Did not match into pulm crit need advice

[carrotcake5566]

Hello,
I just wanted some advice regarding what I should do now that I have not matched for pulm crit this year. I am from a community program in NYC My scores were 23x, 25x, 21x, 7 pubs (mostly GI some heme onc one cardio one) US IMG. I got only 2 interviews outside my program. I am also couple matching with my husband who is at the same program (he wants heme onc). I will be very happy if even one of us matches next year.

I was thinking of becoming chief but the only programs I am currently finding are those that are community programs.

Would being a chief at a community program help for the next cycle or should I stick to being an academic hospitalist at a university program?

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[rokshana]

Hello,
I just wanted some advice regarding what I should do now that I have not matched for pulm crit this year. I am from a community program in NYC that is not very supportive of its residents. They do not really make any calls to try to get you an interview for fellowship. My scores were 236, 253, 214, 7 pubs (mostly GI some heme onc one cardio one) US IMG. I got only 2 interviews outside my program. I am also couple matching with my husband who is at the same program (he wants heme onc). I will be very happy if even one of us matches next year.

I was thinking of becoming chief but the only programs I am currently finding are those that are community programs.

Would being a chief at a community program help for the next cycle or should I stick to being an academic hospitalist at a university program?

So pccm is a back up? Why no research in it? That would be the thought I would have seeing that…

Use this time to try to do some research in pccm… present a poster at sccm next year.

You can’t rely on others to get you into a program or get you interviews, esp as an IMG.

Do any of those programs with chief years have pccm there? And will being chief there give you a spot there in your fellowship of choice.

And you didn’t match at your home program? Did anyone in your class match there? Or do they not take in house?

Would consider making an appt with the pccm pd, have them go over your application and make recommendations on what you need to improve on.

 

[gutonc]

I feel like I've heard this story before.

 

[NewYorkDoctors]

PCCM is getting more and more competitive to match into

You will need to tailor your resume again to fit into a PCCM profile.
You will need letters from PCCM / CCM faculty
You need to do scholarly activity in PCCM fields. Obviously no need for RCTs as that is not what applicant's pedigree. But you need to make case manuscripts, you need to do some literature review / narrative review, you need to do some retrospective chart analysis project, you need to get this into Pubmed and get PMIDs onto your resume.

You could look into those 2 year pulmonary fellowships. Those are few and far in between but are IMG/FMG friendly. But there is no guarantee they take someone from out of their own IM programs.



hey you could always do Nephrology lol.

 

[rokshana]

I feel like I've heard this story before.

Wow! 2 people trying to get competitive fellowships, couple match to boot and not competitive applicants that are being picky…OP who the heck is advising y’all? They have given you piss poor advice…

 

[gutonc]

Wow! 2 people trying to get competitive fellowships, couple match to boot and not competitive applicants that are being picky…OP who the heck is advising y’all? They have given you piss poor advice…

I get the feeling that they got little to no advising from their program. Which really sucks.

To @carrotcake5566, I suggest you review some of the information given in your husband's thread. And maybe sit down and have a chat with him about what your next moves are going to be as a couple.

You are going to have to prioritize one of your careers over the other if either of you ever hope to match a fellowship. I can't tell from his post or yours which of you is the "stronger" candidate, but it appears you've chosen PCCM as a backup while he's been all-in on Hem-Onc (please correct me if I'm wrong here). IMO (based on the little the 2 of you have shared here), you need to focus on finding him the best option for next year that will get him situated for a 2nd run at fellowship. Once that's sorted, find yourself a good hospitalist gig, preferably in an academ-ish (privademic/fakeademic) hospital with IM or FM residents but no fellows and a semi-open ICU. Let him work on his credentials for a year or two while you work your connections.

Once one of you is ready to apply again (and this may take 2-3 years), blanket the country with applications (including NYC) and go to every interview you can make and rank every program you'd rather attend than be a hospitalist forever. Lather/rinse/repeat as needed for one or both of you.

And for f***s sake, don't ever try to suicide match again. That was honestly the worst decision you both made in this whole process.

 

[AlbinoHawk DO]

I'm not trying to be mean here, but it looks like both of you are rather entitled. You couple ranked 1 of 3 programs you interviewed. You guys applied to highly competitive specialties as IMGs coming out of NY community programs. The most rational thing here would be to move on with your lives and make dual income money. Otherwise, you'll need to prioritize one of you matching or start looking to pump your CVs while being apart

 

[chessknt]

Agree with above, you both need to apply broadly and separately and if doing 3 years apart wont work then one of you needs to accept you are probably not going to specialize and be OK with that and not full of resentment. Good luck.

