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It’s Not the Spreadsheet: Rank Order Lists Done Right

By Dustyn Williams, MD February 12, 2019

With applications and interviews now behind you, it’s time to submit your Rank Order List (ROL). You’re in a good place . . . the interview process went well, and even though you’re tired of airports and nursing stations, you realized that you matured along the way. You figured out what mattered, what you wanted, and even which questions to ask to sound smart during the interview. While it would have been nice upfront to have all these insights, you can make a mental review of the earlier interviews and get a deeper appreciation of what you learned there. And—you have a big spreadsheet! We know you do because we did, too.

You made that spreadsheet to demystify the ranking process, and it included all the same features as everyone else’s—location, salary, weeks off, call schedule, EMR, etc. With every criterion assigned points, you can just sit back and let the formulas do the work! Bam, your rank list.

But . . . something doesn’t feel right. Those point values—where did they come from? What if they’re not weighted properly? What if all that scientific accuracy is resting on a merely arbitrary foundation? What if there’s a better way to rank?

These concerns are legitimate because the points-weighted spreadsheet is the wrong way to make an ROL. (But don’t delete it just yet . . . you’ll be using it in a different way than you thought.) The right way is something we’ll call the Three P Approach: People—Philosophy—Passion.


People, Philosophy, Passion: What Really Matters

Though they can be thought of as going from the broadest focus (People) to the narrowest (Passion), the three P’s should be regarded as equally important. We’ll start with People.

By people, we mean the people you’ll be training, working, and living with for the duration of your residency. This includes your attendings as well as your fellow residents. You’ll be spending 80-hour work weeks (plus another 20 hanging out) with your new “family”—so while it’s equal in importance to the other two criteria, people are the factor that will most materially affect you on a daily basis. When you interviewed, did you think, “these are people I’d like to go have a beer with”? Good sign! Were you anxious for the interactions to end? Not so much. Keep in mind that just as one fine day doesn’t make a spring, so also is one nutty or socially grating resident not necessarily a deal breaker when deciding how to rank a program.

Philosophy refers to a program’s core values, ethos, purpose, raison d’être. Closely related to but distinct from “mission,” philosophy explains what gets prioritized, and why and how what gets done gets done. The philosophy of a rural program dedicated to providing clinical services to the community will be radically different from that of an urban research-facing program. Be informed about this, and make sure that your ROL promotes those schools whose philosophy most closely aligns with your own. If you find a mismatch, that’s valuable information—depending on the degree of misalignment, consider moving that program down in rank, or even removing it from consideration altogether.

What you’ll find is that good people (People) who think as you do, and who prioritize the same values that you do (Philosophy), are often the people who make your time in residency worthwhile. You’ll need each other, help each other, and grow alongside one another. When it clicks, life is better.

While People and Philosophy are essentially external, focusing on the global good, there is another “P” that, while equal in importance to the other two, is all about you: Passion. What is your passion? What is your end goal, the thing you hope to accomplish during residency or end up doing at the end? And this can be concrete, practical, even unaltruistic. If you want a fellowship in cardiology, then you should probably rank a program that gets you a fellowship in cardiology. The same is true if private practice is your passion, or research, or whatever. Make sure you consider not just the time while you’re in residency (people, philosophy) but also where residency will get you. Rank programs according to how effectively they promise to advance your journey down that path.

Those are the Three P’s. But straight away a question arises—how do you assign rank when many schools satisfy all three major criteria? They all have good people, all have the same philosophy (which you share), and all show promise of advancing your passions.

This is where the spreadsheet comes in. The categories most of us think of when we make our spreadsheet are actually most useful as ancillary factors: location, salary, benefits/subsidies, time off, proximity to family, what your significant other thinks, program time to completion, and so forth. Tally those up and use them as tiebreakers, if need be.


A Note on Prestige

You might start out by thinking that program prestige is a strong guarantor of your future success. Don’t. To think that program prestige will help you achieve professional success—to say nothing of personal fulfillment—is like thinking that an aristocratic pedigree confers merit. They are both external to you, and thus wholly out of your control. They have nothing to do with your story or your efforts. The only thing in this world you have any real control over is yourself, and to pin your hopes primarily on the merits—or worse, reputation—of someone or something else, is nothing more than a game of chance. Ceteris paribus, it never hurts to go to a name-brand university, so don’t be afraid to put Tier 1 programs on your ROL. But rarely, if ever, should it be a deciding factor in the ranking process.

The common factor bridging all three criteria—People, Philosophy, Passion—is that they are measurable only if you know yourself first—your personality, your core values, and your goals. Only in light of this knowledge can you first weed out programs that don’t fit you, and then put the spreadsheet to meaningful use.


It’s Not Too Late

You probably didn’t tackle your interviews armed with this mindset, but it’s not too late. Reread the notes from your campus visits. Remember each place, and the feeling you got, as concerns each of the three categories. Do this and you’ll have a solid footing for rethinking your rank order.

You may find that the brand-name university drops out of the top rank, and schools that your formulas had relegated to the margins may move up—a lot. And that’s okay because that spreadsheet was probably either prioritizing the wrong things or omitting the right things. The great thing about the “PPP approach” is that your ROL will be so well chosen that any match will be a good match—you’ll flourish at any school on your list. So weigh the right things the first time, and make all that effort count!


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