I get asked about “ROL strategy” a lot, and it’s not what most people think it is. After reading, you’ll see the Rank Order List process is a personal one based on your priorities, not a numbers game. 

The only applicant strategy involved in ranking is deciding on a list of criteria that matter to you. For example: 

• Quality of training
• Location
• Fellowship paths & stats
• Program culture
• Access to technology (like POCUS)
• Research opportunities

Whatever your wishlist for training is, write that down! 

Then score programs in the categories, add up the numbers, and see where that gets you. Use any scale you like, but something like 1-5 is easy to manage (1 = least desirable, 5 = most desirable). 

If you’re disappointed in how programs fell into place on your list, ask yourself why and re-evaluate. Maybe you’re missing a category, or maybe you’re giving too much weight to something like location. 

The point is, ROL “strategy” is simply figuring out how to order your programs from most to least desirable based on what you actually care about.

For some reason, there’s a lot of talk about “gaming the system” by ranking programs according to A) how likely (you think) they are to rank you and/or B) how high (you think) they’ll rank you. Allow me to share why you shouldn’t waste your time thinking about this!

Scenario

Imagine you interviewed at 5 programs, Hospital 100 is your honest-to-goodness, true favorite, your #1 rank. Then you have Hospitals 90, 80, 70, in decreasing order of desire and finally 60, which was your least favorite place but still one you’d be okay training at.

Your ROL, in order of your 100% honest, well-considered preferences:

Option #1: If you are the very first person whose Rank Order List is processed.

• The algorithm checks if Hospital 100 ranked you; if they didn’t, they will check Hospital 90; if Hospital 90 didn’t rank you, they will check Hospital 80, and so on.

• Let’s say Hospital 100 has 3 seats and they ranked you 1, 2, or 3 – it’s a MATCH! You will lock in to that program, you’re done. However, if they ranked you 4 (or any number beyond available seats), this is what will happen:

Since you’re the first application being processed, you’ll be placed at the top of their list, but you might not stay there. When the algorithm processes the next person’s ROL, it will check if Hospital 100 is on it and then check to see where the applicant falls on the hospital’s list (if at all). If they are ranked lower than you, you keep your spot. If they are ranked higher than you, you’ll get bumped down a spot. Repeat until all Rank Order Lists are processed. 

You’re basically hoping A) your #1 ranked you high enough to secure a spot right off the bat (they have 3 seats; you are ranked within the top 3 + you rank them #1 = it’s locked in). If not, you’re just trying to hang on to a seat as the ROLs are processed.

• If you do end up getting bumped from a seat, the algorithm will return to your ROL and begin processing it exactly as above, but with the next hospital ranked on your list.

Option #2: If you are the 322nd, 973rd, or 1,018th Rank Order List processed.

• The algorithm checks Hospital 100’s list to see if you’re on it; if you’re not, it moves to 90, repeat.

• If you are on Hospital 100’s list, the algorithm checks if your rank on the program’s list is higher than anyone currently on the list. If it is, you take their place/bump them down. 

This may or may not lock you into a match, depending on if there is someone ranked higher than you still waiting in the ROL pile. If you don’t outrank anyone currently on the list, the algorithm moves to Hospital 90 and the process starts again.

Takeaways: The (Nobel Prize-winning) algorithm was designed to match you with an open seat at your most preferred program, if at all possible. The major variable at play is how hospitals rank you, but that’s out of your control during ROL season (and not information you should have anyway–it’s a violation on the program’s part to share). 

You are not going to lose your seat at a program that ranked you high because you ranked them low. If you’re high enough on their list (within their open seat count), and you didn’t match anywhere else, you’ll match there. If you weren’t ranked within their open seat count to begin with, and they fill the seats with applicants ranked higher than you, you won’t match there, and you never would have, even if you ranked them #1.

The only reason for not matching is because an applicant wasn’t ranked high enough (or at all) on programs’ lists. It has nothing to do with how you order your ROL.

Of note: The order of processing Rank Order Lists doesn’t impact the final outcome. The outcome is literally determined at the moment of the ROL deadline.

Option 3: If you try to “game the system” just to “make sure you match.”

Let’s say you want Hospital 100 the most, but you are pretty sure they won’t rank you. You are feeling very sure that Hospital 6 is going to rank you highly. It’s your least favorite, but someone convinced you that ranking it #1 increases your chances of matching. You order your programs 60, 70, 80, 90, 100, thinking this gives you the best chance.

The algorithm will check Hospital 60’s list first, and if you are at or near the top as you suspected, you’ll almost certainly get locked in and match at Hospital 60. It is possible of course that Hospital 60 only has 2 spots and you’re ranked #3, so if #1 or #2 ranked the program highly, they’ll bump you off the list, and the algorithm will move down your list and see if Hospital 70 ranked you. You’re very unlikely to make it to Hospital 100 by this method.

Take away: Putting a program you love lower on your list does nothing to help you and substantially reduces your odds of matching there, because your list says you’d rather go to several other places, if at all possible.

Use the Class Act Rank Order Calculator

Couples Matching

If you’re planning on couples matching, definitely visit this NRMP resource for all the details (there are a lot). Couples need to think strategically about one thing in addition to their honest preferences: making sure all possible program combinations are present on their paired lists. 

For example, if both people are ranking the same 2 programs, there are 4 possible rank combinations to create and order:

And there you have it: ROL Strategy, Explained!

Your Rank Order List is an important part of your matching journey and should be exciting to think about and create! Define your dream residency, and rank accordingly.