 

[NewYorkDoctors]

if either of you MUST be a subspecialist to get that "honor" , then consider subspecializing in nephrology or ID. You can always do internal medicine / GIM / hospitalist. If you do that then go private practice later on you can leverage these subspecialist knowledge to get more patient base in addition to PCP/GIM. just a thought

but if you really like PCCM or HemeONc, you gotta put in the work.

If you "want it both ways, then you gotta work at it both ways" if that makes sense.

 

[AlbinoHawk DO]

if either of you MUST be a subspecialist to get that "honor" , then consider subspecializing in nephrology or ID. You can always do internal medicine / GIM / hospitalist. If you do that then go private practice later on you can leverage these subspecialist knowledge to get more patient base in addition to PCP/GIM. just a thought

but if you really like PCCM or HemeONc, you gotta put in the work.

If you "want it both ways, then you gotta work at it both ways" if that makes sense.

I would strongly discourage anyone who doesn't want ID to do the fellowship. It's already hard and tedious when you want to do it. When you don't, it's a nightmare. I think it makes much more sense, at minimum financially, to simply work a hospitalist job with a full open ICU. Sure, you don't manage the vent or do most procedures, but it's the closest you can get while still in the ICU

 

[NewYorkDoctors]

I would strongly discourage anyone who doesn't want ID to do the fellowship. It's already hard and tedious when you want to do it. When you don't, it's a nightmare. I think it makes much more sense, at minimum financially, to simply work a hospitalist job with a full open ICU. Sure, you don't manage the vent or do most procedures, but it's the closest you can get while still in the ICU

true but some individuals want the "honor of being a subspecialist." if that is high on one's priority list, then one can always consider these alternative subspecialties.

still I would advise individuals NOT to do nephrology though lol. see other thread

 

[AlbinoHawk DO]

true but some individuals want the "honor of being a subspecialist." if that is high on one's priority list, then one can always consider these alternative subspecialties.

still I would advise individuals NOT to do nephrology though lol. see other thread

If that's all you want, you might as well do hospice or sleep since they are 1 year. It's really not worth it to just have the title specialist if you don't see yourself wanting this. ID can be very hard because of the culture of ID. Long hours of discussions, unbearably long notes, and management changes are very subtle. You have to at least like it to make it. Even neutral people i can see hating it in fellowship and moving on

 

[gutonc]

still I would advise individuals NOT to do nephrology though lol. see other thread

Except that you literally just did.

if either of you MUST be a subspecialist to get that "honor" , then consider subspecializing in nephrology or ID. You can always do internal medicine / GIM / hospitalist. If you do that then go private practice later on you can leverage these subspecialist knowledge to get more patient base in addition to PCP/GIM. just a thought

but if you really like PCCM or HemeONc, you gotta put in the work.

If you "want it both ways, then you gotta work at it both ways" if that makes sense.

 

[NewYorkDoctors]

Except that you literally just did.

yeah true. I should clarify further. The complete statement should read:

"While I still do not recommend doing nephrology, you could consider it if being a subspecialist is a top priority on your bucket list and you have read the entire Neph is Dead thread and still feel confident about taking the plunge."

 

[NotAProgDirector]

I think the harsh criticism of their decision to only rank a single program is unwarranted. They come from a community NYC program with little research, support, or advising. They received very few interviews as might be expected. They chose to prioritize being together and out of NYC (or at least out of their community program) over matching a spot. It's a perfectly reasonable decision if getting out of the program is more important than getting the fellowship.

Advice on this thread and the other is good. In general, a community chief spot isn't going to help you much without good research opportunities. Research and connections is what you both need. As mentioned, this will be a multi year path if you want to pursue it. How good are you at reaching out and getting involved in projects? If you do a Hosp Med plan, you'll need to make that happen on your own - no one is going to help you. if you do a non-ACGME fellowship, it's essentially part of the plan. Both of you getting non-ACGME fellowships in the same place may be quite difficult, so you may need to prioritize.

Whatever you do, do not fall into the Nephrology trap. Someone is going to tell you that you can do Neph/Critical care as a path. Unless the critical care fellowship is guaranteed up front, do NOT do this. Neph is a tough road, and if you don't love it you will hate it.

