How Should I Rank Residency Choices for the Match?

Question

Do you have any suggestions on how to rank residency programs for the Match?

Response from Daniel J. Egan, MD Associate Attending Physician, Department of Emergency Medicine, St. Luke's-Roosevelt Hospital Center, New York, NY

The other day I was interviewing an applicant for a position in our residency program. She told me, "I think that I know who I want to rank at the top of my list." (This program, of course!). "It's the middle of my list that I'm having trouble with. Do you have any suggestions?"

It's that time of year. All of you fourth-year medical students are wrapping up or have completed your interview journey. You may have traveled all over the country. You certainly spent a small fortune for airfare and hotels. Hopefully you accumulated some frequent-flier miles in the process. You also likely have sat through 10-15 sessions describing programs, listened to residency directors try to convince you that their program is the best, and had one too many "night before" social events with the residents in each program.

So how do you make your list? Is it clear to you which program should be first? Is it less clear to you, like my medical student, what to do with the middle of your list?

The most important thing for you to take home from this process is that your rank list should be truly that. You should rank programs in the order in which you would like to match. Many people believe that there is a way to outsmart the algorithm. Or maybe one program has given you feedback that makes you think they really want you. At the end of the day, you are dealing with perhaps the most formidable time in your development as a physician, and you should go where you want to be. So the list should be your own. It should not be the order that your dean or faculty advisor says it should be (they have their own interests in mind as well) but the rank order that would make you most happy.

There are a number of factors to consider as you think about each program. The first and foremost is something that cannot be determined by a formula or list of pros and cons. The question is, Can you see yourself as a resident in that program? As you have gone through the process, you likely spent a day somewhere where you thought there was no way you would fit in. Additionally, there were likely others that left you almost giddy with the feeling that it would be a perfect fit. I still recall the chairman of the program where I trained meeting with us on the interview day. He casually spoke about a gut feeling of whether or not the glove fits. There is something important about your gut. Frankly, it is something that will get you through many difficult decisions in medicine, and choosing a residency is certainly one of those.

Certain criteria should always be considered when evaluating a residency program: patient population, tertiary care exposure, clinic experience for the specialties with outpatient components, resident independence in regard to decision-making, electives, and where graduates go for fellowships or jobs.

Other criteria that should play a role in your decision-making include:

Location. This is not insignificant. There are many glamorous cities in the country, but not every city is made for every person. Do you know anyone in the city that you are considering? Will you have any kind of support system outside of the hospital? You will immediately establish lifelong friendships during residency, and there is something exciting about starting over in a new place. But everyone has a different personality, and some people find it easier if a network already exists during a very challenging time.

Housing and salary. Is housing provided? If not, will the program's salary allow you to rent an apartment and still have money left over for your usual expenses? (See our previous columns on the accrual of credit card debt and how this should be avoided at all costs!)

Are the residents happy? You will hear rumors along the interview trail. Pay attention. Obviously, rumors are rumors, but hearing that residents in a particular program are very happy is an important piece of information.

Do you know any graduates from your medical school who are there? We all have a loyalty to our school. We want the best for students from our school. Often, these residents will be fantastic resources as you try to get real, honest information.

What is the academic vigor of the program? If you have a long-term goal related to academics, you want a program that will help foster that. If faculty members are not doing research and publishing, it may be more difficult for you to find a mentor. What are the daily or weekly conferences like? What are the academic requirements of the residents?

Teaching environment. With shorter work hours and increased patient volumes affecting all programs, many residents feel that the clinical teaching suffers. Ask about bedside teaching. The accrediting agency mandates a core content of lectures and conferences, but it is really the day-to-day operations that help you develop your clinical skills. You may best experience this with a second look. Show up on a noninterview day. See how the residents interact with each other and their attending staff.

Finally, I'll share some advice that I got from my med school dean. He told us to put Post-It notes around our apartments with each program listed in order. Put them somewhere that you will see every day, preferably multiple times. Believe it or not, that gut will start talking again. Imagine yourself opening the envelope with each program named inside, and likely you will have a different response to each one. Looking at this list and thinking about that feeling may help you tweak the order. It certainly helped me solidify my final list, as I grew more excited about the prospect of my first choice. And remember, the formula should work in favor of you, the student. Don't try to play a game. Do not shorten your list because you think you are guaranteed a spot based on program feedback. Take a phone call or email from a program with a grain of salt. Do what YOU want to do with your list!