After a month of urology residency interviews, setting up the ring light was no longer an issue. I knew which setting to use, how high to place the tripod. But this time I doffed my suit and was wearing my pajamas—my bedhead only outdone by that of my 2-year-old sitting on my lap. After all, February 1, 2022, was going to be a day of celebration. Would I get my top choice? Maybe I’d fall down my rank list a ways. But regardless, I would finally know where I would spend the next 5 years of my training; a thought that was equally exhilarating and terrifying.

Time could not have moved any slower. The urology-inspired cake my wife secretly prepared for me was upstairs in our neighbor’s apartment; she didn’t want to spoil the surprise. Finally, the clock changed to 8:00 a.m., and the anxiety climaxed. 2022 match → Details → Results. *click*

Unfortunately, you have not matched with any programs

Bold. Final. I’ve watched the recording I took on that day several times. You can see the life drain from my eyes the instant I read the result. My wife’s shock began just a fraction of a second after mine. I shut off the video, stammered over to the kitchen, collapsed, and wept. And wept.

For several weeks I was a shell of myself. I had no appetite. I had no energy. Every morning I woke up and the reality crushed me again.

Perhaps the worst part of it all is that my experience was not remotely unique. In 2022, 605 applicants registered, and 365 (60.7%) matched. Of those that interviewed and submitted rank lists (556), 65.6% matched. Nearly 200 people experienced exactly what I did last year, and another 50 also dealt with an uncertain path in urology when they received no interview invites. In 2023, 383 (75.4%) of the 508 who submitted preference lists matched.

Urology is a great field. Applicants are intelligent, compassionate, interesting, and highly motivated. Because the number of residency positions is small, it is inevitable that many applicants will go unmatched. Over the past year, I have reflected on the match process a great deal. I would like to outline some challenges with the current match system and propose ways it can be adjusted to benefit both applicants and programs.

System-level Considerations

1. Lack of Verified Data

As I planned for application season, I looked for all sources of data to try to assess my likelihood of matching. On the AUA website, high-level information for demographics and number of applicants is presented. However, there are no data for many factors that are highly important to residency programs, such as USMLE (United States Medical Licensing Examination) scores, clerkship grades, class quartile, Alpha Omega Alpha/Gold Humanism Honor Society status, number of publications, or other extracurricular involvement.¹ To fill this void, applicants use sources that rely on self-reported data such as a Reddit spreadsheet, Texas STAR, and Doximity Residency Navigator. Unfortunately, each of these sources is limited by response bias and unverified data.

Recently, the Association of American Medical Colleges released the Residency Explorer tool, which uses verified data from several important stakeholders including the National Resident Matching Program (NRMP) and ERAS (Electronic Residency Application Service) to allow applicants to (1) assess their candidacy and (2) identify programs which align with their goals. Because urology does not participate in the NRMP match, applicants can’t use this tool to assess urology programs.

Proposal: Work with ERAS and residency programs to provide verified data, allowing applicants to realistically assess their candidacy compared to matched residents.

2. The Sudden Collapse

The current match timeline causes a sudden emotional drop when an applicant learns they haven’t matched. Within 10 minutes, I went from hoping for my top-ranked program, to lamenting the uncertainty of my path, then being forced to pick up the pieces and quickly start reaching out to programs and mentors about possible next steps. In contrast, the NRMP match notifies candidates if they have matched or not before final match results are released, allowing applicants to process their emotions and next steps asynchronously. In the current system, applicants can hardly afford to wait 1 day to reach out to unfilled programs and research positions, as these positions tend to fill very quickly.

Proposal: Announce binary match results separately from the complete release of match results and encourage opportunities outside the match to wait 1 week before filling positions.

3. Impending Shortages

Current and future urologist shortages in the USA have been discussed and examined elsewhere, and there is a need for more residency positions to address this need.^2,3 Thankfully, the number of positions increased from 365 in 2022 to 386 in 2023, but continued growth is needed.

Proposal: Continue to expand residency programs.

Program-level Considerations

1. Unnecessary Interviews

The interview season is an exhausting time with heightened anxiety and stress. The length of interview days varies; my experience was 2-8 hours, often with 2 hours of informal meetings on the night before the interview. To paraphrase Einstein, “When you sit with a nice girl for 2 hours you think it’s only a minute. But when you sit on a [Zoom meeting] for a minute you think it’s 2 hours.”

