Disclaimer: Disclaimer: Dr.Harpreet Singh is a practicing internal medicine doctor, co-host of Talk Medicine Radio on Big Country 100.9 WWBR,  a wellness coach, speaker, author, a USMLE Instructor and coaches Step 2 Clinical Exams has written this article. He is a founder of Vital Checklist and iCrush.org. He has not been paid by any pharmaceutical companies nor endorses any medications. A part of this article was contributed by Dr.Himanshu Deshwal.

How to create a Residency Rank Order List (ROL)?

Every year, thousands of students on the verge of becoming doctors face this dilemma- How to rank their programs and on what basis?

As a chance would happen, I have read a book on decision-making by Heath Brothers—“Decisive” and according to this book, they have mentioned a WRAP model of natural decision-making. I am going to use their model to dissect the decisions each medical student should make when they create their residency rank order list.

Four Villains of Decision making		How to solve by using these four domains?
NaMEO Model		WRAP MODEL
Na	Narrow Framing	W	Widen your frame
M	My-bias or Confirmation Bias	R	Reality test your assumptions
E	Short-term Emotions	A	Attain distance before deciding
O	Overconfidence	P	Prepare to be wrong
		WRAP MODEL adopted from Decisive by Dan Heath & Chip Heath

 How can you widen your frame?

How can medical students, who have interviewed at many programs, increase their chance of matching? Again, I will use the WRAP model to explain. Don’t get stuck in the rut. Let’s widen your frame by doing these four things—

1. Consider opportunity costs
2. Use Vanishing options tests
3. Multitrack
4. Find Someone who’s solved your problems

Opportunity Costs

Simply stated, an opportunity cost is the cost of a missed opportunity. A carribean graduate wanted to pursue residency in New York but did not have good scores. He was over-confident that being born in America and having contacts will be sufficient to get into the residency but failed to secure any place last year. He missed an opportunity by not applying all over the nation.

Another student who is a Foreign Medical Graduate had already secured 16 interviews last year had an excellent research background. However, his year of graduation was 2011 missed lot of opportunities when he did not prepare for the interviews. I asked him why you did not ask for help; he replied, “I did not have the money.” I would disagree on a very basic note- the student had spent 700 dollars on his latest smartphone, but refused to invest in his future. I agree that money invested does not equate to success, but working hard on getting good resources, and asking people to help regarding interviews does not require money.

Seniors from same medical schools, friends and interview coaches can help tremendously with interview training. It is always advised to seek training and guidance from people who have been through the rigors of the interview process or are a part of the system already. (Doctors, program directors, USMLE coaches)

Disclaimer: At Vital Checklist, I do free interview training for my students who have worked with me and devoted their head, heart, and hands in all my projects. I know students have money constraints. However, I have my limitations especially the time.

As a medical student who is preparing their ROL, don’t take anything for granted. Make sure you write a professional and appropriate email to your programs where you have interviewed. Remember”out of sight-is out of mind.” You have the opportunity to send a polite email to the program director to rank you this season. Most importantly tell them “Why” they should rank you.,

• Be a storyteller.
• Remind them about how much you enjoyed your visit.
• The case presentation was amazing, and you loved interacting with the residents.
• Any point or process that you loved the most
• Your reason for being in that program or city

Action Box
1.	Apply in many programs
2.	Get trained by the coaches, not by students
3.	Don’t fail the exams. If you know that you are not a good test taker, get trained. Do Not Risk USMLE exams!
4.	The first impression is the last impression; spend money on your personal grooming.

Use Vanishing Options Test

No Program is BAD! All ACGME accredited programs will train you appropriately and would guarantee a bright future. Even if you don’t like a program, still rank them, as you don’t want to be jobless in this tough market. If you miss this chance, then you will be an older graduate and this will hamper your chance next year. It will also be unlikely to receive an interview from the same programs next year.

Be humble and rank everybody.

Sometimes, it also depends on you. How hard working and focused you are to the cause. If you are willing to leave your legacy as a great and successful doctor, you can do it even in a program of your least preference. However, always keep you eyes on your preferred institute and leave no stone unturned.

Action Box
Matched	Unmatched
Relieved after a tough and enduring year	Redoing the same thing again
Financial and mental stability	Financially, physically and emotionally burdened
Boost in confidence	Loss of confidence

Multi-track

Many American medical graduates have a chance to rotate in various programs and different fields which give them a liberty to choose from many programs i.e. multitrack. Describe all your options on one piece of paper and spot the patterns. Always think AND not OR. Can you follow multiple paths at once? If not, can you embrace one and sample another? Let me explain this by an example. A foreign medical graduate pays about 2000-4400 dollars to get externship in a reputed program. This is the time to make connections with the senior doctors and do not take this for granted.

