Mailbag: Match Day delay, USMLE score rechecks, Step 2 CS score reporting, and preparing for the SOAP

Welcome back for more real questions from real readers (edited, as usual, for clarity and brevity).

Today I submitted my *final* rank order list – right before the deadline. But Match Day won’t happen for over two weeks! Why in the name of all that is holy do I have to wait so long to learn where I matched? Are they running the algorithm by hand this year or what?

This is a common question – so common that the NRMP actually responds to it on their website.

From the NRMP’s FAQs.

Of all the things the NRMP does between the rank order deadline and Match Day, the most important is verification.

Remember, although many applicants get their top choice in the Match, where most applicants end up is a function of where other applicants end up.

Imagine what chaos would result if the NRMP accidentally matched a few applicants who weren’t actually Match-eligible (maybe because they ended up being unable to graduate this year or couldn’t become eligible for a work visa).

You’d have angry programs that filled with applicants who couldn’t start work on July 1; angry applicants who got displaced by these applicants to lower choices on their rank order list; and angry NRMP executives who now have a P.R. disaster on their hands. That’s why they take the time to do so many double checks: running the algorithm and telling people the results is a one-shot kind of deal.

(Fun fact: other matching programs have not always been so meticulous. In 2005, the American Urological Association match had to be re-run because of a mistake… urology applicants and programs got one set of results on Match Day, and another four days later.)

Portions of an e-mail sent to urology applicants after the 2005 AUA Match debacle (quoted here).

I just got my USMLE Step 2 CK score back: I scored a 225, despite consistently scoring around 240 on all of my practice tests. I’ve heard that you can request a score recheck from the NBME. Should I?

It’s true: if you ask them to, the USMLE will recheck your exam to ensure the score you received is accurate.

Thing is, it’s not free – the recheck will set you back $80. And it’s very, very unlikely to result in a score change. In fact, if it does, you’ll be actually be the first – the USMLE’s website states:

To date, the score recheck process has not resulted in a score change.

I suspect that the score recheck policy is a legacy from the pre-1999, paper-and-pencil days of the USMLE exams. Back those days, students worried that the answers they bubbled-in with a #2 pencil might not get picked up by the scanner. The possibility that you could raise your score a point or two with a recheck seemed much less remote than it does these days with computer-based testing (which really should be foolproof).

Remember, also, that even though we treat USMLE scores as if they are perfectly precise measures of medical knowledge, they aren’t.

As I’ve written before, if an examinee took the Step 2 CK exam repeatedly, using questions that tested similar content, and without gaining or losing knowledge, that person’s score would have a 95% confidence interval of 24 points. In other words, even though a 225 may have been a disappointing outcome based on your practice test scores, it probably was not a statistically implausible one.

I’m a fourth-year student who failed my initial attempt at USMLE Step 2 CS last year. Then COVID-19 hit and I couldn’t re-take the exam. I applied to a competitive surgical specialty this year but fear I won’t match. If I do have to reapply in the future, will my Step 2 CS failure still appear on my USMLE transcript even though the test is permanently suspended?

Unfortunately, yes.

Earlier this month, the USMLE quietly made the following announcement:

As a medical licensing examination, the USMLE program has the responsibility to produce transcripts that report to state medical boards a complete exam history for each examinee. Accordingly, all Step 2 CS results will continue to be reported on the USMLE transcript.

To facilitate the interpretation of transcripts with either Step 2 CS fails or no Step 2 CS attempts, the following statement will be included on all transcripts:

“The USMLE Step 2 CS examination was suspended on March 16, 2020 and formally discontinued on January 26, 2021. Due to the exam’s discontinuation, examinees with a failing Step 2 CS outcome may not have had an opportunity to retest and remediate their performance. The USMLE defines successful completion of its examination sequence as passing Step 1, Step 2 CK, and Step 3.”

