Well, I was exaggerating a little bit. But there is a cadre of usual suspects that you can expect to see at the top.

As for how, I think it has to do with interactions. So when Dr. Dinkydick MD hears daddy's dog whistle and shits out some sad reply, people like and comment because they recognize the bad doctor's account. Which puts him at the top and more people recognize his account. So it feeds into itself.