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Disclosure: current MD student at WashU

The most important detail left out here is arguably price! You will do great from all the programs, so go where its cheapest.

To address some of your cons for WashU:

1) Why would distinction be a con? Not getting a distinction won't hurt you, but getting one can help set you apart in the residency application process.

2) Downward trend in ranking? Among program directors? On admit? Outside of pre-med spaces the pedigree of WashU has not changed meaningfully in decades. It continues to be one of the best medical schools in the country and is generally "ranked" above the other programs listed here.

3) Difficulty matching outside of Missouri? Based on what? If we look at the last two match cycles on their website they matched 79 to the East Coast, 100 to the midwest and 60 to the West Coast, with Missouri (41), California (25), New York (13), Washington (7), Massachusetts (9), Pennsylvania (9) and Illinois (7) being the most popular states. The Missouri number is also inflated because many students match preliminary at Missouri Baptist (BJC) while simultaneously matching specialties (radiology, anesthesia, derm etc.) outside of Missouri.

4) Difficult to view this in isolation. Yale matched 4/12 in derm despite having a T5 derm residency program. So many factors at play here including the quality of the applicants, application strategy, geographical preferences etc.
 
I agree with YellowSalamander that the way you are trying to interpret this year's match list is not useful/meaningful, and I honestly have no idea what you mean by "downward trend" in WashU's ranking. These schools are essentially equal in terms of their research opportunities and ability to help you match derm anywhere in the country you want. So I'd really base the decision on student culture and the curricular differences (1/2 year preclin, P/F vs. graded clinicals, exam structure and whether students feel ready for boards). If you can attend second look weekends, I'd ask current students how they feel about these things. Some students may prefer 1-year preclin over 1.5 or 2. Others are the opposite. Similar, some people may prefer graded clinicals while others prefer P/F. There is no objective better choice so you'll need to think about which you prefer.
 
I appreciate the feedback! I received no aid, so these schools are very similar in price.

I understand WashU is a prestigious school, but it was #2 a few decades ago, so that is what I meant by downward trend. But perhaps this does not matter.
There is no meaningful difference in prestige and pedigree between the T10 programs. The reason the rankings change all the time is due to the rank methodology being updated over time. WashU has invested a TON of money into infrastructure in the last decade and its NIH funding has grown to the second highest in the country among medical schools. I don't think any supposed decline in prestige is apparent in the real world.
 
As an m1 are WashU, you will be able to match Derm as long as you start playing the game early enough. Looks like, across the board at top schools, derm match was brutal this year, but last year washu matched a lot of derm. The admin take things like this very seriously so I wouldn’t be too concerned.
 
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