-to-late 20’s. Think the brat pack, and Julia Roberts, and Sarah Jessica Parker and Ethan Hawke and pre-slap Will Smith. And viewers would learn for the first time about an annual event, and almost every single one would leave the theater saying “I had no idea THAT happens every year.”
She never took the bait, but it’s not too late because the subject of the story has changed very little in the ensuing decades and people still don’t know about it. And maybe the delay is for the best because the entertainment industry has evolved, and now my idea would actually lend itself to an 8-10 episode limited series, or even a documentary or reality series (or both!). All would have the country riveted to the finale and then the concept could easily just be turned back and have another run the next year. It’s like a medical White Lotus, but with more protagonists and less murders.
I’m sharing it with you all now. If you’re a person who’s connected to show business, or know someone who is, have at it. It’s all yours. I’m never going to get around to writing it, and I wouldn’t know where to start getting it made. You can have it for free. All I ask is some sort of acknowledgement (even if it’s just scribbled on the bathroom wall at the studio), assurance that you’ll have a really solid medical consultant (could be me, doesn’t have to be) so that doctors don’t find it cringe-worthy, and that I’m invited to the premiere (Halle Berry is optional) and to the Golden Globes (seems like a blast!) and the Emmys. That doesn’t seem like too much to ask.
I’m making this offer - and writing this blog - today, because the event in question will occur at Noon Eastern time, today, Friday, March 21. Because the third Friday of March is “Match Day”.
Match Day is the moment when essentially every graduating medical student in the United States - and, more accurately, every graduating medical student in the world who is attempting to secure placement in a residency training program in the United States - will find out which hospital they will be assigned to for the next three to seven years of their life.
No kidding. At 11:59, more than 40,000 grown adult men and women have no idea where they will be living and working three months hence. A minute later they all find out at once.
Yes, this means that the folks on the West coast assemble for breakfast to find out where their futures will begin. And every few years the folks at University of Hawaii petition the National Residency Match Program to move the process to later in the day since 6AM is a little inconvenient, and every time the response is the same: nobody says you can’t sleep in and find out later. So just go watch the sun rise over Haleakala and then come in and find out where you’ll be moving.
Med students and residency programs sign up for the match and the rules are essentially this: whatever’s in the envelope (or nowadays, in the email or on the website) is legally binding, and the results will be known at that exact moment. No exceptions. That woman on HBO’s medical drama “The Pitt”, who somehow started med school at 18 (see why I want a consultant) might be the greatest mind to ever enter the field of medicine, but she can’t go have a job interview in November, be offered a job, and accept it. She has to wait till March and open an envelope like everybody else.
Here’s how it works: The students send in a common application to multiple residency programs and then interview at some fraction of those, if invited. It’s said that the average Pediatric applicant applies to 44 programs; the average surgery applicant sends in 70. Since the pandemic the interview days are generally done remotely. And at the end of all that, the student ranks the programs where they have interviewed from #1 to however many they find acceptable. The residency program ranks all their acceptable applicants as well.
There might be hundreds of applicants interviewed by a program. When I was Director of the Pediatrics Residency Program at New York Hospital for a few years around the turn of the century I would typically interview and rank 200-250 people to fill 18, then 20 spots. We went down to the 40’s on that list each year, but it gave me comfort to have that huge line of names behind them. Take no chances. In truth, probably 175 of those people would have been fine, and about half of those would have been great for us. But there were always good reasons to like the first 10 more than the next ten, and so on. I still remember the soul-searching that went with some of those rankings in the 40’s, and knowing that at least a few times I tinkered somebody in or out of a chance to train here. I hope I did the right thing.
After all that, a computer does the matching. The computer is deemed infallible. You go where the computer sends you. There is no appeal process. If your first-choice program is taking 20 residents and you are ranked in their top 20 applicants, then the computer places you there, removes you from the pile, and considers the program as needing only 19 residents. If you’re 25th on their list, but 5 people on their list ranked a different program higher and were high enough on that program’s list to be chosen, then you’re in. And so on. And so on. And so on.
It’s complicated. It’s mysterious. It’s dramatic. And it’s final.
A couple decades ago, the NRMP announced that they were going to adjust the algorithm in some way that gave the applicant the benefit over the program in the event of a tie. I remember some program directors becoming apoplectic over it. I myself read the details and decided there was no way I was losing sleep over it. And after the match the announced that the new algorithm only matched something like 5 people differently than the old algorithm would have.
You may be thinking “Wait! How do they make sure that every student is matched to a program, or that every program gets their allotment of residents?” and the answer, of course, is that they don’t. They just can’t.
