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During the 2020 match cycle, Mahad Minhas, MD, was a 29-year-old fourth-year medical student at the University of Minnesota Medical School. He had 14 interviews lined up for urology residency programs across the country. Minhas knew how competitive urology was as a specialty; that year, there were only available, compared to other specialties like family medicine, which had in 2020.

After completing 12 other interviews, Minhas felt prepared walking into his 13th. He knew how to respond to questions with answers that were honest, while still emphasizing his strengths as an applicant. So, when the chairman of the urology program for which he was interviewing asked him about a hardship he had faced in the past, Minhas had no misgivings telling the interviewer that he had struggled with depression after getting rejected from medical school 2 years in a row. But before he could go any further, Minhas said the interview took an immediate turn for the worse.

"It turned into more of an interrogation, and he took a hostile tone too," he recalled. "He was like, 'are you still depressed? Are you on medications?'" Minhas felt like he was being attacked or penalized for mentioning his mental health. What he thought made him a more empathetic and resilient candidate turned into a big red flag.

"This is priming my brain already, like 'hey, it's not okay to talk about not being okay. It's not okay to talk about mental health,'" Minhas said.

Despite the interview snag, Minhas never expected what happened next -- he didn't match into any urology residency programs. He speculated that it might have had something to do with the candor with which he spoke about his mental health. He felt such a sense of shame and embarrassment that he retreated into himself.

He accepted an offer for a general surgery preliminary year at the University of Michigan, but Minhas didn't match in the 2021 cycle, either. He was able to secure a residency spot after shifting his specialty to radiology through the Supplemental Offer and Acceptance Program (SOAP).

But after 2 years of rejection from residency, the stigma he encountered when discussing his own mental health issues, and seeing some of his classmates die by suicide during his time at medical school -- suicide can start to look like a way out of what feels like a hopeless situation.

"One option is to kill yourself," Minhas told MedPage Today. "It's not really an option, but in some people's minds it becomes an option once you feel like you have nothing else left. The shame, the embarrassment, the soul-crushing debt, trying and trying -- it's just like, what more do you have left to give?"

There are no data as to how many medical students and graduates have died by suicide after going unmatched. Most accounts are understandably kept private by family members or discussed informally between peers. In recent years, however, there have been of suicide deaths in the weeks and months following each match day.

This year alone, there have been at least three reports of suicides by those who went unmatched in the 2021 cycle.

At the same time, residency applicants have also taken to social media in an unprecedented way to talk openly about their struggles to secure a position throughout the match, SOAP, and the ongoing scramble, often via the hashtag #scramble2021. The topic of mental health may still be taboo in professional medical spaces, but MS4s and graduates like Minhas are bringing the conversation to the forefront on #MedTwitter.

Unmatched and $300K in Debt

For those working on-the-ground to provide mental health support to physicians and physicians-in-training, the relationship between not matching and suicidal ideation has been made evident by the surge in requests for help each year after match results are announced.

Pamela Wible, MD, the founder and operator of a suicide helpline for doctors and medical students, frequently speaks to physicians, residents, and medical students struggling with their mental health. She told MedPage Today that the physical and emotional toll of the COVID-19 pandemic has increased suicidality among a population already prone to depression and high levels of stress. Still, she said, the match cycle takes its own toll each year without fail.

"After the match, of course, there's an uptick [in calls] every year," Wible said. "Matchless medical students reach out to me who don't know what to do with their lives, sitting on $300,000 of student loans, sobbing on their couch."

Mona Masood, DO, who founded the Physician Support Line to provide emotional support to doctors at the start of the pandemic, also took notice of how many more calls and tweets came in after this year's match day from unmatched applicants experiencing hopelessness and despair.

"When you feel like you're trapped, when you feel like everything is riding on a single decision that has very little to do with your control over the matter and more to do with some algorithmic system -- that's kind of ripe for there to be mental health crises," she said.

Annual match data from the National Resident Matching Program (NRMP) don't suggest the match cycle will get less competitive in the years to come. The NRMP often highlights the increase in open residency positions and the growing number of fourth-year medical students and graduates who match into them. , the number of successfully matched applicants -- including students and graduates from U.S. MD schools, U.S. DO schools, and international medical schools -- rose from 27,688 to 33,353.

This past match cycle, however, saw its biggest increase in unmatched applicants in the last 5 years, jumping from 7,685 in 2020 to 9,155 in 2021. While the majority of fourth-year medical students from U.S.-based MD and DO schools wind up matching (92.8% and 89.1% in 2021, respectively), these are only two of the seven groups of applicants trying to advance their careers in medicine through residency. When considering those who have already completed their degrees from either U.S. or international medical schools, the rates of not matching are worse.

In total, over 21% of all applicants in the 2021 cycle did not match into a residency program, forcing thousands to balance crippling debt and dwindling career opportunities with the stress, trauma, and hopelessness borne of becoming a doctor during the COVID-19 pandemic. And, with each year an applicant goes unmatched, the harder it becomes for them to lock down a PGY-1 position in the next year's cycle.

Three Years Unmatched

Chrystina Clinton, MD, graduated from Meharry Medical College, a historically Black medical school in Nashville, Tennessee, in 2019. As soon as she started school, she knew that surgery was her calling. But, by the time residency applications rolled around, Clinton knew that her Step 1 scores weren't as competitive as those of her peers. She told MedPage Today that an academic advisor from Vanderbilt, the neighboring medical school, went so far as to tell her not to even bother applying to any residency program, as her scores would be automatically disqualifying.

