Along with 14,356 other fourth-year medical students in the United States, Tanya Smith and Jose Prince took time off from school this winter to make one of the most important, and long-lasting, decisions of their careers—choosing a residency. Because they will spend the next few years of their lives learning their specialties, they wanted programs that would offer the best training possible with top faculty. They also stirred into the blend personal considerations such as geography and lifestyle. Then they further complicated the mix—they applied as a couple.

That meant they would have to find medical centers with strong programs in obstetrics and gynecology, as well as surgery, the specialties Smith and Prince are pursuing. They would have to agree not only on a list of up to 20 programs they found desirable, but rank them in the same order of preference. Then, one of those programs would have to accept both of them.

In the 48 years since the National Resident Matching Program began pairing residency programs and newly graduated physicians, much has changed. Applications are filed electronically, rather than on paper. Applicants get their first view of programs on the Internet rather than in a brochure or on a campus tour. Applicants are increasingly likely to be women and more likely to marry other physicians. Although the Match has always tried to keep couples together, in the early 1980s a new computing algorithm for couples formalized the process. This year, according to the NRMP, 508 couples entered the match and 475, or 95.3 percent, were successful.

But it’s not easy. Between Dec. 3, 1999, and Feb. 4, 2000, Smith and Prince visited a total of 38 residency programs. Smith started at the University of Connecticut, flew to North Carolina the next day, then returned to Hartford for a three-hour layover before catching a plane to St. Louis. From there she flew to Michigan, interviewed in Ann Arbor and returned to Connecticut. She had interviews on Dec. 9, 10, 13, 15, 17 and 18 and Jan. 3, 4, 7, 8, 10 and 29.

Prince drove to Boston three times, crossed the country twice and racked up more than 20,000 travel miles. “You end up flying into one place,” said Prince, “then immediately flying out to another place.” He once left his parents’ home in New York City at 3:30 a.m. to drive to Pittsburgh and save on lodging. He managed to avoid hotels throughout his interview marathon by staying with friends. In early February he spent his first night in New Haven in six weeks.

Increasing the Odds

Smith and Prince, who met in their first year of medical school (they were elected co-presidents of their class), hedged their bets when matching. Instead of the dozen applications a single student might make, Smith applied to 30 medical centers and Prince to 25 before they narrowed their choices. By Jan. 29 the traveling was over for Smith and she turned her attention to completing her thesis. Prince finished his interviews on Feb. 4, at Yale. But the hard part lay ahead—considering their choices and making a priority list. “We agreed on number one, but couldn’t agree on two, three, four and five,” Smith said. “We tried to come up with the best combinations so that one of us wouldn’t have to compromise.”

Both decided in their undergraduate years to become doctors. Prince, whose 90-year-old grandfather retired as a pediatrician in Cuba just four years ago, said he’d always enjoyed science and believed medicine “was a wonderful way of spending my life, helping other people.” As an undergraduate at Georgetown University he majored in biology. Smith, also a biology major, originally planned on becoming a pediatrician and spent the year following her graduation from the University of California at Berkeley doing research in a children’s hospital. In medical school her interest shifted to obstetrics and gynecology. Both she and Prince took a fifth year to complete their medical studies. Smith worked in a lab studying breast cancer, where she co-authored a paper on the genetic basis of the disease that was published last year in the Journal of Clinical Oncology. Prince spent a year doing basic science research on diabetes at the National Institutes of Health.

As they investigated residency programs, they looked for more than good training. Just as it is for many in today’s workforce, lifestyle is an important factor for medical students. They want a program that will allow them to become highly skilled. Reputation is important, as is stability. Given the volatile finances of academic medicine in recent years, they want to be certain the program will last. Single students may prefer large cities, where they have a better chance to make another kind of match. Some students avoid programs with reputations as “boot camps.” Others may want to be near family or otherwise ensure that the program is in a desirable place to live. Both Smith, who grew up in the Bay Area of California, and Prince, from New York City, were under pressure to be near their families.

“The thing everyone is looking for is a place with a strong reputation in whatever field it is that you’re in,” Prince said. “The most important thing for me,” says Smith, “is a place where I can fit in, get very good clinical training and that will give me options for the future.”

This is perhaps a lot to ask for, but at Yale most students match to one of their top choices. According to Cynthia Andrien, assistant dean of student affairs, 90 percent of this year’s class matched at one of their first three choices, and 94 percent got one of their top five. Nationwide, about 86 percent of the more than 20,000 U.S. and foreign medical students who applied matched to one of their top three choices at 3,769 residency programs in the country.

