Rank Order List: Buyers and Sellers Edition

Dear Sheriff,

I just finished my last interview and I’m freaking out. The more I think about what makes each program different, the more I feel unsure what should take priority, and the less confident I feel about where to rank each. Do you have any advice on how to make my rank order list?

Yeah. Yeah, I do.

Making a rank order list is tough – because there are lots of things you can use to rank a program, ranging from the program leadership to the patient population served to the food in the cafeteria. All of them are important – but in my observation, some are consistently overvalued by applicants, while others are undervalued.

So here, I’m gonna tell you which is which. Just like one of those trustworthy talking heads on a business show yelling about stocks, I’m gonna tell you which factors to buy (undervalued) and which to sell (overvalued).

But fair warning: although most of my posts are at least somewhat data-driven, this one ain’t. I’m gonna serve you up a heaping helping of hot takes slathered with a side of strong opinions.

Reader discretion advised.

SELL: Far-flung amenities.

One of my favorite lies that programs tell goes something like this:

“Our program is just 3 hours from [insert big city], 3.5 hours from the beach, and 4 hours from the mountains. You should come here! We’ve got the best of everything!”

Hold up.

For most residents*, a thing that’s 3 hours away from the hospital might as well be on the moon. You’ll never do it. So don’t let it factor into your decision-making too much.

*And yes, I know that there are certain residents who actually use their rare off days to make a long haul truck driver-type of trip to go rock climbing or parasailing. These individuals are crazy, and their actions should have no impact on your rank order list whatsoever.

BUY: Accessible amenities.

When your time is pinched, there is a premium on things you can get your hands on right now.

Good take out food options, safe trails to bike or jog, green space to walk your dog, quick access to shopping/errands, weather that doesn’t ruin your day – these are the things that will actually have a positive impact on your day-to-day quality of life.

SELL: Salary.

One of my mentees showed me a list of programs she was considering, organized by PGY-1 salary. There was a difference of over $10,000 from the highest to the lowest.

Thing is, when you adjust the salary for cost of living, real differences in salary are minimal. Your dollar goes a little farther in Birmingham or Boise than it does in Boston, and programs pay you accordingly.

Don’t believe me? Plug it into a calculator – like those available at NerdWallet or CNN Money. (When I did this with her list, the apparently-lowest salary program actually became the highest – though not by enough that your bank account would notice.)

BUY: Benefits.

Things other than salary will have a bigger impact on your wallet.

Some programs, for instance, charge residents a four-figure fee to park in the hospital garage. In contrast, others provide free lunch every day; give generous travel allowances for meetings; have a quality gym located in the hospital; pay for your USMLE Step 3 exam; or even subsidize health insurance or make an employer contribution to a retirement account.

SELL: What your dean thinks.

Sure, your dean wants you to succeed – but she also wants to see a classy-looking Match list for the school. When in doubt, most deans will default to prestige or their own stale knowledge from years ago.

You can consider their advice, sure – just don’t regard their words as if they were handed down from heaven on a stone tablet.

It’s a truism in life that you can’t be happier than your significant other.

BUY: What your significant other thinks.

This goes out the window if you’re single. In that case, feel free to rank a quality program that’s in a crime-infested rathole or situated at the bare bottom of a volcanic crater. I mean, you’ll be in the hospital 80 hours a week – so as long as the program is good, it won’t matter to you.

However, if you’re not flying solo, you need to prioritize your partner’s needs and desires – because s/he will be your greatest source of support as you go through one of the most challenging periods of your life. Make sure they’ll be supported and successful, and you will be, too.

SELL: Board pass rate.

Remember, program can achieve a high board pass rate in one of two ways:

  1. By providing high-quality educational content directly relevant to the certification exam
  2. By applying USMLE score filters to select a group of residents whose prior test-taking experience predicts a high likelihood of success on the exam, regardless of what happens in the program

If you are a standardized test rock star, the difference between these two situations may not matter. If not, you want to be sure you’re in a program that actually provides added value – not one where the program director expects his ERAS filter has already done the heavy lifting.

BUY: Board prep resources.

In every specialty, the body of knowledge required to competently care for patients and the body of knowledge required to pass the board exam are overlapping but distinct. Simply being a good resident is not sufficient to ensure success on the board exam, and most faculty-curated lecture series are not geared toward success in multiple choice question tests.

Instead, you want a question bank, prep resources, and some time (and/or incentives) to use them. A program that’s willing to put some money behind those things is a program that prioritizes your professional success over your labor.

Garbage in, garbage out (GIGO) is a bad way to make decisions. Unless, of course, you like garbage.

SELL: Hours (supposedly) worked per week.

One of my advisees created a table that included the mean number of hours worked per week, obtained from the AMA’s FREIDA database.

I have little confidence in the accuracy of these figures – and you shouldn’t, either. Using data like these to make an important decision is a case study in the GIGO principle.

