Match, Advising, Rank List, MSIV, MSIII

Creating the Perfect Rank Order List: Real Advice from Current EM Residents

With interview season coming to an end, the stress of making the perfect rank list has started. As Match Day approaches, applicants are charged with the difficult task of distilling months of travel and interviews into a single rank order list (ROL). While there is an abundance of information about this process on various medical education websites, it is difficult to find specific examples from current EM residents regarding how they created their lists. The recent EMRA Hangout featuring Deborah Pierce, DO, of Einstein Health and Travis Eastin, MD, of the University of Arkansas is a great starting point regarding ROL advice from the program director perspective (watch the Hangout here). During the Hangout, 2 residents were included in the discussion and raised some great points from the applicant perspective.

To expand upon the resident perspective, an anonymous survey was sent to EM residents at a random sample of programs across the country. With approximately 70 unique responses, this article attempts to break down the rank order list using direct advice from the resident perspective.

The 3 most popular factors used to differentiate between applicants' top programs were location, fit with current residents, and family/spouse considerations (resident responses are italicized).

Geographic location. #1 was closer to family, but both 1 and 2 were strong and very comparable programs.

It was challenging, as I couples-matched. Location was likely the most influential factor.

I liked my #2 program much better, but the program I ranked #1 would not require me to move. Since I have children in grade school, I chose to try to stay. In the end, I matched to my #2 program. I am happy, but for my family it was, and still is, very stressful.

I asked, “Where can I see myself? How does this affect my family?”

We decided based on whether my wife and I would fit with the particular group of people (couples-matched).

Interestingly, one respondent considered location as a negative influence.

I chose location over anything else, which as a mistake. I ended up matching at my favorite program by pure luck; if I had to do it again I would just rank my favorite program first.

In addition to the major factors of location, social fit, and family concerns, several other factors helped the residents. Some of these included resident happiness, benefits, leadership opportunities, patient population, pathology, quality and reputation of the program, unopposed ED program, 3- vs. 4-year programs, interview experience, curriculum, shift length, faculty, facilities, and willingness of a program to innovate and how program leadership responds to resident feedback.

By order of importance:

  1. Perceived resident happiness

  2. Quality of attending

  3. Quality of program/opportunities

  4. Years of training

  5. Location

Gut feeling on faculty, work-life balance, opportunities for my spouse in that location

  1. Quality of training - no surgical competition, lots of procedures, etc.

  2. Unity/friendship of programs

  3. How much autonomy they gave you

Applicants know that audition rotations are a necessity to obtain a coveted standardized letter of endorsement (SLOE) for their application. Besides obtaining a SLOE, an audition rotation can help in other ways. They helped some learn where they did not want to go or what they wanted in a program.

Had something to compare besides my home institution. It was great to see how differently and similar places operate.

Rotating at different programs gives you a look into the culture of the program.

But, did the audition rotations affect the rank list order? Some of the residents reported that it did not have a factor in their rank list, but for the majority it did. Some reported that it made certain programs less desirable and ranked them lower than they would have otherwise. Some suggested for students to try to audition at places they would like to do residency. It will either solidify the program for the applicant, or turn them off. For the respondents, programs at which they auditioned tended to be ranked higher than others.

4/5 programs I chose to rank, I rotated at. It allowed me to showcase what I have to offer and helped me be confident in my changes of matching it also gave me a clear insight into the program.

Post-interview communication is most commonly done in the form of thank-you cards or emails. 100% of the respondents reported sending some type of post-interview communication to programs, most of which were short emails to program directors or interviewers. However, what about the programs that contact applicants? Did it influence their rank list? 75% of the residents reported being contacted by programs. Interestingly, only 28.5% of those contacted reported that this gesture affected their ranking of that program. Some reported the conversations to be deceiving, while others reported moving these programs higher on their list. For the residents who were not influenced by this communication, most still felt it was a nice gesture and gave them an overall more positive opinion of the program.

There was another program that I could have ranked #2 for location purposes, but I didn't really like that program at all, so the program that contacted me got my #2 spot.

I felt those conversations were superficial because of the process. You don't want to tell a PD you aren't that interested, but most people would rather train SOMEWHERE in their desired field, even at a program that wasn't a good fit. So you really don't want to hurt any chance you have by being truthful in case that puts you further down the program's rank list. One PD only contacted me to tell me how they had ranked me, and did not ask for me to reciprocate.

