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The unmatched

DOI:10.36834/cmej.43231
Authors:
Amit Persad at University of Saskatchewan
Amit Persad
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Canadian&Medical&Education&Journal!2018,!9(2)!
!
Correspondence:!Amit!Persad,!Division!of!Neurosurgery,!University!of!Saskatchewan,!103!Hospital!Drive,!
Saskatoon,!SK,!S7N!0W8;!email:!amit.persad@usask.ca!
e89!
Canadian&Medical&Education&Journal&
Canadiana&
The&unmatched&
Amit&Persad1&
&
1Division!of!Neurosurgery,!University!of!Saskatchewan,!Saskatchewan,!Canada!
Published:!May!31,!2018!
CMEJ!2018,!9(2):e89-e92!!Available!at!http://www.cmej.ca!
©!2018!Persad;!licensee!Synergies!Partners!
This!is!an!Open!Journal!Systems!article!distributed!under!the!terms!of!the!Creative!Commons!Attribution!License!
(http://creativecommons.org/licenses/by/2.0)!which!permits!unrestricted!use,!distribution,!and!reproduction!in!any!
medium,!provided!the!original!work!is!properly!cited.!
!
On!March!1,!2017,!just!over!a!year!ago,!like!all!other!
Canadian!medical! students! participating!in!CaRMS,!I!
woke!up!nervous!but!eager!to!find!out!where!I!would!
be!spending!the!next!phase!of!my!medical!training.!I!
had! avoided! thinking! about! CaRMS! ever! since!
submitting!my!rank!list,!but!the!stress!of!the!situation!
became! more! pressing!with! each! passing! minute.!
With! only! a! half! hour! left! before! results! were!
released,!there!was!hardly!anything!else!on!my!mind.!
I!remember!being!in!my!car!at!10am,!pulling!over!into!
a! grocery! parking! lot! to! open! the! result! page.! My!
phone! was! being! bombarded! with! messages! from!
family!members,!friends,!and!classmates!sharing!their!
results!and!inquiring!about!my!own.!
We& regret& to& inform& you& that& you& did& not&
match&to&a&position.&
My!initial!reaction!was!shock.!I!could!not!believe!that!
this! had! been! my! outcome.! I! had! done! everything!
they! told! me! was! needed,! like! so! many! other!
candidates! before! me! who! had! been! in! the! same!
position.!I!initially!did!not!believe!it,!and!had!to!take!a!
moment!where!I!just!sat!there!in!the!car.!I!must!have!
refreshed!the!page!at!least!twenty!times,!waiting!for!
the! error! to! correct! itself! or! to! reveal! itself! to! be! a!
joke.! The! email! from! the! University! of! Alberta!
Undergraduate! Medical! Education!office! requesting!
my! presence! at! an! urgent! planning! meeting!
cemented!the!crushing!reality!to!me.!!
Though! I! had! recognized! the! possibility! of! being!
unmatched,!I!did!not!dwell!on!the!chance.!Like!many!
other!students! in! my! situation,! I! settled!myself!with!
the!fact!that!I!had!worked!hard!on!my!rotations,!read!
diligently,!and!done!electives!and!research!in!order!to!
strengthen!my!application.!There! was! a! fair! amount!
of!entitlement!inherent!in!this!attitude,!and!I!was!not!
exempt!from!this.!The!difficulty!lies!in!numbers:!when!
too!many!students!apply!to!a!specialty,!some!must!go!
unmatched.!!
There! are! many! studies! that! try! to! identify! what!
makes! a! good! resident.1,2!Factors! like! academic!
inclination,! clinical! reviews,! reference! letters,!
personal!statements,!and!interviews!are!all!taken!into!
account!by! the! reviewing!body! and! used!to! make! a!
gestalt!of!each!individual,!which!is!then!tested!by!the!
interview!process.!It!is!truly!a!subjective!process!that!
is!imperfect!and!based!on! tenets! that! are!unclear!to!
both! the! candidate! and! the! program.3!Ongoing!
discussion! related! to! Wilson! &!Bordman3!reflects! a!
lack! of! clarity! and! a! recognition! that! the! process!
needs!to!be!improved,!with!a!marked!lack!of!objective!
criteria.4!Programs!do!not!know!what!to!look!for!in!a!
candidate,! sometimes! asking!silly!questions! at!
