Financial motives behind programs' rank lists?

[legionella]

For the past couple years I've heard about all the "dancing/flirting" that residency programs and applicants do with each other as a part of this whole match process. You know: thank you letters fawning over programs, telling programs they're your #1, demonstrating ties to that city/region to convince programs you'd actually move there, etc. I can see why applicants would do this stuff- who wouldn't want to be liked by programs and increase their chances of matching wherever they want? But as I've started to hear examples of residency programs courting applicants (with thank you letter from the programs to the applicants or even "we really like you/we'll rank you highly" messages), I've wondered what the programs' incentive is for doing this. Obviously programs want good residents working there. But beyond just wanting a qualified group of residents, I wondered why some programs go out of their way to court individual applicants, and why they place so much (or any) weight on their position on the applicants' rank lists. We all hear applicants brag about matching at their #1 or in their top 3, but it's not like we hear programs brag that they got their top 10 applicants or whatever... so why does it matter whether programs get their top picks or not?

Last week at my school we had a panel of residency PDs from various specialties do an FAQ about the application/interview process. One PD (from a smaller specialty) said something that intrigued me- he said that at some programs, the faculty get paid more (higher salary or a bonus) if the people they rank towards the top of their rank lists end up matching there. He implied that at those programs, PDs may rank highly applicants who they think will rank them highly, rather than strictly ranking in the order of who they like/want. As applicants we are told to rank programs in the order in which we want to go to them, regardless of how we think they will rank us. I had assumed programs did the same, but this makes me think maybe not. Does anyone know if this financial incentive thing is true, and how common a practice it is? Does it tend to occur more in certain specialties or regions of the country or types of programs?

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[IMPD]

Never heard of such a thing. As I've written elsewhere, PDs obsess over their rank list as applicants do and we are very conscious of "how far down" our list we go.

But when you look at this logically, it makes no sense. If you rank the best candidates regardless of their "intentions", you will match the best list and you will go down further on your list.

At the end of the day, PDs are really the only ones I can imagine caring about how far down they went. My Chair cares quire a bit about our match, but Chair's focus is on the names of medical schools, not their position on my list.

 

[Sauce1]

Never heard of such a thing. As I've written elsewhere, PDs obsess over their rank list as applicants do and we are very conscious of "how far down" our list we go.

But when you look at this logically, it makes no sense. If you rank the best candidates regardless of their "intentions", you will match the best list and you will go down further on your list.

At the end of the day, PDs are really the only ones I can imagine caring about how far down they went. My Chair cares quire a bit about our match, but Chair's focus is on the names of medical schools, not their position on my list.

Ive also wondered this as well. Guess its more of a bragging thing to not want to go down too far. And its human nature to want to go somewhere or have someone go to a program that is interested and will be happy there. Id imagine the more people that match from their top 1-3 will be happier rather than if they end up falling and going to an undesired program. And happy residents are usually better residents

Also, why would he care about the names of the medical schools? I guess it makes some sense to brag that you have so many people from top schools, but wouldn't it be better for the program to get the best candidates even if they are top candidates from middle/lower tier schools rather than average/below average candidates from top tier schools?

 

[Law2Doc]

... We all hear applicants brag about matching at their #1 or in their top 3, but it's not like we hear programs brag that they got their top 10 applicants or whatever... so why does it matter whether programs get their top picks or not? ...

Programs absolutely like to brag that they didn't have to go deep in their rank lists -- they just don't do this bragging to applicants. PDs get together at various academic meetings and PD associations and absolutely use this as a yardstick for claiming how popular and prestigious their program is. it is important to them, separates the good program from the wannabees, and so yes they need to feel an applicant might actually come to their program in order to rank them highly, in addition to scores and credentials. So if you are interviewing eg in Wyoming and never set foot in the state before, you had better have some pretty compelling reason to be interviewing there. Nobody will care that you are Albert Schweitzer with a 270 on step 1 if they think you won't come -- you will end up at the bottom of their rank list. It has nothing to do with financial incentives, although its possible some places do what you are describing. It's bragging rights, plain and simple. The PD wants to say that he ranked to match and got his top choices. He doesn't want to have to concede that some other program got all their top choices.

 

[SouthernSurgeon]

No, there is no financial incentive, at least at any place I've ever heard.

 

[NotAProgDirector]

This is an evolving area. The new buzzword in medicine is "outcomes". The idea is that we should all be evaluated on the quality of our work -- a grand idea. The problem is how we actually do that measuring. My institution recently announced that they would be measuring residency programs by their last rank / number of spots ratio. This would in fact incent me to order my list by "chance of matching" vs "how much I want them". There is no suggestion (yet) that my pay will depend upon this, but that's the next step.

I've told my institution that this is stupid, and I refuse to report it. I would be happy to help develop meaningful outcome metrics. Just because ROL matching is easy to measure doesn't make it a good target. I'm hoping that this was a well meaning idea by poorly informed administrators who will be flexible, but we will see.

 

[IMPD]

This is an evolving area. The new buzzword in medicine is "outcomes". The idea is that we should all be evaluated on the quality of our work -- a grand idea. The problem is how we actually do that measuring. My institution recently announced that they would be measuring residency programs by their last rank / number of spots ratio. This would in fact incent me to order my list by "chance of matching" vs "how much I want them". There is no suggestion (yet) that my pay will depend upon this, but that's the next step.

I've told my institution that this is stupid, and I refuse to report it. I would be happy to help develop meaningful outcome metrics. Just because ROL matching is easy to measure doesn't make it a good target. I'm hoping that this was a well meaning idea by poorly informed administrators who will be flexible, but we will see.

Our new Dashboard report evals programs on a range of "outcomes" that seem more or less related to anything that seems like a reasonable for a PD to worry about.

The case for ranking the best candidates regardless of their intent is so rock-solid that it boggles my mind that anyone would disagree with it. Since no one but the PD and the NRMP has access to the Rank List, I would concur in not providing that information, or simply using that request as a chance to educate the well-meaning and poorly-informed.