 

[AlbinoHawk DO]

I think the harsh criticism of their decision to only rank a single program is unwarranted. They come from a community NYC program with little research, support, or advising. They received very few interviews as might be expected. They chose to prioritize being together and out of NYC (or at least out of their community program) over matching a spot. It's a perfectly reasonable decision if getting out of the program is more important than getting the fellowship.

These are adults, man. There's the internet and other people to approach about this. The decision from the wife sounds very cavalier where she doesn't even have research related to the field. Yes, it's reasonable to prioritize each other, but if you just saw that the best you could do was 3 interviews, they should have known they weren't sought after applicants. Even then they decided to suicide rank. They could have prioritized each other by saying one will rank all 3, but they didn't do that. It's not to judge them that we are commenting all this. It's so they approach this with the seriousness it deserves

 

[collegestud2013]

Hello,
I just wanted some advice regarding what I should do now that I have not matched for pulm crit this year. I am from a community program in NYC that is not very supportive of its residents. They do not really make any calls to try to get you an interview for fellowship. My scores were 236, 253, 214, 7 pubs (mostly GI some heme onc one cardio one) US IMG. I got only 2 interviews outside my program. I am also couple matching with my husband who is at the same program (he wants heme onc). I will be very happy if even one of us matches next year.

I was thinking of becoming chief but the only programs I am currently finding are those that are community programs.

Would being a chief at a community program help for the next cycle or should I stick to being an academic hospitalist at a university program?

Becoming chief at outside program only helps if the program has in-house fellowship in the specialty you want, in your case PCCM. That not only leads to a year of lost attending salary, but at most programs there's still no guarantee you'll match in-house, especially as an IMG.

Getting into Pulm/CC for you sounds very uncertain right now. If you want to try your chances again, would suggest working as a hospitalist at an academic setting that has in-house Pulm/CC program to make some connections and do research. Then apply broadly in 2-3 years, and be prepared to be away from your husband for at least 3 years.

Otherwise if you truly like critical care you could forego fellowship altogether and just work at a hospital with an open ICU. Some hospitals, especially the more rural ones, will let you manage manage ICU level stuff like intubating/extubating patients, vent settings, placing central lines as long as you have done enough recently to be certified (even if you haven't done the official critical care fellowship).

 

[dozitgetchahi]

These are adults, man. There's the internet and other people to approach about this. The decision from the wife sounds very cavalier where she doesn't even have research related to the field. Yes, it's reasonable to prioritize each other, but if you just saw that the best you could do was 3 interviews, they should have known they weren't sought after applicants. Even then they decided to suicide rank. They could have prioritized each other by saying one will rank all 3, but they didn't do that. It's not to judge them that we are commenting all this. It's so they approach this with the seriousness it deserves

Yeah, I agree. These sound like people who got zero advising from their program and didn’t attempt to learn enough about this to figure out an appropriate strategy.

I agree that the most prudent thing to do is probably for this couple to get jobs as PCPs/hospitalists somewhere and move on with their lives - especially if they want to prioritize staying in the same place (which I can certainly sympathize with, and agree with). If they’re determined to match these fellowships, they’re going to have to pump up their CVs as much as possible, and accept that if they match they’re unlikely to successfully couples match in the same place.

 

[Splenda88]

true but some individuals want the "honor of being a subspecialist." if that is high on one's priority list, then one can always consider these alternative subspecialties.

still I would advise individuals NOT to do nephrology though lol. see other thread

Our nephrologists here are well respected. They work incredibly hard and are also very rich.

Nephrology might not be that bad if you can find a good niche.

 

[dozitgetchahi]

Our nephrologists here are well respected. They work incredibly hard and are also very rich.

Nephrology might not be that bad if you can find a good niche.

Good luck with that.

Our two nephrologists are currently doing more PCP and hospitalist work than they are nephrology. Apparently it’s necessary to do this just to make ends meet.

 

[NewYorkDoctors]

Our nephrologists here are well respected. They work incredibly hard and are also very rich.

Nephrology might not be that bad if you can find a good niche.

as in the Nephrology is Dead thread -

academic nephrologists are very well respected for their knowlege and expertise. But unless they have big pharma ties, they are woefully underpaid compared to their community counterparts

this "good niche" you refer to usually refers to leaving the oversaturated urban markets and going rural or remote. but not everyone wants to do this.

