Match, Heart of EM

Lord NRMP Match

"We are sorry, but you did not match to any position."
Few sentences are more feared among medical students. Take heart. All is not lost.

“Good morning, Matt. We admitted 2 new patients overnight. Why don’t you see this patient who presented last night with pancreatitis?” My ICU senior resident suggested early on the Monday of March 16.

“Sure!” I responded, realizing this would be an excellent learning case. The ICU had been enlightening for furthering my understanding of emergency medicine. I had found myself immersed in my cases. GI bleeding from esophageal varices, acute respiratory failure secondary to opiate overdose complicated by aspiration pneumonia, stroke in a young female with Graves’ disease. Caring for these high acuity, and medically complicated patients was captivating.

I went to see my new patient, a gentleman in his 50s with a past medical history of alcohol abuse. He came to the ED overnight with abdominal pain and shortness of breath, and was diagnosed with pancreatitis secondary to alcohol abuse; appropriate treatments were administered. Immediately, as I walked into the room, I became concerned. My patient was tachypneic, unable to speak in full sentences, but was still maintaining adequate O2 saturations. Additionally, he had profound abdominal distention.

“This is the largest and most firm belly I have ever mashed on,” I thought to myself. I turned his oxygen up to 6L and told him we would do everything we could to make him more comfortable. I went to find my senior resident to discuss my concerns about abdominal compartment syndrome, then prepared for rounds.

It was an hour before match results were set to be released.

As we were rounding, results of testing ordered by my resident after our discussion were back: our patient with alcoholic pancreatitis had a bladder pressure of 25. A subtle, congratulatory fist bump and a “Good job man, you called that one” made me feel like a contributing member of the team.

Then the clock reached 10 am sharp. My sense of success was short-lived.

“We are sorry, but you did not match to any position.”

I heard the sound of the ice cracking beneath my feet as I plunged into the cold depths of the unknown. “Is this a mistake? Surely, this wasn’t meant for me. Not even one program? I had hit the recommended number of interviews. My advisors had assured me of my chances. We were never concerned.” The thoughts raced through my mind as I became increasingly pale and tachycardic.

But there was no time to process; the clock had already started ticking on the 3-hour window to apply to a maximum of 45 programs listed in the SOAP process.

I realized I had put everything into matching EM and hadn’t even considered an alternative. While applying I had focused on programs near my home in the Midwest. I had hit my number of interviews recommended. I thought I had done all of the “right things” during the application and interview season.

 How could I have not prepared for this? I don’t know where to apply. I don’t even know what positions to apply to. Should I switch fields and apply to a categorical internal medicine position? Surgical or medicine prelim? What the hell even is a transitional year?” I asked myself as I furiously began familiarizing myself with the SOAP.

My phone rang and I was relieved to see my advisor’s name flash onto the screen. “Hey Matt, it’s Dr. T. I heard the news. I wanted you to know that everyone here in the department is shocked. This was unexpected, but you should know we are all here to help. Do you know Dr. C? You may not have been aware of this, but he didn’t match during his first attempt and went through the same process. I think he would be a great help.”

“Dr. C didn’t match? Dr. C, the fellowship trained, POC ultrasound educator and clerkship director?” I thought to myself.

Within minutes I was on the phone with Dr. C. “Hey. Sorry to hear the news, Matt. I want you to know that a career in EM is still an option. I initially didn’t match and was able to successfully reapply. Don’t lose hope on this. A career in EM is still a definite possibility for you. We think the best option for you is to apply to surgery preliminary position or transitional year position and reapply next cycle.”

I took a deep breath, mentally preparing for my next steps. I was not going to drown... and I was not alone.

The next few days were a blur. I reviewed the 45 programs, submitted my applications, and kept researching the 45 possibilities while I waited. Phone interviews could happen at any time after application submission. This was not the type of “being on-call” I had pictured for myself.

“Why do you think you didn’t match?”

I began ruminating my answer to this standard question for people in my position. “The match had failed me. Or maybe, I had failed the match.” I thought as I recounted every decision I had ever made.

