10
LOVE AND MEDICINE: THE COUPLES MATCH
TWO DOCTORS, ONE MATCH
Just like their fellow classmates, medical student couples have to cope with the confusion, frustration, and uncertainty involved in choosing a specialty. But, for graduating seniors involved in a relationship, an additional hurdle awaits: the Couples Match. In this process, every couple has the same two goals: (1) to secure a residency position in the desired specialty of choice; and (2) to match at a program in the same hospital, city, or general geographic region.
The Couples Match is a special arrangement within the main residency matching system. In response to the increasing number of student couples as more women entered medical school, the National Resident Matching Program (NRMP) introduced the first Couples Match in 1984. It eliminated the chaotic behind-the-scenes negotiations couples used to secure residency appointments. The Match system now easily accommodates the additional flexibility medical student couples require to achieve their goals. According to NRMP data from the 2017 Match, 1125 couples (the highest number to date) participated in the Couples Match, representing 5.2% of the total applicant pool of 43,157. However, there are also couples—such as those who participated in an early match like ophthalmology or urology—who coordinated a successful outcome without entering the Couples Match. Because NRMP data do not take into account these unofficial couples, the actual number of medical student couples is slightly higher.
In an official sense (meaning, for NRMP purposes), a couple is simply defined as two partners who are both graduating US seniors and entering the Match process at the same time. They can be from the same or different medical schools. Traditionally, most couples are engaged fiancés or married spouses. However, all types of couples can enter the Couples Match—boyfriends, girlfriends, newlyweds, gays, lesbians, or even close friends simply wishing to remain together during residency. Residency programs do not know which of their applicants are matching as couples, nor do they require couples to reveal the nature of their relationship. Technically, no romantic linkage is necessary. But before you and your best friend decide to Couples Match, remember that both partners in the relationship should be strongly committed to each other. After all, your futures (at least for the next 3 or more years) are intimately tied together. Based on recent Match statistics, the chances of matching together at the same hospital or in the same city are quite good (Table 10–1).
As described in Chapter 9, picking a specialty and then coping with the application and matching process as an individual applicant is hard enough. For couples, who have even more stressful challenges, the problems only multiply. In the residency application process, couples are usually limited to applying only to those programs with overlapping geography. If you are both applying in less competitive specialties, more flexibility exists due to the abundance of good residency programs within every major city. If one or both spouses are seeking extremely competitive specialties, the intense competition for a small number of positions will necessitate much more careful planning.
STATISTICS FROM RECENT COUPLES MATCHES
Because of the extraordinary amount of compromise and commitment involved, the Couples Match can cause much tension and anxiety throughout the fourth year of medical school. You should think long and hard and be sure that your relationship is ready for the stressful planning and possible outcomes. Read this chapter, talk with other successful resident couples, and consult with advisors and deans to discuss different strategies. By doing so, medical students who are planning lives together can prevent the unfortunate painful outcome of matching into programs that are thousands of miles apart (or even in a least preferred specialty!).
HOW THE COUPLES MATCH ACTUALLY WORKS
The residency application paperwork is the same for a couple as it is for an individual candidate. Both partners must separately fill out an online application through the Electronic Residency Application Service (ERAS), collect letters of recommendation, and arrange for the transmission of transcripts and Dean’s Letters. The only point at which you are officially considered a couple occurs at the submission of the final rank-order list (ROL) in February. When each partner registers for the Match on the NRMP website, the system allows the applicant to indicate his or her intention to match as a couple. This process requires both students to enter each other’s name and social security number into the system (and to pay an additional $15 per person for the privilege of using the Couples Match). Remember, the decision to match as a couple is not binding until the final submission of the rank list. You may uncouple yourselves at any point during the application and interview season.
Through the Couples Match, two applicants who are seeking residency positions actually pair together their individual ROLs. For every program on one partner’s list, there is a linked residency program on the other partner’s list. These entries must, of course, be placed in the exact same ranking position; meaning, the program placed in rank position #1 on partner A’s list is considered paired with an active program placed in the same rank position (#1) on partner B’s list. Both lists, therefore, must contain an equal number of rankings.
After submitting the final lists (which may or may not be identical), the NRMP computer performs its magic. The matching algorithm of the Couples Match works the same way as it does for placing individual applicants into program slots. The couple will match to the most highly ranked paired set of programs on the list at which both partners have been offered a position. Because of the coupling involved, each partner receives the exact same choice on the ranking positions. If you fail to obtain matches as a couple, you will both be unmatched. The computer does not rerun the lists separately to generate individual matches.
Are you confused yet? Do not worry. Until you actually enter the programs into the online ranking system, the process may seem overly complicated. Take a look at the accompanying ROL of a fictional couple. It is a good illustration of the rules of the Couples Match and it demonstrates a few of the possible outcomes.
