Residency Advisor
The biggest mistake prelim applicants make is thinking “I can fix this after Match Day.” You cannot. If you ranked preliminary programs, you are on a two-track match, and the clock is already running.
You need a second plan—transitional year, prelim medicine, prelim surgery—running in parallel with your categorical dream. And that means very specific decisions must be fully locked before rank list day, not after.
I am going to walk you through exactly what must be finalized, in order, as you approach rank list certification if you have any prelim programs on your list.
8–6 Weeks Before Rank List Day: Big-Picture Structure Locked
At this point you should already know: “I am ranking prelim programs.” If you are still debating whether to add prelims at 6 weeks out, you are late, but not doomed.
1. Decide Your Overall Strategy: One-List vs Two-List Reality
You are effectively running two strategy paths:
- Path A: Categorical positions in your target specialty
- Path B: Preliminary / transitional year + future re-application
By 6 weeks before rank list day you must:
Decide if you are:
- Ranking both categorical and prelim programs
- Ranking prelim-only (no categorical interviews)
- Using a mix of advanced positions + prelims (e.g., Radiology, Anesthesia, Derm)
Clarify which of these three outcomes you are realistically planning for:
- Categorical spot (dream outcome)
- Advanced spot + prelim
- Prelim-only year then reapply
If you do not know which of these is your most likely landing zone, your rank list will be chaotic and unsafe.
| Category | Value |
|---|---|
| Categorical Match | 50 |
| Advanced + Prelim | 20 |
| Prelim-Only | 20 |
| No Match | 10 |
2. Clarify Your Intended PGY‑2 Specialty
At this stage, “I will figure out later what I want to do after my prelim year” is not acceptable.
By 6 weeks out, you should have:
- One primary post-prelim target specialty
- One backup specialty you would consider if your first choice does not pan out
Why now? Because your:
- LOR strategy
- Elective choices
- Research projects
- PD conversations
all depend on what you claim you want to be later. Prelim PDs hate vague. They want to know, “Is this person using us as a stepping stone to something realistic?”
3. Build and Freeze Your Preliminary Program List
At 6 weeks out, the set of prelim programs you are considering should be stable.
You should already:
Know which:
- Transitional year (TY) programs you like
- Prelim internal medicine programs you like
- Prelim surgery programs you might tolerate (if you are honest with yourself)
Have a working list that includes:
- Program name
- Hospital system
- Location
- Type (TY vs prelim IM vs prelim surgery)
- Call schedule intensity
- Past success sending people into your target specialty
Make a simple grid. If you do not have hard data on outcome (e.g., “3 of the last 4 prelims matched anesthesia”), email residents and ask. They will tell you in one line.
5–4 Weeks Before Rank List Day: Information and Reality Check
At this point you should stop hand-waving and start verifying. Hunches about programs get people into miserable prelim years.
4. Confirm Program Culture and Outcomes
Weeks −5 to −4 are for plugging data holes.
You should:
- Email or text:
- At least 1 current prelim/TY resident at each program you could see yourself at
- Preferably someone in the same track as you (prelim IM vs TY vs prelim surgery)
Ask targeted questions, not fluff:
- “How many people from your program actually matched into [specialty] in the last 2 years?”
- “How supportive is your PD about going into [specialty]?”
- “If you had to do it again, would you rank this prelim program again?”
- “What is the real call schedule, not what the website says?”
Lock these answers into your spreadsheet.
5. Clarify Logistics: Geography, Support, And Reality
By 4 weeks out, you should have decided your deal-breakers that are not academic:
- Maximum acceptable commute or relocation distance
- Requirements about being near family / partner
- Visa sponsorship needs (if applicable)
- Cost-of-living you can afford (NYC TY vs low-cost Midwest prelim IM are not equal)
You need to explicitly rank:
- “I will be okay spending one year here no matter what” programs
- “I can tolerate this for one year if it gets me to my PGY‑2 goal”
- “This would actively harm my mental health or relationships”
If you put any program in group 3 and still rank it, you will regret it on your first 28-hour call.
3 Weeks Before Rank List Day: Communication and Pairings Finalized
This is when the “talks” happen: PD conversations, advanced–prelim pairing, and “are you really interested in us?” emails.