Some residents reported spending a great deal of time filling out notebooks, spread sheets, and lists, all trying to lend some objectivity to the process. In contrast, we asked about “gut feeling,” or the residents' overall impression of the program based on their entire experience. Interestingly, more than 72% of the responders said the overall gestalt of a program ended up being a critical factor in their decision-making process. When compared to all of the previously mentioned factors (location, family, etc.), the overall feeling about a program was the largest individual factor cited by residents as to how they ultimately decided on their lists.

While extremely useful, some of the resident responses did not fit clearly into a particular category or theme. To that end, the following is some general advice from the respondents regarding their approach and advice in creating the rank list.

Don't rank a program high because of the name on the front door. You'll learn much more and be a better doctor if you train somewhere with people you enjoy.

 Decide the type of program you want to train in, i.e. big vs. small, research-heavy or not, and a rough location. Those are the 3 biggest modifiable and consistent factors. For example, one of the factors I used for my current program was that they had block nights for house officer duties and not q3 or q4. However, before my intern year, that was changed into a different system that was less ideal. Who and where you train with usually ends up being the most important factors.

 Don't play the system. Rank your list based on how much you liked each program. Don't fall into the trap of programs contacting you and saying they are ranking you highly and letting that influence your list, because you have no way of knowing what number they ranked you, top 10 or top 50, etc.

 Be objective at first. Make a list of things that are important to you in a residency and then put everything together at the end with objective and subjective data.

 Go with demeanor/attitude of residents, people you meet. They are the best objective representation you have. Every program gives a good presentation (great pathology, diverse population, high acuity...), but at the end of the day, you have to work with these people.

 Some people get real specific, making a list of program specs that they tally to make score to delineate their ranks. I think this is a fine exercise - especially if you're OCD and it soothes your organizational anxieties - but if you're not happy with the way the list comes out, change it until you are. There's a vast amount of intangible data that your brain takes in during an interview that can't be quantified nominally, and your emotional brain is much better at processing that than your conscious brain. Studies of human choice in complex situations have shown that responding to gut feeling rather than adhering strictly to tabulations creates greater long-term happiness with the choice made.

 I would advise on ranking programs based on the people. Are they happy? Do you fit in with them? Have similar interests? Would you hang out with them outside of residency? Residency can be a super-long 3 years of hating your life...or can be a lot of fun if you're surrounded by people you like and can support each other.

 Start with where you want to end up as a doctor (location, the specific employer you want), talk to them, find out what matters to them, then choose your rank list based on what will help you get there.

 Go where you would feel happiest, not where you "think" you need to go (i.e., name/reputation of institution).

 You need to go where you feel the most comfortable. You will learn how to be a doctor essentially everywhere, but your happiness will not be the same in every place. There is somewhere you will thrive, and you should try to go there.

 EM training across the country will generally produce solid attendings if you are willing to put in the work. Focus on what life will be like and what is important to you outside of medicine.

 Remember that matching at the wrong program may be worse than not matching at all. I did not rank one of the programs where I interviewed because I felt I would rather scramble than end up there.

 Rank programs based on where you want to go, not where you think you'll match.

 Rank your programs based completely on where you want to match. Think of your reaction to each program when opening the letter on Match day. How excited would you be to learn you matched at that program?

In summary, most of the respondents recommend applicants to “go with their gut feeling” while considering their individual goals, whether personal or professional. In the General Comments section of the survey, some specifically reminded applicants to rank programs in order of true preference, as the Match algorithm favors applicant choices. Location, fit with the residents, and family were the main factors in helping the resident responders differentiate between their top two programs. The respondents' opinions of the residents themselves were a huge factor in deciding on rank. The respondents reported that being able to “fit in” with the residents and their perception of resident happiness were major factors that contributed to their opinions of residents. Post-interview communication from programs did not have as much influence as the previously mentioned factors.

In the end, creating the rank list is an individual process and everyone will have a different approach.  I am appreciative of all the residents who took the time to respond to the survey. Hopefully, this article helps current applicants explore a few different strategies used by EM residents to make the perfect rank list.