Where is the most desirable place to do a medical residency (2017 edition)?

People in medicine have uniforms. This is not in the same way as police or firemen but once you start hanging around health professionals enough you start to notice the patterns. This sociological phenomenon also becomes much more apparent when you visit the other medical tribes.

This first came to my attention when I took a short course on obstetrical management advances for primary healthcare providers. The participants consisted of me and a gaggle of giggling 20-year-old midwifery students. Being a midwife can be a much more difficult job than an obstetrician because midwives often have to deliver in patients homes without the support of hospital facilities and technology. This informs how they view the over-medicalization of birth and the midwives teaching the course did not hesitate to correct my heretical views on fetal monitoring and pain medications. These exchanges would end with one of the midwives giving me, the naive medical resident, a patronizing smile. The midwifery students would then trade knowing looks about this buffoon in their midst.

Anyway, most of the day was spent glaring at midwives and they all seemed to be wearing scarves – the decorative kind that one might find on the owner of an independent bookstore. I took another medical course last month with a similar gaggle of 20-year-old giggly midwifery students who were all  similarly bescarved. Its almost as if the admittance letter to midwifery school comes with one of these scarfs along with a license to condescend. 

This sense of tribal dress-code is not limited to the allied health professions though. Medical doctors have their own uniforms but whereas scarves are fashionable the informal dress-codes among physicians  often provide a security blanket for clothing choices that would otherwise be considered heinous. There seem to be more fanny packs per capita in pediatrics than on a seniors cruise ship. The only time I’ve ever encountered someone in a hospital in suspenders and bow-tie was on an internal medicine ward. Surgeons wear grimaces.

Family doctors like to wear golf shirts so that we can make our 2PM tee times without going home to change. This made it an easy transition to my new uniform which was that of a graduate student. My golf shirt is now paired with a set of ripped jeans and the ensemble is peppered with coffee stains. Its not particularly glamorous.

But what it lacks in glamour, it makes up for in free time.  This allows me to write (or more often than not, procrastinate) and since it’s the point in the year when medical students across Canada are agonizing over their match preferences I might as well write about something that has become an annual tradition at Strange Data. Let’s rank some medical schools.

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My goal for these rankings has always been to  base the relative rank of a medical school on the desirability of the school to medical students. I didn’t want to base the rankings on journal citations, academic staff, or anything tangible at all. I wanted to use the wisdom of the crowds to determine ranking. Places that do a better job at making their residents happy for whatever reason would attract more medical students. That may be because they are located in nicer cities, they are more academically impressive, or they treat their residents well. I don’t care how or why they are more desirable, just whether they are more desirable. The only thing that should matter is whether a medical student wants to go to there for residency.

Desirability should be an easy thing to measure in this instance because the residency match process literally consists of medical students ranking their preferred medical schools. The only issue is that the Canadian resident matching service (CARMS) doesn't release any data related to how medical schools are ranked. This means I can’t get any public data on numbers of applications or on ranking preferences of applicants. Instead, what I have to work with is outcome data. All I can see is which medical school a medical student matched to for their residency rather than their ranking preferences. So my measurement for desirability is necessarily a proxy for true desirability. What I argue in this ranking is that a medical school that has high desirability is likely one where there are a large variety of medical students from other medical schools who go there for a residency.

The logic in this is twofold. First, a highly desirable medical school will receive highly desirable candidates and there will be a sorting process where the best and the brightest from other medical schools will be concentrated into these desirable medical schools. This should result in more diverse match cohorts. Second, desirable medical schools will receive a high volume of applications from outside medical schools. Just by sheer numbers, an idiot or two is bound to get through the screening process resulting in a higher number of medical students from outside medical schools. This should also produce a more diverse match cohort. You can imagine what process applied to me when I got into my residency. 

