Interesting that you perceive UPenn and BI a tier above UTSW/WashU/Pitt.
My understanding wrt prestige is that MGH/B&W/UCSF/Hopkins are the highest tier.
Then there's another tier that includes several other programs (UPenn, UTSW, WashU, Duke, Mayo, BI, NY-Presbyterian, UCLA, Michigan, +/- Pitt, probably a couple others I'm forgetting).
I'm also planning to apply IM next year. I don't care nearly about prestige as much as I do research prowess/location/lifestyle, but I'm still curious to know lol.
What even determines tiers in your opinion? Is it a mixture of clinical training, location, competitiveness? Because I'm sure that the clinical training in the second tier is not inferior to the top tier. But the top tier schools are all in locations generally viewed as more desirable, or they're named Hopkins lol.