Having said that, I struggle every year to "educate" my faculty interviewers who make this same mistake and down-grade interviews because they didn't "feel" that the applicant "wanted" to come here. Ugh.

We don't want people who *really* don't want us, but that is different from being someone's 5th or 6th choice out of 12. Totally fine with that.

 

[legionella]

Thanks for the responses, especially from the program directors on here! It's interesting to know the incentives/thought processes that go on on the programs' end. I agree that logically, it makes perfect sense for programs to rank by best candidate, much like applicants should rank by best program- regardless of likelihood of matching there.

I'm curious- what do you guys think would be a "meaningful outcome metric" for programs to use instead of ROL matching? I'm not even sure what ROL matching is trying to measure, other than desirability of the program to applicants, and I don't see how that is a valuable thing in and of itself, because it can't be used comparatively. (For example, arbitrarily picking two programs in the same state: say MGH has to go down to #100 on its ROL to fill its 30 spots in internal medicine. And suppose UMass only goes down to #50 to fill its 30 spots. Does that mean UMass is "better" or more desirable to applicants? Of course not, because the applicants who interviewed at UMass probably didn't get interviews at MGH or other programs of that caliber, and the applicants who interviewed at MGH probably interviewed at other competitive/prestigious programs, not places like UMass. So by comparing how far down the rank list these two programs went, you're comparing two different categories of applicants with different levels of competitiveness and different options of programs to match at.) So... do you think programs are measuring a worthless entity? Or is it a useful thing to measure, but using ROL matching is a silly way to measure it?

 

[IMPD]

Thanks for the responses, especially from the program directors on here! It's interesting to know the incentives/thought processes that go on on the programs' end. I agree that logically, it makes perfect sense for programs to rank by best candidate, much like applicants should rank by best program- regardless of likelihood of matching there.

I'm curious- what do you guys think would be a "meaningful outcome metric" for programs to use instead of ROL matching? I'm not even sure what ROL matching is trying to measure, other than desirability of the program to applicants, and I don't see how that is a valuable thing in and of itself, because it can't be used comparatively. (For example, arbitrarily picking two programs in the same state: say MGH has to go down to #100 on its ROL to fill its 30 spots in internal medicine. And suppose UMass only goes down to #50 to fill its 30 spots. Does that mean UMass is "better" or more desirable to applicants? Of course not, because the applicants who interviewed at UMass probably didn't get interviews at MGH or other programs of that caliber, and the applicants who interviewed at MGH probably interviewed at other competitive/prestigious programs, not places like UMass. So by comparing how far down the rank list these two programs went, you're comparing two different categories of applicants with different levels of competitiveness and different options of programs to match at.) So... do you think programs are measuring a worthless entity? Or is it a useful thing to measure, but using ROL matching is a silly way to measure it?

Although proving your status is a never-ending quest, I don't see how ROL are any help to anyone in this.
The traditional method of judging "success" at the Match seems to rely on names of medical schools, AMG vs IMG composition and at the bottom, avoiding the SOAP. If someone wanted to create some crazy formula (10 points for Harvard Med School, etc. etc.) I'm sure they could. In fact, I'm sure it's been done by some insane person.

ROLs are terrible terrible proxies for "success" at the Match. I don't see any use for them.

 

[Law2Doc]

...
The case for ranking the best candidates regardless of their intent is so rock-solid that it boggles my mind that anyone would disagree with it. Since no one but the PD and the NRMP has access to the Rank List, I would concur in not providing that information, or simply using that request as a chance to educate the well-meaning and poorly-informed.

Having said that, I struggle every year to "educate" my faculty interviewers who make this same mistake and down-grade interviews because they didn't "feel" that the applicant "wanted" to come here. Ugh.

We don't want people who *really* don't want us, but that is different from being someone's 5th or 6th choice out of 12. Totally fine with that.

Th program I've been associated with have struggled with this, and have come to the other conclusion. Actually the guy with great credentials who regards your program as his deep back-up (5th or 6th choice qualifies, considering most will expect to get one of their top 3 choices) is going to be very unhappy with getting stuck with your program and might not flourish the way someone more interested might. So there probably is a benefit in filling your program with the best people who actually want to be there, rather than someone who just applied on a whim, but maybe never even came into the state before. The guy who wants out from day one (and some of us have met these types) doesn't ever become a leader -- he cuts his losses, does the bare minimum, milks his vacation and sick/personal/interview days to the max. You get a cog in the wheel, nothing more. Often you are better off with the guy with the shorter CV who actually wants to buy what you are selling. It's why places like that nexus to the location or the program. And why the well credentialed guy who would rank your program 6th out of 12 might not be a better choice than the slightly less credentialed guy who puts it at the top of his list.

IMHO, programs could consider taking a flier on maybe 1-2 exceptional applicants who probably wouldn't come, but the bulk of the top if their rank list ought to be people they liked that actually have some connection. The last thing you want is a group of people with great credentials who really don't want to be there and are looking to keep their head down and stomach through. That may be fine for a prelim program, but anything longer, that's a cancer.

 

[SouthernSurgeon]

Th program I've been associated with have struggled with this, and have come to the other conclusion. Actually the guy with great credentials who regards your program as his deep back-up (5th or 6th choice qualifies, considering most will expect to get one of their top 3 choices) is going to be very unhappy with getting stuck with your program and might not flourish the way someone more interested might. So there probably is a benefit in filling your program with the best people who actually want to be there, rather than someone who just applied on a whim, but maybe never even came into the state before. The guy who wants out from day one (and some of us have met these types) doesn't ever become a leader -- he cuts his losses, does the bare minimum, milks his vacation and sick/personal/interview days to the max. You get a cog in the wheel, nothing more. Often you are better off with the guy with the shorter CV who actually wants to buy what you are selling. It's why places like that nexus to the location or the program. And why the well credentialed guy who would rank your program 6th out of 12 might not be a better choice than the slightly less credentialed guy who puts it at the top of his list.