Note that these lists are not identical. At first glance, you may wonder why the ranking preferences of this couple are different. On closer inspection, the geographical overlap of their choices becomes apparent. Both Partner A and Partner B clearly decided that UCLA was their first choice for their respective specialties. Their second, third, and fourth choices indicate that they both wanted to be in New York City if they were unable to match at their top ranking. Although this couple grouped their programs by city (Los Angeles, New York, Chicago, and Boston), an applicant can certainly mix and match different locations, as long as both partners’ paired programs are in the same city. If a couple applies in the same specialty, each student does not have to rank the same programs.
On Match Day, both partners receive appointments only to those programs at the same ranking position. For instance, Partner A and Partner B could possibly each receive their first choice, fourth choice, ninth choice, or none at all. Because of the pairing, the computer does not perform individual matches. Consequently, several outcomes are never possible, such as Partner A matching to his third choice and Partner B matching to her first choice.
In addition, the computer system allows an applicant to rank a particular program multiple times to generate as many permutations as the couple pleases. This is the reason why Partner B listed NYU twice in rankings #3 and #4, and why Partner A listed Boston Children’s three times in rankings #8, #9, and #10. With more options in a given location, this feature allows for greater flexibility to accommodate one of the partner’s preferences. You should also note that this fictional couple submitted a rank list with 10 paired programs. The NRMP allows for a maximum of 15 rankings, above which each program incurs an additional $30 fee. This policy is identical for individual applicants as well.
Take a closer look at position #10 in this fictional couple’s rank list. Their choices here illustrate another important feature of the Couples Match. To allow for additional flexibility in decision making, the NRMP provides the option of selecting No Match in any of the pairings. If one partner matches with the program in that ranking position, the other partner willingly chooses to go unmatched on Match Day. This selection ensures that the couple can remain together in the same city. The unmatched partner then has to scramble for an unfilled position or apply again the following year. In the 2017 Match, 66 couples (5.8%) found themselves in this situation. If our made-up couple receives their tenth choice, Partner A becomes a pediatrics resident at Boston Children’s, and Partner B scrambles for any open residency positions in the metropolitan Boston area (whether in internal medicine or any other specialty). This outcome is a small risk that some couples are willing to take to remain together.
OTHER ISSUES SURROUNDING THE COUPLES MATCH
One concern that medical student couples often raise is whether their couple status will place them at a disadvantage during the application process. In the 2017 Match, 95.4% of couples obtained a successful match, and a remarkably similar percentage (94.3%) of individual US seniors also received a first-year residency position on Match Day. Based on these numbers, it seems that most couples perform exactly the same in the Match as if they had applied and matched separately. This generalization, however, may not necessarily apply to couples in which one partner is a very strong candidate in a less-competitive specialty. For example, one successful couple, who applied in medicine-psychiatry and pediatrics, found the odds very much tilted in their favor. Program directors of medicine-psychiatry wanted the stellar candidate so badly that they called up the pediatrics residency director to improve the final ranking position of the partner. This situation only happens, of course, within the same institution. Medical student couples generally do not fit nicely into the formulas that program directors use for granting interviews and ranking candidates. Many times, departments often make exceptions for one another. On the other hand, if one or both partners are applying in extremely competitive fields, such as dermatology, there is less of an opportunity to use their couple status to increase their chances.
Regardless of specialty choice, applying as a couple should never decrease an applicant’s chances of matching at his or her highest choices. Instead, the Couples Match usually has no effect on final candidate rankings, or, as illustrated above, yields an improved chance of matching. In general, residency programs look favorably on couples, no matter the level of commitment between the partners. Couples tend to be more stable applicants who are less likely to drop out of the program. In addition, couples who are residents in different departments, such as internal medicine and surgery, can foster better working relationships between two sets of housestaff. Thus, both departments gain something from accepting a couple into their institution.
If one or both members of the couple are applying to very competitive specialties, particularly outside the NRMP Match, they must be more strategic. In this complicated situation, one partner may be interested in an early Match specialty, such as otolaryngology, while the other plans to apply to orthopedic surgery. Non-NRMP matches, such as the San Francisco Match or the Urology Match, have no similar provisions for couples within their computer algorithms. Both organizations also do not coordinate matches with the NRMP. In these cases, your initial strategy should simply be to apply, interview, and rank as many programs as possible within the same cities or geographic regions. Candidates participating in the San Francisco Match will find out their results 1 month before rank lists are due for the NRMP. In this case, by knowing where one partner has already matched, coordination within couples becomes much easier.
If a couple consists of two stellar, highly desirable applicants both applying to extremely competitive specialties, another strategy is to negotiate with one of the programs for an out-of-Match contract. For example, one couple from the same medical school, John and Andrea, sought positions in urology and radiation oncology, respectively. John, an Alpha Omega Alpha (AOA) applicant who was highly sought after by his top choice residency, informed the program director of their situation. The urologist then contacted the director of radiation oncology at the same institution and encouraged him to sign Andrea, also an outstanding candidate, through an out-of-Match contract. By working together, both departments ensured that the couple ended up together at their hospital.
