Considerations for Creating Your Program List and Rank Order List

Applying to residency is an exciting time, but it can also be nerve-wracking. As I’m sure you know, there are so many things to plan for and think about, from your ERAS application to the interviews themselves. Putting together a program list of where you want to apply can be one of the toughest and most time-consuming parts of the process before you even get to submitting your application. With over 220 pediatric residency training programs in the United States, creating your program list can initially seem like a daunting task. You may be asking yourself, “Where do I even begin?” The program list you create is going to depend heavily on what your priorities and interests are, and thus, the process of making that list will be different for each person.


When making your program list, the one overarching question you should ask yourself is this: What is important to me? This is also the key question to ask yourself when it comes to building your rank order list. In answering that question, you’ll realize what sorts of things truly matter to you as a resident and a person, which will help you figure out which programs you should consider applying to. However, there are many factors that can easily be overlooked, so in this post, I hope to cover many of the things I thought about when I was in your shoes as an applicant last year. So, without further ado, let’s get started!


Program Size


What is the size of the residency program and each class? Some programs have combined programs in addition to categorical pediatrics, so that’s one thing to keep in mind in terms of how big of a cohort you’ll be with from year to year. Programs are typically described as being small, medium, or large, and there are pros and cons to each. For instance, smaller cohorts may mean that you get to know everybody very well. On the other hand, if you don’t get along well with someone in your class, that can be pretty impactful in a smaller program. With large programs, you may have slighter better call and cross coverage schedules, which can be helpful if people call in sick or have emergencies that come up.


Reputation / “Ranking”


What is the reputation of the program? How is it “ranked”? You’ll find various “ranking” systems online, with a couple of the most popular ones being the U.S. News and Doximity rankings. Keep in mind that both of these are biased and based on certain metrics that they use, so you should take them with a grain of salt. However, generally speaking, they can help you get a sense of what programs may be more “reach” or “safety” programs for you for getting interview invites. I would recommend talking with a faculty member or mentor too if you have not already done so. You can also always ask residents / people in the field if you need further guidance.


Geography


Geography is extremely important for many people. Do you want to stay in a particular part of the country (East, Midwest, West, South)? Do you want to be close to your family or friends? Are there certain parts of the country you would not want to live in? Do you care if you live in a more rural, suburban, or urban area? Residency is a great time to branch out and explore living in a new part of the country if that is something you’re considering. At the same time, it can be more difficult to secure interviews for programs across the country or in areas you have never lived in before. For instance, if you have spent all of your life on the east coast, you may have a harder time applying to west coast programs, but don’t let that discourage you!


Unique Features


What activities and opportunities may be unique to certain cities/programs? Take the time to go through program websites to learn about opportunities, programs, initiatives, and rotations that may make that program stand out and differ from other programs. One of the things you’ll notice as the application cycle and interview season progress is that most programs actually have a lot of similarities. Everybody does things a little bit differently, but for the most part, the academic side of things is fairly consistent across programs simply given the nature of needing to meet certain ACGME specifications and guidelines. As a result, programs will often start to blend together, so it’s important to take note of and keep track of what makes each program different and stand out!


Salary


Most residency salaries are relatively comparable. What matters more is the salary compared to the cost of living in the city where the program is located. There is some variability in take-home salary after state and local taxes and pre-tax deductions, and cost of living can vary greatly depending on location (the area of the country, whether you live in a city or not, what neighborhood area you choose to live in, what type of housing you are looking for, whether you want to buy or rent, etc.).


Hospital / Department Structure


How is the hospital and department structured? Does the program exist at a standalone children’s hospital, a hospital within a hospital, or just as a floor or two within the main hospital? What is the structure of the pediatrics department like? How intertwined are the department and the residency program, and what does that relationship look like for residents and faculty? These are things you may not often think about, but they can have impacts on how the system functions as a whole, which can have rippling effects all the way down to your day-to-day experience as a resident who works there.


Hospital Appearance


What does the hospital look like (both the exterior and interior)? What about the main lobby, departments, hallways, cafeteria, inpatient floors, and workrooms? You might say this is a bit silly, but if you’re going to be spending a significant part of your waking hours at the hospital, it would be nice to have your workplace look colorful, vibrant, or nice. It can and does make a difference on your mood on a day-to-day basis.


