The initial process when going unmatched is, of course, the Supplemental Offer and Acceptance Program (SOAP). Detailed overview of the SOAP process can be found elsewhere but to highlight one particular consideration: Give some serious thought to the specialties you will try SOAP into. Available anesthesia spots are a given. As above, alternative positions should be those that will put you in a good position to reapply—internal medicine residency or surgical/medical/transitional preliminary internships are probably your best bets. Family medicine is another option, but it may be more challenging to work directly alongside anesthesiology faculty in this setting depending on the program. That being said, you will see many other positions available in the SOAP (radiology, pathology, etc..) some of which may be easier to obtain but not set you up as well for reapplying to anesthesia. The decision to apply to those is ultimately up to you and how strongly you feel about pursuing an anesthesiology training position in the future.
Preparing to Reapply
The match happens in March and you will reapply in September. That leaves approximately six months to prepare. Goals should include a strong performance on the USMLE Step 2 and making connections in the anesthesiology world to obtain solid letters of recommendation and a network of faculty members that can advocate for you in the next match cycle. If possible, you could arrange another elective in anesthesiology at your medical school before fourth year is done. If you start residency training in your backup field, try to reap the benefits of your program—whether it’s internal medicine or surgery, you will gain a strong foundation of knowledge and skills. If your institution has an anesthesiology program, you can try to do an elective with them if possible within the scheduling confines of your program. Maintaining any contact with the anesthesiology program at the institution where you start residency training will be helpful. Consider following your patients to the OR or PACU and talking to the anesthesiologist about how the case went. Schedule a meeting with the anesthesiology residency program director and let them know your interest. If you become a familiar face that may earn you an interview, letter of recommendation, or someone making a phone call on your behalf.
If you choose to reapply next year, in addition to categorical positions, you will also be able to apply to R positions, which are essentially PGY2 spots available in the match. These usually arise either as available positions from attrition in the program or from a program that has had additional positions approved by the ACGME. Assuming you start training in a prelim or non-anesthesia categorical program, you would have completed an internship by the time you would potentially be starting an anesthesia training program, so you will be eligible for these PGY2 spots if any are available. You will see these positions listed when applying in ERAS as R positions. This is really the ideal position since you would not have to redo intern year.
Looking for Positions Outside the Match
Even if you are successful in the SOAP or in the process of reapplying for the next year’s match, continue to keep an eye out for categorical anesthesiology residency positions outside of the match. Such positions can and do become available, often through unofficial channels. The days and weeks following the SOAP can yield a number of these spots, typically looking for PGY1 or PGY2/CA1 positions to start that July or the following year. The NRMP will release a list of positions not filled in the SOAP so this is a good first step. Next, I would recommend a subscription to residentswap.org (please note: I have no personal/financial affiliation with this entity). There is a subscription cost to this although some information about available positions can be viewed for free. The subscription may be well worth the cost, however, since program directors often advertise available positions here instead of through the NRMP. Be ready to apply to these positions very quickly. My recommendation would be to have all your application materials (including your letters of recommendation, if you can get a hold of them) in one PDF ready to send to these programs should a position open up.
Research Year
A research year is another option. The main goal here is a chance to work directly with anesthesiology faculty and have them get to know you with the aim of matching there or gaining strong letters of recommendation and using their connections to match elsewhere the following year. Therefore, this year should be performed at a strong academic program ideally with a home residency program. Again, looking into that research program’s track record for matching their research students is a key indicator of whether this will be a useful endeavor. Lastly, if taking this route, I would recommend if at all possible to defer graduation a year; that is, perform your research year—even at another institution—while still technically an active medical student at your school. The feasibility of this approach will vary depending on your medical school; however, the goal with this is to apply the following year as an active medical student without gaps in your training. Graduating medical school, then completing a research year, will mean you will be reapplying as a previous graduate and, unfortunately, this ‘gap in training’ can often be viewed as a red flag by program directors. Therefore, if deferring graduation is not possible, continuing directly with training in another specialty is likely the best way forward.
Stick to It!
When in the position of being unmatched, perseverance is the name of the game. There are many anesthesiology residents and attendings who were in this position and found their way back to anesthesia. Like going to a code, check your own pulse first and try to make level-headed decisions in a very emotional time. Keep looking for positions inside and outside the match while pursuing training in a back-up specialty or a research year. This is also a time for reflection about what your goals are and what other specialties may allow you to have both a meaningful career and happy life. Lastly, take care of yourself. Especially in the weeks and days after the match, an unwanted result can be completely overwhelming. Please take time to eat, sleep, pursue your hobbies, and stay connected to your social supports. This will only help you as you navigate a challenging time in your life—but one that will ultimately be a small part of your career.