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Rank List Game Theory

Let’s play a game.

Assume you are about to enter a 3 to 7 year apprenticeship that will redefine your character, scramble your personal life, pay you ~$8/hr,  greatly increase your risk of suicide compared to the average population, help you fulfill a life-long dream, and provide you with the privilege and responsibility to comfort and heal. Assume it is both wonderful and a little daunting.

You guessed it: We’re playing a game called “Becoming a Resident Physician.” It is one of the stranger games I have ever played, one that requires a peculiar, very personal calculus. Over the past few months, I have had many conversations with friends who are going through the same process and have been surprised by the diversity of approaches to the game. Anecdotally, it seems to me that the strongest forces within the game are family situation (which increases desire for a good location) and youth (which increases the desire for prestige). All this has made me very curious about how different people think about such situations. That’s why I’m interested what your approach might be. So, play with me?

Here is a very simple scenario:

1)      Assume you must list, in order, your top three choices: Prestigious Hospital (PH), Unique Training Hospital (UTH), Good Location Hospital (GLH).

2)      Assume that each hospital is excellent in its namesake quality and is satisfactory in the other two qualities. For example Good Location Hospital puts you in the city you most want to live in and close to your friends, family, loved ones; however, GLH has only satisfactory prestige and opportunities for unique training.

3)      Caveats:

  1. It cannot be known what effect the prestige of the hospital will have on your career; however, it is not likely to be deleterious.
  2. Optimizing unique training is likely to provide you with a significantly more lucrative career and/or greater academic success overall; however, current and future healthcare reforms are likely to reduce the lucrativeness and/or research funding by an unknown amount.
  3. Good Location provides easier access to places of interest, friends, family, loved ones; however, you will have very little time to enjoy these things.
  4. Assume that all other things are equal (though they never really are).

So, that’s it: PH vs. UTH vs. GLH. What’s your rank list and why?

As you might guess, I’m in the process of finalizing my rank list, which will be finalized February 20th. Then a computer somewhere in Baltimore, or so I am told, will take all the lists of applying medical students and all the lists of students desired by hospitals and create the “Match,” assigning one student to one hospital. The commitment is binding. One must, the following  July, report to the hospital at which one matched or one will not become a physician.  On Match Day, March 15th (beware the Ides of March!) every medical student in the US and Canada will be given an envelope, and at the exact same hour, all across the continent, we will open our letters and discover where we will become physicians.


23 Responses to “Rank List Game Theory”

  • UTH

    Because you really AREN’T going to have a great deal of free time on an on-going basis I think unique opportunities trump being close to home, it also allows you to focus on seeing people and stuff when you DO get a break to go home and encourages you to sleep more in your free time when at your Residency.

    That said, being close to loved ones is better for mental health. So it ranks second.

    While prestige is not unimportant, I think it ranks lowest on this list.

    It’s an agonizing decision I don’t envy you, but I have faith that you’ll succeed and thrive at any match the ALL POWERFUL COMPUTER throws at you.

    • it’s a good point, about the lack of free time. there’s a lot of discussion among my classmates about weather (nor cal has spoiled us) but as one friend mentioned, “whatever hospital you end up in will be 70 degrees and brightly florescently lit, all year round,” which is kinda reassuring, and kinda depressing 😉

  • Vanyel Jeter

    12:33 pm Feb-5-2013


    Honestly, I suppose that would completely depend on your abilities in regard to deferred gratification. If one assumes, as you stated, that you will have neither the time nor the ability to enjoy the benefits of the GLH. I would say that rules out that consideration completely as your life would then, at least for the interim, be the job.

    With that idea in mind, if one could utilize a good amount of personal strength and focus on the idea that you can always change to another location later in life it presses home further that the GLH is a good dream, but sadly only a dream– this is of course an opinion.
    In regards to the PH one can only assume that as stated it wouldn’t necessarily be detrimental to your career, but at the same time one can never assume success because of it either. Given the nebulous nature of that particular idea it would be uncomfortable to hinge to much on it.

