Most applicants who don’t match into their advanced specialty end up partially matching into an intern year position (see below). I chose to forgo that. So when I didn’t match into my advanced specialty, I went completely unmatched. I delayed graduation for another year and continued my status as a medical student. Within six months, I reapplied and matched the second time around. The decision to delay intern year was extremely difficult and contingent upon so many factors. I hope that by sharing my own personal decision-making process, I can shed some light on what options are available to you when you’re making your rank order list in February. Be sure to check out my ultimate medical school survival guide for additional information on applying to competitive specialties.
There are two types of programs in medical residency: categorical and advanced programs.
Categorical programs begin in the PGY-1 (post-graduate year 1) year and provide the full training required for specialty board certification. These include the majority of medical specialties you’ve heard of (i.e., internal medicine, pediatrics, surgery, Ob-GYN, etc).
Advanced programs on the other hand, begin in the PGY-2 (post-graduate year 2) year after prerequisite training. This prerequisite training must be completed in a preliminary or transitional-year (TY) program. Common advanced specialties include anesthesiology, dermatology, neurology, physical medicine & rehabilitation, radiology, radiation-oncology, and ophthalmology.
Preliminary programs offer one year of dedicated internal medicine, surgery, or pediatric training. TY programs offer more diversity in training and may include rotations in Ob-GYN and emergency medicine, in addition to medicine, surgery, and pediatrics.
When you apply into an advanced specialty, you must also apply to preliminary/TY programs. It’s an entirely separate pool of programs that you must submit applications to and interview for. Sadly, double the programs = double the $$$.
Primary and supplemental rank order lists (ROL)
After you finally finish the application and interview process, you get to rank your programs! For categorical programs, the process is fairly straightforward. You rank your programs in numerical order and that’s that. For advanced programs, the process is slightly more complicated. Check out NRMP’s helpful video tutorial below.
In summary, first you create a PRIMARY ROL that includes all of your advanced programs in numerical order. Then, you create a SUPPLEMENTAL ROL that includes your preliminary/TY programs. Multiple supplemental ROLs can be created and linked to different advanced programs on your primary ROL. For example: the New York programs on your primary ROL can be linked to a “New York” supplemental ROL, and the California programs on your primary ROL can be linked to a “California” supplemental ROL. This flexibility allows applicants to plan their future by limiting the number of geographic relocations.
You can ALSO choose to list preliminary/TY programs on your primary ROL if you are worried about not matching into your advanced specialty. This is another form of “dual-applying” aka applying to multiple specialties if you are concerned you may not match into a more competitive one. That way, if you do not match into your advanced specialty, you can still match into a PGY-1 position and move forward with your medical training. This is called a partial match.
Example PRIMARY ROL
Advanced program A in Boston (linked to "Boston" supplemental ROL)
Advanced program B in Chicago (linked to "Chicago" supplemental ROL)
Advanced program C in Philly (linked to "Philly" supplemental ROL)
Advanced program D in Boston (linked to "Boston" supplemental ROL)
Prelim program A in Chicago <-- (MATCH HERE)
Prelim program B in Philly
Prelim program C in Boston
I did not do this.
Instead, I refrained from listing any preliminary/TY programs on my primary ROL. Therefore, I went totally unmatched.
Reasons to rank your preliminary/TY programs (on your primary ROL)
- Avoid the potential possibility of not matching at all. My deans recommended that anyone applying into a competitive specialty either dual-apply or rank their preliminary/TY programs on their primary ROL. If you don’t match at all, you’d be without a job for a year. The financial cost is great.
- It’s hard to SOAP into a good preliminary program. Preliminary programs left over in the SOAP (Supplemental Offer and Acceptance Program) are generally less desirable (rarely you’ll find some diamonds in the rough though!). Strong academic programs rarely go unmatched and that’s probably what you want if you’re reapplying into an advanced program.
- Being an intern at a strong academic center can help you build connections. If you match into a large academic center, chances are, your advanced specialty will have a program there. You can take advantage of the proximity to network within the department and potentially earn yourself a spot for the next cycle.
- You’ll qualify for the physician-only spots when you reapply. A handful of advanced residency spots are available to MD candidates ONLY. You’ll still be eligible to apply for the regular advanced spots, so you’ll have more total options when reapplying!
Reasons to NOT rank your preliminary/TY programs (on your primary ROL)
- Time to improve your application for the upcoming cycle. I ultimately didn’t rank my preliminary/TY programs because I knew if I didn’t match into my advanced specialty, I would want to reapply the following cycle. I was worried I wouldn’t have time to change or improve my application if I was stuck being an intern at the same time.
- Time to go on away rotations and interviews. Intern year can have rigid scheduling demands and it’s difficult to schedule time off for interviews, let alone away rotations.
- Can potentially reapply with medical student status. Reapplying as a medical student (versus an MD) means you’re not under the same level of scrutiny and programs may not even realize you’re a reapplicant. Most people will assume it’s your first time applying and you can potentially avoid awkward conversations about why you didn’t match the first time. This only works if your school is supportive and will allow you to delay graduation until the following year.
In retrospect, I made an incredibly risky decision that paid off only because my school supported me. This meant I could still benefit from the school’s resources (they waived tuition and provided me with research funding), and I didn’t have to reapply as an independent applicant. I had six months between March (when I first found out I didn’t match) and September (when I re-submitted ERAS) to enter a new research fellowship and overhaul my application. During that time, I was able to build a relationship with a new mentor and department, start exciting new research projects, and drastically increase my number of publications.
Had I been forced to do my intern year while reapplying, I don’t think I would’ve had the mental fortitude or stamina to change my application to that capacity. I realistically might’ve made the decision to apply for research fellowships post-intern year, and reapply for residency the following cycle (one year later). That would delay me by two more years, rather than just one.
At the end of the day, the decision to delay intern year is a personal one and depends heavily on the resources you have at your disposable. No one wants to think about Plan B when applying to residency (I certainly didn’t), but it’s smart to consider and weigh all of your options when you plan your future.