The NRMP’s Voluntary Rank Order List Locking Proposal: Winners & Losers Edition

You might have missed it amidst the emotional drama and anticipation of Match Week, but the National Resident Matching Program (NRMP) recently issued a call for public comment on a new policy proposal.

The question is simple: should the NRMP calendar be reconfigured to allow residency programs the option of submitting their final rank order list before applicants submit theirs?

See, if programs certified their rank order list a week or two before applicants, then those programs could offer in-person “second look” visits to help their interviewees decide how to rank their program – without applicants having to worry that failing to attend might negatively impact their ranking.

The 2023 ophthalmology match calendar built in two weeks for no-pressure in-person visits to programs.

It’s a scheme that’s been employed successfully by the NRMP’s ophthalmology doppelgänger, the SF Match, which requires programs to submit rank order lists 2.5 weeks before applicants do. But adapting this into a voluntary system in the NRMP Match would substantially increase the scale and complexity – and introduce potential tradeoffs for both programs and applicants.

So you know what that means.

Yup, that’s right. It’s time to break it down, Winners & Losers™️ style.

WINNER: Applicants.

The past three years have shown that virtual interviews are adequate. But yeah – there’s something lost when applicants don’t visit the program in person.

On Zoom, programs can create the most carefully-curated version of themselves. But when you visit? Then you see with your own eyes the sleep-deprived interns staggering around the ward like zombies or the urban crime zone circumscribing the hospital that you’ve gotta walk through to get home after you leave your ED shift in the middle of the night.

Applicants should be able to visit programs – if they want to. And if they don’t, they shouldn’t be penalized for it. The NRMP’s proposal would at least create a pathway for certain applicants to explore certain programs without fear of being down-ranked for not showing up.

LOSER: February rotations.

Many applicants would benefit from the opportunity to see programs in person. But almost all would appreciate the chance to be wined and dined by programs – especially versus the alternative of another week or two of clinical rotations.

(Now, is this a big deal? Obviously, the educational value of the entire fourth year of medical school is debatable… so what’s another week or two of empty calories?)

LOSER: Caterers.

Allowing programs to submit their rank order list early doesn’t necessarily mean that invitations to the in person second look will be zero pressure.

Why? Applicants need advance notice to make travel plans and arrange time off from rotations. They can’t wait until the day programs certify their rank order list to plan their second-look visits.

That means that programs who want to gauge an applicant’s interest can still do so with the invitation to their second-look. Of course, savvy applicants will realize that you can always back out of an invitation – but you may not be able to undo the damage of appearing uninterested when invited.

In a 2021 mailbag, I made a meme to point out the gaming inherent to accepting second-look invitations.

That’s bad news for the programs’ caterer, whose giant advance order is likely to shrink substantially as applicants who felt pressured to RSVP “yes” end up politely declining after the program’s rank order list is submitted.

WINNER: Uncool cities.

For the past three years, many applicants have faced the challenge of ranking programs in cities they’ve never visited.

Fortunately, we’re all blessed with a shared cultural canon that helps us remember which cities are cool – and which aren’t. So who would choose to live in Cleveland, Baltimore, Rochester, or Oklahoma City when you could live in Seattle, Boston, San Diego, Nashville, or Denver?

In person visits are a double-edged sword – and in some cases, applicants will find that some cities’ reputations are wholly deserved. But at least uncool cities now have a fighting chance to show that – in some cases, at least – they’re actually vibrant and livable.

LOSER: Program budgets.

Even in the Zoom era, residency recruitment is expensive. And adding large, in-person events designed to dazzle and delight… well, that’s gonna increase that expense significantly.

Before COVID, many program budgets included generous allowances for interviewee dinners/drinks, program swag, and sometimes even hotel accommodations or travel reimbursement. But when the pandemic hit and belts tightened, those line items disappeared.

Some departments will pony up the cash for new recruitment efforts. But some program directors will find that those dollars are gone for good – and creating new recruitment events will require taking money from somewhere else in the program.

WINNER: Non-wealthy applicants.

Wait a second.

Shouldn’t non-wealthy applicants be a loser?

Not if you’re playing the long game. Stay with me and I’ll explain.

Look, I’m sure that many medical students will have feelings of missing out as they watch their richer classmates jet around the country to be treated to multiple second look visits. But that’s a feeling they’re already accustomed to, because they see these same classmates hitting exclusive resorts after every exam, or flying to Europe after Match Day. It sucks. But economic inequality exists – and no policy from the NRMP is gonna change that.

Around 1 in 8 medical students has parents who earn more than $400,000 per year. Graphic from the AAMC. (So complain to them about the confusing – potentially, intentionally so – color scheme.)

If you’re a current medical student, you may not know what residency selection was like before COVID. But in those ancient days, all interviews were in person. Then, as now, an applicant who attended more interviews got more chances to match – and though all applicants were ultimately constrained by the limitations of time and travel, some applicants maxed out their credit cards a lot quicker than others.

