How the Heck Does the Match Work?

By Mark Ard

Ah winter, the time during which fourth-year students are racking up air miles interviewing for their next three-to-seven (or more) years of indentured servitude the opportunity to learn, change lives and finally become a “doctor.”

For those who wonder exactly what goes on in the magic hat (that’s my metaphor…I don’t think the NRMP uses a real hat) of the process we call the Match, I will attempt to explain. Every year, I hear seniors say, “Ooooooh, that’s how it works. So how can I game the system?” Hopefully by the end of this post, you will learn that one, you shouldn’t try to play games with the match, and two, there’s no need to; it is designed to work in the applicant’s favor. Your ethical views on the overall match aside, it’s a pretty genius way of getting people where they want to be.

For a more detailed guide, see this informational piece about the Nobel Prize work behind the process, or just browse around over at

Ok so let’s use an example. Aubrey, Bob, and Chris all want to be dermatologists. They all interviewed in residencies in Alabama, Boston, and Chicago where each program has only one spot. First, each applicant makes a rank list and each hospital ranks each interviewee. Here’s everyone’s list:

  • Aubrey: Boston, Alabama, Chicago
  • Bob: Boston, Chicago, Alabama
  • Chris: Boston, Chicago, Alabama
  • Boston: Bob, Aubrey, Chris
  • Chicago: Bob, Aubrey, Chris
  • Alabama: Aubrey, Bob, Chris

Let’s point some things out. Boston is the best program. It’s everyone’s dream residency. Each of these applicants was smart and put that program as their top choice, which leads us to Principle #1:

Order your rank list by your desire to go there regardless of your chances of getting in.

This principle will be important when you see how the process plays out, but in general, rank in order of where you want to go. Bob is the most competitive (all that Step 1 studying paid off!). Aubrey is from Alabama, and that program thinks she’s a better fit than Bob, despite his stellar application. Chris…well, Chris tried.

Here comes the magic hat. One name is randomly chosen. Chris. Where does Chris want to go? Boston. Is there a spot at Boston? Yes. He gets it (tentatively). New name. Bob. Where does Bob want to go? Boston. Is there a spot? No. Where does Bob fit on Boston’s list? Above Chris. Bob gets the Boston spot (tentatively) and Chris get bumped out. Now we automatically look at Chris’s list again. Where is his second choice? Chicago. Is there a spot? Yes. He gets it (tentatively). Next name. Aubrey. Where does Aubrey want to go? Boston. Where does Aubrey fit on Boston’s list? Below Bob. Sorry, Bob stays there (locked in). Where is Aubrey’s second choice? Alabama. Is there a spot? Yes. She gets it! Done. Hope you followed all that. Now multiply it by 40,000 applicants for 27,000 spots. (Gulp).

So let’s say Aubrey’s second choice was Chicago. She’d bump Chris and he’d get his third choice. If Chris only ranked two programs, he’d go unmatched and enter the supplemental match (see the SOAP at the NRMP website). This brings us to Principle #2:

Rank as many programs as you’re willing to go to, despite your chances at getting into any of them.

I’ve seen that go wrong on both sides of the equation. Applicants don’t rank enough programs because they aren’t sure it’s worth it. Conversely (and a sad percentage of unranked applicants every year) there are those who are overconfident from interviews and only rank a few programs. Don’t do that. If you can afford to rank every place you interviewed, do so. Along the same lines, apply broadly. For example, in orthopedics applicants applied to a median 60 programs for a median 7 interviews (which they damn sure went to all of). For pediatrics, 25 applications went out for 16 interview offers, and applicants only went to 11 of them. Lucky. That info can be found here.

Principle number #3:

There are no more principles…so don’t make any more.

I have heard all sorts of rank tricks or tactics to tell programs, and they are all wrong. Now, some programs rank applicants based on their perception of the applicant’s willingness to go there (in violation of principle #1) and those programs should be group shamed, but there’s no way to stop or fix that nonsense on your rank list.

Lastly, I encourage you to look into couples matches, early matches for some specialties, the military match, matching as an IMG/DO, and some strategies if you’re not sure what you want to do (ranking all the med/peds programs, then alternating medicine/pediatrics) or backup plans like all the dermatology interviews you got then some medicine interviews you should be very competitive for. There’s still a lot that goes into deciding how to choose the programs you like, but hopefully this example convinces you to not try any funny business. It really is a system built to match applicants to their top choices.

Questions or comments about the match? Leave a comment below!


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