 

[Splenda88]

as in the Nephrology is Dead thread -

academic nephrologists are very well respected for their knowlege and expertise. But unless they have big pharma ties, they are woefully underpaid compared to their community counterparts

this "good niche" you refer to usually refers to leaving the oversaturated urban markets and going rural or remote. but not everyone wants to do this.

Sacrifices have to be made.

It's not rural here. It's a small city, though it's not Miami suburb.

 

[dozitgetchahi]

as in the Nephrology is Dead thread -

academic nephrologists are very well respected for their knowlege and expertise. But unless they have big pharma ties, they are woefully underpaid compared to their community counterparts

this "good niche" you refer to usually refers to leaving the oversaturated urban markets and going rural or remote. but not everyone wants to do this.

And I live in semi rural America too.

I think the only people doing well in nephrology are the older folks who are longstanding partners in a PP, have joint venture agreements with dialysis centers, etc. It is not a good deal for virtually anyone who is coming into it now. (And the funny thing is that both of these nephrologists nearby are older, and are partners - one is basically retirement age. And they are having to work really hard doing non-nephrology work to get by.) Combine crappy pay + struggling to find a job + one of the worst lifestyles in medicine, and it’s not hard to see why about half the nephrology slots go unfilled these days.

 

[NewYorkDoctors]

Sacrifices have to be made.

It's not rural here. It's a small city, though it's not Miami suburb.

indeed.

but don't forget most people who do nephrology and do not have pre-existing academic aspirations are nonUS-IMG/FMG. Not many want to leave their culture in the big cities. I dont want to speak for others (I am not Caucasian though) but that is the common observation that I have come across.

Hence the compromise often becomes just do Internal medicine.

 

[Splenda88]

indeed.

but don't forget most people who do nephrology and do not have pre-existing academic aspirations are nonUS-IMG/FMG. Not many want to leave their culture in the big cities. I dont want to speak for others (I am not Caucasian though) but that is the common observation that I have come across.

Hence the compromise often becomes just do Internal medicine.

I guess OP and husband have to have a 2-yr game plan.

Sometimes you have to know how to navigate the system. If I were OP, I would do 2-yr pulmonary (very open to IMG) and engage in some research and then apply to CCM (also open to IMG to an extent).

Husband should get an academic hospitalist job and go from there since Hemonc is more competitive.

One of the worst residents in my program when I was in training matched into hem-onc and she matched into a top academic program. All of us could not believe it. However, she is a AMG and took a gap year. Maybe hemonc is not at the level of cardio in term of competitiveness as I though.

 

[Splenda88]

I guess we all should have done hem-onc


Current heme-onc fellow here. Which job would you pick? Location is the same for both. I have $170k of federal loans at 5.6% interest, 6 out of 10 years of PSLF completed at time of graduation. I'm 31, married with no kids.

1. Physician owned private practice
3 year contract, salary: 400k/425k/450k
20-25 patients/day, 5 days per week
Call 1 week every 2 months, no clinic when on call
Partnership starting year 4, 80k partnership buy-in
Partner salary around $1m
Nobody has ever been denied partnership
A LOT of business related meetings/work outside of work hours


2. Community hospital employed position
3 year contract, salary: 500k/525k/550k
20-25 patients/day, 5 days per week
Call 1 week every month, clinic open while on call
501c organization so PSLF eligible
Older docs here make 600-700k
All docs come at 8am and leave before 430pm

 

[chessknt]

What do you mean hospitalist with 10% market gains guaranteed working 80 hours a week you'll have a whole fleet of lambos by the time you finish oncology??? Who cares that they get to sell chemo on margins making 5+ figures per patient in infusion fees while the rest of the suckers only get e/m crap in the 3 figures.

 

[gutonc]

Can we please get this thread back on topic? We don't need to keep hashing hospitalist vs sub-specialty and how terrible nephrology is these days..at least, not in this thread.

 

[rokshana]

Our nephrologists here are well respected. They work incredibly hard and are also very rich.

Nephrology might not be that bad if you can find a good niche.

those rich nephrologist as from an older generation...they dont make that much money now working for the dialysis centers and not getting to own them....but agree, they are some of the smartest people i know.

 

[rokshana]

Can we please get this thread back on topic? We don't need to keep hashing hospitalist vs sub-specialty and how terrible nephrology is these days..at least, not in this thread.

sorry...posted before i saw your post.