Almost 20% of the students don’t match to a program at all, but that is amplified by the International Medical Graduates, who might have only about a 50% success rate in any given year. American medical school graduates match around 95% of the time. That means that almost 1 in 20 American students are left behind by all of the programs on their list. As dramatic as Friday would be, though, those students aren’t waylayed by an empty envelope at Noon today. Match Day is actually the culmination of “Match Week.” Medical schools learned on Monday about students who have not been matched, as do the programs that did not fill. This allows four days for the Supplemental Offer and Acceptance Program (SOAP), or what used to be known as “The Scramble.” It’s somewhat more organized than the bedlam that used to ensue back in my day. I don’t know much about the scramble because thankfully it never applied to me, and I never wanted to think much about it. It only existed in my nightmares. So if Monday passes and you haven’t heard anything, then you know that you’ve matched. No news is good news. Episode 7 of our 8 episode season will be devoted to Monday. It’ll be gut-wrenching when your favorite character gets the email telling them to give the Dean’s office a call. A portion of that episode will take place in fast motion. You’ll be nauseous by the time the filming settles down, and then there’s about 10 seconds of staring silence, and then a verdict, a destination, a match. Friday is a breeze for the ones who have scrambled, er, SOAPed, I imagine. The rest of the week was hell.
There’s another wrinkle that you might not have thought of, but the NRMP did over 50 years ago, and that’s the Couple’s Match. Our producers will love the story lines that can be developed with this. It’s like one of those little pivots that Mr. Beast might toss into an episode of Beast Games.
Here’s what the Couples Match is about: two medical students can decide to enter the match as a tandem. They don’t need to be married, or engaged, or even dating. You can couples match with your roommate, or your best friend too. And what you do then is submit a list of pairs of programs. Maybe your first pair is to both be at Cornell. Maybe your second choice will be to both be at Columbia. Maybe your third choice is for one of you to be at Cornell and the other at Columbia. And your fourth choice is reversed. And so on. And so on. And so on. The permutations can be almost endless. And you aren’t bound by any geography at all. In my med school class we had a couple who had as their first choice for him to be at the preeminent Internal Medicine program, which was in Boston, and for her to be at the top-ranked OB program which was in Baltimore. If they got their first choice, they would have chosen to be obligated to a long term relationship for three years. I won’t tell you how it turned out. You’ll have to tune in to the season finale.
Consider this: if you’re an amazing medical student and you want to be an Orthopedic Surgeon, your dream is probably to train at one of the two greatest Orthopedic residency programs, which are Hospital for Special Surgery (part of the NYP/Weill Cornell universe) and Mayo Clinic. So the envelope will tell you whether to pack for New York City….or Rochester, Minnesota. Fine, if that’s your pick. But now imagine being the other half of that couples match. Oh, yeah, that’s a story line in season one!
Way back when, I actually enrolled in the couples match with my serious girlfriend at the time. We only lasted till November of internship, BTW but that’s the subject of a different blog (or not). After all our interviews, I wanted to be in New York or Philadelphia. She wanted to be in New York or Boston. So we ranked New York Hospital for her and for me first, and got it. What was second? University of Virginia. Yup, if one of us wasn’t chosen by NYH and we were chosen by UVa, I wouldn’t probably be a New Yorker today. I would never have met my wife, who I met, thanks to the computer, three years later when the NRMP plunked her at Weill Cornell. Of course, nothing is random. We’ll never know how much her rank list was affected by the irresistible rising chief resident she met on her second look visit to New York Hospital. She’ll never tell.
Most medical schools have a Match Day ceremony, and it is undoubtedly the pivotal medical school memory for almost everybody. Almost any doctor can tell you infinitely more about their Match Day than their graduation day. I’ll bet they have more pictures too. Here’s how we did it at University of Maryland in 1986: We assembled in the Freshman Lecture Hall. All of the envelopes were placed in a cardboard box. The class president walked up and down the aisles pulling out one envelope at a time and handing it to the person whose name was on front. You had to put $5 in the box to receive the envelope. In point of fact, it might have been a dollar, I’m not sure. And 200 envelopes later, the last name left received the whole box, envelope, money and all. A few year ago I met a recent Maryland grad and asked how they managed Match Day now. It was all the same, but they have to pay $10. I loved that! Don’t mess with tradition!
Some people would stand up, open the envelope and loudly announce the name of the hospital as soon as they saw it. Others would take the envelope and leave the room. In our case, there were of course two different envelopes and there was no guarantee that they would come out of the box together. In fact, hers was one of the first out of the box and mine was about 3/4 of the way through. We pledged to wait until we both had our envelopes before opening either. But about 10 envelopes after getting hers we decided we couldn’t stand it any more, and opened hers, and there is was: The New York Hospital. Great news. Except…….that didn’t guarantee that mine would say the same. After NYH/NYH and UVa/Uva and Childrens Hospital of Philadelphia/Hospital of University of Pennsylvania and so on, there was eventually, way down the list, another run of New York permutations with her at NYH and me at Montefiore, or NYU, or Crazy Eddie’s, or someplace else. So if my envelope said something other than NYH, it would mean that I was passed over by New York Hospital and not only that, one or the other of us was passed over by one hospital in all of the intervening pairs. So there was great drama up until the second envelope. I’m guessing our series could have a great plot twist there.