Canadian&Medical&Education&Journal!2018,!9(2)!
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interviews!and!making!decisions!that!are!life!changing!
for! applicants,! as! suggested!to! me! by! a! program!
director.!!
It! is! impossible! to! ignore! that! th is! system! does! not!
work!for!everyone.!2017!set!a!record!for!the!number!
of! unmatched! students! in! Canada.5!One! student!
unfortunately! took! his! own! life! after! being! left!
without! a! residency! position! for! two! consecutive!
years,!leaving!behind!a!detailed!note!of!his!grievances!
with!the!system.!Typically,!neurosurgery!is!a!discipline!
with! a! similar! number! of! applicants! and! available!
positions.!The! year! I! entered! CaRMS! did! not! fit! that!
pattern,!with!31!qualified!applicants!applying!to!only!
15!positions.!Many! individuals! who! may! have!made!
excellent! residents! and! eventually! neurosurgeons!
were! not! selected! for! admission! to! residency! due,!
almost!entirely,!to!sheer!numbers.!!
For! me,! the! condition! of! being! unmatched! was!
devastating.! I! recall! sitting! through! the! emergency!
meeting!with!our!faculty!counselors!and!not!looking!
up!from! the! floor.! I! could!not!believe!the! situation! I!
was! in.! Two! months! later,! I! remember! writing! my!
MCCQE!Part!1!exam!and!frequently!being!tempted!to!
change!answers!that! I! was!sure!that!I!had! answered!
correctly,!simply!because!I!was!no!longer!as!confident!
in! myself.! I! approached! many! of! the! neurosurgery!
faculty!that!I!trusted!for!advice,!which!was!largely!the!
same:!CaRMS!usually!does!not!work!the!second!time;6!
being! unmatched! would! almost! inevitably! lead! to!
practice!outside!of!neurosurgery.!Even!surgeons!who!
had!given!me!glowing!evaluations!and!thought!that!I!
would! be! a! highly! sought-after! candidate! were! not!
optimistic!at!my!chances!a!second!time.!Their!reversal!
of!opinion!was!earth-shattering.!!
Interestingly! and! fortunately,! as! I! continued! to! seek!
out!opinions,! some! residents!and!faculty!opened! up!
to!me!about! their! difficulties! with!matching.!A!well-
known!faculty!member! I! completed! an! elective!with!
shared!with!me!his!experience! of! being! unmatched,!
but! being! able! to! get! an! empty! spot! in! the! second!
round.!We!agreed!that!it!was!a!confidence-breaking!
situation!that!felt!frightening!and!hopeless.!However,!
now!I!knew!that!there!were!those!who!had!shared!my!
experience.! This! was! a! faculty! member! that! I! had!
worked! closely! with! and! respected,! and! I! was!
encouraged!by!the!similarity!of!his!experience.!!
Another!faculty! member! in! cardiac! surgery,! with!
whom!I! had!worked!during!a!selective,!also! reached!
out!to!me!sharing!his!experience.!He!had!not!initially!
matched!to!his!specialty!of!choice;!instead!of!cardiac!
surgery!he!was! matched! to! general!surgery.!He! had!
come!to! enjoy! his! general! surgery! residency,! but! a!
position! eventually! opened! up! in! his! third! year! of!
residency!and! he!was!able! to!switch!over.!His!advice!
was!that!even!if!you!don’t!match!to!your!first!choice!
specialty,!there!are!often!routes!to!return!to!it.!Even!
though!he!eventually!switched,!he!encouraged!me!to!
give!the!discipline!that!you!are!matched!to!a!chance.!!
The! connections! that! I! made! with! people,! such! as!
these,!while!being!unmatched!were!helpful!to!me!and!
gave!me!a!lot!of!insight!into!the!way!that!they!handled!
themselves! during! their! period! of! not! matching.!