This desirability metric must be adjusted for the fact that larger medical schools can have more diverse matches simply because they can absorb larger numbers of medical students. To adjust for size we imagine that every medical school is equally popular and would take medical students from other medical schools in proportion to the number of overall open spots. Under these utopian conditions, if the University of Toronto has 10% of the total residency spots in Canada, then it should take 10% of the class from the University of Saskatchewan and 10% of the class from UBC and so on. If McGill has 5% of the total residency spots in Canada it should take 5% of the class from UBC and 5% of the class from the University of Toronto and so on. 

The way to measure desirability is then to estimate this utopian scenario and then to see how far real life deviates for each medical school. Deviations above the baseline mean that the medical school is more popular that it would be in a scenario where all medical schools were equally popular. Deviations below the baseline mean that the medical school is less popular than it would be in a scenario where all medical schools were equally popular.

The other important thing to note is that this ranking metric incorporates a measure of the effective spots that a residency class consists of and the effective spots that a medical school contributes to the total pool of match residents. This tries to acknowledge that a medical class consists of leavers and stayers. A medical student who stays at their medical school for residency means one fewer medical student from outside who can get into that class. Often these medical students have a leg up on competitors because they have spent most of their time at their own medical school and are a known quantity. A medical student who stays also means one fewer medical student in the pool of prospective medical student to go to other schools. The effective spots also include how many residency spots at a medical school have gone unmatched.

The statistic for ranking medical schools is then based on the following set of equations. The utopian benchmark case where every medical school is equally popular is defined as:

For a medical school a, the utopian benchmark value B is the ratio between the effective spots at a medical school and the total residency spots available at all medical schools. The effective spots at a medical school is the difference between the total residency spots at that medical school (R) and the medical students from medical school a that go to that school for residency (r). Add to this the unmatched residency spots, U, at the university for a total number of effective residency spots at the medical school. The denominator is the total number of available residency spots across the country. This is all of the unmatched spots, plus the open spots at each university - the difference between each residency class and the number of medical students that stay at their home medical school for residency.

The actual case that we observe is described by the following relationship:

r is the number of medical students from school b who go to school a. Divide this by the total number of medical students available from medical school b which is the difference between the total medical students at school b and the number of them that stay at school b for residency (r).

The ranking statistic for school a is then the difference between the benchmark scenario, B, and the actual real life scenario A. 

Add up all the of these deviations for all of the medical schools in the country (excluding the medical school in question) and take the average and you get a measure of a medical schools desirability for residency.

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For what follows I'm using 2017 match data for the R-1 main residency match. The more desirable a medical school is for residency, the more negative its desirability score will be. This is a result of the difference between the baseline utopian scenario and what we observe in real life. A more negative number means that medical students are going to these universities above what we would expect. These universities are punching above their weight. A university that has a positive desirability score has a baseline utopian scenario score above what we observe in real life. It is a less desirable place to do a residency. A university that has a desirability score of zero means that the utopian scenario is roughly what we observe in real life.

As per previous years what follows is wild and irresponsible speculation on these rankings so take whatever I say with a grain of salt. The first thing to note is that my residency alma mater - the University of Toronto - is in first place.  This is despite the fact that I graduated from there in July which goes to show you how desirable the place is even without a stellar resident such as myself attending. My former medical school, the University of Manitoba is in third last place. 

As per previous years, the more desirable medical schools for residency are in reasonably nice cities like Toronto, Vancouver, and Calgary or at least close to nice cities (McMaster). Most also have pretty decent training and research reputations. Undesirable places seem to be remote (NOSM, Memorial), cold (Manitoba), or predominantly French speaking (Laval, Sherbrooke). As per previous rankings, Quebecois schools suffer disproportionately because much of the rest of the country can't speak medical french ("s'il vous plaît laissez tomber votre pantalon et penchez-vous") which means most Anglo medical students won't apply for residency at these schools. The University of Montreal is the closest exception to this. It operates in French and is not in Quebec City or Sherbrooke. This means it is in high demand for medical students from other Quebecois schools who can only practice in French. This improves its level of diversity and its desirability metric. 

