By Dr. Diana Mora and Dr. Robyn Hoelle
“Life is really simple, but we insist on making it complicated.” — Confucius
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Obviously Confucius did not go through The Match during a global pandemic. Life IS complicated! Here are some tips to conquering your rank list.
1. Start Now if You Haven’t Already
Make your decision as you go and plug programs into a fluid rank list as you do your interviews. When NRMP opens you can put in your list and then sit with your decision. Only make changes that you truly believe in, not ones based on what you think other people value in a program.
2. Know Yourself Young Grasshopper
As cheesy as this sounds, this is VERY important. Not one program is the best for every applicant and no one applicant is the best fit for every program. The first step to understanding what you need in a program, is honestly to find out what is most important to you as a learner. How do you learn best? What are your specific goals during and after residency? This is VERY IMPORTANT to understand BEFORE you even start your rank list (which you should have already started if you read #1!)
Your learning style, your needs for support, your other interests...everything about you is going to be different than the next applicant. You need to deliberately determine what you need to thrive. Your goals in residency are likely to be similar to other applicants, but how you can achieve them will be different. As you read through the rest of this pause and make yourself consider and prioritize your needs.
3. Finding Your Fit
After enjoying your total ‘you’ moment and thinking about what is most important to you, let's throw some information at you. Remember, you will be enjoying your residency for many years and at the end of this time period you will graduate the physician you are destined to be...but you also have to graduate still a human with a soul - potentially a spouse or parent! So here are some key factors to consider!
The location: think not just state and seasons, also city-life versus college town, what there is to do outside of work, how close or far you want to be from your family. If you have kids or there is a chance you might have kids during residency, what about schools and what is there for kids to do? Be comfortable to ask the faculty.
The People: During your interviews think about the interaction you had with the PD and the faculty. Try to see yourself amongst the residents. Is this a group of people that you could learn from, and work with for 3+ years? Would they pass the 3am test? Ask about nursing relationships, how the program is seen in the hospital, are the residents happy, supportive of each other, or miserable? Has the program provided ways for you to assess the overall culture?
Support for ‘your thing’: Whether it is the learning environment, research, leadership opportunities or advocacy, consider what support is available for you. This is going to be different for each person and within each specialty. If there is anything specific YOU are looking for, ask about it. For example, in emergency medicine, and especially if you are talking to us, the ultrasound experience is HUGE. If great ultrasound education is important to you, then ask about it!!! So figure out if there is a specific aspect about your specialty that you feel like you really really need to learn well, and then find out each program's approach.
The Size of the Program: this can really change the “feel” of a program. In a large program you can find your core group people and you may be able to have access to some resources (like grant-supported research and subspecialties) on a larger scale. A smaller program is usually a bit more tight knit with a family feel (making the overall culture of the program VERY important). Think about what you need and want. What will help you become the BEST doctor that you could ever be?
Resident Work Hours and Shift Balance: Work hours of a program is a hard thing to assess. In most specialties (EM specifically) you have to spend the time in the department to see, experience and successfully manage cases. There has to be a balance between working enough hours to achieve appropriate learning and respecting a human’s need for sleep cycles, doctor’s appointments and exercise. Programs ultimately need to produce an excellent physician and that means you still need to have your soul intact!!! My advice would be to ask the residents about how they feel about the balance and how the graduated residents feel about their preparedness!
Clinical Environment of the Program: in emergency medicine we talk about community vs county vs academic programs. I’m going to be honest with you, when I was a student applying to EM, I really did not know in which type of program I wanted to end up in, but I did know I wanted to learn things with a lot of mentorship, not by trial and error. Some of my classmates knew they wouldn’t thrive without being thrown to the fire so to speak. There are traditional generalizations about program types fitting certain learning styles. The lines are a bit greyed now and you really have to ask the residents about their experience in the department.
Competing Learners: having multiple residencies in a hospital improves and elevates the education environment and resource availability for all learners. Be mindful that other residencies in your hospital may have overlapping educational needs. Ask, for example, who has first rights to procedures and privilege to manage certain patient types. For EM peeps it is important to find out who does your reductions in the Emergency Department? Chest tubes? Intubations? Lumbar punctures? Are the current residents having to compete with any other services for experience?