I was standing before the all-powerful judge, Lord NRMP Match. My Judgment Day had arrived, and I had been deemed unworthy. Exiled uncaringly to the Underworld of the Unmatched. If Lord Match could be so callous, how could I hope for mercy from his crony, Mr. SOAP?

But then I got a phone interview for a preliminary position! It lasted 6 minutes and 32 seconds. Brief, straightforward, and formal. The questions were standardized. My ambitions were framed around this snapshot interview.

I checked my phone every few seconds for some sort of contact. I hoped for an offer, an executive pardon, from Mr. SOAP. The offer rounds passed as I commiserated with other lost, unmatched souls in internet forums.

My phone was silent.

My pleas to the Lords of the Match went unanswered. When the final round of offers concluded and I was not offered a position, I turned to my spreadsheet of remaining unfilled positions.

The spreadsheet was fully equipped with program contact information, color coding, and sectioning for programs based on personal interest. My “spam” template email with my application materials and prefilled program contact emails was ready. I was prepared for my final trial: the post-SOAP scramble.

I contacted my advisors about the results of the final SOAP round. Everyone was standing by to advocate for me.

Then SOAP officially ended, the laws of the Match were lifted, and the floodgates opened. Myself and my team of superiors sprang into action.

During the scramble, I received a waitlist offer, meaning I was next in line if another applicant declined during an agreed-upon 1-hour timeframe. As I left voicemails, (and brightened the day of ERAS and American Express stockholders by even paying more application fees) I received a call from the waitlisted offer.

“We’re sorry, the other applicant accepted the position and we are now filled.”

“We’re sorry, but you did not match to any position” echoed in my overly caffeinated and sleep-deprived state of consciousness.

I realized it was time to go home as the afternoon came to an end. I had called programs, left voicemails, and emailed every program with unfilled positions. Time to regroup and ponder my promising future as a well-educated Uber driver.

That’s when I received a text from Dr. C. “I just spoke to a program director for a transitional year position. The PD is an EM doc and he’ll be calling you soon. Also, he mentioned the hospital is working on opening a new EM program. Hopefully, this is an opportunity for you.”

“Is Dr. C really still advocating and making calls to programs for me? It’s so late in the day.” I had tried everything without success. I had also started warming up to the idea of my life as Dr. Uber. But Dr. C still had hope. I allowed myself a brief, half-hearted flash of a smile.

During the phone interview, I conversed with the program director for some time. I explained my thoughts on why I had failed to match and spoke of my ideas for the future. We talked about the excitement of EM as a career. I was able to ask questions in a more conversational manner than I had previously experienced over the past week. By the end of the interview I was left with a good impression.

“What do you think about the idea that when we get off the phone, I’ll have my coordinator send you an offer and we can both call it a day?”

“I am ready to sign.”

It was Thursday, March 19, 4:35 pm. I made it. I was in. I was going to be included in tomorrow’s Match Day.

My transitional year at HCA Healthcare West will be a welcome experience in my journey to EM.

I was drawn into emergency medicine for the same reason that I needed to share my story. This story is about the PEOPLE in emergency medicine, where going above and beyond is the norm. Throughout all of the chaos, turmoil, fear, and uncertainty, I was never alone. Emergency physicians embody the greatest heroes of fiction, venturing into chaos headstrong with bravery. They are leaders fighting on the front lines amongst a team of residents, scribes, nurses, students, social workers, law enforcement officers, pharmacists, EMS workers, and, thankfully, unmatched EM applicants.

Whether working against a worldwide pandemic or rushing to the aid of a code blue, emergency medicine providers serve to keep the fibers of life, humanity, and order from tearing apart. While my journey is still uncertain, my story and gratitude must be shared. To me (and others in my position) the future is simple. Continue the fight through failure, chaos, and uncertainty. Continue to learn and grow. Continue to exemplify these values inherent in emergency medicine. And when the time comes... look straight back into the cold eyes of Lord NRMP Match.

Special Acknowledgment
I can hardly express my sincerest gratitude, respect, and admiration to the emergency medicine faculty at Saint Louis University, but hopefully this was a start. A special thank-you to my advisors, Dr. Tina Chen and former EMRA Board member Dr. Kene Chukwuanu, for their unwavering guidance and support.

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