This assumes that nothing changes from the day the applicant submits their rank list to the day they graduate. IMHO, some of our best residents, and the biggest "cheerleaders" for our program, are residents who originally didn't rank the program that highly but have ended up loving it here. I wouldn't assume that everyone who didn't initially rank the program #1 will be permanently insulted.

IMHO, programs could consider taking a flier on maybe 1-2 exceptional applicants who probably wouldn't come, but the bulk of the top if their rank list ought to be people they liked that actually have some connection. The last thing you want is a group of people with great credentials who really don't want to be there and are looking to keep their head down and stomach through. That may be fine for a prelim program, but anything longer, that's a cancer.

This all comes down to that extremely hard to measure "fit" factor. It's not just a geographic nexus or a #1 on the rank list. Some people will thrive anywhere. Some people will only thrive if surrounded by the right type of people - and the applicant may not even correctly perceive that themselves. This is why I don't envy PDs. Hard job. I have a hard time with the 10-12 applicants per year I interview.

 

[Law2Doc]

The majority of people a program invites to interview has something going for them and could do the work. Its relatively few that you meet and dislike. So how best to decide which of the remaining diamonds in the rough to keep? Is the person who really wants to come the wrong choice? Sure you will miss out on a couple of superstars. You would if you went the other way as well. But if you pick people who want your program and location, you increase the odds that they will be happy and as a result thrive. You wont have the guy who has to suck it up an suffer through. That's worth an extra publication on the CV or a couple of points on Step 1, I suspect. And the PD will get to brag about getting their first choice to boot. So it's win win.

 

[mvenus929]

So there probably is a benefit in filling your program with the best people who actually want to be there, rather than someone who just applied on a whim, but maybe never even came into the state before. The guy who wants out from day one (and some of us have met these types) doesn't ever become a leader -- he cuts his losses, does the bare minimum, milks his vacation and sick/personal/interview days to the max. You get a cog in the wheel, nothing more. Often you are better off with the guy with the shorter CV who actually wants to buy what you are selling. It's why places like that nexus to the location or the program. And why the well credentialed guy who would rank your program 6th out of 12 might not be a better choice than the slightly less credentialed guy who puts it at the top of his list.

But how do you figure out who the guy (or gal) who wants to be there is? I mean, I've known my top choice for ages, and they're my top choice because they're an awesome program and because they're in a great place (that I grew up in, so I'm quite familiar with what the town has to offer), but I've been really surprised by how much I've liked a couple of the programs on my list--I applied primarily because of location and size, but when I met the residents and faculty oniew day, I was impressed with everything I saw, even if I have kept my top choice the same. Two such programs, I had never been to the town before, so that wouldn't be a good measure as to how I, as the applicant, rank the program and how much I want to go there.

 

[Law2Doc]

But how do you figure out who the guy (or gal) who wants to be there is? I mean, I've known my top choice for ages, and they're my top choice because they're an awesome program and because they're in a great place (that I grew up in, so I'm quite familiar with what the town has to offer), but I've been really surprised by how much I've liked a couple of the programs on my list--I applied primarily because of location and size, but when I met the residents and faculty oniew day, I was impressed with everything I saw, even if I have kept my top choice the same. Two such programs, I had never been to the town before, so that wouldn't be a good measure as to how I, as the applicant, rank the program and how much I want to go there.

Some people will fall in love with a program they applied to on a whim, but that's not really playing the odds. also the fact that you are likely keeping as your top choice a program where you have a definite nexus kind of reenforces my point. It's pretty easy to learn during an interview day whether someone has a specific reason to apply to your program -- it's hard to fake a good nexus.

 

[Psychotic]

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[POW16]

Take a chill pill. If you conveyed genuine interest in those programs, you may very well match there.

Sent from my SAMSUNG-SGH-I537 using Tapatalk

 

[Psychotic]

Take a chill pill. If you conveyed genuine interest in those programs, you may very well match there.

Sent from my SAMSUNG-SGH-I537 using Tapatalk

Take a chill pill. If you conveyed genuine interest in those programs, you may very well match there.

Sent from my SAMSUNG-SGH-I537 using Tapatalk

Nexus is a factual determination, not subjective. If programs care so much about nexus, they should only invite local bumpkins to interview, save me the expense and frustration of trying to convince them that my lack of nexus should not concern them, and the issue has definitely been raised at some of my interviews, so I know that Law 2 Doc is on to something here. My hope is that he is overstating it, that's all.

 

[SouthernSurgeon]

Nexus is a factual determination, not subjective. If programs care so much about nexus, they should only invite local bumpkins to interview, save me the expense and frustration of trying to convince them that my lack of nexus should not concern them, and the issue has definitely been raised at some of my interviews, so I know that Law 2 Doc is on to something here. My hope is that he is overstating it, that's all.

As I've said previously, at least from my experience at my program, L2D is way overstating it.

I imagine the whole "nexus" concept varies in importance depending on geographic location (I.e. More of a concern for a program in Minnesota than one in Boston), size, field, and competitiveness of the program.

Honestly at my program, we really try to go after the best candidates we can. If someone truly seems disinterested in our program then sure, we are gonna knock them down on our rank list. But that's about it. So if you can sell yourself as motivated to come here (not hard to do) on the interview day, you're fine.

 

[Doodledog]

This is an evolving area. The new buzzword in medicine is "outcomes". The idea is that we should all be evaluated on the quality of our work -- a grand idea. The problem is how we actually do that measuring. My institution recently announced that they would be measuring residency programs by their last rank / number of spots ratio. This would in fact incent me to order my list by "chance of matching" vs "how much I want them". There is no suggestion (yet) that my pay will depend upon this, but that's the next step.

I've told my institution that this is stupid, and I refuse to report it. I would be happy to help develop meaningful outcome metrics. Just because ROL matching is easy to measure doesn't make it a good target. I'm hoping that this was a well meaning idea by poorly informed administrators who will be flexible, but we will see.

This amazes me. The residency and fellowship I'm very familiar with wouldn't do this in part because the chairs are closely involved in the actual ROL decision. This would be an awful and destructive metric for almost any program in almost any field.