Without! exception,! all!had! reflected! on! themselves!
and! where! they! might! have! gone! wrong,! and! had!
become! more! grateful! for! their! position! after! their!
experience.!All!were!motivated!to!securing!a!position!
in!their!disciplines!of!choice!after!securing!a!spot!in!a!
different! residency,! and! eventually! became! highly!
successful!in!the!field!of!their!dreams.!!
I!also!had!the!opportunity!to!talk!to!a!few!residents!in!
other! disciplines! who! had! not! matched! to!
neurosurgery,!but!had!wanted!to.!I!asked!them!about!
their! own! experiences.! Most! of! them! were! bitter!
about! CaRMS! and! toward! neurosurgery! as! a!
discipline.! Moreover,! they! were! somewhat!
disparaging! of! many! of! their! colleagues! who! had!
matched!to!neurosurgery.!In!some!cases,!previously!
unmatched!candidates!were!quite!acidic,!particularly!
regarding!the! individuals! who!had! left! the! specialty.!
In! their! eyes,! this! was! a! waste! of! precious!
neurosurgical! positions.! Certainly,! I! understand!
where!these!individuals’!feelings!stem!from,!but!this!
animosity!neither!makes!one!a!stronger!individual!nor!
one! suited! to! train! in! a! program.! In! fact,! it! may!
subvert! the! learning! that! can! come! from! being!
unmatched.!!
The! experience! of! being! unmatched! was! certainly!
negative.!In!fact,!it!was!likely!the!worst!thing!that!has!
ever! happened! to! me.! But! what! I! want! to!
communicate!is! that! the! experience,! because!it! was!
the!worst!thing!that!happened!to!me,!was!good.!One!
of!the!most!important!abilities!of!a!resident!physician!
is! the! ability! to! cope! with! stress.1!A! prior! study! on!
attitudes! of! staff! neurosurgeons! towards! incoming!
neurosurgery! residents! is! that! the! ability!to! handle!
stress!is!a!skill!that!is!more!difficult!to!teach!and!more!
Canadian&Medical&Education&Journal!2018,!9(2)!
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important!to!have!when!entering.!I!did!not!know!how!
I! would! handle! failure! befor ehand,! but! now! I! know!
that! I! am! able! to! tolerate! and! recover! from! failure!
related!stress!relatively!effectively.!!
In!addition,!I!was!met!with!a!situation!that!had!come!
about! in! large! part! due! to! my! actions! and! choices.!
Many!poor!outcomes!in!medicine!can!be!written!off!
as! circumstantial! or! multifactorial,! and! in! a! lot! of!
cases!this!is!certainly!true.!Even! in!my!case,!it!would!
be! easy! to! attribute! my! lack! of! success! to! numbers!
and! circumstances!(15! spots! and! 31!applicants).!
Again,!this!is!likely!partially!true,!but!to!ignore!the!role!
that!I!played!in!my!failure!to!match!would!be!to!miss!
out!on!the!learning!that!came! from! the! subsequent!
journey.!!
Many! people! applying! to! medical! residencies! will!
have! the! same! set! of! experiences! that! I! did!
beforehand,! with! no! real! exposure! to! failure.! A!
lifelong!string!of!uninterrupted!success!fosters!a!quiet!
sense! of! entitlement,! which! is! sustained! with! each!
consecutive! achievement.! This! is! not! necess arily! an!
active! sentiment,! but! rather! one! that! comes! from!
continual! success.! For! me,! it! was! a! transformative!
experience.!I!knew!that!I!could!not!rest!on!my!laurels!
and!simply!re-apply!again!with!a!similar!application;!it!
did!not!work!the!first!time,!why!would!it!work!again?!
I!would!need!to!be!the!best!that!I!could!be,!and!that!
attitude!translated!into!the!rest!of!my!work.!I!gave!a!
lot! more! of! my! effort! to! the! task s! before! me,! from!
clinical!work!to!publications.!I!decided!that!I!would!try!
again;!I!took!the!mindset!that!if!every!neurosurgeon!
who!failed!something!along! the! way! gave!up,!there!
would!be!none!practicing.!!
