Every year on the third Monday in March, medical school deans across the nation warn their senior students to stay alert for a pager call. Worse than a late-night code blue, that ring, if it comes, portends terrible news.

Stanford medical student Adam Warren's pager went off that Monday in 2004, and when he saw the number of the dean's office on its screen, the blood drained from his face. He called the office, and the staffer on the other end confirmed his fears: After six years of intensive medical training, he'd struck out in the lottery that places students in residency training positions. Without a residency, Warren had no job, no prospects for becoming a surgeon, and no salary to pay off his massive student debt.

Warren had dreamed of being an orthopedic surgeon since high school. An energetic and muscular athlete, he was then a track standout who later played football for UC Berkeley. Between his own inevitable injuries and those of his teammates, he developed close relationships with the athletic trainers and sports medicine specialists, which only strengthened his career ambition. During his pre-med dance at Cal, Warren developed an interest in immunology and supported himself by working in labs, including a stint at Emeryville's Chiron Corporation. His scientific aptitude earned him a slot in Stanford's prestigious medical program.

Warren kept an open mind about his prospects. When Stanford researchers, noting his lab skills, urged him to get a Ph.D, he pursued it for two years. But then he returned to med-school classes, concluding he didn't want to be a scientist.

Pediatric surgery also tempted Warren, and he so impressed Stanford doctors during his third year that one pediatric transplant surgeon offered him a general surgery residency a full year before anyone else could apply. But the job came with strings attached. "There was an unwritten rule that I'd have to first go and prove myself on their surgery trips to the developing world," Warren recalled. "Plus, neither Stanford nor general or pediatric surgery felt right." He would have had to toil for five years on adult gallbladder removals and amputations before getting to operate on kids.

Orthopedic surgery was what Warren really wanted. So he did what every medical student must do. He entered the Match.

The Match is the complex lottery used to place medical students in residency programs at the nation's teaching hospitals. It's a make-or-break moment in a young doctor's career. These programs are where physicians are trained in their specialties and become eligible for certification by the state medical board. Across the nation this week, tens of thousands of budding MDs receive the match results that will profoundly affect their life direction. The news will in large part dictate where they live and work for the next three to seven years, what field of medicine they practice, and their future earning potential.

While a medical school acceptance letter is popularly seen as a ticket to autonomy and financial comfort, the Match turns the nation's future neurosurgeons and cardiologists into hapless supplicants compelled to juggle their hospital duties with applications, interviews, and cross-country hospital visits. The process can be nerve-racking, exhilarating, or devastating. And for those who think strong scores and great letters of recommendation are tickets to success, the inherent subjectivity of the Match can come as a rude awakening. The results can alternatively jumpstart a glorious career at a prestigious hospital or place a fledgling physician in an inferior training program far from where he or she wants to be.

"The Match is stupid," says David Goldenberg, a journalist whose wife, Sara Thierman, is preparing for the 2007 Dermatology match. The San Francisco couple wants to live near family in Alabama or New York City, but they know they could end up anywhere. "Its full purpose is to drive students crazy. It's a load of pressure — you may end up here, you may not; might match, might not. Pretty much everyone is unhappy."

Even in the best-case scenario, the Match sentences recent med-school grads to at least three years of low wages for the privilege of treating the patients of attending hospital physicians at all hours of the night.

In Warren's case, it left him unemployed.

The Match

The National Resident Matching Program was established in 1952 to make the residency application process less chaotic. Before that, top contenders might sit on offers from multiple programs while holding out for their first choices, leaving less-competitive applicants in limbo for months. For the latter group, this meant eleventh-hour moves across the country as the cards fell where they might. Like pro sports teams, hospitals would compete for prime students by extending offers as early as the sophomore year of medical school. Some sent "exploding" offers that would expire in 24 to 48 hours if the applicant did not reply.

The Match is actually several matches. The largest, which takes place this week, is that of the National Resident Matching Program, catering to internal medicine, family practice, pediatrics, and other specialties. The American Urological Association runs its own match for urology programs. Finally, the San Francisco Matching Program handles ophthalmology, neurosurgery, pediatric neurology, and plastic surgery. Hopefuls submit their applications in the fall, and the newly minted doctors typically start their residencies the following July.