6. Lock Advanced + Prelim Pairings (If Applicable)
If you are going into an advanced specialty (Radiology, Anesthesia, Derm, Neuro, PM&R, etc.), you must treat the PGY‑2 and PGY‑1 as a pair, not separate universes.
By 3 weeks before rank list day, you should:
For each advanced program you liked:
- Decide which prelim(s)/TY program(s) in the same city/region you would ideally pair with it
- Decide how far you are willing to split locations (same city vs same state vs “does not matter”)
Identify:
- 1–2 “integrated-feel” pairings (e.g., Advanced Anesthesia in City A + TY in City A)
- 1–2 “safety” pairings (e.g., Advanced Anesthesia anywhere + solid Midwest prelim IM)
You are not literally linking them in NRMP (unless the specialty uses a supplemental process), but you are ordering your list so the combinations that make sense appear higher.
| Step | Description |
|---|---|
| Step 1 | Choose Advanced Program |
| Step 2 | Pair with Local TY/Prelim |
| Step 3 | Pair with State Prelim |
| Step 4 | Pair with Best National Prelim |
| Step 5 | Same City Prelim Available |
| Step 6 | Same State Acceptable |
7. Final PD and Resident Conversations
At this point you should be done “collecting impressions” and instead be clarifying specifics.
Focus your outreach:
To prelim/TY PDs or chiefs (1–2 programs you are truly interested in):
- Short email reaffirming interest and your intended PGY‑2 specialty
- Clarify any unspoken concerns (schedule flexibility for away rotations, letters, interviews during the year)
To current prelims:
- “What surprised you most after starting?”
- “Has the program been supportive about interviews / second looks for PGY‑2 spots?”
If there is a prelim that you know must be in your top 3, this is also the time to understand exactly how they treat prelims matching out. Some places treat prelims like disposable labor. Others practically guarantee you interviews.
2 Weeks Before Rank List Day: Rank List Framework Set
Now you stop collecting data and start structuring your list. Two weeks out, your rank order should already exist in a draft that looks close to final.
8. Construct Your “Groupings” Before Exact Order
Do not start by arguing whether Program 7 should be above Program 8. That is noise.
At 2 weeks out, you should:
- Divide all your prelim / TY options into clear tiers:
| Tier | Description | Example Rank Range |
|---|---|---|
| Tier 1 | Strong training, humane culture, good outcomes for your specialty | #1–#3 |
| Tier 2 | Solid training, mixed culture, acceptable outcomes | #4–#8 |
| Tier 3 | High workload, variable support, but still safe for one year | #9–#12 |
| Do Not Rank | Would damage well-being or PGY-2 prospects | Not on list |
- Within each tier, decide:
- Geographic priority
- Support for your PGY‑2 specialty
- Call / schedule intensity you can tolerate for 12 months
You want a rank list that—if you matched your last prelim—still allows a coherent story and survival.
9. Decide What You Will Not Rank
By now, there are programs that you know, in your gut, are a bad fit.
Two weeks before rank list day, you must:
- Make a clean “Do Not Rank” list. Really write it down.
- Remove those programs from your NRMP rank list entirely.
Typical red flags that should push a prelim into DNR:
- No track record of grads matching into your intended field
- Toxic culture reported consistently by residents (“everyone is trying to leave”)
- Wildly unsafe hours or chronic RRC citations
- Location that would isolate you from all support systems with intense workload
Your worst-case scenario should be “hard but survivable,” not “I burned out and quit medicine.”
10–7 Days Before Rank List Day: Fine-Tuning and Contingency Plans
Now the structure is set. This week is for tightening the screws.
10. Finalize Your Exact Preliminary Rank Order
At 10–7 days out, sit down once and commit to exact order, not vibes.
Check each step:
- Read down your prelim/TY section slowly.
- For each program A above program B, ask:
- “If I end up stuck at B instead of A, will I be annoyed?”
- If the answer is “yes,” swap them and read again.
You are done when you can read the list top to bottom without any internal protest.
11. Make Your “If I Match Prelim-Only” Playbook
Prelim-only is not failure. It is a one-year bridge. But only if you treat it as such.
A week before rank list day, you must have a written plan for:
If you match prelim + no PGY‑2:
- Who will be your letter writers during the prelim year?
