From Unmatched To Matched: Looking Back At The Challenging Year-Long Journey Of A DPM To Find An Optimal Residency Program

Nicholas Thompson, DPM, is my guest blogger for this month. As this year’s match is revealed, he writes about his experience as an unmatched graduate and how he used this year to prepare for the career in podiatric medicine and surgery he envisioned for himself. 

By Nicholas Thompson, DPM

I first want to thank Aaron Warnock, DPM, for his 2013 guest article on Dr. DeHeer's DPM Blog, “How An Unmatched Podiatry Graduate is Forging Ahead.”¹ It inspired me while I was going through my own experience as an unmatched graduate. Without that DPM Blog there is no way I would be in the same positive place that I am today. When Dr. DeHeer asked if I would like to contribute my own story, I couldn't pass on the chance to shine a light on my experience and hopefully offer similar hope to any future podiatry graduates who may find themselves in these shoes.

I couldn't help feeling overwhelmed with disappointment in the weeks following the release of “The Match” last year. Our school had tried to prepare the class for the various outcomes that awaited each of us on match day but the anticipation for this humongous career landmark blinded me to any potential reality of not matching. No fourth-year medical students are fully prepared for the moment when they realize the degree they are about to receive is temporarily useless and that their career advancement is being put on hold indefinitely. I was under the impression that the shortage of podiatry residencies was a thing of the past, surely something that a qualified soon-to-be graduate like myself did not need to be concerned about.

This pinnacle milestone of the match would mark my professional transition from that of a medical student to a future hospital's resident doctor. The hurdle transitions of medical school were nearing an end and I eagerly prepared to jump into a new position with added responsibilities. Residency was the next foreseeable chapter in my career, where I could cement and dedicate myself.

Immediately after being informed that I did not match, my future seemed unpredictable and it was honestly a pretty terrifying time for me. Despite this, I somehow managed to maneuver through the scramble process following the match, holding onto a blissfully optimistic mindset that a program would eventually recognize the value and commitment that I offered.

Sharing Some Hard-Won Wisdom About Ranking Residency Programs

The best advice I have for students before ranking residency programs is to know what you want to achieve with your training and to avoid committing somewhere that you know will not provide what you want to achieve. It is impossible to end up at a residency against your will. You must have either committed to ranking the program at some position in the initial match or ranked the program in the scramble.

I have talked with multiple residents who have confided to me their regret in matching to their current residency, the majority of them admitting that they felt inclined to rank their current program as a “safety net” to avoid the potential for going unmatched. I too experienced this same type of frantic "at least lock down something" mindset. While life is full of decisions that require compromise, I am happy I was firm in committing to myself during my residency selection.

For example, I ultimately intend to practice in a small community and I want to receive rearfoot surgery credentials so I am not limited in my treatment options for every potential patient with foot and ankle pathology who comes through the door. As one of my primary residency requirements, I ultimately avoided ranking programs that could not provide this to me. In total, I participated in six residency interviews following Match Day. Four of these programs were desirable to me. The other two programs extended me an offer but despite having been a student extern at both programs before Match Day, I did not wish to commit myself to either one. I will admit to purposely not overthinking either of these decisions at the time. The rotations at both programs confronted me with multiple ethical dilemmas and I reminded myself of my commitment before Match Day on what programs I would avoid ranking.

Ultimately these decisions did cause me a great deal of misery after the fact, considering that I had willingly forgone a guaranteed position and instead pursued other programs that I felt were better fits for me. Looking back on my decision, I know I made the right choice.

The Initial Search For Alternative Options During An Unmatched Year

After overcoming several unavoidable weeks of self-pity, I began planning my comeback. I knew I hadn't stood out enough as a candidate to end up in this position. "It's not as though you were a bad candidate. There were just others that stood out more than you," was shared feedback I received from multiple residents and attending friends. The consistent reply of genuine disbelief after telling someone I did not match also helped me come to grips with my position. The residency application process had exhausted me and I dreaded the idea of going through it all again without having anything to show for my time spent unmatched. I realized I needed to take advantage of every presented opportunity to improve myself if I were to have any hopes of landing a residency program the following year. Another primary concern I faced was how to support myself as I was about to graduate with nearly $250,000 in debt and I was not thrilled with the idea of taking out additional loans.  