Virtual interviews leveled the playing field. Now, anyone could do 15 or 20 interviews – assuming you got 15-20 interview invitations.

But make no mistake, this has put an increasing strain on many programs. If the average applicant interviews at 15 programs, how many applicants does the average program need to interview to fill each of their positions? (You don’t have to be a math whiz to figure it out.)

The most prestigious programs love virtual interviewing. It lowers their cost and doesn’t hurt their recruiting. But the farther you get from the ivory towers of medical education, the more you find equipoise, ambivalence, and occasionally, even outright antipathy toward virtual interviews and the powers-that-be who continue to recommend them.

Unless we give programs the tools to manage overinterviewing, you can expect more and more programs to move away from virtual interviewing.

Here, expanding innovations like preference signaling will help – it gives programs a way of focusing attention on applicants who are truly interested in their program. But allowing second looks may help, too. It gives programs a middle way, where they can still enjoy the ease and realize the cost savings of virtual interviews while still having a chance to put their best foot forward and recruit the applicants that they really want.

If you take the long view, to the extent that this policy protects virtual interviewing, lower income applicants will benefit.

It still won’t be fun to feel like you can’t take advantage of something all your peers are doing. But compare that to the potential counterfactual of returning to a system in which students from lower income families attend fewer interviews because they’re priced out of being considered at as many programs as their higher income classmates. The former may not be fun, but the latter re-creates a system that perpetuates systemic inequality.

The average number of ranked applicants needed to fill each position varies widely by specialty.

LOSER: Metric-chasing PDs.

Intelligent readers may wonder: why do applicants worry that attending a second-look event will impact their ranking? Why does it matter if programs perceive strong interest from the applicant or not? More to the point, what incentive is there for a program director to increase the ranking of a mediocre applicant who said they want to come there, or downgrade the ranking of a strong applicant who was wishy washy about attending the second look?

To be sure, many programs don’t engage in this kind of foolishness. They realize that there’s no reason to rank applicants in any order other than the order in which they truly hope to match with them. If you upgrade the rank of an applicant who you didn’t really want, just because they said they wanted to match with you – well, you just played yourself.

But some program directors do care. They need to know who likes them, because they are trying to keep their “number of ranks needed to fill” number as low as possible.

Almost always, behind every foolish and vain metric-chasing PD is an even more foolish and vain metric-chasing GME dean who believes that the number of ranks needed to fill is an accurate measure of program quality, or provides some useful comparison between programs in different specialties. It doesn’t.

For these metric-chasers, it sure would have been nice to have a second look visit to gauge applicant interest – but now they’ll feel pressure to submit their rank order list before doing so.

LOSER: Time-pressed applicants.

Most residency applicants have their entire application tied up in a neat little bow by early September.

But not everyone.

Some applicants are in a desperate race against the clock to become Match-eligible. Maybe they need the scores from their USMLE Step 2 CK re-take, or maybe they’re waiting on a work visa or ECFMG (excuse me, Inthealth) certification. For a small number of applicants, these key items may not come through until the last week or two before the rank order list certification deadline. Unfortunately, programs certifying early will leave these applicants out in the cold.

WINNER: High-pressure second looks.

In part due to concerns over applicants waiting on late-breaking documents, the NRMP has essentially ruled out a mandatory staggered rank order list deadline. Instead, they’re seeking comment only on a voluntary system in which programs could choose to submit their rank order list early – or not.

That’s good news for programs who need an extra week or two to conduct interviews or wait for test scores or work visas to come through. But it does leave open the door for less benevolent programs to continue to use the standard certification deadline… while offering second-looks at the same time as the programs that submitted their rank order list early.

Some programs will perceive a strategic benefit in doing this. Maybe it will enable the foolish metric-chasing I highlighted above. Or maybe – and even more insidiously – it will enable them to compete more effectively with their peer programs by pressuring applicants to attend their second look instead of the one offered by their archrival. (It’s easy to imagine some prestigious programs deliberately scheduling their events on the same day to force applicants to choose one or the other – just as some notorious programs do with their interview scheduling now.)

(Obviously, there’s nothing keeping programs from doing this now – they don’t need an NRMP policy change to do it. So my best advice to applicants is to vote with your feet. If a program treats you like this during recruitment – how do you think they’re gonna treat you once they have full control of you as a resident?)


If you want my opinion, this policy is ultimately a good move.

I think most applicants will benefit. Meanwhile, concerns that second looks will hurt medical education are overblown, and fears about disadvantaging lower-income applicants are probably incorrect if you examine the realistic counterfactual and take the long view. And if a few bad apple programs try to game the system and pressure applicants while submitting their rank order list late? Hey, thanks for showing us who you are.

But of course, ultimately, whether this proposal wins – or loses – is up to you. Make your voice heard by submitting your comment to the NRMP before April 19, 2023.

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