A Two-Stage Match: Winners & Losers Edition

This week, the National Resident Matching Program issued a call for public comment on a proposal to replace the current matching system with a two-stage match.

The idea is this: get rid of the Supplemental Offer and Acceptance Program (SOAP) – the chaotic 3-4 days during Match Week when unfilled programs and unmatched applicants frantically try to find each other – and replace it with a more orderly period of application review, interview, and rank order list submission. It’s an interesting proposal that would generate a number of tradeoffs.

So who wins – and who loses – when we move to a two-round matching system?

Yup, you guessed it: it’s time to break it down, Winners & Losers style…

LOSER: Match Day celebrations.

Medical schools have grown accustomed to hosting a single Match Day celebration. But now, they’ll have to throw two: one in February, and one in March.

If approved, a two-stage matching system – with two Match Days – could be unveiled as soon as 2024. (Graphic from the NRMP.)

Since >90% of graduating MD and DO students typically match, the February Match Day would be the big one, while the March celebration may be more an expression of relief than joy.

WINNER: Senioritis.

You can make a good argument – and many have – that the educational value of the fourth year of medical school is low. The Match looms large, and once it’s over, many students are effectively checked-out till graduation day.

With Match Day in February, the most intense phase of medical student senioritis would last an extra month, during which students will continue to pay full-price tuition for what is likely heavily discounted educational value.

WINNER: Most applicants.

An early Match Day ain’t all bad… it would give successful applicants an extra month to plan their move, find a job for their significant other, arrange a work visa, or just enjoy life without the uncertainty of “where will I be for the next 3-7 years?” hanging over their heads.

And since most applicants match, the majority of applicants could find a two-stage match beneficial.

Most applicants match.

LOSER: The other applicants.

It sucks to be unmatched.

Justified or not, many unsuccessful applicants cope with intense feelings of failure, shame, and fear as they enter SOAP week. But at least SOAP is over quickly. Now, initially unsuccessful applicants will face several weeks of uncertainty.

For some, this will be offset by the opportunity to fully consider their options. But for others, the extra time will simply prolong their suffering.

Advertisement for the NRMP, highlighting their algorithm (c. 2014).

WINNER: The Roth-Peranson algorithm.

Instead of offering or accepting individual offers in SOAP, applicants and programs in the second round would submit a formal rank order list and let the NRMP’s algorithm do its magic.

(Wanna know how the NRMP’s algorithm works? Watch the NRMP’s video here. And if you wanna know the undertold stories of the trainees whose contributions shaped the algorithm into its current form, give me a few minutes of your time here and here.)

WINNER: Holistic review.

Program directors for unfilled programs are under intense pressure during SOAP week. There are a ton of applications, and the tight schedule doesn’t exactly permit leisurely pipe-sucking and beard stroking while sitting in an overstuffed chair and carefully poring over ERAS files. Application review is quick and dirty.

But with an extra couple of weeks to review applications, it’s possible that PDs could be a little bit more deliberate in their evaluations, rather than defaulting to the most convenient filterable metric.

Around half of the positions available in the SOAP are preliminary (PGY-1 only) positions.

LOSER: Holistic review.

Of course, it’s also worth noting that around half of the positions typically available in the SOAP are preliminary (PGY-1 only) positions. Some of these prelim surgery and medicine programs don’t even bother interviewing applicants during the regular application season, preferring instead to efficiently snap up their future interns with quick offers in the SOAP. It’s not clear that these programs would have much interest in holistic review, even if given the time to do it.

Moreover, even if a two-stage match does make holistic review easier in the second round, it may make it harder in the first.

Most interview offers are extended within ~4 weeks of ERAS opening, Data from Thalamus.
(n.b. – Due to COVID-19, ERAS opened on October 21 for the 2020-2021 interview season. It will open on September 28 this year.)

Remember, programs will need to have their interviews completed and rank order lists submitted by early February – so there may be even more pressure to review applications rapidly and get interviews started in the fall.

(This will be less problematic for specialties like OBGYN, general surgery, orthopedics, and dermatology, which have committed to common interview notification dates – and could increase pressure on other specialties to do the same.)

LOSER: Future innovation.

Pulling off a two-stage match within the constraints of the typical September-to-March application season is logistically possible… but it will be tight. There really won’t be room to add anything else without pushing the application season back into August. (That’s a non-starter, as it would put pressure on applicants to line up LORs and take USMLE Step 2 CK even sooner; pressure on deans to write the MSPE earlier and with less information; and pressure on PDs to evaluate applications while their current interns are still wet behind the ears.)