(n.b. – Choosing to disregard data from a survey with sloppy and inconsistent methodology is very different than choosing to disregard credible accounts that residents in a particular program violate and/or lie about the ACGME Duty Hour Requirements. The latter should be viewed as a huge red flag and failure of program leadership, and should be sufficient to move a program to the bottom of your rank order list – if you rank it at all.)

Last year, I gave a lecture to the graduating class in which I recounted a story on the value a good senior resident can provide. I also broke off some real wisdom from David Foster Wallace.

BUY: Good attitude co-workers.

Among programs that adhere to the ACGME rules, here’s the reality about how much you’ll be working:

A lot.

What will make the hours tolerable is doing it with co-residents and faculty who are supportive and share a sense of purpose.

BUY: Autonomy.

Let me be clear what I’m talking about here.

There are a handful of residency programs that have a very strong culture of supervision. These programs are very comfortable to step into, because you know you’ll have the senior resident or fellow by your side at all times to help with every query and double-check your every move.

Of course, over time this system becomes less comfortable and more chafing. You didn’t go to medical school just to serve as a medical scribe and play a glorified game of Mother May I with every decision. Prioritize programs that allow you to function at the highest level that you can – without leaving you unsupported.

SELL: Visions of Match Day.

Come on, admit it: wouldn’t it be cool to have the name of a famous program called out along with your name on Match Day? Won’t your classmates be impressed?

Many of the most famous programs provide outstanding training – but if you’re using a program’s name to offset other negatives and justify a higher position on your list, you’re probably making a mistake.

BUY: Program director.

Honestly, few things matter more.

Look, life happens during residency. A certain number of residents will experience a personal, professional, or family crisis before their training is over.

Find a program director who truly cares about you and your success – and you’ve just purchased an insurance policy against Murphy’s Law.

A commute never sounds that bad – until you actually start doing it.

BUY: Proximity to the hospital.

Some programs are located in parts of a city that price out residents. Other hospitals are in dangerous areas where it is simply not safe to be coming and going at all hours of the day and night. It’s tempting to talk yourself into matching at such a program, even if it means you have to live somewhere that requires a commute.

My advice? Don’t.

Sure, if you ask the residents who commute what it’s like, they’ll tell you it’s fine. That’s because they don’t know what they’re missing.

Even if you just spend 20-25 minutes each day getting to and from work, that’s 45 minutes that you could have spent binge-watching the latest series on Netflix, compulsively updating your Instagram account, meaningfully engaging with your significant other, exercising, grocery shopping, sleeping, or doing any one of the other many things that make life meaningful.

The line between being buzzed/busy – and being burned out – is often slim. Streamline your life, and set yourself up for success.

SELL: Doximity rankings.

The Doximity rankings are fine if you need to know the handful of the most prestigious programs in the specialty. As if you didn’t know already.

But even if you care about prestige – and to be honest, unless you’re hell-bent on an academic career at a similarly prestigious institution, you shouldn’t – there’s often a bigger distance between #1 and #3 than there is between #5 and #30, or #50 and #200. Treating their numbers as precise measures of anything will only lead you astray.

BUY: Parents and in-laws.

This is a special consideration for those who have children, or who think they might have children by the time residency is over. If either of those things apply to you, please understand that your #1 source of stress during residency is gonna be childcare.

If you have parents or in-laws who might be interested in alleviating some of that stress by providing loving care for your offspring, and there is an acceptable residency training program in a geographic location that would facilitate their doing such, you should strongly consider ranking it #1.

Most post-interview communication is the equivalent of a handshake from Rush Chairman Eric Stratton.

SELL: Post-interview communication.

As the rank order list deadline approaches, some programs may reach out. Others won’t. Neither one should influence your rank list too much.

If a message from the program feels genuine, it probably is. Take it for what it’s worth. And a program that remains silent is probably just following their policy. Don’t take it personally.

(On the other hand, a program that tries for a hard-sell – by demanding a commitment that you’ll rank the program #1 in order for to them to rank you – is committing a Match violation. They’re also providing you with a credible signal that the PD is a clown who is better suited to run the hospital gift shop than the residency program. Disregard this signal at your own peril.)

BUY: Gut instinct.

Many of the best decisions I’ve ever made in my life are ones where I went with my gut, and many most regrettable are ones that I tried to overthink. So maybe I’m biased, but I say, if you have a good feeling about a program, go with it.

More importantly, if you get a bad feeling about a program – don’t try to talk yourself out of it. The version of a program you see on interview day should be viewed as a best-case scenario – especially this year, when interviews are virtual and programs can present the most carefully-curated version of themselves.

Do yourself a favor and listen to that little voice in your head – even if it’s telling you something different than what I said.

(If you’d prefer to watch – or share – a video version of this post, there’s one at the Sheriff of Sodium YouTube site.)

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The Match, Part 1: Why Do We Have a Match?

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