I am a fourth-year DO student who applied this year in OB-GYN. I only got 2 interviews, and I think I’m going to end up in the SOAP. Is there anything I can do now to prepare for SOAP week?

Yes.

First and foremost: think carefully about your career goals, and decide what types of programs you’d target if you are in the SOAP.

I say this because once you get the e-mail saying you didn’t match (which goes out around noon EST on the Monday before Match Day), things are gonna happen fast. If you haven’t thought deliberately about your back up plan before then, it’s hard to make non-emotional decisions in the 60 minutes you’ll have before SOAP applications open up.

Unfortunately, for competitive specialties, there will likely be few (or no) positions left over after the Match. (For instance, last year, there were only 3 categorical OB-GYN positions available in the SOAP.)

However, there usually are positions available in less competitive fields like family medicine and internal medicine. (Use Ben Solomon’s outstanding website to explore previous years’ Match data to get a sense of the number and type of positions that are likely to be available.)

Be brutally honest with yourself. Would you be happy doing medical oncology instead of GYN-ONC, or regular endocrinology instead of reproductive endocrinology? If so, maybe fighting for a categorical IM position is worth it. If not, you’re probably better off taking a year off and reapplying.

Another key decision is whether you’d consider a preliminary rather than a categorical position. Whether a prelim position will end up being a career stepping stone or a dead end is highly dependent on your career plans (and what other options you have available).

Second – be honest with yourself about why you didn’t Match.

This may sound strange, because most applicants who SOAP have no uncertainty about how they got there. They’re realistic about the weaknesses of their application; they were just unable to successfully build a time machine so they could apply to more programs, get a higher Step 1 score, or matriculate to a more famous medical school.

But believe me when I say that a minority of applicants have blind spots, and are completely shocked when they learn that they didn’t Match.

Don’t be one of these people. Think critically about how you appear on paper. If you were the program director, what would have made you concerned?

If you ranked your ‘home’ program, you may be able to ask the PD there for an honest assessment. (This could give you some insight into potential weaknesses in sections of your application – like your letters of recommendation or MSPE – to which you don’t have access.)

Again, SOAP moves quickly – and you won’t have much time to sell yourself to programs. Ideally, this exercise should leave you prepared to tackle the perceived weaknesses in your application head on. You’ll have the opportunity to submit a new personal statement and new letters of recommendation, which can be used as vehicles to alleviate specific concerns, too.

Third – make sure you know the traffic rules.

The NRMP has an applicant guide for the SOAP, which includes some helpful nuts and bolts, and also reviews the rules. Two of these rules deserve special emphasis.

First, programs have to contact you. Tempting as it is to reach out to them first (or to have someone reach out on your behalf) you’re not allowed to.

The NRMP is serious about this rule. (You know this because it’s highlighted in red in their guide.) Breaking it may result in a Match violation – which can seriously jeopardize your chance at matching next year.

Second, if you’re in the SOAP, you can only apply for positions that are in the SOAP. You can’t accept an outside-the-match position at a Match-participating institution until SOAP week has ended.

This is particularly relevant to applicants who might consider ‘research fellowship’ positions, as illustrated in the cautionary tale below.

Not long ago, this e-mail made the rounds among otolaryngology program directors.

Last – be good to yourself.

After all that you’ve put into getting in and getting through medical school, going unmatched may feel like the floor just fell out beneath you. It can be incredibly difficult not to let the whims of program directors’ ERAS filters or the vagaries of the NRMP algorithm determine your own self-worth.

But remember this: the potential that admissions committees and faculty have seen in you was not misplaced. You’re still the same person that you were before Match Day, with just as much to contribute to the lives of patients and the broader profession as you did before.

Give yourself permission to grieve, but surround yourself with the people in your life who will help you keep the negative self-talk in check. Whether you’re successful in SOAP or not, this is not the end.

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The End of USMLE Step 2 CS: Winners and Losers Edition

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The Match, Part 5: The Lawsuit

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