I must be honest with you, even though I had incredible scores and a decent number of interviews, every single interview I went, I hoped and wished that I would be offered an out of match offer. While none of the places I interviewed at were problem programs (these are programs on probation or have a bad rap for multiple violations), and I would have gladly taken up the offer should I was provided one, many applicants face a classic Morton's Fork dilemma. Should they accept an offer from the program or wait till the match process has run its course?
There are 2 reasons why an applicant may be offered a out of match offer.
- They are exceptional candidate
- The program does not want to participate in NRMP
Since 2011, the NRMP has changed its policy such that a program has to declare prior to initiation of the match season, if it is going for ‘all in’ or ‘all out’. To explain this in simple terms, a program cannot have few spots out of the match and rest in the NRMP, either they have to open up all the positions and place them in the common pool or stay out of the match algorithm and fill their positions ALL out of match. Typically, programs that are aware or expect to go unfilled at conclusion of the match are the ones which opt for out of match pattern.
If you interview at a program that is not participating in the NRMP match and you are offered a position, please consider very strongly the following factors prior to agreeing and signing any contracts.
Conditions when you should reconsider accepting prematch
1. Work hour and duty violations: many programs in inner cities or poor neighborhood are hospitals that need manpower to keep the place up and running. Residents are often the low wage labor the place needs to keep it running. While 80+ hours per week work was possibly normal in the past, ACGME has devised some ground rules as to how much a resident can work, in order to balance the work:education ratio. If you are not aware why or how the duty hour rules came about then read about Libby Zion Law.
2. Inadequate teaching: this point cannot be stressed hard enough. As a resident, it is your right to have quality education which will help in taking care of the sick and heal the patients. If the teaching at a program is subpar and all you end up doing is scutwork [tasks that are tedious and monotonous or trivial and menial, usually inherent in the operations of a larger project] you are not going to be a good clinician, an astute physician and a critical thinker.
3. Problems with faculty: many programs have issues because a program is as good as the people who run it. It there are personality flaws in the administration and/or faculty then residents will suffer the consequences of poor leadership.
4. Dismissals: do a background check of the place and find out if there were dismissals or dropouts from the programs. If residents have left the program, ask why.
5. Litigation: read up about hospitals or programs getting sued. Also if possible Google search and read through the actual case filed against and for the program. This will help you understand what the issue was if it was system problem or a personnel problem.
6. Financial condition of place: I have done an article on how to check up on the financial health of the institution. If the place is making profit and getting a good patient turnover, then everyone from physician to the patient is going to be happy because the care giver and care receiver will benefit from a healthy economic condition of the institution. However, hospitals with poor economic outlook often have to adopt austerity measures which end up being more of hardship for the hardest working class (residents)
7. PGY1 only: Think very hard before you take up a position if it is only for the first year. You will have a difficult time getting in to a PGY2 position if the program where you did your internship is not willing to absorb you.
8. Unhealthy and unhappy work place: if the place is just sad, then don’t devote 3 years of your life, time, effort and hardship at such a place.
These are some of things to consider, if you are offered an out of match offer. This is also true for many programs in the match process and it is only a matter of common sense, thorough investigation and elementary detective work to help you make the right decision.Of course, if you have no option but one then better to take it than be left with none. Thus use better judgement in taking up the offer. And, yes I was not offered a single out of match offer and since good things happen to those who wait, matched at wonderful place!