One unintended consequence of a two-stage match is stifling any innovation that might require another calendar shift. For instance, crowding the calendar would make it nearly impossible for programs to offer no-pressure ‘second look’ visits after the program has submitted their rank order list, but before applicants submit theirs. Similarly, the tighter calendar would foreclose the possibility of an Early Result Acceptance Program (ERAP) as proposed for OBGYN.

(In fairness, the NRMP has shown little appetite to shift their calendar to allow no-pressure ‘second look’ visits, and they’ve come out in formal opposition to the OBGYN ERAP – so this may be more of a hypothetical loss.)

LOSER: Away rotations and “audition” electives.

With the rank order list submission deadline pushed up by nearly a month, applicants will have less time to do away or ‘audition’ electives. Whether this is a good or bad thing depends on your point of view.

In the most competitive specialties, a substantial portion of applicants matched at programs where they completed their ‘audition’ rotations. (From Winterton et al, BMC Med Educ 2016).

Away rotations have become increasingly important for selection, especially highly competitive and surgical specialties. But the away rotation arms race is also a source of financial toxicity and inequity for applicants. So while away rotations themselves may be a loser, it’s not clear whether applicants as a whole would be.

WINNER: Application caps.

In 2022, over 47,000 registered applicants competed for over 39,000 residency positions in the Main Residency Match. That’s a ratio of 1.2 registered applicants per position in an application season that plays out over 5 months.

The number of positions available in the SOAP has increased in recent years… but still reflects just 5.8% of the positions offered in the Match.
Graphic from 2022 NRMP Main Residency Match report.

In contrast, just 2262 positions were available in the SOAP, with 12,836 eligible applicants vying for them. In other words, there were 5.7 applicants per position during an application period that plays out over 4 days.

To cope, the NRMP and ERAS have imposed some traffic rules that apply during the SOAP but not during the main match. For instance, SOAP applicants are not allowed to contact programs (so that program directors aren’t overwhelmed in last-minute ‘love letters’ from applicants desperate to find a position).

But the biggest difference is that, in contrast to the unlimited applications you can submit in the regular season, SOAP applicants are limited to submitting just 45 applications.

Even if you expand the time available for review, it hard to imagine a functional system in which unlimited second-stage applications could be allowed. Try it, and many applicants will apply for every position available – giving attractive categorical programs that are trying to fill 1 or 2 positions >10,000 applications to review.

Of course, if there is an application cap during the second stage of a two-stage match, it may normalize caps – and make program directors wonder why there isn’t a cap for the first stage.

(You all know I’m an application cap guy – so I see this as a potential benefit.)

Gimme a chance to convince you that we need application caps. YouTube

PUSH: Stigma.

In theory, getting rid of the SOAP would eliminate the stigma that still attaches to programs and applicants who participate in it.

In reality, this stigma will just get transferred to the programs and applicants who participate in the second-stage of the Match.

For programs, this may not matter. Programs that don’t fill in the Match are identified in the annual NRMP Main Residency Match report. – and applicants notice. Presumably, applicants will regard programs that fill only in the second stage with the same suspicion.

But for applicants, a two-stage system makes anonymity impossible. An applicant who SOAPs into the program is indistinguishable come July 1. Unless they choose to tell their colleagues that they got in on a last-second Hail Mary, their co-residents are none the wiser.

But with a two-stage system, an applicant who doesn’t Match in February is gonna miss out on the initial celebration, group e-mails, the inside jokes in the group text chat, etc. – and may show up in July feeling even more like an impostor.

Match rates by specialty and applicant educational background (MD, DO, IMG) in the 2022 NRMP Match.

PUSH: Match rates.

Curiously, some of the initial chatter about this proposal is how it will improve the Match rate for some particular group. I don’t see it.

The Match is a zero-sum game. One applicant gets in; another is left out. Unless you change the number of positions available (or the number of applicants for them), you’re gonna have the same number of winners and losers, whether you have one round of matching or 20.


A two-stage match would most benefit the applicants who match in the first round. It might benefit some applicants who match in the second.

But it will come at the cost of a more compressed interview season; a bit more pressure on programs to rapidly review applications and conduct interviews; increased stigma for applicants who match in the second round; the loss of traditional Match Day celebrations; and less flexibility for future innovation.

Whether a two-stage match is a net benefit or not depends how you weigh those payoffs… so I’d encourage everyone to submit their comments to the NRMP by September 2, 2022.


Match Day 2022: Winners & Losers Edition

The Case for Residency Application Caps

The Match: The Movie

The Residency Selection Arms Race, Part 2: Anatomy of an Arms Race