However, when it comes to foreign medical graduates, they will always shy away from applying into observership and externships. They think of it as a waste of time and money to do observerships. If you don’t multitrack, you are losing the opportunity to interview. You get interview calls from the program where you have done your externships and observership.

It is not only the institutes where you did observership that matter but also the city or state. Sometimes, a pattern is noticed when students do a lot of rotation in a state; they are likely to be invited for the interview by different programs in that state. e.g Students rotating in New York are likely to get more interviews from New York.

If you are a Caribbean medical graduate, don’t sit for the opportunities to come, rotate with many people, find research opportunities You will need to prove yourself and your clinical acumen. You are again competing with American medical graduates with whom you had already completed when you gave your MCAT.

Action Box
	Internship	Volunteer	Externship	Observership	Research	MPH
1
2
3
4
5
6
7

Find someone who’s solved your problems

Look out for the seniors who have matched last year. Email them and ask them questions. Mind you that residents are very busy and will not have time to respond appropriately to your messages. Be polite and don’t burn bridges. Everybody loves to help, but keep in mind their limitations. Be open and ask from Facebook friends and LinkedIn mentors. Try to follow mentors, teachers, and coaches on Twitter.

Action Box	Names
1.
2.
3.
4.

Reality tests your assumptions

Don’t discount the information that contradicts.

1. Consider the opposite
2. Ask for the specific information
3. Assume Positive Intent
4. Find outside view in addition to the inside view
5. Ooch

Consider the opposite

Many students get offended when they don’t get answers according to their taste. Always listen to the more experienced people and make a list of what they are telling you. I received an email from a medical student that she has failed step 2 CS. However, she scored 240 in step 1 and 242 in step 2ck exam. I asked her who told you not to take coaching. Everybody is different and have different constraints.”

 

Students frequently go underprepared for their exams. Once they fail the exam, then they get all stressed out. I usually ask them this question, ” Michael Phelps, a world class swimmer and Olympic gold medalist did not win medals by getting trained from a fellow swimmer so why did you learn from the fellow study partner who has less experience in pinpointing mistakes.” You need an experienced teacher or a coach for training. You must take some form coaching to ace the exams. In the end, it does not matter, but if you fail the exam, the chance of matching decreases.

Play the devil’s advocate and plan the future correctly. If you did not match, “What will be the future?”

Ask for the specific information-

This is probably to a most important aspect of your decision for ranking programs.

We will use P4 strategy over here—people, place, process, and profit. I have adapted this concept from Marcus Lamonis’ show—The Profit on CNBC.

We have modified it a little bit by giving points to each factor and developing a scoring system to decide your preference

People
Were the people interviewing with you happy and welcoming?	1
Were they friendly?	1
How were the residents and fellows?	1
How are the nursing staff and the ancillary staff?	1
Did the residents appear happy and content?	1
Overall, how was the mood of that place?	1
Did the residents and faculty appear to be very casual and friendly to each other (tells you about interpersonal relationships and work ethics at that place)	1
Were the residents good friends amongst each other (an essential factor if you want to survive the rigors of residency for the next three years)
Is there a relative or a friend or a senior already in the program?	1
Total Score	8

 

 

Place
Did you like the institute/ program/ hospital?	1
Is the city of your preference? (Always look around the city when you interview at a particular place.)	1
Is the accommodation inexpensive?	1
How are the accessibility and transport options?	1
Preference may vary from student to student. Some like big cities, some like small towns.
(Young bachelor students vs. married couple with kids)
Are there options to have a life out of work?	1
Good schools for kids, job opportunities for spouses?	1
Accessibility to a major international airport for parents and yourself to travel?	1
How are the climate/ weather/ seasons at that particular place around the year?	1
Total	8

 

Process
Visa Options (H1B vs. J1)	1
Housing subsidy	1
Mentors- Counselor, Research, Clinical	1
Flexibility in schedule and cross coverage options	1
Vacation time	1
Review courses provided by the institution	1
Educational Schedule (Morning reports, Noon conferences, grand rounds, teaching facilities, Question answer sessions)	1
Rotation Schedule (4+1 system vs. Half day clinic)	1
Research opportunities (Basic vs. clinical)	1
Availability of Biostatistician
Opportunities for away or international electives	1
Accessibility and relationship with the Leadership of the program	1
Total	11

 

Profit
Board Pass Rate	1
Fellowship opportunities (in-house vs. match rate)	1
Research publication and presentation opportunities	1
Job placement after graduation	1
Salary	1
Opportunities for extra courses like MPH, Research, fellowship, etc.	1
Paid Travel for poster/ paper presentation	1
Total	7

The P4 are to be treated individually based on your preferences. Some students prefer a better place, some find a better process, and some consider better people or profit.

