OK, I know the above scenario is pretty unlikely, especially for a US grad like myself who ranked 9 programs (none of the MGH, BWH, JHU variety, and 2 "community" programs), but just curious as to what tactics people applying in IM who found themselves in this situation used. Would it be better to directly scramble into a lesser known categorical program with available spots, or to scramble into a prelim position at a higher ranked program with hopes of getting bumped up to categorical the next year (at the same or similar hospital)? I actually know some people who were in a prelim year at really strong programs, planning to either reapply for or go into Rads, Optho, etc, and ended up joining a categorical program as a PGY-2 (e.g. Maryland, UPenn, Wash U!) because they enjoyed IM so much. Any thoughts? Personally, I'd go with the direct categorical scramble, but I'm not a big risk taker.. Also, there are often really good categorical positions available via the scramble (Pitt, UNM, Vandy, UVM, WFU, Maine, and Carolinas this past year); does anyone know someone that scrambled successfully into such programs?