n 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.

Writing love letters 

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 fourth-year medical student at the Warren Alpert Medical School of Brown University.

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  • To Mario Aguilar
    What if US tax payer patients prefer to receive medical care from a knowledgable and competent foreign doctor rather than a less competent US-grad or US-IMG tax paying physician who may not bave been good enough to be selected in the competition? United States owes its progress in large part to policies that attract talents of other countries to America. And if the country wants to keep prospering these policies should continue.

  • The only thing the Match does is create the ILLUSION of a fair and level playing field. Everybody knows that those who have friends in Medicine already somehow, magically manage to get into better residency programs. Moreover, it seems rather strange to me how many program directors and higher-ups, who happen to be either Indian, or Muslim, always seem to find their programs dominated by Indian & Muslim residents. When a white program director has to rank residents, he or she always makes sure to rank a good deal of minorities so as to avoid the dread that goes along with the label “racist”. Funny how no other race other than whites are required to discriminated against their own.

    • So sorry that you have been the “white card” going for you. You life must have been so very hard, living in White America. Does it just burn you that non-whites are just as bright?

  • Both students and programs game the system at their own peril. It happens, in search of more certainty on both sides. But changing the ranking of a candidate or a hospital based on the predicted preference of the other side rather than one’s own preference can only backfire – in a less desirable, if more secure, match.
    Ultimately both sides need to understand and trust the process in order for it to work best for them. Students with geographic limitations may need to explore a wider set of specialties in order to maximize their chances of landing in the location they want/need. And never ever rank a program that one would not want to work at, regardless of how much love the program shows, because 3, 4, or 5 years is a long time. Problem is, as the writer notes, the downside is probably less for the program, which can view interns as interchangeable. And many programs take pride in filling their slots in the fewest number of ranked candidates, motivating them to prioritize certainty over quality of candidates. But over the long run that is a short-sighted strategy.

    • Geographic “limitations”? Wanting to be with your partner or not ask your family to uproot for what may well be no more than a three year gig is not a disability.

  • Residency training programs have strong preferences about applicants, too. But we are aware that due to the vagaries of the match, we need to make our peace with potentially welcoming any of the medical students we rank in our top 10-15 (for 5 spots). I am not sure why it wouldn’t be the same for medical students ranking training programs. There are limited spots, and no guarantees in life that you will end up at your first choice, or your second choice or your third choice…

  • Dear STAT,
    FYI: Every year about 4,000 US citizens physicians both, graduated in the US (US-Grads) or International Medical Graduates (US-IMG’s) are left unemployed or under-employed when they are displaced from residency positions by foreign national doctors (F-IMG’s) that have never paid US taxes.
    The majority of these positions are funded by the US Government through MEDICARE. Therefore, while the foreigners are getting trained and paid with US taxpayers money, the displaced -also taxpayers- US physicians are left unemployed or forced to take unstable and low paying jobs in the medical field as lab techs or medical assistants where they are easily exploited and mistreated. We must change this.

    Just last year a total of 4,915 US physicians (2,561 US-Grads and 2,354 US-IMG’s) did not obtain a residency position, partly because 3,641 of all available spots were given to foreign doctors (REF#1).
    The recent accreditation of 17 new Medical Schools in the US since 2007 (REF#2) AND the availability –now- for US citizens to obtain Federal Financial Student Aid to pay for International Medical Schools, has significantly increased the number of new US doctors graduating every year. For example, in the year 2000 a total of 17,677 US citizens physicians were eligible to enter residency compared to 25,988 applicants in 2015 (REF # 3). This is an increase of more than 8,000 new US physicians in the last 15 years. To make matters worse, the number of these residency positions -funded through Medicare-has not change in twenty years since 1997, when US Congress froze and capped the number of residencies per year (REF#4), which is also the cause of the current shortage of physicians in the US.

    The definitive solution to these problems lies in the hands of lawmakers, by lifting the 1997 freeze and increasing the number of residency spots with funds obtained from the re-structuring of Obamacare. The creation of more residency positions in turn will alleviate the the shortage of physicians in the US. However, this will take time and while this happen, the current limited number of residencies funded with tax payers monies should be assigned to tax payers American doctors, as a priority.