Being!unmatched!in!CaRMS!created!the!potential!for!
immense! growth.! For! me,! th is! took! the! form! of! no!
longer!taking!success!for!granted,!increasing!my!work!
ethic,! and! learning! to! cope! with! stress! and!
uncertainty.!This!growth!may!look!and!feel!differently!
for!others.! My! aim! was!not!to!point!out!the! flaws! in!
CaRMS,! or! to! critique! resident! selection,! but! to!
emphasize! to! students! and! programs! that! those!
applicants!who!have!endured!an!unmatched!cycle!are!
not!necessarily!the!same!people!they!were!when!they!
moved! through! the! process! of! electives! and!
interviews! the! first! time.! The! experience! of! going!
unmatched!can!elicit!profound!changes!and!personal!
growth! through!intense!introspection.! To! other!
students!in!this!same!position!as!I!was,!I!am!not!saying!
it!is!by!any!means!a!desirable!journey!one!should!long!
for,! but! it! is! an! opportunity! for! reflection! and!
improvement.! And! it! could! become! a! marker! of!
desirable! residency! candidates.!Jordan! Peterson!
wrote!in!his!book!12&Rules&for&Life:&“There!are!so!many!
ways! that! things! can! fall! apart,! or! fail! to! work!
altogether,!and!it!is!always!wounded!people!who!are!
holding!it!together.!They! deserve!some!genuine!and!
heartfelt!admiration!for!that.!It!is!an!ongoing!miracle!
of!fortitude!and!perseverance”.7!This!was!in!reference!
to! those! ill! or! wounded,! but! for! the! candidates!
recovering!from!the!shock!of!an!unsuccessful!match!
it!may!have!some!relevance!as!well.!To!move!forward!
shows!a!fortitude!that!would!serve!the!candidate!well!
in!a!gruelling!residency.!!
I!have! been! granted! a! position! with! a! neurosurgery!
program! only! four! months! after! being! unmatched.!
However,! those! are! four! months! that! I! will! never!
forget! and! have! taught! me! lessons! that! I! hope! will!
benefit! me! throughout! a! challenging!residency.! My!
experience!has!left!me!with!an!openness!to!learn,!an!
ability! to! recognize! my! limitations! and! areas! for!
growth,!and!a!sense!of!gratitude!to!be!able!to!work!in!
the! field! that! I! fell! in! love! with.! To! any! of! my!
colleagues! and! future! colleagues! enduring! the!
hardships!of!an!unmatched!cycle—try!your!hardest!to!
find! opportunity! buried! in! disappointment,! replace!
your! fear,! self-doubt,! and! hopelessness! with!
determination! and! humility,! and! you! will! emerge! a!
stronger!CaRMS!applicant.!!
!
Conflicts!of!interest:!There!are!no!conflicts!of!interest!
to!declare.!!
!
References!
1. Myles! ST,! McAleer! S.! Selection! of! neurosurgical!
trainees.!Can&J&Neurol&Sci.!2003;30(1):26-30.!
2. Lipsman! N,! Khan! O,! Kulkarni! AV.! "The! Actualized!
Neurosurgeon":! A! Proposed! Model! of! Surgical!
Resident! Development.! World& Neurosurg.!
2017;99:381-6.!
3. Wilson! CR,! Bordman! ZN.! What! to! do! about! the!
Canadian! Resident! Matching! Service.! CMAJ.!
2017;189(47):E1436-7.!
4. Persad! A.! The! overall! culture! of! residency! selection!
needs!fixing.!CMAJ.!2018!Apri!9;!190(14):E443!
Canadian&Medical&Education&Journal!2018,!9(2)!
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e92!
5. Vogel! L.! Record! number! of! unmatched! medical!
graduates.&CMAJ.!2017;189(21):E758-9.!
