by Kirsti A. Dyer, MD, MS, FAAETS

Out of every crisis comes the chance to be reborn, to reconceive ourselves as individuals, to choose the kind of change that will help us to grow and to fulfill ourselves more completely.
Nena O'Neill

It doesn't seem possible, but this spring it will be ten years since I went through the Residency Match and ended us scrambling for my internship spot. At the time, the scrambling experience was a monumental life crisis. For the tenth year anniversary of this event, I decided to revisit an article that I had written about the experience [1] and confirm what I knew then, it was not the end of the world.
On some level, I instinctively knew that I wouldn't match. Prior to the match, many of my classmates had received some confirmation from their program choices that they had been ranked highly, practically guaranteeing them a spot. I had not. I had chosen a highly competitive specialty-obstetrics and gynecology-and restricted my interviews to California programs. I had handicapped my chances of a successful match from the start. In hindsight, considering the number of programs I interviewed at and the number of applicants, my odds might have been better at winning the lottery.

On the day prior to match, the day when those who do not match are notified, I still hadn't heard anything by 11:00 a.m. I thought was in the clear, but gnawing doubts caused me to called my medical school.
"I was just calling to check…"
You're glad that I called. You were getting ready to call me? Why?…
You needed to let me know that I didn't match…"
I didn't match…didn't match…. The words echoed in my head. The unspoken fear of not matching, a subject so unpleasant that no one ever discusses it, was now my reality; this was only supposed to happen to those at the bottom of the class. I was stunned, numb. I could barely register the instructions given to me.
It wasn't supposed to happen this way. I'd worked too hard and sacrificed too much for too many years. I should have been rewarded, not punished. So much time, money and effort applying and interviewing for everything to end like this. Then the doubts emerged. How would I restore my shattered self-esteem to make it through the scramble, the following day? Perhaps this was a sign that I wasn't meant to be a physician, a confirmation of my deepest fears that getting into medical school had been an accident, a fluke.

The afternoon passed in a blur calling family and a few friends to tell them the news, to get some support and much needed encouragement. Somehow in the midst of this turmoil, I remembered a quote from Eleanor Roosevelt: "The future belongs to those who believe in the beauty of their dreams." Now all I needed to do was to find some new dreams. I spent the night mulling over my options:

1. Postpone graduating and reapply the following year.
2. Take a one-year transition or preliminary year position.
3. Finish medical school and see what job options existed with just a medical degree. (Michael Crichton seemed to have done pretty well.)
4. Quit altogether.

Next I started weighing my options. First, I had to decide if I wanted to finish medical school. That was easy. Between my loans, my parents and my patients, I had no choice-I had to finish. Postponing graduating and taking another year would result in more financial setbacks and not necessarily strengthen my application. The "Michael Crichton" option had a certain appeal, but I knew it was pretty risky, required talent and a lot of luck to succeed. I also knew that in order to be licensed to practice in California, I needed to at least complete an internship.

Next, I considered my original specialty choice, obstetrics and gynecology. Given the previous year's odds-30 open spots in OB/Gyn and 200+ scramblers-I began accepting that I probably would not match in any of them. And even if I could, was I willing to go anywhere to sacrifice life-style, to leave my family, friends, and home state for a career in obstetrics and gynecology? I had chosen Ob/Gyn halfway through my third year as a compromise field having been interested in aspects of internal medical and surgery. By the spring of my fourth year, with interviews completed and match lists submitted, I was having doubts about this choice of specialty, questioning the stress level, professional liability and obstetrics life-style. The night before the scramble, I could find 20 reasons for changing to internal medicine and few for staying with obstetrics. So I began to create new dreams.

The best option seemed to be taking a one-year transition or preliminary position and hope that as an intern, I would have enough time to decide what to do and then apply for a residency position. I selected back-up programs in internal medicine from the list of unfilled spots.

In the pre-Internet days, scramblers and unfilled residency programs relied on busy phones for contacting programs and fax machines for sending information and applications. (I heard of one person who actually bought a FAX machine so he wouldn't have to wait to use the medical school's machine.) I accepted a preliminary year position in a California internal medicine program, little more than two hours away from my parents, where several of my scrambling classmates had also accepted spots. By 11 a.m., just two hours after the scramble had started, at least for me it was over.

In the midst of the chaotic experience, it is important for medical students to remember that having to scramble is not a sign of incompetency. Contrary to popular belief, scrambling does not happen only to those at the bottom of their medical school class. Not matching is often the result of inadequate planning, insufficient ranking, misunderstandings about a promised position, circumstance, bad luck, a poor original specialty choice, or restrictions on location or life-style. Frequently it is the risk one takes in applying to a highly competitive field with too many applicants for a limited number of residency positions.
It may be difficult for many medical students to believe that something positive can emerge from a negative situation but in many cases it can.

1. Programs that did not consider an applicant initially may select him/her during the scramble. Every year, some prestigious programs do not initially fill. The applicant may get a better spot than ones he/she initially had chosen.
2. Scrambling can help the applicant seriously consider other options. Another specialty may be the best ultimate career choice.
3. The applicant can play a more active role in determining where to spend his/her intern year. (Not all of my classmates were as happy with their matched choice as I was with my scrambled one.)
4. Scramblers can get into good residency programs and become capable, competent physicians

Reflecting on the past, I now realize that part of the reason I may have had difficulty matching was because I didn't match well with any of the existing available specialties in 1992. Many of the areas I was interested in-integrative or complementary medicine, women's health, primary care/ambulatory medicine, palliative care, thanatology (death education), medical informatics, and the psychology of loss- did not yet exist as specialties. These areas have only recently become recognized fields of study.

The experience of not matching and having to scramble, although at first was devastating taught me an invaluable lesson. Much as we might try, we cannot predict or control the future-a hard lesson, but an important one to be learned early in the professional career of a physician.

Looking back on this experience has made me realize how different my life would have been if I had matched in my original specialty choice. Not matching and having to scramble was one of the major events that helped lay the foundation for much of the work I am doing now-educating colleagues and the public in coping with loss and life-changing events and in understanding the grief response. Facing a series of life-changing crises over the years forced me to find out who I am professionally and personally, to turn my adversities into opportunities for growth, re-evaluate my life's priorities and determine what was important for me, for my career, for my husband and for my children. I have learned how important it is to accept what I can control and what I can't. I have been able to fulfill myself more completely than I would have it I had never faced crises. Most of all I have learned the importance of living life. John Lennon may have expressed these sentiments best:
Life is what happens to you when you're busy making other plans.

References:
1. Dyer KA. It's Not the End of the World. JAMA 1993;269(9):1184.
This article appears in the original longer version on the Journey of Hearts website at: http://www.journeyofhearts.org/jofh/resources/world_end

© 2002 Kirsti A. Dyer, MD, MS, FAAETS