One of my first steps was to reach out to previously unmatched Scholl College of Podiatric Medicine graduates who had gone on to match at residency programs and ask how they chose to spend their time between graduation and securing their future residency. The one common denominator in all the advice I received was to stay busy.

Most suggested that I inquire about participating in the Scholl preceptorship program at the school's podiatry clinic. The graduates involved in this preceptorship informed me they had received a stipend in exchange for their time working at the clinic and that the school granted them free enrollment into its master’s program.

After what felt like countless evasions from multiple members of the faculty for my answer, I learned the school clinic would no longer be providing a preceptorship. I found out that since no unmatched students from the previous several graduating classes had chosen to participate in this program, the venture no longer had support. In regard to the school’s master's program, the school had only offered the free enrollment of its master's certificate course in 2013 due to the unusually high number of unmatched graduates that year. I learned the vast majority of those unmatched graduates enrolled into the master's program in 2013 had unenrolled after having secured a residency, as the program had served its purpose as a talking point and presumptive resume-builder during residency interviews. Those in charge had decided against continuing this support, having felt candidates took advantage of this free master's course enrollment after these previously unmatched graduates failed to complete it. I would need to personally enroll and take out an additional $10,000-plus in loans to cover the cost of the master's certificate if I wished to pursue it.

Beyond the typical stresses medical students encounter in the month leading up to graduation, I still had no definite plans for afterward. While my school did provide several soft leads to potential podiatry internships, my inquiring phone calls and emails went mostly unanswered, and no position materialized.

I then decided to contact The Institute for Podiatric Excellence and Development (IPED) and completed an application for their Graduate Management and Clinical Program to be paired with a practicing podiatrist in a region that I wish to spend my year unmatched. The IPED also aims to create a starting point in negotiations between the unmatched graduate and employer by providing a suggested sample contract: compensation of a $15/hour wage, potential benefits, and an agreed upon allotment of paid time off for continuing the residency application process. I was eventually paired and met with a very successful podiatrist who affiliated himself with a residency program.

The IPED had never employed an unmatched graduate before but informed me that my position would be equivalent to that of their medical assistants: rooming patients, cleaning rooms, observing patient care, and little to no surgical exposure. When I inquired about my ability to contribute more significantly to the practice, the program informed me that it was not comfortable with allowing me to perform nail or callus care on patients as I did not have an active license and the IPED was not familiar with the potential medicolegal repercussions. The finale of this introductory meeting was the discussion of my compensation, which the program informed me would be “considerably less” than that of the suggested IPED sample contract. This visit left me deflated.

While appreciating this physician's willingness to open a door to me during my time unmatched, I couldn't help but feel strong-armed in the negotiations. I yearned for the opportunity to contribute to a podiatry practice by engaging my hand skills and the thrill of working in the operating room had been one of the reasons that drew me to becoming a foot and ankle surgeon. I wanted more.

I did not feel ready to celebrate but my graduation attendance was an implied obligation by my parents. I cringed at the idea of being surrounded by all of my cheery classmates and being faced with the unavoidable question, "So what are you planning on doing now?" I wanted an answer that would allow me to reply proudly.

How A Paid Preceptorship Made A Significant Difference

Graduation was now just two weeks away, and I found myself returning religiously to reread an article from PodiatryToday.com that I had stumbled upon months prior written by a previously unmatched graduate and his excellent preceptorship experience.¹ I wondered how was this person—who was just like me without an active podiatry license—able to perform nail and callus debridement, give injections and assist in surgical cases? Although I had never met or admittedly known of Dr. DeHeer, I decided to send him an email. Convinced that another unmatched graduate like myself must have already contacted him, I was merely looking for an answer to how he was able to offer these opportunities to someone without a license to practice in what sounded like an ideal position.