    The UTH however leads to the thought that specialized knowledge will always be useful no matter how many policies change. Knowing things that others do not, or having skills that others do not will always remain in demand. By definition.

    So given the original thought of deferred gratification and the question of your ideas on that…

    Though in a most personal opinion, I’d just run off and join The Gesundheit! Institute– but honestly I’m just a do-gooder at heart in the extreme.

    • huh, thanks vanyel, that’s a very good analysis. coincidentally, one of the doctors i most admire at my hospital is named Dr. Gesundheit. funny coincidence. maybe i need to watch patch adams again…

  • the truth is Blake you should seriously consider foregoing residency. You won’t take this advise, I know, but one day you can look back and realize sage advise was left by an anonymous poster on your blog. Residency as it turns out will crush your creativity, imagination, and optimism. I know not one person who is more happy as a resident, and they simply accept this. Do something important in the world, don’t fall into the obscurity that goes hand in hand w going through residency

    • hey jim,

      i can’t say that you’re the only one ever to suggest this. and i can’t deny i fear some of the things you list. but, as you mention, it’s impossible for me to imagine doing anything else other than residency. my heroes are wonderful doctors who thrived as residents. however, i realize that there is a selection bias there; only those who thrived as residence become professors of medicine. i very very much hope i will turn out to be one of them…and just can’t imagine a world in which i didn’t try to become one of them…

  • That is a real toughie, but here we go:

    And the reasons why: as stated by others, being near family/friends is good for mental health, and if a resident is crashing and burning they aren’t grasping any unique training and prestige can go right out the window. Being nearby will allow the brief time available to be better utilized in recharging.

    Prestige? The people who you will care for will think for about two minutes “ooh, he went to PH for his residency” (if they learn that at all), but mostly are thinking, “Help me.”

    In which the UTH might be able to give you an advantage, but with medical advances all that training is ongoing anyway and opportunities for UT can happen in the future.

    Wishing you the best in this opportunity!

    • Thanks Beth. What I love about your thinking her is that you are thinking about the patients. I think that in this whole process, graduating medical students think too much about what other doctors will think or where they might do the most prestigious research. Not that those things are unimportant, but when it’s my turn to fall off the perch, i want to look back at what I did in my life and remember what i had done for those under my care…thank you!

  • UTH

    (Funnily enough I’m in a similar situation, although completely different field)

    Because the unique training will get you ahead in the game, will keep your brain interested even with the little amount of free time you may have, and will give you a feeling of accomplishment.

    Prestige is never high on my agenda… it does not mean that much unless you want to play the political game (if you do want to play that game, it should be higher on your list).. the unique training will allow you to compensate not having the prestige, by offering you networking opportunities nonetheless…

    Closeless to family and friends etc is great, but as already mentioned, there will not be that much time to enjoy that, and on top of it (and this does happen) you do NOT want to put yourself in the situation where you have regrets for choosing “easy” over “harder” just because you would prefer to be close to your loved ones… And lets face it, they’re your loved ones, they will not suddenly disappear if you choose a placement further away….

    Good luck with your choice, Blake!!

    • Thanks Cindy. It is true. And in these situations I think we really have to evaluate what relationships we have with our loved ones. It is after all, the love–rather than the proximity–that masters most of all. And, if it’s true, distance doesn’t diminish love.

      • Not saying of course that relationaships with loved ones are not important… Think that, although advice is always great, this all depends mostly on you…. What you feel like will also impact on how you perceive the choices…. Ask yourself what you want out of this residency… Do you want to specialize, do you want to end up teaching, do you want to care for patients and leave time over for other endeavors (wring..), do you want to go into research… All very valid points to look at before deciding…

  • before i answer this – and i can see it’s a complicated thing – is the medical area you’re looking at so specialized that you’re *confined* to certain choices?

    i know second-hand that residency is a bitch – but i know, too, that there are other factors than knowing that.

    you have the advantage – and i’m not talking about writing – of having a previous career and made this decision later than some/a lot of others. i think that this means you know you’re not locked in. you’re a dedicated physician; however, you know you have other options. and i think the fact that you know you have other options will cement your intent more clearly.

    the above is about as clear as mud, but i know what i mean. *wry smile*

    would you like to be at a teaching/research facility?

    these are the first things *i* would look at…

    • hi ashley, i’m not _completely_ sure i follow you, but i can say that i am not so confined. the above is a scenario that, i though, would pull at the fundamental issues. i am, in fact, lucky enough to have a wide range of possible choices. possible, bc of the way the game is played. even if i chose some place, i might not “match” there come the faithful day. all of the institutions i am look at are teaching/research heavy.

