Submitting a rank order list is the last step (but crucial and important) towards residency match. You need to rank the programs to hit where you fit in, for your career and future life. Lots of variables influence prioritizing the residency program you want to be in. Here are some very important factors to consider before you finalize your rank order. All these factors may not apply for everyone and there are factors which overlap greatly. Going through this article in detail will help you decide what variables matter to you. It is highly encouraged that you read this carefully and completely so that you learn how to rank residency programs.
TRAINING
Patient Care – Academic time balance: Preparing for your board exam at the end of residency is an important step. But you will have to give your time to patient care, case discussion, solving multiple choice questions, reading theories and protocols. There are some residency programs which keep residents busy with patient care and have little time allotted to academic learning. Heavy patient care burden can cause fatigue which can impact studies. On other hand, if there is low patient volume, it could impact bedside learning. Number of Patients per intern/resident impacts your training quality a lot. So, a program which has a perfect balance will help you to get through the board certification exam and will make you a competent doctor.
Available Tracts/Pathways/Concentrations: During your medical school, you will develop specific interest to pursue a career. That is where residency programs have tracts or pathways (for example primary care tract). While primary care tracts gear more towards outpatient, categorical training gear towards hospital medicine. What is that niche which you want to build your career in? Ask yourself. Which programs amongst the one you interviewed, provide that tract? Make a list. Remember to rank residency programs higher which provide the dias for you to sharpen the skills you are interested in, and make you feel accomplished.
Burden of Scut Work: Physicians have a specific role in patient care. That is to diagnose and treat. Documentation and paper works are a huge part of patient care which takes up the majority of work. Documenting (not only helps in reimbursement) helps to provide clarity on your thought process. However, there are people who help physicians and nurses in printing the patient label, phlebotomy, faxing the medical record to outside providers, pushing patient carts etc. These are not necessarily a resident physician’s job. The amount of these scut work (example, printing the patient label) done by resident physicians vary from program to program. While one can argue that these are all what a resident physician must know how to do, a program which trains physicians to perform at a higher intellectual level will give you a sense of accomplishment and prepares you to be a better physician.
Program based on Age/Size: Like any other project, residency programs take time to evolve. So, older programs usually have better structure (This is not always a rule) and experience to cater service to the residents. So, if you are a kind of person who performs well in a stable environment, old and structured programs may be a great fit. However, newer programs are open to suggestions and grow. They may be more flexible in terms of rotations and giving individual care. So, if you are kind of a person who works well in a flexible environment, newer programs may be a great fit for you. You and program can grow together!
Size of the program also matters. The smaller program has more interactions among the peers and becomes a close knitted family. Remember, you will spend 3-7years in the program depending on the program length. On the other hand, larger programs who have residents rotate in different hospitals, enable you to work in different work patterns and provide you a dais for diverse experience. Think about what works for you before you rank your residency program!
Didactic/Conferences: Case presentation, group discussion, theory lectures, noon conferences, grand rounds…there are many ways residency programs teach their residents. Some didactic are residents led and others are faculty/fellow led. Extent of these didactic vary from program to program. That is why programs explain their didactic approach during your interview. Open up your notes and see how much didactic you need to excel. If you have completed your residency program back in your home country and/or have practiced medicine for a long time, these didactic may not be your deciding factor.
Mentors: Quality and quantity of physician mentors provide practical advice and empower mentees to make decisions. This could be simple clinical decisions or major career decisions. Residency mentor-ship programs guide you even at personal level to combat burnout or to advocate on your behalf. If you have worked in research or have done extensive clinical rotation and have found a mentor, it will be a huge plus because they know how to mentor you. If you do not have one, don’t worry. You can find one during your residency.
ACADEMIC OPPORTUNITIES
In house Clinical fellowship opportunity: Significant fraction of folks who enter residency want to pursue sub-specialties clinical fellowship, including IMGs who match. Even though there is no written rule, a program which has a clinical fellowship program usually will highly consider “internal” candidates. Also, if the hospital/university has sub-specialty fellowship, that will significantly help you towards having mentor-ship, research and networking.
On the flip side, if there are fellowship available, your responsibilities will be shared between fellows and you. That may significantly help you in heavy rotations like intensive care, it may decrease clinical exposure for you as a resident. In addition, one or two fellowships in the program may dominate the residency training and may hamper your training, if you want to remain a generalist.