With regard to the other issues in this thread, I agree that programs will certainly try to gain some understanding of whether an applicant for residency or fellowship has a true interest in the program. This includes both factual types of connections, which can be more than geographic and often include our trainees who are practicing across the country, and also interview and post-interview impressions. However, in many cases, especially for residency, we're left with "not sure" but we think they are interested. Trying to pin it down beyond that is impossible and probably would lead to a bad result with that applicant. So we don't do it. We like folks in our programs from throughout the country anyway, so why not take a stab at folks from throughout the country.

I am puzzled at the thought that someone who matches at a place, wherever it might be on their ROL would give less of an effort in their training. This is very obviously self-defeating related to matching into fellowships or obtaining career goals. Even those going into private practice in many fields will wish their PD to think well of them when asked. More relevantly, in my experience, most folks come to like where they matched and only a few (actually I don't remember any and my n is rather large) maintain a type of useless bitterness that is reflected in their performance.

Ultimately, both my residency and fellowship follow the primary guidance described above. If there is not an OBVIOUS disconnect to our place or evidence of disinterest, we rank based on whom we want. We want the people we want more than the privilege of uselessly bragging about how minimally we went down our ROL.

 

[gutonc]

As I've said previously, at least from my experience at my program, L2D is way overstating it.

I imagine the whole "nexus" concept varies in importance depending on geographic location (I.e. More of a concern for a program in Minnesota than one in Boston), size, field, and competitiveness of the program.

Honestly at my program, we really try to go after the best candidates we can. If someone truly seems disinterested in our program then sure, we are gonna knock them down on our rank list. But that's about it. So if you can sell yourself as motivated to come here (not hard to do) on the interview day, you're fine.

I think "nexus" is a real (and frankly stupid) thing but I definitely agree that L2D is overstating the case. When interviewing candidates I do always ask "why here?" but it's mostly to see if they have any idea about the location or program. That's all I really need to know...that they've done their homework. I don't care if this is their first time in the city/state/time zone, if they express rational interest in the program and location, that's good enough for me.

 

[SouthernSurgeon]

I think "nexus" is a real (and frankly stupid) thing but I definitely agree that L2D is overstating the case. When interviewing candidates I do always ask "why here?" but it's mostly to see if they have any idea about the location or program. That's all I really need to know...that they've done their homework. I don't care if this is their first time in the city/state/time zone, if they express rational interest in the program and location, that's good enough for me.

Exactly.

 

[Laryngophed]

Ranking based upon supposed likelihood to match seems incredibly short-sighted. And that it would be an outcome measured to evaluate the PD seems like an even worse idea.

 

[Raryn]

I think "nexus" is a real (and frankly stupid) thing but I definitely agree that L2D is overstating the case. When interviewing candidates I do always ask "why here?" but it's mostly to see if they have any idea about the location or program. That's all I really need to know...that they've done their homework. I don't care if this is their first time in the city/state/time zone, if they express rational interest in the program and location, that's good enough for me.

I don't know what specialty L2D is in, but the impression I've gotten over the years is that he's in a smaller surgical subspecialty. The type that can afford to be pretty picky, and the type where having one dud resident probably makes a big difference for a number of years. On the other hand, IMPD is an... IM PD. The average IM program takes 15 or 16 categorical residents yearly, with the range being something ridiculous like 5-60. Having one possible dud but getting those extra 2-3 superb candidates is a very different story when you're talking about 20 residents/year in your program compared to 2.

Mind you, I haven't read a fraction of LTD's 27,000 posts, so I could be completely wrong.

 

[gutonc]

Good point. I often forget that not everyone is in IM and that it's much different when you're talking about small programs.

 

[mercaptovizadeh]

L2D also has a contrarian and authoritarian personality. He likes people being punished for using vacation time, reprimands for arriving 30 seconds late to work, people failing to match into a Florida program because they're from Montana, etc. His spiritual brother is skinMD, who trolls the IM forums and tells applicants with 270 step 1/AOA/PhD that their chances are slim at Albert Einstein's program, etc.

 

[Law2Doc]

L2D also has a contrarian and authoritarian personality. He likes people being punished for using vacation time, reprimands for arriving 30 seconds late to work, people failing to match into a Florida program because they're from Montana, etc. His spiritual brother is skinMD, who trolls the IM forums and tells applicants with 270 step 1/AOA/PhD that their chances are slim at Albert Einstein's program, etc.

I haven't taken any of the positions you suggest, and it's not appropriate to slander people on an online site in order to undermine their statements.

I'm just saying what I've seen first hand -- that if an applicant doesn't have an obvious nexus to a program, they are going to have to do a lot more to sell the program as to why they are applying. No program wants to be someone's safety/fallback, and honestly the person who has never set foot in the state probably will be hard pressed to sell us as to why they would come to a program over one they have more connections with. A lot of programs aren't going to throw the dice and say, this guy has a 270 step 1 and great letters/research so we will rank him highly even though it seems like we were the afterthought program he added because he felt like he needed a tenth interview. I'm not saying you can't ever overcome this perception, but I am saying that by the time you leave the interview, the program had better believe you are ready to sign on the dotted line.

 

[Psychotic]

.

 

[SouthernSurgeon]

I'm just saying what I've seen first hand -- that if an applicant doesn't have an obvious nexus to a program, they are going to have to do a lot more to sell the program as to why they are applying. No program wants to be someone's safety/fallback, and honestly the person who has never set foot in the state probably will be hard pressed to sell us as to why they would come to a program over one they have more connections with. A lot of programs aren't going to throw the dice and say, this guy has a 270 step 1 and great letters/research so we will rank him highly even though it seems like we were the afterthought program he added because he felt like he needed a tenth interview. I'm not saying you can't ever overcome this perception, but I am saying that by the time you leave the interview, the program had better believe you are ready to sign on the dotted line.

And again I think this varies a ton, and that you are still way overstating it.

The vast majority of folks with "270 step 1s, great letters, and research," will be at the top of most programs' rank lists, unless they are complete duds in person.

 

[Raryn]

I haven't taken any of the positions you suggest, and it's not appropriate to slander people on an online site in order to undermine their statements.

