Such rankings do mean something. For one thing, being associated with an elite institution probably opens doors throughout the remainder of a physician's career, and there is real benefit to training with top students. In some cases, however, the reputation exceeds the reality. Education is not the only factor in the rankings, and research prowess does not necessarily equate to teaching excellence. And while there may be a real difference between the number one and number 100 schools, it is questionable whether there is any real difference between the number 20 and 30 schools.

Another increasingly important factor is cost. The median cost of a 4-year medical education is now over $265,000. Over 85 percent of students graduate in debt, and the average indebtedness is over $160,000. Due to accumulating interest on loans, most students will need to pay back considerably more. There is some evidence that this high level of indebtedness is influencing students' decisions about which medical fields to enter, placing a premium on ones that offer a higher income and steering students away from fields in which the need is greatest, such as the primary care specialties.

The most important issue in choosing a school should not be cost but value: the ratio of quality over price. Some offshore medical schools that function as "last resorts" are able to charge very high tuition. On the other hand, the tuition at some top-flight public medical schools is relatively low. Of course, tuition isn't the only factor contributing to cost, and students also need take into account differences in cost of living between locales. Also, many students get married or have children during or shortly after school, which can further magnify the importance of the cost factor.

Students and their families and advisors tend to spend too much time thinking about rankings and costs, in part because they are easily quantified. Whether such quantitative factors are really valid or not, the numbers seem to make it easy to compare schools against each other. But merely relying on an aggregate value score (ranking/cost or something to this effect) would leave out vital features that deserve to be taken seriously. For lack of a better term, we aggregate these factors under a general category that we call "culture."

Some might assume that, because culture cannot be quantified, it is somehow soft rather than hard, subjective rather than objective, and ultimately, far less reliable than quantitative measures. Yet we should bear in mind that though many of the most important aspects of our lives are similarly non-quantifiable, we do not rely on them any less. For example, imagine choosing a spouse based strictly on quantitative measures. What would we measure -- body mass index, IQ, and expected lifetime earnings? Most would find any such ranking ridiculous.