when people say "lower tier" what is an example of some places for example?
I don't know anything about DO FM residencies. I trust
@cabinbuilder.
As for ACGME residencies, there aren't any tiers. There are some rankings that are relatively useless, such as Doximity that measures popularity of programs among PDs.
The tier suggestion just means that you need to go after FM programs that aren't competitive. Which is dog whistle for "look at a program's current residents, and evaluate how popular the residency is on the USMD/DO/IMG/FMG continuum." That's really all you have to go on. Yes, I'm saying that in general, more USMDs, more competitive, more FMGs, less competitive. Are there stellar FMG/IMG candidates that crush less stellar USMDs? You betcha. Do PDs always have time to see that FMGs/IMGs are stellar when the pile already has too many USMDs and DOs in it? Nope. Are there MD programs where the PD will consider DO equivalent to USMD, or top-3-IMG as superior to lesser-known-DO, etc? You betcha. Do PDs try to minimize the amount of time they spend agonizing over which candidates to invite to an interview, because they have to do it every goddamn year? You betcha. Can you necessarily find out which residencies are going to be fairest to you because of your school, other than looking at the med schools the residents are from? Nope. Do you sometimes have to do extreme internet gymnastic Sherlockery to find out what med schools populate a residency? Yup. Are coastal and metropolitan residencies harder to get into in FM like in other specialties? Yup. Should you apply to every FM residency where an alumni from your school matched in the last 5-10 years? Yup.
If you have little on your CV to make you compelling to an FM PD (community engagement, underserved activities, nontrivial leadership, nontrivial FM interest, nontrivial recommendations from FM docs, prior nontrivial work experience, etc), that's just as bad or worse than crap stats. PDs aren't confused that FM is the universal safety (along with IM). About half of my target residencies required a program-specific essay. (Imho this speaks positively about a program.)
From the interview trail I learned that some people apply to as few as 5, some over 200. If you're going to research residencies to make good choices, you can apply to fewer. If you're
not going to rigorously research residencies, then you need to apply to more. There's no way to predict whether you'll get invited or not.
I suggest that money can be used as a deciding factor. I suggest that if you want to be in a coastal or metropolitan area, you need to spend a boatload of money. I suggest that with a poor app you should probably be initially thinking in terms of 40 well researched or 100 poorly researched apps and hope for at least 10 interviews. Here's what ERAS charged in 2015:
Programs Per Specialty Application Fees
Up to 10 $97
11-20 $11 each
21-30 $16 each
31 or more $26 each
Getting more interviews than you want to go to isn't a bad thing - you just cancel a less preferred residency for a more preferred one when you get more than you can handle or afford. (Be organized. Be considerate.)
I think there are definitely some FM residencies that are worse than nothing, which you should be able to figure out on the interview trail (and from SDN, to a lesser extent) and then don't rank them. I think there are some more-likely-academic programs that make it really hard to get good training and make the prospect of independence really sketchy. And as you'll see in
@cabinbuilder posts, if you decide to be the grownup in charge of getting what you want and need out of your residency, and if you decide to train the crap out of yourself, then you don't really have anything to worry about in terms of employability.
Best of luck to you.
