Preference Signaling in Residency Applications: Does It Make Sense for Oral and Maxillofacial Surgery?

For medical school graduates, the opportunity cost of going unmatched following residency applications has resulted in what many call an epidemic of application fever. According to data from the Association of American Medical Colleges, the average number of applications submitted per applicant through the Electronic Residency Application Service (ERAS) among United States citizens was approximately 78.2 in 2022, nearly double the amount recorded a decade ago.1ERAS StatisticsAssociation of American medical Collages.https://www.aamc.org/data-reports/data/eras-statistics-dataDate accessed: August 29, 2023Google Scholar This trend is amplified for surgical subspecialties, such as orthopedic surgery, urology, otolaryngology, neurological surgery, and obstetrics and gynecology, which are ranked as the top five residency specialties with the highest average applications per applicant, respectively.1ERAS StatisticsAssociation of American medical Collages.https://www.aamc.org/data-reports/data/eras-statistics-dataDate accessed: August 29, 2023Google Scholar Oral and maxillofacial surgery (OMS) has seen a similar inflation in residency applications. The number of applications received per OMS residency program has surged from 69.1 in 1990 to 119.3 in 2020.2Health Policy Institute. American Dental Association: Trends in Oral and Maxillofacial Surgery Education Programs in the U.S., 2021Google Scholar In addition, the number of applications submitted per applicant continues to rise, with the most up-to-date data estimating an increase from 27.8 in 2015 to 34.9 in 2021. This is despite an only modest uptick in the number of applicants in the match from 396 to 408 between the years 2014 and 2023, respectively.2Health Policy Institute. American Dental Association: Trends in Oral and Maxillofacial Surgery Education Programs in the U.S., 2021Google Scholar Although the match algorithm has been proven to be an effective and efficient tool to match applicants and programs to their most preferred ranked choices,1ERAS StatisticsAssociation of American medical Collages.https://www.aamc.org/data-reports/data/eras-statistics-dataDate accessed: August 29, 2023Google Scholar the finite number of interview slots still serves as the greatest source of inefficiency throughout the residency application process. Namely, residency programs are tasked with the arduous burden of sorting through the often hundreds of lengthy applications (consisting of 3-5 reference letters, personal statements, and academic/extracurricular endeavors) in an attempt to correctly identify sincere, genuine interest among applicants. This is compounded by the multitude of challenges facing OMS residency recruitment. These include inconsistent grading metrics across dental schools (eg, pass/fail curricula vs traditional grade point average) and the limitations of in-person externships/in-person interviews that have persisted in the wake of the COVID-19 pandemic. Often, program directors will use arbitrary academic cut-offs to help quickly trim down the number of applications to review. This puts individuals who may be close to the cut off and highly interested in a specific program at a disadvantage as their application has never been considered. To counteract this problem, many medical specialties have chosen to implement preference signaling as part of the application process to both cut down on the number of applications submitted by applicants and to provide program directors with further guidance in deciding who they want to interview. The origin of preference signaling dates to 2006 when it was first introduced as part of the recruitment process for economics graduate students administered through the American Economic Association. Applicants were provided with up to two preference signals used to express interest in interviewing with programs. The idea is that signals are considered scarce resources and the act of sending signals to a program carries a significant opportunity cost - namely the inability to send signals to any other program. The theory of preference signaling has been studied extensively in the economics literature, suggesting that signaling mechanisms have the potential to improve outcomes in congested labor markets such as those experienced at the residency application level. The concept of preference signaling in graduate medical education was first proposed in the orthopedic surgery literature by Bernstein in a 2017 perspective piece as a way of counteracting the inundation of residency applications. A year later, Salehi et al outlined a novel approach to preference signaling in otolaryngology known as the star system, intended to reduce the number of applications submitted per program, increase the transparency and simplicity of the match process, and improve outcomes for applicants and programs alike. This theory was finally tested in 2019 using a computer simulation model published in the Journal of Graduate Medical Education that found offering applicants an option to indicate program preference improved the practical number of interview invitations and enabled programs to review applicants more holistically.3Whipple M.E. Law A.B. Bly R.A. A computer simulation model to Analyze the application process for Competitive residency programs.J Grad Med Educ. 2019; 11: 30-35Crossref PubMed Scopus (42) Google Scholar Preference signaling is defined as the process by which