Letter: Importance of Signaling in the Neurosurgical Match

This is the authors' abstract. We don't add key points for this paper.

To the Editor: As another March arrives, the thrill of Match Day ignites a new chapter for hundreds of medical students, launching them into transformative journeys that will shape the future of health care, but amidst this excitement, have we, as a specialty, paused to truly reflect on the lessons this process has revealed in recent years? Postgraduate residency training has been the cornerstone of academic medicine in the United States since its inception. This year, the National Resident Matching Program achieved historic milestones, offering 43 237 positions to 52 498 applicants—a 4.1% increase from last year—through the Electronic Residency Application Service.1,2 Over the years, neurosurgery has continued to attract an ever-growing pool of ambitious and talented applicants. In 2025, the field shattered records with 600 applicants—a staggering 22% surge compared with 2020—underscoring its rising prestige and the unwavering passion of those eager to shape the neurological care future.3 In 2025, applicants to neurosurgery submitted an average of 64 applications each, which was significantly higher than other highly selective fields such as dermatology (42), orthopedic surgery (46), and plastic surgery (39).3 The high volume of applications, averaging 330 per program in 2025—a nearly 18% increase compared with 2020—has made holistic application review challenging for residency programs.3 This surge must be considered in light of the limited new residency slots per program. In 2022, a new paradigm-changing approach was adopted by Electronic Residency Application Service, the preference signaling system. This system allows applicants the opportunity to express interest in a residency program at the time of their application by allocating them 25 “signals” to distribute.3 Other competitive specialties, such as dermatology and orthopedic surgery, have studied how the signaling system affected their match in recent cycles.4,5 Research among orthopedic surgery applicants and program directors revealed that preference signaling has been well received, leading to a reduction of applications submitted over recent years4—a trend that continued into the 2025 match cycle.3 This reduction was particularly notable among US MD applicants but less so for international medical graduates. Similar findings have been observed in dermatology.5 Interestingly, studies across these specialties indicate that applicants are unlikely to receive interview invitations from programs they did not signal unless prior connections to the program existed. Although preference signaling is effective in influencing interview invitations, it does not seem to impact how programs rank applicants on their final match lists. This suggests that signaling serves as a valuable tool for aligning applicant-program interests during the interview selection phase rather than during ranking decisions.4,5 In neurosurgery, during the first year of preference signaling (2022-2023), only 6% of applicants who did not signal a program were invited to interview at that program, compared with 31% of applicants who sent signals.3 In the following match cycle (2023-2024), the use of signaling for screening interview invitees became even more pronounced. The percentage of applicants who did not signal a program and still received an interview dropped from 6% to just 1%. This trend was consistent across different applicant groups. Among US MDs, 31% received interview invitations from programs they signaled, compared with only 1% from programs they did not signal. Meanwhile, for international medical graduates, the percentages were 3% for signaled programs vs 0% for nonsignaled programs. Data for DO students could not be assessed because of their small sample size. Taking all these data together, it becomes clear that programs across the country, particularly in highly selective specialties, are leveraging the preference signaling system as a powerful tool to screen applicants for interview invitations. This innovation has led to a notable reduction in the number of applications submitted per applicant in many specialties—especially among US MDs. However, neurosurgery remains an exception to this trend. Why neurosurgery differs from other specialties in this regard remains an open question. Given the staggering relevance of the preference signaling system in the match since its inception, we foresee that this will ultimately shape the application process in neurosurgery. Other important factors to consider include the financial burden of applying to residency—estimated at $10 000 per applicant (in a 2017 study,6 now likely much increased by inflation) and the reintroduction of in-person interviews by most neurosurgical programs—which inherently limits the number of interviews an applicant can attend. These may lead to a decrease in the number of applications submitted per applicant, particularly among US MDs, in the coming years. This shift could help alleviate reviewer fatigue for programs and encourage a more holistic evaluation of applicants. It therefore seems, at least for now, that a program that is not signaled by a candidate is almost certain not to extend an interview invitation to him/her. Candidates should keep this statistic in mind during their planning. Whether the trend will change as the signaling initiative becomes more mature remains unclear. Further studies are needed to explore the perspectives of both applicants and program leadership on this change. Such research could either validate or challenge trends observed in other highly selective specialties. As this process continues to evolve, we remain eager to see how it shapes the future of our specialty and academic programs.