Rotation Sites


Where will you be working and rotating through? Are there different sites that you’ll go to for inpatient rotations, ED, outpatient clinics, newborn nursery, or NICU? How much time do you spend at your main hospital compared to other sites? How far away are these sites (as well as continuity clinic), and will transportation be difficult for you? There are certainly pros and cons to having more or fewer rotation sites.


Scheduling Structure


What is the scheduling system? In the past few years, more programs have started moving towards an X+Y format, while the majority of programs still utilize a more traditional block structure with weekly continuity clinic. How many weeks long are the blocks? Programs can often vary from two-week to four-week blocks most of the time.


Work Hours


How are inpatient shifts structured? More specifically, what time does sign out occur in the mornings and evenings? Essentially, how long are shifts? You may find that a lot of pediatrics programs have sign out to the day team somewhere around 6 AM or 6:30 AM. However, some programs do not have sign out until closer to 7 AM, which some people like.


Call


Building off of work hours, what is the call schedule like? Does the program have a night float or night team system, or does it utilize a more traditional 24-hour call system every few days? Does the program have a short call and long call system, or is there some other system in place? How does jeopardy work, and what is the culture of jeopardy? Is it a payback free jeopardy system? Some of these may be harder to figure out without reaching out to residents if the information is not available online.


PICU


When are PICU rotations? The majority of programs won’t have residents doing a PICU rotation until second year, but some programs have PICU built into intern year.


NICU and Trauma


What is the NICU level of the hospital? What level trauma center is the hospital? A vast majority of major academic programs will have Level 4 NICUs and be Level 1 trauma centers. Many programs aren’t at hospitals that are necessarily burn centers, so if that is something you have a particular interest in, that may be something to consider.


Electives


How much elective time do you get, and how is it divided up throughout the three years of residency? You may find that some programs provide you with more elective time than other programs, and some programs may have elective time relatively evenly spread out, while others backload it more into the latter years. Different approaches can lend themselves to being more or less helpful to early career exploration or having more “easy” blocks earlier on in residency.


Education


How is protected educational time structured within the program? What is the conference schedule? Does the program have daily noon conference or academic half day? What is morning report like, and are there separate morning reports for interns and seniors? Is there a night curriculum or ambulatory curriculum for those particular settings and experiences?


Autonomy


What program initiatives are in place to encourage and promote resident autonomy? Are there intern-only or senior-only teams for certain rotations? Is there an attending in-house overnight for certain rotations? Does your program have no-attending rounds on any days for any rotations? Most importantly, does the program tend to be more resident-driven or fellow-driven? From speaking to numerous residents from many programs across the country, I have found that resident-driven programs tend to produce more confident residents, which is something I kept in mind.


Career Interests


Do you have particular interests that you want to pursue, and does the program offer tracks, concentrations, certificates, courses, or other opportunities to engage in those interests during residency? While residency will be your primary focus, residency training also encompasses more than just clinical experience. You can and should still find ways to do the things that interest you (medical education, advocacy, global health, research, primary care, etc.)?


Fellowship Matches


Many people go into pediatric residency without knowing for sure whether they want to do primary care or subspecialize, and that’s okay! However, if you have some idea of what kinds of subspecialties you may be interested in down the road, it can be helpful to look at fellowship matches for that program within those particular subspecialties. How have prior residents at the program done in terms of fellowship matches (both match rates and what programs residents have matched at), particularly in the past five years or so? On the flip side, if you are considering primary care, how does the program do in terms of preparing residents for that setting?


Fellows


While we’re on the topic of fellowship, does the program have fellows? If so, within which subspecialties? This is important to think about when it comes to how much autonomy, support, and teaching you might anticipate receiving. Like I mentioned before, some residency programs may be more fellow-driven than others. It’s also important to consider if the program or geographic location is someplace you think you may end up wanting to stay at for fellowship.