I was beyond shocked to receive an email reply in just seven minutes. Dr. DeHeer briefly informed me that he had treated this previous unmatched graduate like a physician's assistant, acting as an extension of himself while in the clinic and the operating room. He allowed this intern to provide care and checked that each of his patients had satisfactory treatment to maintain the malpractice coverage for the office visit. He ended the email: "Are you interested in Indy?"

The next week, I made arrangements to drive down to Indianapolis and meet Dr. DeHeer at his practice Hoosier Foot & Ankle. He informed me he was not willing to offer a position blindly and he first wanted to make sure I would be compatible with his practice. As he was now training a fellow, Dr. DeHeer admitted this may reduce my opportunity for first-assist cases but noted that I would still be able to either assist in or observe all of his surgeries. At the end of my visit to Indianapolis, Dr. DeHeer extended me the offer of a paid preceptorship position at his practice until I was able to secure a residency of my own. I graduated in Chicago two days later with a renewed confidence in continuing my training as a podiatrist.

The opportunity to work in this thriving practice as an extension of Dr. DeHeer and his fellow has been fantastic. They treat me as an extension of them both, performing all levels of patient care necessary from dispensing orthotics to ulcer debridement. The ability not only to maintain but also improve upon my hand skills before beginning residency has been invaluable to me. My problem-solving skills are challenged routinely as a clinician in training as Dr. DeHeer regularly receives patient referrals with unique and challenging pathology from other providers in the area.

One thing I have grown to appreciate while training under Dr. DeHeer is his dedication to practicing evidence-based medicine. He is a firm believer in using research to justify his treatment approach. There are also many valuable lessons I have taken away from being continuously engaged in charting patient visits and preparing billing statements before Dr. DeHeer's review. I receive ample opportunity to observe his hospital-based surgeries and can scrub into surgical center cases on a regular basis.

Currently holding multiple positions within the American Podiatric Medical Association (APMA), Dr. DeHeer has actively encouraged my attendance at numerous meetings of our profession during my time working for him. Last fall, I was able to visit Nashville for the APMA National and will return there for the American College of Foot and Ankle Surgeons annual meeting as well as both the annual Indiana and Michigan state Podiatric Medical Association conferences.

Words can't express how valuable my early exposure to these troves of knowledge has been and this foundation will only expand as I continue further in my residency training.

My chance to work for a leader in the field of podiatry has provided me with many experiences that I would otherwise never have encountered. A certified pedorthist extended me an unexpected scholarship for enrollment into an Indiana-based pedorthics school. This pedorthist had trained under Richard Lundeen, DPM, the same mentor who served as Dr. DeHeer's residency director. I would recommend this ten-day boot camp of a course to anyone looking to strengthen their comprehension of clinical biomechanics.

I left podiatry school feeling weak in my ability to interpret and implement knowledge of this field. It felt like a hurdle that I and a vast majority of my classmates quickly scrambled to overcome to begin learning the more “sexy” topic: surgery. Throughout my preceptorship, I have fortunately been put on the spot countless times in the operating room by my current mentor, who embodies his mantra that “A surgeon should not be performing any part of the operation without first knowing the biomechanical repercussions.” I couldn't help but appreciate the similarities drawn by Pam Haig, CPed, the Dean of the Robert M. Palmer, MD, Institute of Biomechanics, Inc., who regards herself as a surgeon without a knife. The wealth of knowledge that I have been exposed to while studying under these two masters of biomechanics, Pam Haig, CPed, and Dr. DeHeer, has easily justified any of my initial discontent after going unmatched. 