Cornell did it differently when I was Program Director, and I think they still do it this way. The class and invited guests assemble in the Faculty Club on Friday morning for a reception. All of the envelopes are laid out on a table behind a velvet rope. At Noon the Dean pulls back the rope and the students can go take their envelope. It’s kind of a scrum, but not the bedlam that you’d expect. The gunners might knock people down to get their envelope. Others have a glass of champagne and mosey to the table a few minutes later. Some grab the envelope, open it and shout the results. Others, like in Baltimore, get the envelope and quietly walk away. There’s a lot of shouting. A lot of tears, mostly tears of joy. A lot of beaming parents. It’s fantastic.
Of course, the results are available online now too. I suppose a student could just sleep in, log on, get the info, and head out for brunch. But hopefully, most won’t.
There are countless endings to the story. Wouldn’t you tune in?
As anxiety-provoking as Match Day is for the students, I remember it being almost as bad as the Program Director. As a student I went into the day knowing I would have a job by the end of the day. As Program Director I was never sure. The Chair of Pediatrics at the time, and my direct boss, was a brilliant woman, a true pioneer of women leaders in academic medicine, and a real medical superstar. But she was also remarkably…..mercurial. Our results were always remarkable, thanks to a really fantastic small group of folks who helped me more than they ever received credit for. And we recruited amazing people who anybody in subsequent years would die to work with. As I said, we went into the 40’s, after my predecessor had gone 150 deep into the list in the years before, and we held off any notion of merging the Cornell and Columbia Pediatric residency programs when New York Hospital and Columbia Presbyterian merged into one entity. But it was never enough. I might not have enough students from Ivy League schools. I could never have enough MD/PhD students (future field-advancers, not always great interns. Skill sets are different). And believe it or not, she never thought I recruited enough men, even though our field is overwhelmingly female. By the time the results were out I needed a drink as much as the students did. But the students have the rest of the day off, and I had to go back to reading echocardiograms.
I would bask in the glory of the great folks that I had been able to collect for our program. And I couldn’t help but wonder what happened to the ones in-between. There were always a couple of applicants that I really thought were coming here, and weren’t on the list. I wondered if I could have done something differently to attract them. And I tried not to think about the folks in the 50’s and 60’s, all of whom would have been great here, some of whom, I know, were disappointed to not see our name in their envelope. Yup, there’s a lot of emotions on Match Day.
Yeah, there will be a couple of Program Directors in our cast.
So now you know about Match Day. I think it’s a story that needs to be told, not just because of the potential for great ratings success but also to honor the people who go through this. I’m hoping if someone ever tackles Match Day for entertainment purposes they’ll capture the essence of the moment. For the great majority, it’s a moment of triumph. We’ll have to be careful to dole out only one or two climaxes of abject disappointment per season. But I hope we will demonstrate that it’s also just another inflection point in a long, long ordeal toward a career in medicine. Think of where these people are in life, They graduated college four years ago, or more. Their classmates, their frat brothers, their roommates, are four years along in their lives and careers. Our senior med students are back where those people started. They’ve invested four years of studying, but it’s full-time studying. Forty hours a week of classes, not fifteen. And that’s just the start. Countless hours in the hospital for the last two years. Piling up debt, not earning a salary or saving a nickel for the future. All the alma mater football weekends not attended because there are exams on Mondays. You’re four years older chronologically, but you’ve aged ten years. All so that you can open an envelope and find out where it is that you are going to dive from the top of one totem pole to the bottom of another one. So that you can work 80 hours a week for another 3 to 7 years and emerge on either side of 30 and THEN get a job and try to start your real life. Unless of course you pursue a fellowship which would probably involve climbing the next totem pole for three more years.
For one afternoon, there is - for most - exhilarating joy. But even that joy exacts its cost in uncertainty, insecurity and turmoil.
I hope some day somebody takes the bait and does a good job with this.
In the meantime, if you’re intrigued by this, I suggest picking a few medical schools (start with Weill Cornell!) and liking/friending/joining their social media sites in order to join vicariously in the fun and the drama. They’ll all be posting photos, videos, comments. I promise you’ve never seen anything like it. Feel free to congratulate these perfect strangers. I promise you they deserve it. And one day you might be on one side of the hospital rail and they’ll be on the other. At least you’ll have some understanding of what it took for them to be there for you.
And then let’s start casting our series! Patrick Schwarzenegger? Jacob Elordi? Ayo Edibiri (hey, the Bear makes working in a hospital look like a hoot)? Sydney Sweeney? Halle Berry as the Dean? I suppose all of the actors don’t need to be beautiful. But in some way, all of the characters will be.
Congratulations to the matched applicants. Have a great life and career, and always remember the thrill of today. Let it carry you through the dark times ahead.
Congratulations to the Program Directors. Take a break and start preparing for the 2026 Match. You can start on Monday.
Congratulations to the advisors and the rest of the folks in the med schools who put so much effort into other people’s dreams.
And lastly, congratulations to the current interns! Glance back at the photos from one year ago and marvel at how far you’ve come. And, remember, help is on the way, and now it has names and faces!
