The Agony of Choice, or welcome to NRMP rank list season!

It’s that time of year again – rank lists are due for the civilian match in just a few weeks, on Feb 24th. This time last year, I was agonizing over my own rank list. I kept rearranging the top 5 programs, trying to decide which was most important: a program that I love, a location that I love, a location that my family loves…  Here is what I learned from the whole rank list process:

Talking to a good friend was more helpful than talking to a “real” advisor.

I know it sounds counter-intuitive, but I found myself intellectualizing the process more than I should. I was trying to find a way to make a scientific choice, to come up with the “right” rank list. Then I sat down with my friend, an attending in a different specialty, and we “ran” the list of programs. She had me tell her about each of the programs, and she had some really good insights. She didn’t really know a whole lot about the programs besides what I told her, so she was able to “reflect” back my own thoughts. For example, after I described one program she said something along the lines of “You keep telling me about this program’s numbers and reputation. It sounds like you really like this program on paper, but you don’t sound all that excited about it.” Other programs didn’t sound as good on paper, but I really liked the people and the location. If you can find a friend outside of your specialty of choice, sit down with them and run through your rank list with them. They may save you from yourself! My advisor just didn’t know me well enough to give me that kind of insight.

Your rank list is not the “be all and end all” of the match.

Think of your rank list like a Christmas list. It’s your way of saying what you want, if you could have your choice of every program where you interviewed. It isn’t a guarantee that you will get what you ask for. If you are a strong applicant in a less-competitive specialty, you have very good odds of matching to one of your top-choice programs. If you are applying in a more-competitive specialty (like ENT, emergency medicine, or OB/GYN), odds are decent that you will match lower on your rank list. It’s 50% what you want and 50% what the programs want. So yes, you should put a lot of thought into your rank list. But try not to panic over whether to rank that program #4 or #5.

January-February is likely too late to reach out to programs.

Some people tell you to reach out to programs, but the time to do that is #1 right after your interview and #2 towards the end of interview season for that program. By late January or early February, when you are finalizing your list and trying to decide who will be #1 and who will be #2, the programs have probably already finalized their lists. Sending the program director a nice email the day before rank lists are due is a nice gesture, but it’s unlikely to change your position on their list. 

Don’t be influenced by nice emails, cards, or letters from the programs.

I received a very nice, handwritten card from the program director of one of my top choice programs. She said how impressed she was and how she really hoped to have me as an intern next year. I matched to a program that was lower on my rank list than her program so I know that, despite the nice card, I wasn’t actually ranked in their top four. Try not to change your rank list because a program sent you a nice letter, and don’t be too confident in your position on their list. You never know how many people they emailed/wrote to, or where the other people that they wrote to stand on their list.

Would I rather go here, or go through the SOAP?

I have heard some people say they weren’t planning to rank several of the places where they interviewed. When you are considering whether to rank a program that is at the bottom of your list, ask yourself if you would rather go to that program, or if you would rather scramble for a position and risk not matching at all. This depends on your specialty, and the state of the SOAP (the Supplemental Offer Acceptance Program) in that specialty. The residency crunch has really changed the SOAP lately. (See this article for more on the residency crunch and the ways in which it affected the main match in 2015.) In OB/GYN, for example, last year a lot of highly-qualified candidates failed to match in the main match, and there were very few spots in the SOAP, all of which filled. On the other hand, internal medicine had a lot of open spots in the SOAP. So for people applying in OB/GYN, the question is really “Would I rather go here, or not match in OB/GYN this year?” Give that some serious thought.

What if I’m a military applicant?

The question about whether to rank a program is a bit more complex for military applicants. If you matched to “civilian deferred” or “civilian sponsored” in the military match and you fail to match to a full residency in your specialty in the civilian match, you can attempt to match in the SOAP within your assigned specialty. If you don’t match in the main match or in the SOAP, you go into a PGY-1 in internal medicine, general surgery, or transitional year. After that PGY-1 only, you can reapply to the military match to complete a full residency, but odds are good that you will be doing a flight medicine tour. So for military applicants, ask yourself, Would I rather go here and be an OB/GYN right away, or would I rather do a PGY-1 and probably a year or two of flight medicine? That’s not to say that you can’t ever go back and do a full residency, but the stakes are definitely higher. There’s a chance that you would need to complete your active duty service commitment before reapplying to residency, which for most people would set you back 5 years (1 year of PGY-1, four years of active duty commitment). Personally, I decided I would rather do 4 years of OB/GYN residency at a program that I wasn’t wild about than do 5 years of internal medicine/family medicine, so I ranked every program that interviewed me. 

In the end…

All you can really do is cross your fingers, hope for the best, and make the best of whatever happens. People always say that the match works out the way it should, and I think that’s true, even if we don’t always realize it when we open those envelopes. The programs have a better idea of whether you will fit in there than you do – they know more about you and about the culture in their program than you know about them. So even if you don’t match at your top choice program, your top 5, or even your top 10, chances are good that you will fit in and have a great experience.

So take a deep breath, hit the “certify” button, and go have a drink. You’ve earned it.

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