My appreciation for sports extends to the responsibility and pride that I receive from returning an athlete to the activity that gives his or her life meaning. While I once personally considered myself an avid fan of basketball, Dr. DeHeer humbled me with his knowledge and dedication to the game from high school through the professional level. For several decades, he has served as the podiatric consultant to the Pacers as well as the Fever, Indiana's NBA and WNBA teams. He is open to sharing his learned strategies for treating these elite athletes, and I was fortunate to co-author a piece with him several months ago in Podiatry Today titled, “Keys To Managing Heel Pain In Basketball Players.”² The article highlighted the vast treatment armamentarium available to practitioners looking to efficiently return a basketball player with plantar fasciitis to the court.

There are currently a mixed handful of other research projects and articles that Dr. DeHeer has encouraged my involvement with, and I just wish I were able to keep up with bringing all of his many ideas to fruition. Research is another topic that had once severely intimidated me but I have learned that publications are nothing more than translating knowledge into words and the only person that should be intimidated by this process is one with no experience to share.

Now a year has passed since I found myself in the position of being unmatched and temporarily questioning my entire career's future. I expected to be lead down many disappointing roads of compromise and never could have imagined the 180-degree return to confidence in my future that awaited me 12 months later.

I was recently thrilled to find out I secured a residency this year, and because of the approach I took this time around I am assured it will be an outstanding program. It was mildly upsetting during my residency interviews how many programs chose to advertise themselves as being "not very academic." These swiftly moved to the bottom of my list. I knew I needed a program that wasn't identified as a “country-club” residency but preferably one that would continue to challenge me. I want my training to leave me prepared to manage any disorder below the knee that can potentially show up in my office once I begin practicing. Two topics that interest me the most are trauma and plastic surgery reconstruction related to skin and muscle flaps. Whichever residency I land this week, it will assuredly offer ample opportunity for exposure to both of these fascinating topics.

‘Consider This An Exercise In Patience’

This advice came from a faculty member at my school the day after the match. While this comment initially left a bitter taste in my mouth, I came to appreciate the sentiment.

I admittedly have never been a very patient person. However, I often tell patients who have grown frustrated with the sluggish progress of their healing that "Good things happen slowly and bad things happen fast." I was not about to let myself quickly pivot out of this career that I had worked so hard to get into and that I continue to care so passionately about. After patiently embracing this process, it has since turned into the single most significant opportunity of my adult professional career. I had a chance to build on my strengths, confront my shortcomings and meet plenty of great new people along the way.

I was fortunate to be taken under the wing of a phenomenal mentor who has opened my eyes to the impact physicians can have beyond their patients, sharing their insights with their colleagues and giving back to their profession. While I don't wish any future graduate to go through the experience of going unmatched, there was a fortunate silver lining to my story. I want to encourage any physician contemplating taking an unmatched medical graduate into a practice. You too will receive the same unwavering gratitude that I can only assume you might gather from my accounts of this experience.

How We Can Change Match Day For The Better

The match day process has received one significant overhaul in comparison to years prior.

This past Monday (March 19), all residency applicants were informed if they had matched. The subsequently unmatched applicants then get the week to participate in the scramble process. Meanwhile, all applicants who had successfully matched sit idly by throughout the week until this Friday (March 23), when everyone is informed where they have matched. I understand the logic of this changed process only too well.

It was a horrible day for myself and my fellow unmatched classmates to be surrounded by our recently matched classmates who were celebrating their residency placements. While the match celebration raged on for the next several days, we were forced to put on our blinders as we continued to search for vacant residency positions.

Providing the unmatched with a head start in securing a residency program through the scramble process before releasing all of the residency placements is a well thought out means of softening the blow from this massive disappointment during an already stressful time. There is no doubt there are many naysayers among the initially matched residency applicants about this new process as it delays their celebration. I feel that postponing the release of Match Day is a great thing, and may serve as an exercise in patience.

References

1. Warnock A. How an unmatched podiatry graduate is forging ahead. Podiatry Today DPM Blog. Available at https://tinyurl.com/yarx4d3u . Published Dec. 19, 2013.

2. DeHeer PA, Thompson N. Keys to managing heel pain in basketball players. Podiatry Today. 2017; 30(11):28–37.

Contact Dr. Thompson at nicholas.thompson@my.rfums.org.