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A word on CaRMS...

Updated: Mar 25, 2022

"You are afraid of surrender because you don't want to lose control. But you never had control; all you had was anxiety."

So goes a quote from Elizabeth Gilbert, which hits extra close to home during what is colloquially termed 'CaRMS season' in the world of medical trainees.

For those who may not know, the Canadian Residency Matching Service is an organization that is responsible for determining the collective futures of graduating medical students across Canada. Through its much-discussed though ever-elusive algorithm, CaRMS seeks to match as many hopeful graduates to their top choice residency programs as possible. Doesn't sound so bad, hey? Let me elaborate a little bit on how it works.

While the algorithm is said to favour the applicant, there is truly no way to 'game the system' so that you get what you want -- there are simply too many moving pieces. Your fate depends not only on what you want and your interview performance in trying to achieve that, but also on how many other people applied to and ranked the programs that you are interested in, as well as how you stack up against everyone else on each program's own rank order list. So, while you can do your best to try and ensure you match to a particular specialty at a particular program, in the end, it is somewhat of a crapshoot. And no matter how it all shakes out on Match Day, by including a program on your rank list, you are entering a binding contract to train with them. You were hoping for your #1 choice of internal medicine in Victoria, BC, but matched to your #12 choice of obstetrics/gynecology in Hamilton, ON? Better call the moving company -- the next 5 years of your life awaits!

This puts applicants in a bit of a (potentially very expensive) predicament. Should they apply to 20 different programs (at $55 a pop on top of the $300 it costs to enter the match in the first place) to maximize their chances of matching SOMEWHERE? Or, should they only apply to 5 programs, knowing that adding anything more would risk having to move to a city they don't want to be in, or training in a specialty that they don't really want to do? It seems like an impossible choice; personally, I think it mostly boils down to how a person answers these four questions:

How much clarity do you have about what you want?

How confident are you that you will be able to achieve it?

Is the worst outcome not matching at all or matching somewhere you don't want to be?

How much uncertainty are you willing to tolerate throughout the process?

Ah yes. Not matching. Did I forget to mention that? After slogging through 4 years of gruelling studies and clinical rotations to complete medical school (plus however many years of post-secondary education you did before that), there is STILL a chance that you will not match to a residency program. This means that you can either enter what is called the 'second iteration' of the match and apply for whatever positions are leftover after the first iteration; or, you can do a 5th year of medical school (including tuition!!) and try again next year. I wish that this was a joke, but it is not. I wish that this doesn't happen to people, but it does. I wish for the people that it happens to that it isn't a complete and total shock, but it is.

Now, the vast majority of students WILL match. And there is advice and career counselling available along the way to help students maximize their chances of matching. For example, if I really want to do a specialty that only has one seat per school for an incoming resident (which, thank goodness, I do not), I would probably either apply to every program across the country that has that specialty, and/or I would apply to other specialties closer to home that have higher numbers of seats for incoming residents. If the worst outcome for me is not matching, then I will do this even if on some level I hope I will not match to the whole second half of my rank order list. It is a mix of strategy and pragmatism. But again, total crapshoot.

During a regular year, students have the ability to travel around the country in their fourth year of medical school doing various electives to 'test out' the different programs to see which schools and cities might be a good fit for them. Then, when the interview period rolls around a few months later, applicants would fly around the country to all of these sites AGAIN. Perhaps this sounds a little over the top (and again, expensive), but at least applicants knew what they were signing up for when they ranked a program.

The classes of 2021 and 2022 were not afforded this same luxury. Due to the COVID-19 pandemic, all inter-provincial electives were cancelled, and residency interviews went virtual. This meant two things: 1) We were going to save a LOT of money, and 2) We were going to have to go in somewhat blind to one of the biggest decisions of our lives.

At a time like this, do you trust your intuition, or fall back on trying to logic and reason your way through it? What if trusting your intuition actually means you need to go out there and gather more information? I love this quote from Brené (cmon, you knew this was coming) in The Gifts of Imperfection:

"Sometimes our intuition or our gut tells us what we need to know; other times it actually steers us toward fact-finding and reasoning. As it turns out, intuition may be the quiet voice within, but that voice is not limited to one message. Sometimes our intuition whispers, "Follow your instincts." Other times it shouts, "You need to check this out; we don't have enough information"..."

As it pertains to the match, there is a bit of a problem in trying to 'trust your gut'...

"...In my research, I found that what silences our intuitive voice is our need for certainty."

What might this look like in the context of CaRMS? Instead of listening to what someone's inner voice is telling them to rank first, they might start asking everybody else what they think they should do with their rank order list, in order to absolve themselves of the anxiety caused by the uncertainty of whether their decision was the right one. Their intuitive knowing is clouded by the opinions of others, but they don't notice because they are too busy being comforted and reassured about their decision and their need for certainty by everyone around them. This is a slippery slope if what everyone wants for you is not actually what you want for yourself. But I digress...

If you have made it this far, you are probably wondering where I fall along the spectrum of this tolerance for uncertainty. And I will say that the way I handled things this year was profoundly impacted by the learning and the work I have put into myself over the past year or two. In fact, if you met me four years ago and asked me these questions, the answers would have been profoundly different. But here it is as it stands today:

How much clarity do I have about what I want?

On choosing psychiatry as a specialty, I am very clear. I have spent a lot of time reflecting on myself and my values, and what kind of career in medicine would bring me the most joy and meaning.

How confident am I that I will be able to achieve it?

This one is trickier. I do feel fortunate to be drawn to a specialty that has many (though not a ton of) seats. I feel that I have a natural affinity for the work, and that I have found the thing that I was put on this earth to do. I also feel that my genuine love of and passion for psychiatry came through in my interviews. I hope that programs see the same potential in me that I see in myself, but of course, I can never be sure.

Is the worst outcome not matching at all, or matching somewhere I don't want to be?

For me, matching somewhere I truly don't think I would be happy, or matching to a specialty other than psychiatry, would be worse than not matching at all. Sound dramatic? Maybe to you, but the way I see it, if I am clear about what I want, then it is absolutely worth a victory lap of medical school to get it. I am more scared of being stuck in a place and/or job that makes me miserable than I am of being perceived as a'failure' by others if I don't match. My self-worth is not tied to the outcome of the match; it is, however, tied to how true to myself and to my values I am.

How much uncertainty am I willing to tolerate throughout the process?

I think the answer to this is actually 'quite a lot', because even if the worst happens, what I know for certain is that life goes on. Do I have less 'chances' to match because I have a smaller rank list? Yes. Do I have a higher likelihood of not matching at all for this same reason? Probably, yes. Do I have a greater shot at matching to a program that I am genuinely super excited about? Also, yes. When you know what you want and are clear about why you want it, it gives you a new perspective.

So... it is safe to say that the whole CaRMS process is inherently stressful and full of uncertainty. And, unfortunately, not everyone will be happy on April 12th when Match Day rolls around.

My hope is for those of us who are happy with our results, that we may find it within ourselves to celebrate with both humility and grace. And for those of us who are not so lucky, that we may find the courage to be vulnerable and to reach out to someone close to us who has earned the right to hear our story.

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