On March 17 at noon, about 18,000 medical students will open envelopes telling them where they will spend the next several years of their lives. It’s residency Match Day, and for many, that letter is one of the most important they will ever receive.

The process is supposed to be straightforward. Medical students, like me, submit applications to hospitals and health systems where they would like to work. Then, if they like what they read, residency committees invite us for interviews. In late February, both applicants and programs rank their preferences, and an algorithm matches us up in a way that most efficiently allocates training positions. It’s not perfect — every year there are empty slots and a few doctors who don’t match.

The process is also supposed to be ethical. The National Resident Matching Program says the people running residency programs can’t ask applicants where else they are applying, can’t ask them to communicate after the interview, and can’t themselves reach out to prospective applicants after the interviews in a way that might influence their rank lists.

Many programs do these things anyway. So do many medical students.

There’s too much at stake: eight years of college and medical school, hundreds of thousands of dollars in education costs, and significant debt. We want to go where we feel our careers will take off.

But there’s a personal aspect, too. For me, the difference between two residencies is suddenly living 3,000 miles from my partner. For some medical students, the difference is uprooting spouses and children or keeping them in their jobs and schools. And for others, it’s a calculated risk on cost of living and paying back those five- and six-figure loans.

So medical students and residency programs game the system. Here’s how.

Forbidden questions

At several interviews, doctors asked me where else I was thinking about going. This question put me in an incredible bind — I was essentially telling them information that they could use to rank me. I could have refused to answer, but, by doing that, I also could have put that match in jeopardy.

At one interview, someone asked me to rank my away rotations — this is training we get outside our home medical school during the clinical phase of our education, and for many people, it’s a way to try out a hospital where you might want to be a resident. I felt cornered by that doctor and really wasn’t sure what to say.

So, I didn’t answer. I changed the topic.

This is the most common way to game the match. Applicants send emails to residency program directors expressing their interest in the program, hoping to influence how the director ranks them. Applicants sometimes end up writing multiple letters professing their love to different programs. Sometimes, they tell more than one program director that their program is their first choice.

While programs often say that they don’t adjust their rankings based on “love letters,” some do. For one of my friends, a residency director for surgery told her, “the love letter could be a deciding factor in how we rank you.”

So, we’re stuck: If you don’t send one, it might look like you’re not interested.

Getting love letters 

Residency programs can send favored applicants “love letters” of their own. These emails almost always convey the same message — we are ranking you highly.

Since the design of the match algorithm encourages applicants to only rank programs based on their own preferences, these letters should not matter. However any hint of certainty can be a powerful force: Studies show that many applicants change their rank lists after receiving one.

Behind-the-scenes phone calls

We can also ask higher-ups to make phone calls to their colleagues on our behalf. The idea is to see if the interest is mutual. These calls can give applicants a sense about their chances of matching at a program and many will adjust their rank lists. A colleague of mine, for example, shifted a program lower after one call because he felt that it would be better to prioritize programs at which “I have the best chance of matching at.”

All things considered, the match and the algorithm are really a noble attempt to fix what was once a real problem with filling residency positions. Before the match, the system was disorganized and everyone was dissatisfied — programs wanted to fill their positions as early as possible, but students wanted to wait to get the best offers.

Now, however, programs benefit hospitals more than students. Matching a fifth-ranked resident instead of a fourth is not exactly a catastrophe for a residency program. The majority of medical students are qualified to handle residency — as one interviewer said to me on the interview trail, “all of you are more or less interchangeable.”

But for us, the situation is very different. Obviously, we all want to match at our first-ranked programs, but it’s no secret that this does not always happen. This uncertainty, and the stigma tied to not matching, means that we all end up ranking programs that we don’t really want to attend. My hope is that matches happen because all residency programs choose their residents based on grades, test scores, and personal fit, like the system intends. Ending up at a program that we didn’t really want to train at because we didn’t write a letter or answer a question at an interview is profoundly unfair.

So I think residency programs ought to respect the rules and the governing body should more vigorously enforce them. I also would like to see them better protect applicants who report violations. Currently, programs that fail to abide are supposed to be identified and temporarily banned from the match, but few are actually sanctioned. It is time for that to change.

That being said, I sent my love letter a few weeks ago.

Kunal Sindhu is a medical student. This article originally appeared in STAT News.

Image credit: Shutterstock.com