i was shocked how a residency program compile their rank order list.

there are 2-3 tiers that most places use. the 1st tier is usally a rank order list for us grads. the second tier is usually for DO. the third tier is for IMG. most residency can rank up to 99 applicants in total.
the concern for most residency is their reputation and ability to attract future applicants. they are afraid of haing too many IMGs, even if they have better STEP scores.

it is an unfair system, but as an img attending residency with other us grads, i received more honors than they did. again, if you are determined and work hard, very little can stop you. a good doctor is not about scores, a lesson everyone learns during residency.