applicants can formally express specific interest to a program through their ERAS application. Currently, there are 20 medical specialties and over 4,000 individual programs participating in preference signaling for the 2024 ERAS application recruitment season (Table 1). Since the inception of preference signaling, there have been several modifications to the system including tiered signaling, geographic preferencing, and setting preferencing. In tiered signaling, applicants are offered gold or silver signals, which are designed to identify an applicant's most preferred and preferred programs, respectively (in contrast to a single tier system where applicants can only designate a single level of interest). In geographic preferencing, applicants are asked to indicate their preference (or lack of preference) by selecting up to three United States Census divisions (Fig 1), whereas setting preferences asks applicants to indicate their preference (or lack of preference) for an urban, suburban, or rural setting.Table 1Medical Specialties Participating in Preference Signaling for the 2024 ERAS Application SeasonAdapted from "The MyERAS Application and Program Signaling for 2023-24" by the Association of American Medical Colleges.SpecialtyNumber of Program SignalsAnesthesiology5 (Gold), 10 (Silver)Child neurology 2) location of program/geographic preference (66%); and 3) strength of the program's clinical training (54%). From the program director's view, nearly every director reported using preference signals as part of the holistic application review (95-96%). Most program directors also used preference signaling as a tiebreaker for deciding whom to interview (84-94%) and to help identify applicants they would otherwise have overlooked (75%).1ERAS StatisticsAssociation of American medical Collages.https://www.aamc.org/data-reports/data/eras-statistics-dataDate accessed: August 29, 2023Google Scholar Data from several different medical specialties also provides further insight into the effects of program signaling. For example, among applicants applying to otolaryngology, the rate of receiving an interview offer was significantly higher from signaled programs compared to both nonsignaled programs and the comparative nonsignal program.4Pletcher S.D. Chang C.W.D. Thorne M.C. Malekzadeh S. The otolaryngology residency program preference signaling experience.Acad Med. 2022; 97: 664-668Crossref PubMed Scopus (66) Google Scholar Similarly, the majority of surveyed orthopedic surgery program directors agreed that applicants will have an increased chance of receiving an interview at programs they send a preference signal.5Mun F. Suresh K.V. Li T.P. Aiyer A.A. LaPorte D.M. Preference signaling for Orthopaedic surgery applicants: A Survey of residency program directors.J Am Acad Orthop Surg. 2022; 30: 1140-1145Crossref Scopus (13) Google Scholar Most applicants and program directors across several specialties, including dermatology, urology, otolaryngology, and orthopedic surgery, are in favor of continuing preference signaling. Preference signaling in OMS serves to benefit both applicants and programs by enhancing the transparency and efficiency of the high-stakes application process. Applicants who may have otherwise been overlooked due to low academic testing standards (such as class rank or Comprehensive Basic Science Examination score), geography, or other factors may be evaluated on a more holistic level. In fact, during the 2023 ERAS cycle, 75% of program directors agreed that program signals helped identify applicants who, on the surface level, appeared not to be viable matches.1ERAS StatisticsAssociation of American medical Collages.https://www.aamc.org/data-reports/data/eras-statistics-dataDate accessed: August 29, 2023Google Scholar Furthermore, providing a uniform, equitable method of expressing interest to programs may reduce courting outside of the interview process including excessive emails from applicants. Program signaling may influence future applicants to submit fewer total applications. Not only would this reduce the overall burden on programs experiencing application inflation, but would also curtail the financial burden experienced by some applicants (with regards to application submission costs and travel expenses), especially those of a lower socioeconomic status. Programs might invite less interviewees knowing that the selected applicants all heavily consider attending the program. By doing so, programs may choose to reduce the number of interviews given and augment face-to-face interactions between interviewers and interviewees, providing evaluators more bandwidth to delve deeper into each application. There are numerous considerations that need to be considered that are unique to OMS when implementing preference signaling. What is the ideal number of signals an applicant should receive? Providing too many signals may dilute their value and render the system as inconsequential, whereas too few signals may prevent applicants from displaying interest to all their top choices. Should applicants be allowed to indicate preference for 4-year programs, 6-year programs, both, or neither? Answers to these questions may require engaging various OMS residency application stakeholders including applicants and program directors regarding their view on this novel system. In sum, preference signaling has the potential to help the specialty achieve a more equitable, efficient, and sustainable residency application process for both applicants and programs.