Benefits


What benefits does the program provide? Most programs will have some form of educational stipends and/or conference funds. Other benefits may include moving stipends, Step 3 reimbursements, cell phone stipends, board and certification feeds, and gym access or discounts. What about food? Does the program provide free breakfast or lunch, and do residents receive meal credit/cards/tickets? For those considering having children during residency, how much maternity and paternity leave is provided? Do residents get free or discounted parking (you’d be surprised by how expensive parking is if you have never really had to pay for it before).


There’s also retirement and insurance to consider. What retirement plans and packages are offered by the institution? If you’re considering putting money into a retirement savings plan and/or individual retirement account, what limits are in place, and how much of your investments are matched?


Does the program offer you insurance (healthcare, dental, vision, lifetime, disability, and professional liability)? What is contained within those plans/packages? Are they free or do you have to pay for insurance (and if so, are there premiums)?


Resident Union


Is there a resident union? There are many potential benefits to being unionized, including annual or semi-frequent negotiations for increases in salaries and benefits, as well as changes to promote higher quality work environments. It also provides a platform and means by which to advocate for residents in general.


Vacation / Holidays


Clerkship year in medical school may have been the first time you might have realized how valuable vacation and holiday days and weeks can be. How many weeks of vacation do residents get each year, and how are they divided throughout the year? For example, are they all split up into one-week vacations? How much input do you get in terms of where your vacation weeks fit into your schedule? If you are couples matching, it can be nice to know how realistic it may be to line up both of your vacation weeks (for at least one vacation during the year). Lastly, is there built-in time off during the holiday season at the end of the year? Having that additional week off can do wonders, particularly given the time of the year.


Significant Other


If you have a spouse or significant other, and they are moving with you for residency, what kinds of job opportunities are available for them and how good are they (quality, field, salary, benefits, etc.)? Is that city someplace they can see themselves living in and being happy, while also being able to support you through your residency training? If your significant other may have to live or work a slight distance away (as may be the case with couples matching at different programs in the same city or geographic area, for instance), how long is the commute, and how feasible is that distance for maintaining a healthy relationship?


Children


If you have children, and they will be attending school during your residency training, what is the quality of the public school systems in the areas surrounding the institution your program is based out of? For those interested in private schooling options, you should look into those as well. If you plan on potentially having children during residency, are there affordable and accessible daycares nearby that fit your needs, if daycare is something you would consider?


Electronic Health/Medical Record


We all have our own feelings about electronic medical records. The most commonly used ones are Epic and Cerner, but there are a number of other ones that programs may use, including Allscripts and MEDITECH, just to name a couple. Regardless of where you end up for your training, you’ll come to learn the system and become more comfortable using it with time. However, if this is something you truly care about, it’s not a bad idea to take note of this, although I would say that it shouldn’t make or break how you rank programs, generally speaking.


Patient Population


What is the patient population and catchment area for the hospital? Depending on the geographic location of a program, your training there may provide exposure to certain unique populations, such as Amish, indigenous, or refugee communities that have certain considerations when it comes to culturally competent patient care. A program’s location or training sites may mean opportunities to work with more low socioeconomic status patients as well. You may want to go to a program that provides a good amount of diversity in the patient population you will encounter to prepare you to be a good pediatrician.


Diversity, Equity, and Inclusion


On the topic of diversity, is the residency program itself diverse, both at the resident level and the leadership level? What efforts have been made to support and promote diversity, equity, and inclusion? Are there curricula being developed or already in place at the institution? Have that been issues in the past regarding diversity? What measures are in place to protect residents and create a safe work environment?


Faculty


Who are the faculty? This includes program leadership, clinical faculty who will be working with and teaching you directly, and research faculty. Does anybody share a particular interest of yours or conduct research in a field you want to pursue research in? Are there individuals that have certain careers or positions that align with your particular interests? Is anyone well-known for something that would draw you to want to work with or be mentored by that individual or be at that program? Mentoring is an important part of maintaining wellness and launching career development, so it is worthwhile to take some time to look at the people you would be spending the next 3+ years with.