 

[Splenda88]

Can we please get this thread back on topic? We don't need to keep hashing hospitalist vs sub-specialty and how terrible nephrology is these days..at least, not in this thread.

Agree.

But they already told OP what she should do. I don't think there is much thing to add.

 

[collegestud2013]

I guess we all should have done hem-onc


Current heme-onc fellow here. Which job would you pick? Location is the same for both. I have $170k of federal loans at 5.6% interest, 6 out of 10 years of PSLF completed at time of graduation. I'm 31, married with no kids.

1. Physician owned private practice
3 year contract, salary: 400k/425k/450k
20-25 patients/day, 5 days per week
Call 1 week every 2 months, no clinic when on call
Partnership starting year 4, 80k partnership buy-in
Partner salary around $1m
Nobody has ever been denied partnership
A LOT of business related meetings/work outside of work hours


2. Community hospital employed position
3 year contract, salary: 500k/525k/550k
20-25 patients/day, 5 days per week
Call 1 week every month, clinic open while on call
501c organization so PSLF eligible
Older docs here make 600-700k
All docs come at 8am and leave before 430pm

What do you mean hospitalist with 10% market gains guaranteed working 80 hours a week you'll have a whole fleet of lambos by the time you finish oncology??? Who cares that they get to sell chemo on margins making 5+ figures per patient in infusion fees while the rest of the suckers only get e/m crap in the 3 figures.

Heme/onc pay per RVU is relatively high for a non-procedural specialty right now due to being being able to profit from chemo from buy and bill (on top the usual E&M billing for patient visits that most non-procedural specialties bill for). However, I suspect it won't last long with the ability to buy and bill going away. In addition to major pushes across the board including on a federal level to control costs of drug including oncological drugs, some insurances are no longer allowing buy and bill and require "white bagging" of oncological drugs, which effectively bypasses any profits that can be made by buying and billing; if that becomes the norm would suspect heme/onc pay to be more in line will be more in line with other non-procedural specialties like Neurology, IM, endocrinology, etc...

In academics though, from what I've heard heme/onc pay is much lower and about same as hospitalist or even a bit lower some times (usually in high $200s-mid$300s for younger grads). I guess as an employee, the system instead keeps most of the chemo profits.

 

[TexasMed22]

Heme/onc pay per RVU is relatively high for a non-procedural specialty right now due to being being able to profit from chemo from buy and bill (on top the usual E&M billing for patient visits that most non-procedural specialties bill for). However, I suspect it won't last long with the ability to buy and bill going away. In addition to major pushes across the board including on a federal level to control costs of drug including oncological drugs, some insurances are no longer allowing buy and bill and require "white bagging" of oncological drugs, which effectively bypasses any profits that can be made by buying and billing; if that becomes the norm would suspect heme/onc pay to be more in line will be more in line with other non-procedural specialties like Neurology, IM, endocrinology, etc...

In academics though, from what I've heard heme/onc pay is much lower and about same as hospitalist or even a bit lower some times (usually in high $200s-mid$300s for younger grads). I guess as an employee, the system instead keeps most of the chemo profits.

People have been saying buy and bill is going to end for the last 20 years on SDN, but I've seen no evidence that this is actually the case.

 

[ROBINHO]

Hello,
I just wanted some advice regarding what I should do now that I have not matched for pulm crit this year. I am from a community program in NYC that is not very supportive of its residents. They do not really make any calls to try to get you an interview for fellowship. My scores were 236, 253, 214, 7 pubs (mostly GI some heme onc one cardio one) US IMG. I got only 2 interviews outside my program. I am also couple matching with my husband who is at the same program (he wants heme onc). I will be very happy if even one of us matches next year.

I was thinking of becoming chief but the only programs I am currently finding are those that are community programs.

Would being a chief at a community program help for the next cycle or should I stick to being an academic hospitalist at a university program?

