Congrats on great options! It's interesting that leaving pittsburgh is a con for Duke but staying in pittsburgh is a con for Pitt. I don't know you enough to know what your true preference is, but it sounds like you've enjoyed pitt but you're ready to leave. I also think it's a good idea to get used to moving around for the rest of your medical education. Furthermore, Duke is closer to family so you'll still have support in the area. I think the con about having to build new networks for research is irrelevant unless you truly love the work you're doing right and it's related to your specialty of interest. You'll have no trouble at Duke, like Mr.Smile12 said. The prestige difference between Duke and Pitt is minimal enough that I would not at all let it influence your decision. If you can visit Duke during their admit weekend, I'd recommend that. But for now, it sounds like Duke is the choice here, especially if they can match or beat Pitt's financial aid.