Clinton forged ahead with her applications anyway, but she didn't end up matching anywhere. Instead, she secured a 1-year preliminary spot. Although she was disappointed, she still felt optimistic about her path to becoming a surgeon.

Over the course of the next year, Clinton worked hard. She scored better on her Step 2 exam and pushed to be the favorite among her small group of prelims. Despite her efforts, 2020 would be the second year Clinton didn't match into a residency program. Instead, much like the year before, she secured a PGY-2 preliminary spot. Approaching her third year in the match cycle, Clinton said that her advisors kept urging her to forgo her dreams of being in the operating room, and try for a different, less competitive specialty. But Clinton insisted that she would rather walk away from medicine altogether than pursue something other than surgery, just for the sake of being able to say she had matched.

In the 2021 cycle, Clinton didn't match for the third year in a row, and went through her third unsuccessful SOAP process. Through the scramble, however, she was able to secure a spot as a PGY-3 surgical resident, after which she will complete her training. Clinton won't have to go through another match; still, even after years of hard work finally paying off, she doesn't feel at peace.

"I'm still stuck in this black place. My co-residents are like, 'I'm worried about you because you have an offer, but you're still not happy,'" Clinton said. "I dread going to work, I still cry every day. Even when I try to go to the beach and have fun, I come back and I'm still in this dark place."

Clinton went in to see one of her prelim program's administrators, a family medicine doctor, to tell her about the feelings she was having. To her surprise, she told Clinton that she was exhibiting symptoms of post-traumatic stress disorder and encouraged her to seek treatment. Clinton, however, said that she does not want to open that floodgate just yet, due in large part to the stigma surrounding mental health.

"I don't even know why I just want to keep resisting it," Clinton told MedPage Today. "I feel like we secretly get judged. When you interview places, they always ask you those questions like, 'Do we have any mental things, have we ever been diagnosed with anything, take meds for anything?'"

For others, like Sara Singh, MD, an international medical graduate (IMG) who also went through 3 years of unsuccessful match cycles, her third rejection prompted her to give up on trying to match altogether. Each year, she applied to an array of specialties to increase her chances of matching, got interviews for various positions, and entered the SOAP once she didn't match. Still, Singh was never able to lock down a position that would advance her career as a physician.

"I just couldn't afford it anymore," she said. The NRMP's Electronic Residency Application Service (ERAS) requires a series of fees for registration, individual applications, and for transcripts to be sent to residency programs. According to provided by the Association of American Medical Colleges (AAMC), a conservative estimate for total application costs would be between $300 to $400, excluding the costs that come along with the interview process. have found that the average applicant can spend a total of $575 just to apply to residency programs through ERAS.

After her first 2 years of not matching, Singh had hope for the next year. "I was like, 'everything's going to change in March.' And every March, I was so depressed," Singh remembered. "This was the first March I wasn't depressed, because I wasn't waking up Monday finding out ... that everything [from the last 9 months] came tumbling down."

The Tipping Point

In the most severe cases, not matching -- especially after several years, or in conjunction with other serious life events -- can be the final trigger for a suicide attempt. That was the case in 2020, when 35-year-old Leigh Sundem, MD, after her third year of not matching into residency. In her last wishes, she noted that she wanted her reasons for her suicide to be understood, not veiled in vague language.

During her late teens and early 20s, as she described in front of members of Congress in 2010, Sundem struggled with substance use disorder and moved through the criminal justice system. She later began her recovery and graduated summa cum laude from Georgia Southern University in 2012. According to the Georgia Southern's site, Sundem went on to score in the 99th percentile on her MCAT and a number of scholarship awards and prizes during her tenure as a medical student at the University of Rochester Medical School in New York. Despite her successes, Sundem did not match into any residency programs year after year.

"She exemplified how her past was an asset and not a liability, and she participated in a voluntary monitoring program for 12 years to prove that she was serious about her recovery," Sundem's friends and family wrote in her memory. "However, many programs were unwilling to admit anyone with a criminal record involving drugs and alcohol."

Sundem ended her life after 2020's match cycle, citing the hopelessness she felt from mounting debt, waning job prospects, and the stigma she continued to face from her past substance use and involvement in the criminal justice system.

Sundem's death isn't an isolated incident. One fourth-year student at a South Carolina medical school also died by suicide this year in the wake of not matching, coupled with the grief of losing his father just a few months before.

Addressing a Mental Health Crisis

Geoffrey Young, PhD, the AAMC's director of student affairs, told MedPage Today that the mental health of residency applicants -- and particularly those who feel lost after not matching -- is a serious issue that should not be minimized. "We care deeply about those learners and young professionals," Young said. "It's very complicated. It's a perfect storm when a student doesn't match."

The AAMC assembled a for medical student wellbeing in 2019. The group's chair, Chantal Young, PhD, who also serves as the director of student wellness at USC's Keck School of Medicine wrote in an email to MedPage Today that the group's planned initiatives for 2021 include "facilitating a national dialogue on institutional student wellness programming," "analyzing survey data on the current makeup and function of medical education wellness programs to identify effective practices," and "creating a wellness program evaluation resource," among other efforts.

As residency becomes more competitive and matching becomes even harder, Minhas believes that non-profits like the AAMC -- which reported more than $200 million dollars in revenue in 2019 -- should provide struggling medical students and graduates with some sort of relief.

"If you claim responsibility for no other group, you must claim responsibility for the U.S. MDs, and you have now allowed them to sacrifice years upon years of their life, they are now in hundreds of thousands of dollars of debt, and they have gone unmatched," Minhas said. "They're having a mental health crisis. Do you not feel obligated with your millions of dollars that you make off of these applicants to do something about this?"

If you or someone you know is considering suicide, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).

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