Of course, applicants want as many interviews as possible. Interviews represent a chance to learn about a program, assess goodness of fit, and increase the overall odds of matching. However, programs should be judicious about the number of interviews they extend to avoid unnecessary interviews that contribute to the overall bloating of the process. If, for example, a program historically does not match below their 15th choice, it is probably unnecessary to interview 50 candidates, especially if many of the top 10 rank positions will be occupied by individuals who are known to the program (eg, home students, visiting sub-interns, research fellows). If a program conducts fewer interviews and subsequently has an unfilled position, they will be able to fill this position after the match with one of the immensely qualified candidates who go unmatched each year. Additionally, unnecessary interviews may cause an applicant to forgo an interview with a program that would be a better fit, especially since interview invitations are often only date-specific rather than date-and-time–specific.

Proposal: Critically examine the number of interviews conducted, trim excess interviews, and extend time-specific interview invitations to allow better planning for applicants.

2. Lack of Transparency

It is extremely challenging for a candidate to assess selection criteria at prospective programs and determine fit. Of the 135 residency programs with websites, less than half report information about selection criteria, salary/benefits, and call schedule.^4,5 As I reviewed website information before my interviews, I found several programs that had outdated and incorrect information on their website. Other times, information was overly vague and therefore unhelpful.

I applaud Montefiore for their recent publication of selection criteria as part of holistic review during COVID.⁶ If more programs were to similarly publicize their selection criteria, it would allow applicants to assess whether they are likely to receive interviews at different programs. This is particularly salient with the transition of Step 1 scoring to pass/fail.

Proposal: Update information on program websites, including concrete evaluation criteria, program priorities, and salary/benefits information.

3. Need for Improved Counseling

Inevitably, every year there will be some applicants who, despite incredible accomplishments during medical school, go unmatched. However, more commonly there are applicants for whom it would be unlikely to match given their academic performance, USMLE scores, and/or research activity. In these cases, the group that is best suited to advise these applicants is the home program of the applicant. The home program will know how the applicant compares to previous applicants from their institution on important factors related to match probability. This will occasionally require difficult but essential conversations about contingency plans.

Proposal: Home programs should collect relevant data of previously matched and unmatched applicants from their institution to provide concrete career counseling to students.

Applicant-level Considerations

1. Application Fever

The average number of applications increased from 63 in 2015 to 88 in 2023, and the rate of increase has grown in the past 2 years despite the adoption of preference signals. This is a classic prisoner’s dilemma—all individuals face incentives to behave in a way that creates a suboptimal outcome for the collective. This environment bogs down the match market, hinders a program’s ability to assess genuine interest, and costs applicants thousands of dollars each year. Yet, realistically, this trend will not reverse without systemic change because of the incentives faced by the players. Systemic change may include enhanced preference signals,⁷ tiered applications, application caps,⁸ or other interventions. For the 2023-2024 match cycle, the Society of Academic Urologists/AUA elected to expand from 5 to 30 equally weighted preference signals, mirroring the process used in orthopedic surgery.⁹ While systemic changes like this may be initially received negatively by applicants by functioning as a pseudo-application cap, these interventions may be necessary to improve the match market in concert with increased program transparency.

Proposal: Applicants should be open to compromises that may limit flexibility but improve the match process.

2. Unmatched Stigma

Failing to match is, for many medical students, the most feared outcome of medical school. Going through this challenge feels isolating, uncertain, and perhaps even shameful. But it doesn’t need to be.

Graduating medical school is an incredible accomplishment; the culmination of roughly 20 years of education. There are countless hurdles and challenges along the way, and reaching graduation demonstrates incredible resilience and dedication. For urology candidates, there will be opportunities to practice medicine in a field you find fulfilling, even if it is not urology. Ultimately, your job does not define you, your abilities, or your worth.

Proposal: Talk openly about your experience, offer empathy, and reach out to others who go unmatched.

Match day 2023 happened to fall on Groundhog Day. One year wiser, I was ready for the possibility of facing a Bill Murrayian repeat of the 2022 proceedings. But I was filled with joy and relief as I matched to an incredible training program in San Antonio. The recording of my reaction again ended with me in tears, this time tears of relief that I will always cherish. I am thrilled that I have a future path in urology, but my heart aches for those that are experiencing what I did just 1 year ago. With continued effort and compromise on system, program, and applicant levels, we can improve the match process and ensure that we “first, do no harm.”