DO and IMG Students


If you are a DO or IMG applicant, it’s important to look at whether programs are DO or IMG friendly. You can often find information about this on websites, but it can also be helpful to reach out to programs or residents to ask. I would also highly recommend looking at the entire composite of current residents to see how much of the program (and each class) is comprised of DO or IMG applicants. This will give you a good sense of how receptive they are to DO and IMG applicants, and whether that has shifted over the past few years or not.


STEP Cutoffs


Alas, programs are trying to do a better job of performing holistic reviews of applications, which I think is great. However, if you consider the sheer number of applications that programs receive and the often quick turnover with which interview invites are sent out following the release of applications to programs for viewing, it shouldn’t be a surprise that there are still certain metrics that can aid with the process of reviewing applications. Part of that has traditionally been STEP scores. While not all programs care as much about STEP scores as others, some programs will still have hard or soft score cutoffs for applicants. You can find information about that on program websites and online resources like FREIDA. These numbers are not always reliable or updated, so keep that in mind. I would encourage you not to be afraid to apply for a program if you’re close to a cutoff provided you are truly interested in that program.


Magnet Recognition


This is something that I think most people do not think about, but I felt it was fairly important, so I have included it here as something for you to think about. Does the hospital have Magnet recognition? The Magnet Recognition Program was launched by the American Nurses Credentialing Center and recognizes nursing excellence. I think that Magnet recognition speaks volumes about the quality and culture of an institution and our nursing colleagues who work there. You will be working with nurses on a daily basis, and I felt that a Magnet recognized institution gave me reassurance about the higher education, higher employee satisfaction, lower turnover rate, and greater positive practice environments I would encounter. I have seen the benefits of this play out firsthand throughout the first few months of my intern year.


Program Culture


I leave this as the last point, but in my honest opinion, it is actually possibly the most important. What is the vibe or culture of the program? This can be incredibly difficult to assess just from looking at websites and reading about programs online. Therefore, this is where social media and reaching out to residents can be very helpful prior to interview season. Check out Twitter accounts for the residency programs you are interested in applying to learn about aspects of the programs that you might not be able to find otherwise. On Instagram, take a look at both stories and highlights in addition to regular posts to get a sense of day-to-day activities and the culture and personality of the program and the residents there.


Don’t be afraid to reach out to residents or send e-mails asking to talk with them. Many residents you reach out to will likely respond and be receptive to questions you have. Besides, they were in your shoes not that long ago. Generally speaking, I found that residents tend to be quite real and honest when it comes to talking about their programs and residency families, including the things they specifically like and don’t like about their programs. Nevertheless, it can be hard to gauge the vibe and culture of a program better until the resident socials associated with your interviews. I know there are concerns about being able to get a sense of the “feel” of what programs are like because of virtual interviews, but based on personal experience having gone through the entire process myself last year, I would argue that you can actually get a good sense of the vibe even virtually.


Wrapping It Up


As you research all of this information and go through interviews, programs will start to blend together, and it can be easy to mix things up. I recommend having an organized way (e.g. an Excel spreadsheet) to write down this information so you can easily refer to it later on, update it as necessary throughout interview season, and compare programs when developing your rank order list.


It’s not uncommon to go back and take a second look at programs you’ve already researched. Similar to last year, FuturePedsRes hosted a number of webinars that provided program overviews across all of the major geographic regions. They are a great way to get a bird’s eye view of programs, and the slides that programs produced even highlight many of the points I have talked about so far. If you missed any part of the Webinar series for the 2021-2022 application cycle hosted by FuturePedsRes, you can check out recordings of the breakout rooms.


Phew! We covered so much in such a short period of time. As you can tell, there are so many different factors to consider, and their importance will depend on your priorities. This is also not an exhaustive list. You don’t have to think about all of these criteria, but I tried to be thorough and consider all of my options when I went through this process. Hopefully, this gave you an idea of many of the things you could be thinking about to help you create and refine your program list and rank order list to best fit your needs. I wish you all the best of luck on this exciting journey!



Kevin Chiang, MD, MEd is a first-year categorical pediatrics resident at UPMC Children’s Hospital of Pittsburgh in Pittsburgh, Pennsylvania. You can find him on Twitter @KevinCChiang or on Instagram @kchiang16.

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