Research and QI Opportunity: Residency training is a clinical training. Research is not the primary focus. However, there are residency programs who value scholarly activities and provide research electives and mentor-ship during residency. This is for the people who are looking to build a research career or go to academic jobs. If you are passionate about research during residency or want to apply for university based clinical fellowship, programs emphasizing research can be a great fit for you (You may also want to read how important is research for residency.) If you are purely interested in clinical medicine, then research during residency may be your lower priority but QI projects are something which can help you to build organizational development skills. Community fellowship programs/hospital leadership love residents who have quality improvement based system building experience.
Teaching Opportunities: ACGME does expect you to teach medical students and pharmacy students. However, if you are a person who likes to teach while you get trained, or are passionate about nurturing/influencing the next generation of physicians, residency provides you a good opportunity. Attending physicians love when residents take initiative in teaching. Together, it improves the spirit of inquiry and provides a learning atmosphere. Residency programs vary from one another about the extent of teaching opportunities they provide. This is something to consider when you rank the residency program.
In house Conference/Symposium: This is probably not a high yield which can make or break the residency applicants’ ranking strategy. However, there are university programs which provide opportunity for the students/residents to publish their scholarly activities/experiences. Such programs usually have greater emphasis on training residents in scholarly activities.
PATIENT AND PATIENT-CARE FACTORS
Patient Population and Diversity: Patient populations in the US are very diverse. For example, county hospitals cater to many low socioeconomic status people where there are shared risk factors associated with poverty and food insecurity. University health systems may cater to the people who can afford medical insurance. Veteran hospitals cater to the veterans and they have unique exposure and risk factors. Similarly, ethnic diversity also is significant based on the city, county or the hospital. Ideally, you want the training program in the most diverse patient population as it gives you wide exposure. Learn about the patient population which the hospital you are aiming for, while you prepare your rank order list.
Patient Acuity and Pathologic Diversity: Level of care and wide range of clinical medicine is a huge plus. For example, there are residency programs who do TAVR and mitral clip procedures on one hand and on the other hand there are programs who transfer out the STEMI patients. Higher the level of care the programs offer, better for you to be prepared. However, if your goal is to be a primary care physician, lower acuity of inpatient cases and wide outpatient services may be ideal for your training. Give this a thorough thought before you finalize the rank order!
Support from Allied Health Staff: Supporting staff like nursing, phlebotomist, respiratory therapists, physical therapists are huge assets during your residency. Not only do you learn from them, but also they will contribute heavily in team work. Extent of their support will significantly influence your residency training/clinical experience. So, their availability should definitely influence your ranking strategies.
Community Participation: This factor may not be significant in internal medicine or general surgery programs. If you are considering public health/preventive medicine residency or family medicine residency, community participation makes a difference. This includes participation by local county/city governments, non-profits or unorganized interest groups online and offline.
PEOPLE YOU WORK WITH
Residency Program Leadership: Good physician leaders are like intellectual horsepower. They make better decisions for the residency programs. Leadership capacity, experience and ownership which training programs take really matter into the quality of training. Receptive leadership takes your feedback and adapts the changes to enhance your experience. Responsible leadership will incubate your interest and help grow in your career. This is very important especially because of the power disparity between residents and attending/program. You should look for a program which is open to the feedback/constructive criticism from a vulnerable resident.
Attending Physicians and Residents Diversity: Appreciating diversity negates prejudice, promotes openness and nurtures humanism as a philosophy. This is very important because, as healthcare professionals, we deal with diverse human beings who are sick. They are vulnerable not only because of their illness, but also because of the difference in medical knowledge and power associated. One of the best ways to provide humanistic patient care is to have equal opportunity policy and actually implement it in the residency program. Diverse in terms of gender, race, nationality, language, culture, religion etc among the faculty and residents talk a lot about openness within the program. Look for that!
YOUR SCHEDULE
Core Rotations: Most of the residency programs have sample schedules online which explains core rotations. Some provide you on your interview day. They do so because your schedule is an important factor. Balance between inpatient/outpatient/ambulatory, how many months of floor, ICU, CCU, away rotation, ER rotation etc.. It all matters. If there are more than one hospital you rotate in, how many months in each hospital is something you may want to learn.
Continuity Clinic: Continuity clinic is where you have your own set of patients and you take care of them for the duration of residency. Some programs emphasize continuity clinics and others do not. Having a continuity clinic matters. Learn about it before you rank the residency programs.
