As someone who was in your position a few years ago, I can tell you it is a big problem. My home program, and the programs I did aways at interviewed me. Besides those there were only two others that invited me for an interview. I applied widely, but what it came down to is that some programs don't even bother looking at your file unless you meet their magic number. Others may look at your file, but will need to be convinced based on your other data. I was a female applicant coming from a school that was pass/fail for the first two years, so there wasn't a lot to help me there. You will get asked about it on your interviews (I did at every one, and by pretty much every different interviewer). Not matching will be just about the worst day of your life (depending on your other life experiences, I was diagnosed with thyroid cancer around the same time, and it helped put things back in perspective). Scrambling sucks, and you probably won't be able to scramble into an ortho spot. You can then choose to do a prelim year, or research, or give up and pick a different specialty. Your school will be pushing you to pick something, even in another specialty, because people without residencies make them look bad. You can then go through the process again a year later, and theoretically continue until you match ortho, pick another specialty, or quit. I opted to do research, got some publications, applied even more broadly, still only got five interviews, and decided if it didn't work out it probably never would and applied to 10 g-surg programs concurrently. Ended up with my first choice g-surg program (figured if I was going to go into my fallback specialty I could at least do it at a place where they didn't treat the residents like crap). Applied for a few openings for second year positions around the time I was doing my ortho rotations since my ortho attendings thought I was a great fit for ortho and offered to write me letters, but nothing panned out. Now I am in my third year, and I have made peace with the way things are. I don't regret trying for ortho, because I really think it is the better specialty for my interests and personality. But, I also didn't want to spend forever trying when I knew there wasn't much else I could do to change my application (rocked step 2, clinical evals were great, did as much as possible with research short of doing it for several years) or my gender (which may or may not have made things harder). That said, if I had been "kinda interested" in ortho, or if I equally liked two specialties, and the other was one where my chances were better, I probably would have saved myself the heartache, headache, and expense of it all.