Applying - The Rank List

A Guide to the “Perfect” Rank List
This is a guide to help students in the Emergency Medicine (EM) match formulate the best possible Rank List to fit their needs. This guide was prepared on behalf of the Council of Residency Directors in Emergency Medicine (CORD-EM) Student Advising Task Force, a group that seeks to provide guidance to students applying to EM and to all those that advise them.

Introduction:
Congratulations on finishing your interviews; now here comes the hard part, compiling your rank list!
Making your personal rank list has been associated with common symptoms such as confusion, insomnia, aggression, depression, elation, and general malaise. The goals of this blog are to review tips and recommendations based on the National Resident Matching Program (NRMP) data from 2009 to 2015, as well as expert opinions from your fellow residents and attending in order to alleviate the psychosomatic stressors affiliated with the entire process. At the end of the day, it is still your personal preferences, interview experience, and family-social obligations that will drive you to create your “perfect” rank list.

Spoiler: There is NO spoon or the “Perfect” rank list. 




Background: 
According to the NRMP data from 2015, there were a total of 2352 applicants for 1821 nation-wide EM positions, with only 8 positions unfilled. The number of EM programs has been steadily increasing in the last decade, from 141 programs in 2009 to 171 programs in 2015 in order to meet the increased popularity of this amazing specialty, reflected by the 19% increase in total applicant since 2009 [Fig. 1]. Despite the rising number of programs, the NRMP dataset reveals a steady decline of unfilled position; in 2012, all programs were completely filled. Fortunately, 18 EM programs were added with 153 new available positions since 2012, allowing applicants to select from a larger pool of EM programs with less fear of scrambling.


Figure 1 – Application trends for EM Residency. Taken from NRMP dataset 2009-2015.


Questions to ponder:
What is the Matching Process?
The Matching Process is a time-honored (and feared) tradition where a mathematical algorism is used to place applicants into residency and fellow ship position (http://www.nrmp.org/match-process/match-algorithm/). The process begins by matching the applicant’s rank order list (ROL) to the respective programs. If the applicant cannot be matched to the first choice program, the computer algorithm will automatically attempt to place the applicant into the second, third, and so forth until he/she is matched. A tentative match occurs when a program also ranked the applicant “A” and either:
  1. The program has an unfilled position, in which case there is room in the program to make a tentative match between the applicant “A” and program, or
  2. The program does not have an unfilled position, but applicant “A” is more preferred by the program than another applicant “B” who already is tentatively matched to the program.  In that case, applicant “A” will be granted the position instead of “B.”
All matches are “tentative” because applicants who are matched to a program may be removed at any time from that program to make room for an applicant more preferred by the program (see example above).  When the applicant is removed from a tentative match, an attempt is made to re-match that applicant, starting from the top of the applicant’s ROL.  When the Match is complete, all tentative matches are considered “final.”


Will I get my first choice?
According to the 2014 NRMP data based on matched applicants to all specialties in relationship to their specific rank list, most students get their top 3 choices: 52%/16%/10%, as their 1st/2nd/3rd choice [Fig 2]. This means that your top 3 rank list matter the most, so choose programs carefully! 


Figure 2 – Percent of Matches by Choice and Type of Applicants. Taken from NRMP 2014

Should I rank every program? 
This is a tricky question, but fortunately the answer is bluntly straight forward: YES!
When you leave a program out of the rank list, you will not be matched to that program, END OF STORY. If you were an EM applicant who failed to match in 2012, your only option to become an EM resident was to reapply for the following year as there were ZERO unfilled EM positions in the entire country. Fortunately by 2015, the number of unfilled programs rose to a total of 4, providing a small breathing room for the scramblers. 
My opinion, if you already invested your time and money for the interview, then just rank the program. It is okay to not rank a program, as long as you understand that the risk involves scrambling into a non-EM Program [Fig. 3].
  

“Scrubbing for EM in 2012 – Gonna need a bigger SOAP next year!
Figure 3 – In 2012, NRMP reported zero unfilled EM positions across the country. Not matching meant scrambling to a Non-Emergency Medicine Program.  SOAP stands for Supplemental Offer and Acceptance Program®.

Which rank list reigns supreme? Applicants vs. the Residency 
Based on the NRMP Match Algorithm (as described above), the applicant rank list is reviewed before the program rank list, placing a higher priority to applicants’ preference over the residency’s. So, just like a game of blackjack, you, as the applicant are the “Dealer,” with just a slight advantage over the residency, aka “Player.”

Which program should I rank 1st?
Unfortunately, this article will not be able to tackle the complexity of picking the “perfect rank list.” Your rank list will likely be affected by numerous factors, some of which you may have known, while others surface as you progress through the interview trail [Table 1]. In writing this article, we have collected numerous strategies to assist in making the ideal rank list, but at the end, the most common advice was to “follow your gut feeling.” Nevertheless, this article includes some general and useful suggestions for picking out your top 3 programs:
  1. Ask your local EM program directors for advice – Program Directors are there to help and guide you through the application process. Their knowledgebase is formidable and they read thousands of applications annually. Sure, some may try to persuade you to join their program, but that is a good sign.
  2. You will make new friends – This may sound silly, but many applicants are reluctant to leave their medical school institution, fearing they will lose touch with their friends due to the increased distance. Rest assured, however, you WILL make new friends, either intra- or extra-departmental (or even outside the hospital, GASP!)
  3. Location, Location, Location! – This is true with the housing market, and it is equally pertinent in residency selection. If a particular EM Residency is your dream program, but it’s located in a region that you are unfamiliar with, or have limited access to your hobbies (i.e. an outdoorsman in NYC or a Californian surfer in Colorado), then you should strongly reconsider. After all, your wellness matters.
  4. Don’t be distracted by gizmos and gadgets – What differentiates a strong EM Residency program is the cohesive nature of the residents, the supportive faculty, and the willingness to respond to feedback. Fancy technologies such as EMR, CT/MRI scanners, and even scribes can be enticing, but they are only as functional as the organization that utilizes them. Friendly consults, however, are always added bonuses.
  5. Are the residents happy? – This is one of the most important things to assess during your interviews dinners. Most accredited residency program ensures that you will learn to be an effective and efficient healer, as a result, why not have a good time? If the residents at the dinner seem miserable and depressed, that is a big RED FLAG!



Table 1 - Common Factors Affecting Rank List Decision Making



What if I don’t even know myself?
When all else fails, there is a trick you can play on yourself to test your subconscious mind.
  • Step 1 – Grab a friend
  • Step 2 – Write all of your EM programs on pieces of paper, then fold and place them in a bag.
  • Step 3 – Pretend it is Match Day! Have your friend pull a random piece of paper from the bag and tell you that you’ve matched to the program listed on the paper. 
  • Step 4 – Make facial expression (very important step)
  • Step 5 – Ask your friend for your reaction.

Conclusion:
Please remember, you have already chosen one of the most rewarding and exciting field of medicine, and you will have a great education and experience regardless of where you match. Just make the list, cross your fingers, and get ready for the next exciting chapter of your life!

- Tony

Xiao Chi (Tony) Zhang is an Emergency Medicine Resident at Brown-Alpert School of Medicine and a member of the CORD-EM Student Advising Task Force.

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