I'm just saying what I've seen first hand -- that if an applicant doesn't have an obvious nexus to a program, they are going to have to do a lot more to sell the program as to why they are applying. No program wants to be someone's safety/fallback, and honestly the person who has never set foot in the state probably will be hard pressed to sell us as to why they would come to a program over one they have more connections with. A lot of programs aren't going to throw the dice and say, this guy has a 270 step 1 and great letters/research so we will rank him highly even though it seems like we were the afterthought program he added because he felt like he needed a tenth interview. I'm not saying you can't ever overcome this perception, but I am saying that by the time you leave the interview, the program had better believe you are ready to sign on the dotted line.

This may be the case in small, competitive specialties where the programs in places like Kansas might be afraid of applicants who consider them a backup at best AND there's a glut of overqualified candidates around. This is NOT generalizable. Most programs want the best candidates, not the ones who most dearly want to go there.

While I wouldn't ascribe the same positions as claimed above to L2D, my observation is that he is is a "realist" to the point of significant pessimism. He is a valuable voice on the forum but much like everything else on SDN (myself included), his opinion should be taken with a large grain of NaCl.

 

[mercaptovizadeh]

The pediatrics program director at my school said that she doesn't care one bit how much "you" (meaning the applicant) "want to come to our program." She then said "we want the best people we can get."

I think that's the only logical way of doing things, to be honest.

 

[Jubears09]

Good point. I often forget that not everyone is in IM and that it's much different when you're talking about small programs.

Still doesnt make sense. I can see a small competitive program with more qualified applicants than they can interview screen interview offers based on the perceived nexus, or a state school with the mission of training providers for their area placing an emphasis on this, but either way interviewing and then not ranking someone based on this is a very cost-ineffective way to screen.

If nexus is such a big deal the program should just send out a "secondary" to people they are considering asking for this info (which many derm programs already do). It makes a lot more sense than not ranking otherwise qualified individuals who took the time to travel and whom you put in the resources to meet.

 

[Psychotic]

.

 

[Law2Doc]

... She then said "we want the best people we can get."...

yes, but I think if you put the emphasis on the "we can get" part of the sentence instead of "the best" the element of nexus creeps in.

 

[Law2Doc]

And again I think this varies a ton, and that you are still way overstating it.

The vast majority of folks with "270 step 1s, great letters, and research," will be at the top of most programs' rank lists, unless they are complete duds in person.

Im sure it does vary, but I happen to know that multiple programs do it exactly as i am describing, which is why the topic is good fodder for a discussion board. I'm not saying what the best approach is so much as tossing out an opposing view to the "obvious" approach IMPD suggested above. Program directors and applicant committees are and do struggle with these issues. You want the best people, but you also want people who are happy and excited to be there. The guy who feels kicked in the teeth after free falling in the match process might not hit the ground running with the same vigor as the guy who was elated to land his first choice. There are exceptions to anything, but some programs have certainly found this to be the case. This is particularly true if the program isn't located in everyones favorite destination. Just a devils advocate food for thought.

I don't agree with your statement that applicants with great credentials will automatically be at the top of every programs list. In some fields its a buyers market. When you are getting hundreds of applications from superstars all within a similar range of board scores, and all applying to the same group of programs, some in more or less desirable locations, it doesn't always serve a program well to have the identical rank order list as their competitors. so this concept of nexus is helpful. Programs do want "the best applicants they can get". But "they can get" also incorporates a notion of "who would rank us highly as compared to our competitors". And that necessarily takes into account nexus and geography. If a program has an "inside track" to one of the superstars because he's a local, why shouldn't that influence how they rank him? (I'm asking, not telling).

So sure I'm overstating things maybe a little. But not as much as some people on here are underplaying things. I'd be lying if I said the issue of nexus didn't come up regularly during the residency interview process.


Great discussion thread!

 

[Law2Doc]

A secondary makes a lot of sense for these questions of nexus if that is a program's chief concern.

In my case, assuming my nexus based on what a program learns about me from my ERAS info, is flawed and misleading. First, is everyone aware that the most prominent geographic location listed on your ERAS is where you were born? I haven't lived there since I was like 10 months old, yet you could assume I have some "nexus" in that state (I don't). Next, the place where I lived from a very young age through high school is nowhere to be found on ERAS (I attended college and med school out of state) - since I started med school, my parents moved to another state, a state that I now use as my legal residence for drivers license and tax purposes (and it is shown on ERAS and is the permanent address where I receive program postal mail), yet I have never actually lived in that location a day of my life. To an ERAS reader, though, it could be assumed that it is my true nexus, and it is not.

And here is the biggest joke of all: I have not heard from 2 programs located in my supposed state of nexus (my parent's new home state). And these are not big time competitive programs, but community-like university programs (edit: I was officially rejected from one of these programs, and have not heard anything from the other, a program that has a history of not filling in the match, so go figure).

So the programs in my presumed state of nexus rejected me, and other programs are questioning why I am interested in their state since I have no nexus there. This is not sour grapes: I have had more interviews than I could handle from around the country, and at programs of far greater repute than these instate programs, but still the point is that my so-called nexus has been ignored instate and is being questioned out of state.

There is nowhere on the ERAS application to easily "explain" one's nexus problem (not that I realized it was going to be this big of an issue) - it would read like hell in a PS - and there is nowhere to list it on the rest of the app.

So I find all of this emphasis on nexus pretty damn frustrating and disgusting. Again, if a program like Law2Doc's is so freaking preoccupied with this nexus BS, then do the applicant a favor and don't offer an interview invitation. Otherwise, shoot all your applicants a secondary and ask to your heart's content about nexus, and ties to the area, and just why in the hell you would want to leave lovely X to live here in Z? And so on. I seem to recall some secondaries for med schools asked these sorts of questions, so why not residency programs?

I am convinced that Law2Doc's program is the exception and not the rule, but still this bugs the hell out of me.