  • i knew that wouldn’t come out right. argh.

    i’ll try again, if i can.

    given what i understand of what you said…i’d go with UTH –> GLH –> PH

  • be very careful about academics. It is a political place where creativity is not accepted. Those that stay in academic medicine are not necessarily those that excelled, it is a common misperception, esp at Stanford, I know bc I was there too. You could make a much bigger contribution by being around truly creative individuals that aren’t afraid to ask questions and explore. This will be immediately stripped as a resident. You will see it in your coresidents right away, then slowly you will see it in yourself. You should go to see what it is like bc you have come this far but number one on your list is proximity to friends and family without a doubt. There is no place worth sacrificing that. They blind us in medicine and make us think there is; don’t let them take that from you.

    • now i’m all kinds of curious where you trained and what you trained in. i cannot say that i will heed your advice, but i certainly won’t forget it. i’ll be on the look out for how things change. and, at the very least, it should make for some excellent material for my fought book 😉

  • We are social creatures, and for our mental health we need family around us
    So I have to go location location location first. Then unique training, and prestige is last. You’re already a doctor, which is a sign that you’re education has already sent you to rarified heights. But we only get one life(can you do some research on making it longer, thanks!) and 8-12 years without bring able to steal little moments with those who are precious?

    • well said, TJE, and you have seen my fbook pictures of the World’s Cutest Niece, whom sat on my lap the other day and said “don’t become a hospital guy on the other side of the earth.” my sister, she doesn’t fight fair, but it was so cute, maybe i don’t care 😉

  • My ranking would be:

    My reasoning is as follows:
    Residency is a b****, it’s draining, can be soul-crushing, and for many it’s more a matter of surviving than thriving. As some have said above you’ll be so busy with work, that family and social life will be put on the back burner anyway and distance will make the scarce time you do get to spend with loved ones all about them, instead of an addendum on your spare time. So GLH would be last for that reason.
    PH is never detrimental and will offer better opportunities, especially if at some pointyou want to go back to teaching, this time in medicine. Plus, by teaching the doctors of the future about the importance of doctor-patient contact and exams, would benefit patients too (like Dr Verghese’s work). Thus, PH ranks second.
    One way to combat the soul-crushing and draining is to be challenged with interesting and unique learning experiences. You might be tired, but you’ll be an excited tired 😉 And also, looking to the future, unique skills are marketable. It might make it easier to get that job as an attending at you dream GLH. So challenge and opportunity would make UTH my first ranking choice!
    Hope that makes some sort of sense to you 🙂

    • it does make good sense indeed. thank you for this (and i think i fixed the double posting problem. lemme know if this didn’t come out the way you originally wanted it).

  • First, go with any residency you got a good gut feel for. You liked the residents, thought they seemed reasonably stimulated and happy, and the program is good enough on all other accounts.

    Second, I disagree with those who rank GLH lower because they say “you won’t get much free time anyway.” I had free time enough even during internship to go to parties and have a blast with friends and family. And beyond intern year I met and married my husband and have had a ton of good memories with my loved ones. Quality of life is vital in residency to keep your soul from getting crushed, and it gets more important the further you go. Just my two cents.

  • thanks eleanor! i think you make the flip side argument of the issue. lots of ppl have told me that internship is sooooo busy that it doesn’t matter where i am; others that intern ship is sooo busy that it is terribly important when you have a rare day off to be able to do something fun with that time….i think i would agree more strongly with the second way of thinking 😉

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