By having so many different specialties and matching systems, there are scores of possible scenarios for the Couples Match. There is, however, one other important and common possibility to mention. What if one or both partners of a couple apply to advanced specialties, such as anesthesiology or radiology, which require a separate PGY-1 rank list? Unfortunately, the Supplemental ROL, which is used only for these internship positions, is not part of the Couples Match algorithm. As such, both partners must prepare this list separately. Because the goal is simply to remain in the same city during that year, you should only rank those PGY-1 programs on the supplemental list that are geographically acceptable. Otherwise, the hopeful medical student couple may find themselves in a long-distance relationship for this rather difficult year.
WORDS OF WISDOM: SIX TIPS FROM MATCHED-AND-MARRIED COUPLES
Good Communication Is the Key for Surviving the Couples Match Intact
After assessing your relative competitiveness in the application process, you should have an honest discussion with your partner about career goals and professional needs. Both partners should talk about what they are looking for in a residency program. The couple must decide together which desires are open to negotiation and which cannot be compromised. These needs may range from location to program size, or from the call schedule to research opportunities. Most likely, both partners will not fall in love with same programs or hospitals. As such, you should seize this opportunity in your relationship to be open and honest and to get to know your partner even better.
For new medical student couples, the decision about where to attend residency training may be the first significant compromise they have had to reach. Whether the issue is location, program, hospital, or even specialty, both partners must be flexible and open to negotiation. Without excellent communication throughout the entire process, the outcome on Match Day may elicit feelings of disappointment or resentment. But participating in the Couples Match can be a stress-free, even enjoyable, experience. Remember, the final decision on the ranked list of paired programs does not occur until February. Every couple can allay much anxiety by pushing the strategizing and compromising until the end. By doing so, medical student couples will prevent the Match process from creating any rifts in their relationship.
When Deciding Where to Apply, Geographic Location Is the First and Most Important Consideration
The purpose of the Couples Match is to ensure that both partners obtain residency positions in the same city, not thousands of miles apart. Thus, the first step in the application process is to decide together on the list of programs to which you are submitting applications. If a couple applies for the same specialty, they do not have to interview at all the same programs. Instead, simply apply to a large enough number of hospitals within the same city. Strong candidates in less-competitive specialties often have more freedom in interviewing at programs in smaller cities and towns. If one or both partners seek very competitive specialties, they usually focus their efforts on larger metropolitan regions, like New York City, Los Angeles, and Chicago. Because these areas have many hospitals with multiple programs in a given specialty, the odds of matching together are significantly higher.
Apply Early to as Many Programs as You Can
Because most medical student couples are typically constrained by geography, they submit more applications to increase their chances at matching in the same city. If one or both partners are seeking very competitive specialties, like dermatology, it is even more important to apply early to the longest possible list of programs.
Always Inform Your Interviewers and the Program Director That You Are Matching as a Couple
Although not all applicants mentioned their partners in their personal statements, nearly all agreed on identifying themselves as a couple during the interview and postinterview stages. The NRMP does not reveal this information to residency program directors. At this point in the process, honesty serves you better than secrecy. Couples should be specific in mentioning the name of their partner and the specialty for which they are also interviewing. One successful couple, who sought positions in anesthesiology and radiology, felt that “we would not have matched if we had not told them we were couples matching.”
Be Assertive and Aggressive as a Couple
The NRMP only knows that two applicants intend to match as a couple when the final paired ROL is submitted. As such, there may be times during the application and interview season when your status as a couple can help your chances at certain programs or hospitals. For couples applying in the same specialty, one partner may receive an interview at a desired program while the other does not. Instead of expressing jealously or resentment, be forceful and confident. Inform the residency program director of your intent to match as a couple.
For example, one couple from the same medical school, Julie and Ken, applied together to similar programs in internal medicine. At one competitive California program, Julie received an interview and Ken did not. When they explained their situation to the program director, Ken was promptly granted an interview. The moral of the story: Couples should not allow their egos to prevent them from doing what it takes to make the Couples Match a successful reality.
The Perfect Couples ROL Involves Both Compromise and Strategy
Before entering the official rank list into the computer, both partners should first sit down and order their preferences alone. Ignore your partner or spouse, and disregard what you think the other would want. Instead, each of you must figure out your own rankings and only then compare lists. At this point, couples should discuss, negotiate, and compromise on specific factors (such as location, size of program, call schedule, research opportunities, etc.). The only required common factor, of course, should be the same city. Otherwise, what was the point of entering the Couples Match?
In preparing the final rank list, refer to the guidelines in Chapter 9 on how to make a good ROL. In general, couples often rank two to three times more paired programs than an individual applicant does. As you assemble the preferences in order, remember that you do not necessarily have to match at the same program (if applying in the same specialty) or at the same hospital (if applying in different specialties). The rank-order system allows all applicants, whether individual or couples, to enter many possible combinations, such as different program types, specialties, hospitals, and locations. The end result is a list of mutually acceptable programs in the same city where both partners are content to begin their training.