Residencies continue to struggle with the best approach, but their goal is to end up with what works for THEM, not what is fair or what benefits the atypical applicant who wants to end up in a location to which they have no connection. I don't pretend to know what the right approach is, but wanted to point out that in practice there isn't a single approach being implemented, or obvious, as seemed to have been suggested earlier in this thread. Im not saying what should be the approach so much as suggesting what some places are, in fact, doing, and why.

Can you overcome the nexus hurdle? Sure. But IMHO it will require a lot more salesmanship than the guy/gal who has an obvious reason to be applying.

 

[Psychotic]

Residencies continue to struggle with the best approach, but their goal is to end up with what works for THEM, not what is fair or what benefits the atypical applicant who wants to end up in a location to which they have no connection. I don't pretend to know what the right approach is, but wanted to point out that in practice there isn't a single approach being implemented, or obvious, as seemed to have been suggested earlier in this thread. Im not saying what should be the approach so much as suggesting what some places are, in fact, doing, and why.

Can you overcome the nexus hurdle? Sure. But IMHO it will require a lot more salesmanship than the guy/gal who has an obvious reason to be applying.

I am working hard to overcome my nexus dilemma, and I realized it was a dilemma when I got zero interest from the 2 low to mid level "instate" programs I mentioned. I was frankly floored by this.

My strategy: I point out in interviews that I "left home" and moved pretty far out of state at 18 to attend college, lived out of state between college and med school, and then went to another place out of state for med school, all of these places distant from my "nexus" home, and I have never returned home for anything but short visits, and furthermore I have no overarching desire or need to return to that home now, either. When I have been asked about it indirectly (why here?) or directly (why not there?), the interviewers seem to accept my answers at face value, and often nod in approval or tacit agreement that my history does reveal a lot about me and the lesser importance of family nexus in my case. I try to shift the focus of my interest to "program" over "place" in my interviews, or I at least try to push the "place" issue into the background. I care about place, a lot, just not in the traditional nexus sense. Regardless, they may fully accept my answer, but still rank me lower because I don't have a nexus to their program and place, but it is the best I can do with what I have.

Nonetheless, it irks me. Cripes, I am an independent adult pushing 30…nexus? Please, don't go there, or if you do, at least consider that in my case nexus is a poor litmus test.

Honestly, I think the nexus thing can signal a backup "safety" strategy, too. Consider an applicant with interviews all over the country, who appears to be slumming when he interviews at a low/midrange community program near the 'rents…nexus can cut both ways, right? Clearly I believe it worked against me with the instate programs that passed on my app. Otherwise, I will never understand how I wasn't invited to these programs given that they seem to be exactly the kind of programs in backwater/flyover country that place a very high value on nexus, which I certainly had in spades, at least on paper...

 

[swamprat]

I also am skeptical it matters once you are at interviews.. I think if they werent sure you would want to come there they wouldnt invite you. Thats been my experience anyway..all the out of state applications that I sent out I've gotten rejections from and some of them are new programs or community not big name places ( i just thought itd be cool to go check out a new part of the country). Had I did an away in that area, or had something on my application to tie me to that area I bet I would have gotten a lot more love from these programs. As it turns out, all my interviews have been in any of 4 states that are either in or close to my medical school or family.

edit: oh and lastly, match is a binding contract so even if a particular intern doesn't want to be there they have no choice, and lets be honest I feel most people hit the ground running being its their first real time being a doctor and getting to do doctor things. I could see that mid year lull where they realize they have no family and no one around them starting to slack.. but I feel thats probably the exception than the rule since most people are pretty dedicated to their specialty and graduating.

 

[Laryngophed]

I also am skeptical it matters once you are at interviews.. I think if they werent sure you would want to come there they wouldnt invite you. Thats been my experience anyway..all the out of state applications that I sent out I've gotten rejections from and some of them are new programs or community not big name places ( i just thought itd be cool to go check out a new part of the country). Had I did an away in that area, or had something on my application to tie me to that area I bet I would have gotten a lot more love from these programs. As it turns out, all my interviews have been in any of 4 states that are either in or close to my medical school or family.

edit: oh and lastly, match is a binding contract so even if a particular intern doesn't want to be there they have no choice, and lets be honest I feel most people hit the ground running being its their first real time being a doctor and getting to do doctor things. I could see that mid year lull where they realize they have no family and no one around them starting to slack.. but I feel thats probably the exception than the rule since most people are pretty dedicated to their specialty and graduating.

I think the contract with the Match is only binding for the first 45 days of the residency contract. The employment contract between the resident and program/hospital probably includes some penalties too.

 

[mcl]

At my program, the nexus issue is more likely to be considered in the initial application evaluation to extend an interview invitation rather than after the interview for the rank list. As Psychotic pointed out above, ERAS does not give a lot of good data to go by, and I'm sure we end up regretting candidates that do have a reason to be looking in this geographic area. For us, the issue isn't the Rank Order List, it's the interview cancellation rate. Typically, a candidate that doesn't have a tie to this area (usually involving family) is more likely to cancel. Once someone cancels, it can be difficult to fill the spot on short notice (and for some reason it always seems to be short notice). As we extend invitations/fill slots, the selection committee's decision making process becomes more difficult, and they'll start considering likelihood of the applicant to come if invited.

Of course, those decisions are mostly based on guess work. If I could change ERAS in only one way, it would be to include a space for someone to include their rationale for applying to a program. I don't see how that would work actually, since the CAF has to be the same for all programs, and rationales would likely differ from program to program, but a girl can make wishes on anonymous forums.

As it is, we use the information we have (applicant's birthplace, location of undergrad/graduate school and medical school) to see if we can glean any glimmer of the applicant's mindset. To be clear, strong applicants always get an interview invitation regardless of geographic tie. Weak applicants hardly ever get an invitation, even if they came to our institution as an undergrad. It's the "average" applicant that causes the quandry--but there are a lot of them. In the end, I hope that applicants who have an inobvious tie to the area but who haven't received an invitation within a few weeks of the MSPE will call or email me to state their interest (I recognize that I may be the only coordinator in the country that feels this way) so I can relay that to our committee.