    Historically, WE Americans have been a country with open arms inviting and welcoming almost everyone around the world. Also, foreign national physicians are extremely qualified and competent, in fact, many of them after finishing their training will join the US physician force, currently composed by 25% of doctors graduated from International Medical Schools.
    But, in a marked contrast countries like India -from where the majority of foreign doctors come to the US- does not allow foreign doctors to train and practice medicine there. The practice of medicine in India is a privilege only for Indian nationals (REF#5). Just last year 754 foreign doctors from India took away the jobs- residency positions- from the same number of American citizens (REF#6). Other countries like Spain, that also sponsors medical training for foreign physicians, only offers 4% of all available spots to visitors only after nationals or members of the European Community have been given priority. Even Mexico, that also offers training in medical specialties to a great number of Latin American graduated physicians, gives preference to their nationals over foreigners.

    For all the above, the US won’t be the first country that gives priority to their nationals in terms of assigning them the limited number of medical residency positions currently available while legislation takes place to increase the number of funded positions.

    Priority MUST be given to us, Americans doctors.
    US tax-payers funded residency positions should be given to US tax-payers doctors.

    Thank you so much for your valued time reading my point of view.


    Mario Aguilar, MD, M.S.
    US Citizen, IMG. ECFMG Certificate Holder
    MS in Biotechnology, Georgetown University
    Former NIH fellow with Cancer Research peer review publications.
    Proud father of an active duty US Marine.
    Currently UNEMPLOYED.


    1- http://www.nrmp.org/wp-content/uploads/2015/05/Main-Match-Results-and-Data-2015_final.pdf ). Table #4; page #15.
    2- http://www.usnews.com/education/best-graduate-schools/top-medical-schools/articles/2016-07-11/map-where-to-find-the-newest-medical-schools.
    3- http://www.nrmp.org/wp-content/uploads/2013/08/resultsanddata2000.pdf
    Table # 2; page #5
    5- http://timesofindia.indiatimes.com/nri/other-news/NRI-doctors-will-soon-practice-in-India/articleshow/45667851.cms
    6- http://www.ecfmg.org/resources/NRMP-ECFMG-Charting-Outcomes-in-the-Match-International-Medical-Graduates-2014.pdf

    • so very true and very sad that so many americans are losing these federallly funded positions to foreigners that have never paid taxes. ive worked my ass off and I am sick of this system being so inconsiderate. just terrible news today.

    • Mr. Aguilar — Sunday afternoon in New Orleans — reading your post has compelled me to wish you well – for all you do and have done. Thank you.

    • I realize this is an old comment, but I reeaaaaly feel like this needs to be addressed. First of all, refer to the latest match data available, not data from 2015. 2016 Match data is reported at the following link: https://www.nrmp.org/wp-content/uploads/2016/09/Charting-Outcomes-US-Allopathic-Seniors-2016.pdf. 2017 Match data is reported at the following link: http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Results-and-Data-2017.pdf.

      Ok. Look at Table 4 on page 15. Same table you referenced. Now find the heading: “U.S. Citizen Students/Graduates of International Medical Schools”, and look at the percentage of unmatched graduates. I’ll save you the time, it’s 45.2 percent.

      Great. Now stay on the same table and same page. One section below, there is the heading “Non-U.S. Citizen Students/Graduates of International Medical Schools”. Now check out the percentage of unmatched graduates there. 47.6 percent.

      What conclusion can we draw from this? That hospitals don’t give a shit whether you’re a US citizen or not. If you are a post graduate of a foreign medical school, you have the same chance at getting hired at a US hospital regardless of your citizenship.

      Ok so the meat of my comment: As a consumer of health care, this is what I want. As someone who pays healthcare professionals for their medical services, I want the most qualified individuals on the globe to be available to me here in the US. I understand first-hand the downsides of the field competitiveness and the crunch it puts on medical professionals, but I prefer those downsides to an alternative wherein highly-qualified professionals are not allowed to practice where I live.


  • I followed the association of program directors and refrained from have post interview communication. I feel that if they want you they rank you with or without these so called love letters. In 1 week I’ll see if it matters.

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