I am not positive that a chief year will help you

Not having pulm critical care research is definitely an issue. Being an IMG, from a community program, couples matching is an uphill task.
You need more scholarly activities---always the pathway to improve IMGs chances
You may want to consider some away electives, before you graduate to give you the chance to demonstrate that you perform at a high level outside your community program.
As you alluded to you may need to be flexible---matching at same time, flexible about cities etc

good luck

 

[carrotcake5566]

I am not positive that a chief year will help you

Not having pulm critical care research is definitely an issue. Being an IMG, from a community program, couples matching is an uphill task.
You need more scholarly activities---always the pathway to improve IMGs chances
You may want to consider some away electives, before you graduate to give you the chance to demonstrate that you perform at a high level outside your community program.
As you alluded to you may need to be flexible---matching at same time, flexible about cities etc

good luck

Unfortunately our program does not allow for away electives. We don't mind the location of the program as long as we are together. The programs that we did not rank were not ranked due to the fact that some programs had heme onc but not pulm crit and some had pulm crit but not heme onc.

 

[carrotcake5566]

true but some individuals want the "honor of being a subspecialist." if that is high on one's priority list, then one can always consider these alternative subspecialties.

still I would advise individuals NOT to do nephrology though lol. see other thread

lol no we don't want the "honor" of being a subspecialist. If one of us does not match in what we want we will happily be hospitalists until we get the positions that we would like. We just want some advice on what we should do going forward. I have started research but am trying to see if anyone has any unique experience that could give us advice on what to do

 

[rokshana]

Unfortunately our program does not allow for away electives. We don't mind the location of the program as long as we are together. The programs that we did not rank were not ranked due to the fact that some programs had heme onc but not pulm crit and some had pulm crit but not heme onc.

Sorry, but y’all dont have the luxury to be that picky.

 

[NotAProgDirector]

The content of this thread and the other give you the path forward. You both need research and connections to have a better chance at fellowship. In addition, you probably need to consider one of you getting a fellowship first, and after they complete it, the other then tries -- that way you can move and stay together. Or it's possible that one of you decides they are happy enough doing hospital medicine.

In the match this year, you only had a single overlap program -- where you both would be at the same location. Did you also rank options where one of you matches and the other does not? If so, then you both simply didn't match at all of your interview locations. If you didn't, then why did you do that? Were you not aware you could do this? Or did you do this for a reason?

 

[dozitgetchahi]

People have been saying buy and bill is going to end for the last 20 years on SDN, but I've seen no evidence that this is actually the case.

From a rheumatology standpoint, I’d also agree with that statement.

 

[Residentdoc86]

I wouldn't give up on your fellowship dreams but will say couples match is tougher in fellowship than residency.

Next cycle, consider applying individually to programs in the same city or close by. Rank programs within proximity of each other and hope for the best. You may not work in the same hospital but if you're lucky, you'll be close to each other. The time will fly by.

 

[NotAProgDirector]

Next cycle, consider applying individually to programs in the same city or close by. Rank programs within proximity of each other and hope for the best. You may not work in the same hospital but if you're lucky, you'll be close to each other. The time will fly by.

I'm going to disagree somewhat with this advice. If there is concern that announcing you are couple's matching on your ERAS application is going to hurt you, then don't list it there. But if the OP decides to apply again and both of them are applying in the same year, then they can couple in the NRMP and they cannot do any worse than submitting individual match lists -- assuming they list all possible combinations. And, if being separated is simply unacceptable to them, then they can list all acceptable combinations, followed by each of their individual preferences with a "no match" option for the other. This cannot turn out any worse, and gives them much more control over the process. if training apart is acceptable, then they just list all possible combinations. As long as they both don't have more than 14 ranks, the results can be no worse.

 

[Dominus]

I'm going to disagree somewhat with this advice. If there is concern that announcing you are couple's matching on your ERAS application is going to hurt you, then don't list it there. But if the OP decides to apply again and both of them are applying in the same year, then they can couple in the NRMP and they cannot do any worse than submitting individual match lists -- assuming they list all possible combinations. And, if being separated is simply unacceptable to them, then they can list all acceptable combinations, followed by each of their individual preferences with a "no match" option for the other. This cannot turn out any worse, and gives them much more control over the process. if training apart is acceptable, then they just list all possible combinations. As long as they both don't have more than 14 ranks, the results can be no worse.

For my own curiosity what about 14 ranks in the couples match makes the odds start to change?

 

[NotAProgDirector]

The NRMP only allows 300 total ranks on a list. If two people each have 15 ranks, then there are ((15+1) * (15+1)) - 1 = 255 combinations. So my memory is off - if both have 17 ranks, then it's 18*18-1 = 323 combinations needed, which won't fit. Once you can't list all combinations, then it's no longer true that results of couple's matching must be equal or better than just ranking separately.