6. Bumsted!T,!Schneider!BN,!Deiorio!NM.!Considerations!
for! Medical!Students! and! Advisors! After! an!
Unsuccessful!Match.!Acad&Med.!2017;92(7):918-22.!
7. Peterson!J.!123! Rules! for! Life:! An! Antidote! to!Chaos.!
2018.!Penguin!Random!House.!ISBN!978-0-345-81602-
3.
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... [1][2][3][4][5] Specifically, critics have flagged the process as being opaque and plagued by bias and subjectivity. 1,6,7 Furthermore, the CaRMS selection processes are not standardized among programs that has led to uncertainty and frustration among applicants. 8,9 While Best Practices in Applications and Selection have been published, 10 implementation rates are variable. ...
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Objectives The Canadian Resident Matching Service (CaRMS) selection process has come under scrutiny due to the increasing number of unmatched medical graduates. In response, we outline our residency program's selection process including how we have incorporated best practices and novel techniques. Methods We selected file reviewers and interviewers to mitigate gender bias and increase diversity. Four residents and two attending physicians rated each file using a standardized, cloud-based file review template to allow simultaneous rating. We interviewed applicants using four standardized stations with two or three interviewers per station. We used heat maps to review rating discrepancies and eliminated rating variance using Z-scores. The number of person-hours that we required to conduct our selection process was quantified and the process outcomes were described statistically and graphically. Results We received between 75 and 90 CaRMS applications during each application cycle between 2017 and 2019. Our overall process required 320 person-hours annually, excluding attendance at the social events and administrative assistant duties. Our preliminary interview and rank lists were developed using weighted Z-scores and modified through an organized discussion informed by heat mapped data. The difference between the Z-scores of applicants surrounding the interview invitation threshold was 0.18-0.3 standard deviations. Interview performance significantly impacted the final rank list. Conclusions We describe a rigorous resident selection process for our emergency medicine training program which incorporated simultaneous cloud-based rating, Z-scores, and heat maps. This standardized approach could inform other programs looking to adopt a rigorous selection process while providing applicants guidance and reassurance of a fair assessment.
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Delivering CaRMS Transparency: Applicant Review and Selection Process of a Single-Center Diagnostic Radiology Residency Training Program
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Purpose: To report the current application review and selection process in our Canadian diagnostic radiology program at the University of Ottawa for both Canadian and international medical graduates. Application review and selection process: Submitted applications fulfilling institutional requirements were selected for a detailed file review after preliminary screening. A diverse group of file reviewers and interviewers was selected. Interviews were offered based on file review score sheet outcomes. Each interviewer generated a postinterview rank list. Applicants were reviewed and discussed from highest to lowest rank based on a preliminary compiled rank list generated from the average of the postinterview rank lists. Group discussion and a consensus model were used to create a final applicant rank list. Conclusions: We outlined our systematic, consistent selection process which aligns with current best practices. This description may inform other programs wishing to adopt or optimize strategies to improve candidate assessments and selection processes.
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Journey of candidates who were unmatched in the Canadian Residency Matching Service (CaRMS): A phenomenological study
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Background: Each year, a number of medical students are unmatched in the Canadian Residency Matching Service (CaRMs) match. There is little information on the experiences of unmatched candidates. This study seeks to explore the experiences of applicants who were unmatched in the first iteration of their CaRMS applications Methods: We interviewed 15 participants who were previously unmatched, using a semi-structured interview guide to ask them of their experiences on the following domains: the overall unmatched experience; circumstances leading to their unmatched status; resources employed; barriers experienced; recommendations; and, their eventual career outcomes. We independently identified major themes from field notes to code the data using a phenomenology approach. Results: Our participants universally reported negative emotions, concerns regarding privacy and confidentiality breaches, and stigma faced (real or perceived). Systemic challenges included: lack of information, pressures faced from undergraduate medical education, and logistical issues such as financial challenges, licensing and scheduling issues. The utility of peer support differed for individual participants, but all those who had support from other unmatched candidates felt that to be useful. Conclusions: Our participants reported significant challenges faced after being unmatched. Based on these experiences, we identified four major recommendations to support candidates through their unmatched journey.