Streamlining the Process

The Match began in 1952, an answer to the frustrations of medical students who too often felt pressured to take a bird in the hand. Programs offered positions and demanded immediate acceptances before students knew all their options. The Match ensured that everyone learned where they had been accepted on the same day, the third Thursday in March.

At Yale the process starts in the third year of medical school with faculty-led workshops describing the process and preparing students for interviews. It ends almost a year later when students open the letters that tell them where they’ve been accepted. Those letters are final. Upon entering The Match, students agree to abide by its decision. “If you make the wrong call and end up at the wrong place, it’s a big chunk of time,” says Prince.

Making the perfect match begins and ends on the Internet. Smith and Prince started with tours of Web sites, and by the Nov. 19 application deadline they had narrowed their choices. Like most Yale medical students, they filed their applications electronically, submitting them on computer disk to the Office of Student Affairs, which added deans’ letters and supporting documents to the file.

One thing hasn’t changed in the electronic age. Applicants still have to travel to interviews that afford them a chance both to make a good impression and take a look at residency programs. Along the interview trail they run into the same people again and again. First viewing them as competitors, Prince and Smith began to see their peers as future colleagues and friends. “You think, ‘I hope I end up with this guy because he will be fun to work with,’ ” Prince said, adding that he kept in touch with his new acquaintances by e-mail and often made dinner dates at future interview locations. New friends on the trail also provided information they couldn’t get elsewhere. “They were one of the most valuable resources,” Smith said. “They had been to the same places as I had been, but had different impressions or met a different faculty member.”

Medical students and residents provided a fuller picture of each program. “People are so eager to tell you about the positive components of their program and they are very slow about telling you their faults. Caveat emptor,” says Prince. “It’s usually a red flag if you don’t get to meet the residents.”

Interviews followed a pattern—an introduction and orientation over coffee and donuts, a round of three or four interviews, lunch and a tour. Some interviewers were familiar with his resume, said Prince, while others appeared to be leafing through it for the first time. The first set of interviews in December was daunting, he said. By February the trick was to answer a question for the umpteenth time without sounding rehearsed.

With interviews over, the Match’s final deadline loomed in February. By 11:59 p.m. on Feb. 16, Smith and Prince had to log onto the NRMP’s Web server and submit their list of choices, in order of priority. Number one on their list was the University Health Center in Pittsburgh.

The Match

The day of reckoning arrived on March 16. Assistant Dean Andrien, accompanied by Nancy R. Angoff, M.P.H. ’81, M.D. ’90, HS ’93, associate dean of student affairs, carried a stack of about 100 letters to the ground-floor mailroom at Harkness Hall. Ignoring the eager and expectant faces around her, Andrien closed the mailroom door and began placing letters in slots. Outside, the tension was growing. “You could not pay me enough to relive this week,” said Megan Lisska, who, along with her boyfriend, Matthew Falk, had sought a pediatrics residency. They weren’t matching as a couple, as Prince and Smith had done, so there was a chance they would end up apart. “This process is brutal,” said Lisska.

Prince arrived, gave Smith a hug, and the two went off to find their friends. Along with their classmates, they had been relieved to learn on Monday that they had avoided The Scramble. Although most Yale medical students get one of their first choices, the occasional few fail to match anywhere. They may have chosen only the top programs in highly competitive specialties, or they may have decided not to include a safe program on their list and been unpleasantly surprised. The Scramble is a last-minute race to find a residency slot. Students may opt to spend a year doing research or accept a preliminary residency for a year before trying again.

A few minutes before noon, an over-eager student popped his head into the mailroom. He was shooed out. “I have 11:59,” said Angoff with a mock frown, as she and Andrien slipped letters in mail slots. Then she laughed. “OK,” Andrien said. “Let the craziness begin.”

The students started streaming in. Some were in tears before they even got to their mail slots. Others held hands with friends. Some ripped open their letters and started cheering. Others left the mailroom with their letters unopened.

Lisska and Falk had reason to celebrate. They both would be going to Stanford University in California. “We got our first choice,” Lisska said.

This year’s class continued a trend away from specialties and towards some form of general medicine. About two-thirds of the students chose residencies in internal medicine, primary care, pediatrics or obstetrics and gynecology. Programs in Boston drew the most students in this class, 21, followed by New York City, where 17 students found residencies. Sixteen students chose to stay in New Haven for residencies at Yale-New Haven Hospital. (For a complete list of placements, see Student News)

Outside the mailroom, Smith and Prince were celebrating their joint acceptances at University Medical Center in Pittsburgh, their first choice. “It’ll be a great place for us,” Prince said. “The professors are down to earth. They have a good sense of balance between work and play.” Tanya nodded, tears in her eyes. “I’m so happy,” she said. YM