February 2 might best be known as Groundhog Day, but for fourth-year medical students, it’s the door to the beginning of their professional lives. It’s the day when ranking begins.

Medical students all know the term, but for those who do not: ranking refers to putting in order the preferences a medical student has for their residency wishes. After months of interviewing with and applying to residency programs across the country, fourth-year students have from February 2 until March 4 to complete their ranking lists. They may list up to 20 residency programs without paying an additional fee.

Should they choose, they can list up to 300, but that will cost extra — $30 for each one after the first 20. And it might not be a good strategy. Most students already have interviewed with the programs to which they will match and those programs are likely the ones that will list them on their own match lists.

After students rank, their preferences are processed through an algorithm that considers how institutions ranked them. Residency programs also have a March 4 deadline. After 2 weeks, matches are made, and final matches are announced on March 20.

Across the board, experts and current residents offered this advice for this all important process: To thine own self be true. Rank programs that you truly want, in the order you want.

Jeanette Calli, chief of match operations at the National Resident Match Program (NRPM), said the biggest error she sees is when students rank residencies by where they think they might get in, and not where they really want to go.

This is especially true if they rank that program first.

“There’s no point to that,” she said. “If they rank that program first, it will stop. They didn’t give the algorithm the chance.”

Calli was referring to the proprietary algorithm that the NRPM uses to match students to programs. When a student ranks a program first, the algorithm will seek to match that student to that program. If the program has selected the student, then that’s the end of the process. A match was made, and there’s no going back.

“The match program is set,” said Hilit Mechaber, MD, senior associate dean for student affairs at the Miller School of Medicine at the University of Miami, Miami. “You are basically telling the program to go in and match you.”

Once ranking opens, students can go into their profiles as often as they wish to re-order their files until the hard and fast deadline of March 4. Mechaber and others recommended that students use the 4 weeks to talk with advisers at their medical schools, review notes they took during their interview process, and to reach back out to residents and others they met if they attended open houses at the various residency programs. But most important, students need to really get in touch with their goals and their values to assess what is most important.

The variables can be endless. Proximity to one’s family, financial benefits, work hours, the prestige of the program, the mentorship it offers, and research opportunities are all important. And even small details like parking and cellphone reimbursement can play a role when comparing the financial aspect of the residency.

“It’s definitely a stressful process,” said Aliya Redd, a fourth-year medical student at the University of Florida College of Medicine, Miami. Redd had just finished her last interview in mid-January and is beginning to consider her preferences. She wants to match with the residency program where she can learn the most, but she also wants to know what it’s like to be a resident there.

“Do you get food, do they feel overworked,” she said.

A residency’s location is also paramount, Redd said.

“In residency, location is big. You want people around you who can support you at a difficult time.”

Janice Cousin, MD, a first-year resident at The University of Chicago, Chicago, and recent graduate of Meharry College of Medicine, Nashville, Tennessee, said location was one of her major considerations.

“I definitely wanted to come home to be close to my family,” said Cousin, a Chicago native.

Like Redd, Cousin suggested reflecting on the experience of residents in the programs. She attended open houses and socials at various programs, which was a tremendous help, she said.

“It kinda helped me see if I could see myself working with those residents,” Cousin said. Because residency programs are small — perhaps five or six in any given year — it’s important to consider whether you align with mission of the program and the people working in it, Cousin said.

While sharing a vision and mission are important, students should not overlook the prestige of a program, particularly if they plan to seek a competitive fellowship after residency.

“What program is going to help them be successful” is the question, said Calli of NRMP. “If it’s the prestige of a program, then absolutely consider prestige. Or if there is a particular faculty member they want to work with. It’s so multi-variate.”

If residents gave medical students their contact numbers for follow-up, but all means reach out to them during this period.

“I was trying to differentiate between my number one and number two programs, and it was really helpful,” said Aisha Jimenez, MD, now a first-year psychiatry resident at Meharry Medical School.

Jimenez urged students to also consider what resources a program has for wellness and mental health.

Diane Howell, MD, interim assistant dean for student affairs at the University of Florida College of Medicine, said students should consider their own financial resources.

“They really need to check out the cost of living in that area,” Howell said. Florida, for example, has no income tax, while most other states do. That can be a shock. Also, utility prices vary from area to area, and students should check that out. Residents are not highly paid. And while programs in pricey areas often pay a little more, students still need to go into detail about the cost of living.

“They really need to do their homework,” Howell said. “Maybe they didn’t consider the state income taxes, the utilities, and they end up eating ramen noodles.”

Having financial stress makes for a stressful residency, she said. She knows of at least one resident who had to ask for financial help from her parents for rent because she underestimated the cost of living in a big city.

Brian Hou, MD, a first-year resident at Vanderbilt University Medical Center, Nashville, Tennessee, knew exactly where he wanted to go for his orthopedic surgery residency — Vanderbilt. He had gone to medical school there, knew the faculty, the programs and Nashville. There was no doubt. So he sent a letter of intent to Vanderbilt, which signals to a program that the student is very serious about committing to it. Not all programs allow letters of intent, so students should check with the program.

And they must also be absolutely certain that the program to which they send a letter of intent is their first choice.

“You have to be absolutely 100% sure that you are willing to go there,” said Howell. “If you were not truthful, that will burn a bridge. If you are perceived to be disingenuous, that will hurt your chances later on for a fellowship, or even a job.”

Hou said he had that 100% certainty about Vanderbilt.

“There was definite anxiety,” he said. “But after I sent my letter of intent, there was literally nothing else I could do.” So that freed him up in some ways, he said. He would either get his first choice, or he wouldn’t.

And, like all fourth-year students going through match, Hou had to deal with the possibility that he would not match at all. All the stars can line up right and a student can still not match.

“Just by the numbers alone, some people are not going to match,” Hou said.

That’s one reason students need to focus on their preferences and not try to figure out where they may get matched.

“There’s no penalty for ranking their true preferences,” Calli said. “The match algorithm works best when they do that.”