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"We regret to inform you that you did not match": Reflections on how to improve the match experience
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Background: With the increasing awareness and action amongst stakeholders in addressing the concerning rise of unmatched Canadian Medical Graduates (CMGs), little is known from those who go unmatched. We use our unmatched experience to contribute to this dialogue. Methods: We present an issues-based examination of the matching process by reflecting on the pre- and post-match period, providing suggestions related to the Canadian context from the unmatched perspective. Results: The challenge in the pre-match period was handling uncertainty in elective scheduling. This uncertainty was largely manifested from not knowing elective availability at the time of elective application submission, as well as not knowing what “strategy” we should follow in how to structure our elective schedule. For the post-matched period, we were challenged by making decisions during a time-sensitive period, deciding on career issues like scheduling post-match electives, handling our finances, and trying to improve our future residency applications without feedback. Conclusion: Providing a real-time document of elective availability, providing focused feedback from our residency applications, and implementing and expanding upon extended curriculums for all medical schools to continue CMG training for their unmatched students for upcoming match cycles would greatly improve the unmatched experience.
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Medical students in Canada must make career choices by their final year of medical school. Selection of students for a career in neurosurgery has traditionally been based on marks, reference letters and personal interviews. Studies have shown that marks alone are not accurate predictors of success in medical practice; personal skills and attributes which can best be assessed by letters of reference and interviews may be more important. This study was an attempt to assess the importance of, and ability to teach, personal skills and attitudes necessary for successful completion of a neurosurgical training program. A questionnaire was sent to 185 active members of the Canadian Neurosurgical Society, asking them to give a numerical rating of the importance of 22 personal skills and attributes, and their ability to teach those skills and attributes. They were asked to list any additional skills or attributes considered important, and rate their ability to teach them. Sixty-six (36%) questionnaires were returned. Honesty, motivation, willingness to learn, ability to problem solve, and ability to handle stress were the five most important characteristics identified. Neurosurgeons thought they could teach problem solving, willingness to consult informed sources, critical thinking, manual dexterity, and communication skills, but honesty, motivation, willingness to learn and ability to handle stress were difficult or impossible to teach. Honesty, motivation, willingness to learn, ability to problem solve and handle stress are important for success in a neurosurgical career. This information should be transmitted to medical students at "Career Day" venues. Structuring letters of reference and interviews to assess personal skills and attributes will be important, as those that can't be taught should be present before the start of training.
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Article
  • Dec 2016
Background Modern neurosurgical training is both physically and emotionally demanding, posing significant challenges, new and old, to residents as well as programs attempting to train safe, competent surgeons. Models to describe resident development, such as the Accreditation Council for Graduate Medical Education competencies and milestones, address the acquisition of specific skills but largely ignore the stresses and pressures unique to each stage of resident training. Methods We propose an alternative model of resident development adapted from the developmental psychology literature. Results Our model identifies the challenges that must be met at each stage of junior, intermediate, and senior and chief residency, leading ultimately to an “actualized” neurosurgeon (i.e., one who has maximized his or her potential). Failure to overcome any 1 of these challenges can lead to specific long-lasting consequences, including regret, identity crisis, incompetence, and bitterness. In contrast, the actualized surgeon is one who has successfully acquired the virtues of hope, will, purpose, fidelity, productivity, leadership, competence, and wisdom. The actualized surgeon not only functions safely, confidently, and professionally, but also successfully navigates the challenges of residency and emerges from them having fulfilled his or her maximal potential. Conclusions This developmental perspective provides an individualized description of healthy surgical development. Our model allows programs to identify the basis for residents who fail to progress, counsel residents during their training, and perhaps help identify resident candidates who are better prepared to meet the developmental challenges of residency training.
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123 Rules for Life: An Antidote to Chaos
  • Jan 2018
  • J Peterson
Peterson J. 123 Rules for Life: An Antidote to Chaos. 2018. Penguin Random House. ISBN 978-0-345-81602-3.