Regarding the ROL, we feel that if the applicant made the effort to get here for the interview, he/she has a proven level of interest and will be ranked without regard for how we think the applicant will rank us. I imagine this will be true until the DIO starts making funding decisions for programs based on some rediculous factor, such as how far down we went on our ROL and/or our intern class's average step 1 score. The GME office does gather this information--and lots more in addition--so that sometimes I worry that we're heading in the direction described by the OP at the top of the thread. Maybe I'll get to retirement before that can happen.

 

[IMPD]

At my program, the nexus issue is more likely to be considered in the initial application evaluation to extend an interview invitation rather than after the interview for the rank list. As Psychotic pointed out above, ERAS does not give a lot of good data to go by, and I'm sure we end up regretting candidates that do have a reason to be looking in this geographic area. For us, the issue isn't the Rank Order List, it's the interview cancellation rate. Typically, a candidate that doesn't have a tie to this area (usually involving family) is more likely to cancel. Once someone cancels, it can be difficult to fill the spot on short notice (and for some reason it always seems to be short notice). As we extend invitations/fill slots, the selection committee's decision making process becomes more difficult, and they'll start considering likelihood of the applicant to come if invited.

Of course, those decisions are mostly based on guess work. If I could change ERAS in only one way, it would be to include a space for someone to include their rationale for applying to a program. I don't see how that would work actually, since the CAF has to be the same for all programs, and rationales would likely differ from program to program, but a girl can make wishes on anonymous forums.

As it is, we use the information we have (applicant's birthplace, location of undergrad/graduate school and medical school) to see if we can glean any glimmer of the applicant's mindset. To be clear, strong applicants always get an interview invitation regardless of geographic tie. Weak applicants hardly ever get an invitation, even if they came to our institution as an undergrad. It's the "average" applicant that causes the quandry--but there are a lot of them. In the end, I hope that applicants who have an inobvious tie to the area but who haven't received an invitation within a few weeks of the MSPE will call or email me to state their interest (I recognize that I may be the only coordinator in the country that feels this way) so I can relay that to our committee.

Regarding the ROL, we feel that if the applicant made the effort to get here for the interview, he/she has a proven level of interest and will be ranked without regard for how we think the applicant will rank us. I imagine this will be true until the DIO starts making funding decisions for programs based on some rediculous factor, such as how far down we went on our ROL and/or our intern class's average step 1 score. The GME office does gather this information--and lots more in addition--so that sometimes I worry that we're heading in the direction described by the OP at the top of the thread. Maybe I'll get to retirement before that can happen.

Lovely description of how it is many places.

The "average applicant" dilemma is real. Sorting out who to invite from that pool is a crap-shoot much of the time. People can start arguing about ridiculously small differences in applicant's portfolios (quotes from their 3rd year Medicine rotation, or worse, their Ob/Gyn rotation).

I don't say the above to provoke further neurosis in SDN'ers (as if that were not going to happen anyway), but to reinforce the aspects of this process that truly are somewhat random. I remember the offense at learning of this, and as I've gotten older I've worked to BOTH accept that much of life does depend on fortune and worked to reduce it in my realm. Thus, I do pursue an algorithmic approach to inviting (and ranking) applicants. The work of sabremetrics (sp?) in baseball fascinates me and I've long sought to bring those sorts of measurements to medicine.

You can't totally quantify what it is that makes a good resident or a good doctor, but that won't stop me from trying.

 

[Obnoxious Dad]

I am working hard to overcome my nexus dilemma, and I realized it was a dilemma when I got zero interest from the 2 low to mid level "instate" programs I mentioned. I was frankly floored by this.

My strategy: I point out in interviews that I "left home" and moved pretty far out of state at 18 to attend college, lived out of state between college and med school, and then went to another place out of state for med school, all of these places distant from my "nexus" home, and I have never returned home for anything but short visits, and furthermore I have no overarching desire or need to return to that home now, either. When I have been asked about it indirectly (why here?) or directly (why not there?), the interviewers seem to accept my answers at face value, and often nod in approval or tacit agreement that my history does reveal a lot about me and the lesser importance of family nexus in my case. I try to shift the focus of my interest to "program" over "place" in my interviews, or I at least try to push the "place" issue into the background. I care about place, a lot, just not in the traditional nexus sense. Regardless, they may fully accept my answer, but still rank me lower because I don't have a nexus to their program and place, but it is the best I can do with what I have.

Nonetheless, it irks me. Cripes, I am an independent adult pushing 30…nexus? Please, don't go there, or if you do, at least consider that in my case nexus is a poor litmus test.

Honestly, I think the nexus thing can signal a backup "safety" strategy, too. Consider an applicant with interviews all over the country, who appears to be slumming when he interviews at a low/midrange community program near the 'rents…nexus can cut both ways, right? Clearly I believe it worked against me with the instate programs that passed on my app. Otherwise, I will never understand how I wasn't invited to these programs given that they seem to be exactly the kind of programs in backwater/flyover country that place a very high value on nexus, which I certainly had in spades, at least on paper...

Residency programs do not exist to further your career goals. They are not "about you". They exist to meet the medical workforce needs of the people who own and finance them. You are going to be a much happier person in so many ways when you discover that the world does not revolve around you. I would bet that you have been turned away by programs that are beneath your sterling credentials because their PDs read your personal statement, read between the lines of your letters of recommendations and found you repulsive. When you use expressions like "slumming" and "backwater/fly over country" it reveals a douche nozzle personality that no one would want to be around.

 

[anonperson]

Residency programs do not exist to further your career goals. They are not "about you". They exist to meet the medical workforce needs of the people who own and finance them. You are going to be a much happier person in so many ways when you discover that the world does not revolve around you. I would bet that you have been turned away by programs that are beneath your sterling credentials because their PDs read your personal statement, read between the lines of your letters of recommendations and found you repulsive. When you use expressions like "slumming" and "backwater/fly over country" it reveals a douche nozzle personality that no one would want to be around.

Residency programs have the goal of service AND education. Sure at some garbage residency programs that are FMG mills this may not be the case, but any decent PD knows that they owe it to their residents to help develop them into competent physicians.