Elective Rotations: There are a number of electives which programs offer. These are to provide an opportunity to accommodate your interests as far as they are in line with ACGME guidelines. Such electives vary from sub-specialty fellowship, research, Quality improvement, point of care ultrasounds, clinical procedures, medical technology, international medicine etc. Learn about the electives the program offers. Some programs are flexible in creating your own electives. Some large programs have international electives and check if they have such opportunities in your home country! Wouldn’t it be nice to rotate (as a part of international elective) in your home country (where you are licensed to practice) and visit your family? Think and explore!
ABOUT HOSPITAL/S
Community vs University program: Is there a difference? No much data to prove. However, the perception is that the community programs are smaller, nearer to the community and provide greater clinical exposure whereas, university based programs are larger, more inclined towards research, innovations and scholarly activity along with teaching. Remember that, both university and community programs have the same ACGME accreditation criteria and the difference between two settings is minimal. In addition, there are hybrid models where there are county/community hospitals affiliated to University which have medical schools. When you rank the residency program: size of the program, number of beds, level of care, clinical exposure, reputation of the hospital and support for scholarly activities probably is more important than what setting does the program belong to.
Connection in the Hospital: NRMP data suggest that the personal prior knowledge of the applicant significantly influenced the match. This means that people who have connections in the program perform better and program directors look for connections with candidates. So, if you have a connection (for example, research mentor) in the hospital, that is a huge plus. We all work better with familiar faces!
Hospital Infrastructure: Level of patient care and training what a hospital can provide depends on infrastructure and human resources. So, infrastructure like cath lab, library, online educational resources, bio-statisticians, call rooms, plays a significant role in the quality of training.
QUALITY OF YOUR LIFE
Good work-life balance: ACGME has restrictions on work hours for resident physicians but these restrictions allow 24 hours call with another 4 hours to wind up. There are some program directors who understand sleep physiology and develop a schedule for residents to work not more than 16 hours at a time. However, there are programs who have 24 to 28 hours of call schedule which makes life challenging. If you are a person who performs well when you get adequate sleep, then a program which has a better work schedule will make your life better. Work life balance during residency is something to consider when you decide rank order list
Work culture: Environment in which you work directly influences your quality of life. As a resident, you will spend the majority of your days in the hospital. Clear goals, recognition for your hard work, respecting your knowledge/skills are vital for your patient-care. A good leadership will provide transparency which promotes great work culture. While onsite rotation can give you a better picture about work culture, telerotations may give you limited exposure.
Near to Your Family: Just like life work culture influences your life outside hospital, family support plays a vital role during your residency life. If you have a family member (even extended family) who can render support for you during your residency, they will be your great asset. Remember to reciprocate their love by recognizing their help!
Wellness Support: Resident physician burnout is well known. Particularly as an IMG when you come to the US, there will be a steep learning curve in terms of work culture, learning system, learning medicine, patient care etc. It can be overwhelming. A good residency program will have a system in place to nourish your physical, mental and social well being to walk you through. That includes not only by providing mentor-ship, psychological counseling and teaching you resilience but also by taking leadership in system change, decreasing administrative scut works and promoting health attending-resident relationships. That is the leadership you should look for to prevent physician burnout.
Fitness: Along with sleep hygiene (You may also want to read how sleep impacts your USMLE studies) which we talked about above, a good residency program should have workout areas and provide healthy food. There are programs who provide energy drinks and other sugar sweetened snacks to the resident physicians. Nutritional significance of such snacks are minimal. With rampant metabolic diseases prevailing, it is not a contradiction to evidence based human science in expecting a scientific healthy diet from a residency program leadership instead of sugary snacks. Also, since you will be working for long hours in the hospital, it is reasonable to expect a fitness gym or work out area to keep yourself fit.
SWEET HOME
Job opportunity for significant Other: Residency match is a legally binding contract. When you move to a new place for residency, it will be great to move in as a family. So, the possibility of your significant other getting a job plays a significant role in the residency ranking strategy. For example, if your spouse is an engineer, getting a job in rural areas may be challenging. Another option is to rank the residency program higher where your significant other has a job!
Childcare and School quality: As a resident physician, your work hours are unpredictable. So, child care should be thought about. The best way to know is asking current residents when you interview with the program. If the hospital has daycare on campus, know their hours and costs. Similarly, school quality is important. With the internet at your fingertips, spend some time learning about schools available nearby, cost, safety, hours and quality. A thorough learning will definitely improve your ranking quality.
VISA
Visa: There are residency programs which are IMG friendly but do not sponsor visas. Some sponsor only J1. Some sponsor only H1b (they require their residents to moonlight). Some are flexible. Your visa requirements, EAD, green card, availability of J1 visa waiver jobs, moonlighting opportunity, fellowship plans are important to consider while ranking the residency program to match.
