Clinical, Featured, GME, Psychiatry
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The Match, Round 2

The following manuscript was published as part of the March 2019 s/p The Match — One Year Later theme issue.

June 20, 2018: The Decision

Originally, I wasn’t going to enter the fellowship match. I had started my psychiatry residency fully intending to do the four years, then maybe a fellowship. Then, in my second year while sharing dinner with friends who had just certified lists for the general residency match, my plans to go into child and adolescent psychiatry came up. Immediately my friends and then fiancé inquired why I was not planning on fast-tracking. My hesitation came from my own fears of inadequacy. Would my Step scores cut it for fellowship? Would I even be competitive? In my first match, I was just trying to get a spot — any spot — in psychiatry. Doing all four years of general psychiatry would give me time to learn more diplomacy and practice working with families. I was also starting to enjoy working with my adult patients, and I had vague dreams of getting more experience in administrative medicine. Plus, I was in the middle of wedding planning. Would I even have time to put together an application?

Ultimately, the arguments of my friends and fiancé won out. I was planning on doing this fellowship eventually and we would have to uproot ourselves. Why wait? By not fast-tracking, I was losing out on about $150,000 of salary over the next three years. Was fourth year worth that? With a bit more research, I found out I could still get more administrative exposure in a fellowship as a chief, or on an elective. Plus, when we looked through the Match statistics for the last few years, there were many more spots in child and adolescent psychiatry than applicants. My one condition was that I refused to work on my application until we were married. So, after our honeymoon, I started writing.

August 20, 2018: Press ‘Send’ and…

I’ve revamped and updated my personal statement, added in a few more personal details, and new perspectives. I sent emails to program coordinators about their requirements, asked for letters of recommendations, and paid all the fees. As I complete my application, I am suddenly faced with my new responsibilities as a third-year psychiatry resident. Entirely clinic based, I’ll spend this year working on psychotherapy techniques and outpatient medication management. My patient schedule quickly filled and I’m learning how to navigate the clinic, work with multiple different supervisors, and manage the never-ending paperwork. While simultaneously working on research projects, giving lectures to students, writing thank you cards from the wedding, and trying to enjoy being a newlywed. Despite the numerous digressions, pauses and false starts, I managed to get everything sent out. Then came the waiting…

Waiting for my letter writers to submit. Waiting to hear if anything was missing from my application. Waiting to hear back about interviews. Waiting for my patients to come in for their appointments. I got nervous. I had only applied to a few places, and my colleagues started getting more and more interviews. This was just like the residency match all over again. I sent out a second round of applications, trying to maximize my chances without blowing my budget.

September 10, 2018: The Unexpected

In applying for residency, I got rejections and non-answers from most of my programs. This time, I was dumbfounded by the response to my application, and I had to quickly figure out how to handle this unexpected wealth of interest in me. The task of planning a reasonable travel schedule proved impossible. Originally I planned to schedule interviews in the same week. That plan failed. I’ll be traveling across the country every week for three weeks in both October and November. Planning interview travel around calls, coordinating both clinic coverage, and planning date nights with my husband are tasks I didn’t have in my last match. Asking for forgiveness from patients, while not being able to tell them why I am taking so much time off feels terribly awkward and insincere. Early termination of therapy can truncate a patients progress, bring out abandonment issues, cause inappropriate curiosities, distract patients from their issues, and what’s the point if they’re going to have to start with someone new all over again. Balancing all these responsibilities, while trying to not reveal too much, and still be my empathetic and sincere self has proven more difficult than expected.

October 20, 2018: #InterviewSeason

Suddenly, the interviews started! The gauntlet of travel was by far the hardest part of this process. For starters, the interview days are longer with up to eight 30 minute one-on-one interviews in one day. By the end of the day, I’m tired, and my impulse control has fallen apart. When prompted with, “Any questions?” I’m asking things like: “What does your tattoo say?” and “Can you tell me about your clock?” My once stringent self-care is starting to slip. I had been running daily, and avoiding alcohol and sugar. This rigor fell apart. One day, my husband and I had brownies and wine for dinner. Even as I am failing in my self-care, I find myself feeling more dedicated to my clinic and my work. Getting off a red-eye flight and going directly to an 8 a.m. appointment; driving from a 12-hour emergency department shift to an interview dinner. In all this travel, I find myself thinking about my patients often, recognizing their patterns faster, and hearing new interpretations and connections. I can’t wait to see my patients! Instead my time is spent waiting for airplanes, waiting for an Uber, waiting for the coffee to kick in, waiting for the next interview to start, waiting for this to be over.