- When will you schedule electives that align with your target specialty?
- When will you work on research or projects to strengthen your re-application?
If you match advanced + prelim:
- How much time will you have for sub-specialty exposure during your prelim?
- Does the prelim schedule allow PGY‑2 program visits / second looks?
Write this like an actual mini-timeline for July–next February. Otherwise your prelim year will just happen to you, and you will wake up in November without applications ready.
6–3 Days Before Rank List Day: Locking and Sanity Checks
Everyone gets twitchy this week. This is when people ruin a carefully thought-out list by panic editing. Do not be that person.
12. Perform a Structured Sanity Check
Around 5 days out, do one review session with a clear rubric:
Check geographic sanity:
- Are you ranking a nightmare location above a reasonably good one purely out of prestige?
- Are you over-weighting “big name” for a year that is mostly about survival and letters?
Check specialty alignment:
- Are the prelims you ranked highest demonstrably supportive of your PGY‑2 goal?
- If not, why are they above programs that are?
Check wellness reality:
- Are you putting a notoriously malignant prelim higher than a humane TY only because “it will look better”?
- Quick reality: no PGY‑2 PD cares which prelim you did as long as you performed well and have strong letters.
If any rank violates common sense on these checks, fix it once. Then stop.
| Category | Value |
|---|---|
| Location | 80 |
| Workload | 70 |
| Specialty Support | 90 |
| Reputation | 50 |
| Salary | 40 |
13. Verify All Administrative Details
Under 1 week, errors become deadly. I have seen people mis-rank a program because of a similar name or wrong track.
3–4 days before the deadline, verify:
Program codes:
- Are you ranking the prelim track, not the categorical track, for those programs?
- Are TY vs prelim IM vs prelim surgery correctly selected?
Duplicate programs:
- Some hospitals have multiple prelim options (e.g., prelim IM vs prelim “medicine-neuro”).
- Confirm the exact track you interviewed for is what you ranked.
Contract / visa issues:
- Any program that told you verbally “we cannot sponsor your visa” should not be on your list.
- Any program with funding or accreditation concerns should be re-checked.
This is tedious. Do it anyway. Once.
48–24 Hours Before Rank List Deadline: Commit and Stop Editing
This is where people sabotage themselves with last-minute fear.
14. Freeze Your List 24 Hours Before the Actual Deadline
By 48 hours out, your list should already be:
- Ordered
- Double-checked
- Saved in NRMP
At 24 hours out, you should:
- Confirm your list in NRMP (hit certify)
- Screenshot or print your final rank list
- Close all rank list spreadsheets/documents
Do not be the person editing at 7:50 pm for an 8:00 pm deadline. The NRMP servers do not care about your anxiety.
Day Of Rank List Deadline: Final Single Pass Only
On the actual deadline day, if anything, you do one calm pass. That is all.
15. One Last Read, No Major Changes
On deadline day:
- Log into NRMP once
- Read the list from #1 through the last ranked prelim program
- Ask yourself:
- “If I matched my last ranked prelim and nothing else, can I do that year and come out ready to pursue my specialty?”
If the answer is yes, you are done. If not, you must either:
- Remove that last program entirely, or
- Move a more tolerable program above it and consider DNR for the miserable one
No adding new programs. No major reshuffling. Micro-corrections only.
After Rank List Day: Do Not Undo Your Own Work
Once the list is locked, your job shifts from “architect of the future” to “executor of whatever happens.”
If you ranked prelims, you should:
Mentally rehearse:
- Scenario A: categorical or advanced + prelim
- Scenario B: prelim-only
- Scenario C: SOAP (rare, but you should know the process)
Prepare basic materials:
- Updated CV
- Draft personal statements for both your intended PGY‑2 specialty and a realistic backup
- A short list of attendings who have agreed to support you with future letters
That way, if Match Day gives you “prelim-only,” you are moving on day 1, not starting from zero.
Your Next Step Today
Open your current rank list or spreadsheet and do one specific thing: mark every prelim or TY program as Tier 1, Tier 2, Tier 3, or Do Not Rank based on how survivable and supportive it will be for your PGY‑2 goal. If you cannot confidently put a program in Tier 1–3, it either needs more information this week—or it does not belong on your list at all.