ABOUT THE LOCATION
Climate/Weather: Weather in the US can be extreme. Usually, southern states are warmer compared to northern. This means that the summer can be very hot in southern states and winter can be colder in northern states. Humidity, day time light, wind etc may influence your decision. Think what climate suits you the best.
Urban vs Suburban vs Rural: Rural places provide quiet atmosphere and peace while cities provide you diverse cultural experience and entertainment. City has higher crime rates and pollution whereas rural areas have low density social life and access to technology. Rural places may force you to have your own vehicle and city may force you to get a public transport (parking can be challenging). Consider these factors and think about what you are looking for, for the next 3-5 years.
Neighborhood safety: Safety is not just absence of crime. It is about the vibrant feel which you get when you live in the neighborhood. It is about the shared public infrastructure which promotes social well being. You want to be in a program which is in a safer neighborhood where you and your family feel secure and homely.
Social Life: Are you a beach person? Mountain hiker? Camping freak? Foody? Do you love fishing? Everyone needs some activity to get away from day to day life and get acquainted with nature. Look for the place which makes you connected. At the end of your week after tough patient care responsibility, you will need a refreshing location which works for you.
ABOUT INCOME AND SAVINGS
State Tax: This varies from Alaska to Illinois and impacts your income. This is something to consider especially if you and your spouse are earning. Matching your taxable income with the state tax may give you some insight.
Residency Salary and cost of living: Living in NYC with a resident salary is different than living in Peoria, IL. Cost of living is not just about renting an apartment. You may have additional expenses such as buying a car, house mortgage , paying off educational debt, getting into a family life or kids education. Even the cost of food varies from place to place.
Extra Stipend/Moonlighting Opportunity: Moonlighting opportunity significantly increases your income. Some programs allow moonlighting and others do not. Some allow moonlighting outside residency programs and some only allow in house. Some programs are just busy where you can not have additional time to moonlight. Knowledge about this is useful.
Financial Benefits/Perks: Resident programs provide additional perks for electronics, books, travel, research, entertainment, food, conference expenses, USMLE step 3 exam fee etc. Some help with medical school loan repayment. Even though they are a small amount individually, those collectively are a huge benefit. Websites of these programs are usually a good resource to learn these benefits.
INTERVIEW VIBES
Your experience during the interview: NRMP data shows the importance of residency interviews. Particularly, interaction during the interview with the program faculty/house staff plays a significant role in creating rank order lists. Interview questions provide a lot of subtle vibes which enable you to prioritize during the ranking process. Some programs have extensive interaction with pre-interview dinner as well. Utilize the opportunity to learn if the program is a good fit.
Feedback from current residents: When you attend a residency interview, you will get multiple opportunities to interact with current residents. They know the program well from the resident perspective and can be your near peer mentors. They will give you a lot of information about the cost, work culture, work load, neighborhood etc.
TECHNOLOGY SUPPORT
Electronic Medical Record (EMR): There are multiple EMR systems for billing and all vary from one another in terms of complexity, user friendly and information load. If the residency program where you match makes you rotate in different hospitals, you may have to learn more than one EMR system. You may not know all the difference between these but a quick internet search on reviews and talking to residents may help you identify its user friendliness. EMR may not make or break your residency ranking deal but this is something to consider and good to know. Also, know if residents have remote access to the medical record which will enable you to finish notes or prepare for your clinic.
Medical Dictation Software: During residency, you will have to learn/do a lot of documentation and communication works. Typing notes will be a major part of your residency life. A medical dictation software will definitely make your life easier in terms of notes.
Point of Care Ultrasound (POCUS): POCUS enables clinicians to have a quick noninvasive diagnosis. More and more programs have incorporated point of care ultrasound courses into clinical medicine and provide portable ultrasound machines in the inpatient critical care units and inpatient wards. However, some are behind. If you know and/or interested in learning and/or utilizing the technology in your practice, being in a program which is conducive to your POCUS skill growth will be great! Knowing point of care ultrasound is one of many ways you can stand out from the residency applicants’ crowd.
CONCLUSION
This is a comprehensive list with an explanation to make you aware about the variables which may influence your residency ranking priorities. However, not all the variables mentioned above matter to you equally. Some variables may not be applicable to you.
Pick top 7-10 variables which matter to you the most and qualify them as 1 (low priority), 2 (moderate priority) and 3 (high priority). Then list the residency programs which you have interviewed with, and match them against the priorities qualitatively. Sum of the qualitative score will enable you to objectively rank the residency program!
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