Evaluate your programs in these four spheres and see which programs top the list in

1. Your preferred sphere (People, place, process and or profit)
2. Overall Scores (Total of all spheres)
3. Seek advice from a family member for personal decisions
4. Seek advice from a senior or mentor already working as a resident or faculty (with similar experience in the past)
5. Seek advice of your spouse and, if possible, your kids)

Assume Positive Intent

“Never ascribe to malice that which can be adequately explained by ignorance.”

 The primary reason for being doubtful is miscommunication, and it is not that another person is trying to make your life hell, but is not knowledgeable about the process.

	People	Intent
1.	Spouse
2.	Kids
3.	Parents
4.	Siblings
5.	Coaches
6.	Friends
7.	Friends
8.	Friends
9.	Friends
10.	Enemies	Remember everybody is not Mother Teresa

Write on a piece of paper, people, friends, family and mentors in your inner circle. Also, write all those acquaintances that you have met during the interview season.

Ask the opinion from your inner circle and also the outer circle.

Take advice from your top 10 people who know about you and preferably know about the programs.

Sometimes when I encourage my students about the processes, they start doubting the intent, and this is the reason we come to our next point in this domain.

Consider outside view in addition to the inside view

With the advent of social media, students feel they know everything, but they should not discount the experience of the seniors. Inside view is their view of the situation, but they should also look at the outside view of the situation or other people’s viewpoint. In this case is making of the “Rank Order List.”

To delve into the depth of this, I will use Simon Sinek’s Golden Circle “Start with Why.”

Before you go to the next step, I would like to ask students to define themselves and their goals in one word or one sentence. This is the “why” you want to become a doctor. Don’t tell that you want to become a doctor to earn money.

Write down if you wish to become a good internist, good cardiologist, good pulmonologist or be good in patient experience. If you can define the “why” then comes the “how” of the problem and this will tell us the ways to achieve that field. If you can chalk out these, this will lead you to “what” of the problem.

The best person to give you is the person who has seen you from the close quarters. They can be your parent, coach or mentor. You have to pick up one person over here.

 

	Inside View (your view)	Outside view (the person you trust the most)
Why of the situation
How of the situation
What of the situation

Ooch

Ooching is a mostly applicable to the American medical graduates, and Caribbean medical graduates as they have rotated in the US. Students from foreign medical school don’t have the luxury to OOCH.

Ooch is basically small experiments. Heath brothers introduced the idea of the “Ooching” where they test an idea before fully jumping on board with it. This methodology of Ooching is an excellent way to reality test our assumptions. We bring the real world experience into our decision. To attend physical therapy graduate program at Hunter College at the City University of New York, students have to spend hundred hours in observing physical therapists. Similarly, Jim Collins advocate the strategy of “firing bullets then cannonballs, ” i.e., to arrange for small experiments and then focusing on what works. Ooching is the best way to collect the trustworthy information. Therefore, when you rotate at a hospital, spend more time in obtaining the data about the people, place, process and the profit will automatically follow. The biggest mistakes students will do is not do internships in different places

Attain Distance Before Deciding

For creating rank order list, I will be using 10/10/10 rule, invented by Suzy Welch, a business writer for publications such as Bloomberg Businessweek and O magazine.

1. How will we feel about your decision in 10 minutes from now after you submit the ROL?
2. How will you feel about your decisions about 10 months from now?
3. How will you feel about your decision 10 years from now?

Due to emotions—anxiety, greed, fear, nervousness we don’t take decisions and get distracted. By using this 10/10/10 rule, we shift the spotlight from the short-term emotions to long-term goals.

Prepare to be wrong

Under this domain, we especially focus on the American and Caribbean Medical graduates. Sometimes the medical students will not rank the programs, which they don’t feel is up to the standards. However, we would recommend that each and every program should be ranked.

Some students will feel confident and will start canceling the interviews because they feel that they will match in the previous programs. I would strongly suggest they interview in every program.

Good Luck for your Match!

If you have any questions, please email us at hi@vitalchecklist.com. We will do our level best to answer any question in timely fashion. However, because of email volume we will try to lump the answers in one email.

Coming soon ROAD to USMLE Step 2 Clinical Skills Book