“Wellness”: It's not necessarily about ‘having fun’ but respect for your wellbeing. How does the program approach the wellness of their residents? Is there a mindful approach? Is it just two days a year off of clinical duties? Is there consideration for health needs and mental well-being. Ask directly what a program's approach is during the interview!
Ultrasound in EM...Aaaaaand other subspecialties: Sorry! We just HAD to put this in because it is our obsession! Not all programs are made equally. Do you have a subspecialty or an aspect of your education that you feel is really important to you to have a very robust experience in that interest? Then ASK about it! Specifically what is the experience like? Make sure you like the answer.
Mentorship in the department and out: Maybe you would benefit from a lot of one on one, or maybe you prefer to figure it out on your own first and get feedback. Have you thought about how much mentorship you want? Or direct feedback? Do you thrivethe support and friendship from fellow residents (#InitTogether)? Or is there something you love like advocacy or social medicine and want a program that will support you in this?
Post-residency goals: vary from person to person. You may want to get into a certain fellowship or pursue an academic or research position or you may want to be prepared to work in a rural setting. It's possible too that you are not exactly sure of where you want to be, and in that case, it's important to find a program that supports any interest you may develop and can open any door for you. Ask where past graduates have ended up and how they have felt about the program.
‘The Feel’:And finally, possibly the most important: How YOU FELT watching the tour videos, talking to the PD, looking at the curriculum etc. Did the program faculty and residents share your end goal? Your drive?
4. To Rank or Not to Rank
Even though some people may think it's better to make your rank list as long as possible, you should be happy if you end up at one of your “safety programs”. Picture yourself at every program in your list and if your reaction to matching there is absolute dread, please don’t rank that program. Include in your list a mix of different programs: more and less competitive ones. The number of programs you should have will vary depending on your specialty and how competitive you are. You can try putting the names of the programs in a bowl and pulling them out at random and imagining that is where you matched; if you are heart broken (or your partner is!) when you read one of the names, consider not ranking that one.
5. You should know (even though it’s not official) the match algorithm favors the applicant.
Data from the 2020 NRMP match showed that 46.3% of U.S. applicants matched in their top ranked program and 71.1% of U.S. MD seniors matched to one of their top three choices. The percentage of independent applicants who matched to their first-choice programs was 33.6% and 55.0% matched to one of their top three choices. Regardless of whether you are an MD, DO or independent applicant, chances are you will end up in one of your top programs. There is no “gaming” the system, the system is already set forth to match you with your highest choice possible. This is the way I see I can wrap my mind around the match algorithm: first, it looks at your number one and then cross references with the programs. If you are anywhere in their top-mid list (which is A LOT of spots) you match there. It does this for all the applicants simultaneously. If you are not in the programs upper mid-top list or if the program is already filled with applicants that were higher in their list, then it moves on to your number 2, and so on. Don’t do your list based on where you think you have a good chance, do it based on where you truly want to end up! Even if it’s a “reach program”! If you do your list based on your “chances'' and where you think programs might place you on their rank list, you are shooting yourself in the foot and cutting your own wings. If they interviewed you, they will most likely rank you, even if you were in their waitlist to get an interview. -- As a side note, being on their waitlist doesn't mean you will automatically be ranked lower -- Your decision on where to rank a program should not be based on where you think you are going to be in that program's list. All lists are confidential and their ranking of you is not going to be affected by your ranking of them. While a program can tell you they will rank you highly, they can’t ask you how you will rank them (or anything about your rank list! Or even where you interviewed!). You shouldn’t alter your list based on this type of communication!
6. Cross the Finish Line
Don’t forget to certify your list! When you certify your list you enter a binding agreement, take a deep breath and do it. You have worked hard to be where you are (don’t let anyone tell you it's just luck!). Also don’t wait till the last minute. A lot of people might be doing it right before the deadline, what if the website crashes, your internet stops working or you simply just forget? (That would suck!)
Have enough courage to start and enough heart to finish. – Jessica N. S. Yourko