 

[Psychotic]

.

 

[anonperson]

Th program I've been associated with have struggled with this, and have come to the other conclusion. Actually the guy with great credentials who regards your program as his deep back-up (5th or 6th choice qualifies, considering most will expect to get one of their top 3 choices) is going to be very unhappy with getting stuck with your program and might not flourish the way someone more interested might. So there probably is a benefit in filling your program with the best people who actually want to be there, rather than someone who just applied on a whim, but maybe never even came into the state before. The guy who wants out from day one (and some of us have met these types) doesn't ever become a leader -- he cuts his losses, does the bare minimum, milks his vacation and sick/personal/interview days to the max. You get a cog in the wheel, nothing more. Often you are better off with the guy with the shorter CV who actually wants to buy what you are selling. It's why places like that nexus to the location or the program. And why the well credentialed guy who would rank your program 6th out of 12 might not be a better choice than the slightly less credentialed guy who puts it at the top of his list.

IMHO, programs could consider taking a flier on maybe 1-2 exceptional applicants who probably wouldn't come, but the bulk of the top if their rank list ought to be people they liked that actually have some connection. The last thing you want is a group of people with great credentials who really don't want to be there and are looking to keep their head down and stomach through. That may be fine for a prelim program, but anything longer, that's a cancer.

This seems completely bizarre. I just went through the interview process for fellowship and interviewed at ~15 places. Ranked them all. If I matched at number 10 or even 20, I would have been fine and talking with other people on the interview trail, most had similar feelings, at least openly.

I think a program does a real disservice to applicants when they play this game. Unless there is some legitimate study that looked at resident performance (maybe inservice exam scores etc) based on whether an applicant matched in their top three versus lower down on their list, I have a hard time buying that these residents are going to perform poorly. It's all completely anecdotal. Conversely, I matched at my second to last place for residency, in a list that had ~20 programs. Sure I was bummed but I can say that my performance in residency has been above average.

Prospective residents are adults. People are willing to live in new areas/try new things.

 

[Law2Doc]

This seems completely bizarre. I just went through the interview process for fellowship and interviewed at ~15 places. Ranked them all. If I matched at number 10 or even 20, I would have been fine and talking with other people on the interview trail, most had similar feelings, at least openly.

I think a program does a real disservice to applicants when they play this game. Unless there is some legitimate study that looked at resident performance (maybe inservice exam scores etc) based on whether an applicant matched in their top three versus lower down on their list, I have a hard time buying that these residents are going to perform poorly. It's all completely anecdotal. Conversely, I matched at my second to last place for residency, in a list that had ~20 programs. Sure I was bummed but I can say that my performance in residency has been above average.

Prospective residents are adults. People are willing to live in new areas/try new things.

Some thrive despite a free fall, some dont. But when you are interviewing so many qualified people for each spot you don't always have to take the gamble when you think you have a surer bet.

 

[Jubears09]

Some thrive despite a free fall, some dont. But when you are interviewing so many qualified people for each spot you don't always have to take the gamble when you think you have a surer bet.

So why interview them in the first place versus a phone call or email with this question prior to extending the interview offer? I was under the impression it took a significant resource investment to interview applicants.

 

[Law2Doc]

At my program, the nexus issue is more likely to be considered in the initial application evaluation to extend an interview invitation rather than after the interview for the rank list. As Psychotic pointed out above, ERAS does not give a lot of good data to go by, and I'm sure we end up regretting candidates that do have a reason to be looking in this geographic area. For us, the issue isn't the Rank Order List, it's the interview cancellation rate. Typically, a candidate that doesn't have a tie to this area (usually involving family) is more likely to cancel. Once someone cancels, it can be difficult to fill the spot on short notice (and for some reason it always seems to be short notice). As we extend invitations/fill slots, the selection committee's decision making process becomes more difficult, and they'll start considering likelihood of the applicant to come if invited.

Of course, those decisions are mostly based on guess work. If I could change ERAS in only one way, it would be to include a space for someone to include their rationale for applying to a program. I don't see how that would work actually, since the CAF has to be the same for all programs, and rationales would likely differ from program to program, but a girl can make wishes on anonymous forums.

As it is, we use the information we have (applicant's birthplace, location of undergrad/graduate school and medical school) to see if we can glean any glimmer of the applicant's mindset. To be clear, strong applicants always get an interview invitation regardless of geographic tie. Weak applicants hardly ever get an invitation, even if they came to our institution as an undergrad. It's the "average" applicant that causes the quandry--but there are a lot of them. In the end, I hope that applicants who have an inobvious tie to the area but who haven't received an invitation within a few weeks of the MSPE will call or email me to state their interest (I recognize that I may be the only coordinator in the country that feels this way) so I can relay that to our committee.

Regarding the ROL, we feel that if the applicant made the effort to get here for the interview, he/she has a proven level of interest and will be ranked without regard for how we think the applicant will rank us. I imagine this will be true until the DIO starts making funding decisions for programs based on some rediculous factor, such as how far down we went on our ROL and/or our intern class's average step 1 score. The GME office does gather this information--and lots more in addition--so that sometimes I worry that we're heading in the direction described by the OP at the top of the thread. Maybe I'll get to retirement before that can happen.

A lot of programs will invite in people without knowing for sure if they have a nexus -- its not always clear. Sometimes things like couples matching or a local SO, etc gets fleshed out on interview day. And the only cost of giving a superstar the chance to sell themselves to a program is a few hours on an interview day (maybe an open slot on a day they already have scheduled). So no, the weeding out for nexus isn't Always done preinterview.

 

[Law2Doc]

So why interview them in the first place versus a phone call or email with this question prior to extending the interview offer? I was under the impression it took a significant resource investment to interview applicants.

It only costs time.

 

[mercaptovizadeh]

I would love to have the word "nexus" purged from this thread.

 

[gutonc]

It only costs time.

No...there's real money involved. Not a lot but with tight budgets it's stupid to interview people you wouldn't consider ranking.