December 9, 2018: Reflections — Three Days Before Lists are Due

This time in the Match, I have felt recruited more than scrutinized. I think this sense of being valued has allowed me to reflect on my own growth over the past few months. I have become a more adept therapist, a more careful pharmacologist, a better partner, a more grateful co-worker. I have made a huge step towards my goal of providing care to children and families, effecting their growth and development to improve their future. I’m thinking about not just what I want to practice in medicine, but how I want that practice to be structured.

Of course at the end of interview season, there is always the final flurry of flirting emails, letters, and phone calls. Navigating this final storm has also been a careful challenge. The world of child and adolescent psychiatry is rather small, I will probably meet everyone I interviewed with at some point in my future. In the end, I’ve certified a list that I built with my partner. Last time I was in a Match, I was just trying to secure a job. This time feels like I am deciding on a direction for my career and my life. The process has made me feel more confident in my decision to fast track, and more eager to get started on the next phase of training. For now, it’s back to waiting.

December 31, 2018: Two Days until The Match

The waiting is cruel and this time it’s different. I find myself ruminating and trying to avoid the all-encompassing thought. I took extra calls right before the Match because working is a “healthy” distraction from my anticipation. I’m having Match dreams nightly. I am not worried about where I will go, but I just want an answer so badly. I think its worse this time because, unlike the general Match, I am choosing something different from the standard path. Residency is the next step in training that the vast majority of us take after graduation to practice medicine. Fellowship is different. It is a choice. It is not expected or required for me to be able to work in this field. I felt more recruited than interviewed for most of this process. In this moment I am terribly aware of why I have been recruited. I have offered myself for a job that is not required for me to continue to work. Now I have pressed certify. I am committed to vying for a spot. Right now, it feels like I pulled a lever on a slot machine. I’ve already paid in, and no one made me sit down. Now as the machine turns and flashes, trying to build excitement for the results. I’m just here. Waiting.

January 2, 2019: Match Day

The morning begins with counting the hours. Counting the half hours. Trying eat up time until we get the results. I am so happy I have patients this morning. Having them in my office forces me to focus on their fears and anxieties — not my own. Still, I occasionally have a surge of nausea or wave of cortisol pump through me. Little reminders that I am worried. When my last patient of the morning no-shows, I leave the clinic to walk to where I am meeting my husband to get the results. My phone keeps buzzing with the texts of my colleagues who are also in this match. We’re all nauseous, over- or under-eating, and sweaty. One person asks if it’s too late to withdraw, if there’s anything to end this anxiety. As I walk through the neighborhoods near the clinic, I think more about the Match and ranking. What I am really hoping for?

I want to practice caring for children and their families. I want to learn specialized psychopharmacology and therapy techniques. I want to be the best provider I can be. As I am walking, I realize that these are goals that are influenced by myself and how I go about learning, much more than where I am in the country. I consider my list and my interviews, and I realize that I would really be happy to match at any of these places. The idea of ranking is a fallacy, setting me up for disappointment if I don’t get my number one. I don’t have to subscribe to that thought. Instead, I walk into the restaurant for lunch, and I feel calm. We still stretch the final 59 minutes, trying to talk about anything else, trying to ignore the texts and emails wishing us luck. We refresh the page 30 minutes early, then again at 20 minutes, 15 minutes, 10, 5. Then we wait.

January 3, 2019: The Day After

As I greet my first patients for their medication management appointments, I am struck with the thought that in reality, nothing has changed. Mr. C is still mourning the loss of his friends, Ms. R is still missing his children, and I am still here to listen, reflect, and offer perspective and treatment when I can. While something big and exciting has happened for me, there has been no impact on the rest of the world. It’s too early to look for housing, too early for my husband to find a job, too early to pack. These changes and so many others won’t start for months.

Until then … more waiting.

Image sourceBrain Anatomy Hoop Art by Hey Paul Studios licensed under CC BY 2.0.

Xiomara P. Urban, MD Xiomara P. Urban, MD (1 Posts)

Resident Physician Contributing Writer

Albany Medical College

Xiomara P. Urban M.D. is currently a PGY-III in the General Psychiatry Residency program at Albany Medical Center. She has successfully matched in Child and Adolescent Psychiatry at UCSF, and will be starting there in July 2019. At work, she is notable for her enthusiasm, and playful curiosity. This tends to manifest itself with unexpected compliments, and sporadic investigations into changes in their grooming habits. She brings this same energy and inquisitiveness to all her patients regardless of age. Her main interest is in effecting systems of care in order to better serve those they are designed for.