There are a couple of discrepancies to these general rules. McGill is the obvious outlier, being in Montreal and having an excellent reputation. In many of its residency programs it is highly recommended that applicants know both English and French at McGill which means both Anglo and Quebecois medical students are at a disadvantage. English students also have the opportunity to train anywhere else in Canada where resident pay is much higher so McGill really gets screwed in the rankings. 

Queen's continues to baffle me placing an impressive second in terms of desirability. Queen's retains the lowest proportion of it's medical student body which means that it has a large number of effective residency spots relative to size (allowing for a greater chance for a diverse match cohort). Queen's only retains about 17% of its medical students whereas the average retention is closer to 50%. I originally thought that such a high number of effective spots was driving this result but Queen's also gets penalized because the ranking metric requires it to have a proportionally higher level of diversity so I don't think this is the explanation.

What may be happening with Queen's is that it is a major second choice destination especially in Ontario. It isn't that far from from Toronto, Ottawa, McMaster, or Western and these medical schools send a decent proportion of the their classes to Queen's. It seems likely that being runner-up on everyone's preference list boosts Queen's ranking to make it one of the most desirable medical residency programs in Canada.

The University of Saskatchewan is another notable exception to the above rules. Somehow despite being in the only province more cold and boring than Manitoba (I can make fun of both of those provinces because I'm from Manitoba), it beats out a number of seemingly more attractive medical schools including Ottawa and McGill. Relative to other provinces, Saskatchewan is also on the lower end for resident compensation so I'm really not sure whats going on here.

As I have metrics for the last two match years we can also compare how these rankings have changed. This first panel is how the rankings have changed from 2016 to 2017.

McGill, Montreal and Ottawa all suffered precipitous drops in their rankings. There is probably a reasonable amount of variance in the rankings for the two medical schools in Montreal because of their location and so they top out in the middle of the rankings in good years but when they have bad years they have really bad years because of all of the things discussed above. Your interpretation of why Ottawa changed so much in this ranking depends on whether you think that it is doing significantly worse now or if it was overvalued by the rankings in 2016 and is reverting to it's true ranking. I don't have a good explanation for it though.

Saskatchewan also did a lot better in 2017 than it did in the 2016 match. Part of this may be that it was facing the possibility of having its entire medical school accreditation stripped during the year leading up to the 2016 match. Its hard to understate how embarrassing that would have been and it was likely dragging down its ranking. They apparently did some things to prevent that from happening so kudos to the deans at Saskatchewan for turning that dumpster fire into just a dumpster. 

The change between 2015 and 2017 also reinforces some of the above observations. This second panel shows the rankings for each university in 2015 and 2017.

Results are similar to the previous graph in that Ottawa had a humongous collapse in it's ranking while Saskatchewan was the main mover in the opposite direction. I will note that 2015 was my match year while 2017 was my graduation year. My residency school, Toronto, moved up a rank during my tenure there (coincidence?) while my medical school, Manitoba, dropped two positions during my absence (coincidence?!?!). 

So a word of encouragement to you who are worried about matching to a program that may be  considered "undesirable": those of you doing a specialty will probably be miserable and studying and inside a hospital for the next five years. To a certain extent it doesn't matter where you end up because for you, all roads lead to the library. Those of you doing family medicine have the great pleasure of laughing at those going into specialties. The schadenfreude should compensate for wherever you end up.

I've said this in the past, and I'll say it again - how desirable a place is for a residency to the average medical student may have little bearing on your own ranking. Keep that in mind if you happen to be going through the hell of the match process this year. I know a doctor who loved the chance at living in the snowy waste land of Manitoba because they could buy a house and live well. I know a doctor who decided that they would rather leave the excitement of Toronto because it meant they got to transfer into a residency they preferred. Both are happier for it even though these rankings say they shouldn't be. What other people find desirable is only a small signal of information that should be part of the larger decision you make on your personal medical school ranking. The wisdom of the crowd is a signal that tells you something but not everything. 

As for me, I'm done with residency. I've managed to evade gainful employment by going back to graduate school. I'm willingly taking a massive pay cut in order to write an unsuccessful blog and argue with economists over nothing. That's probably a signal that you shouldn't be taking my advice on any of this.