Preference signaling in orthopaedic surgery: applicant perspectives and opinions
Authors: Howard Conner , Martinez Victor H. , Hughes Griffin , Zaheer Aroob , Allen Christian , Hanson Chad , Norris Brent , Checketts Jake X. 
Published: July 2024

Abstract

Context
Orthopaedic surgery has become increasingly competitive over the years, with the COVID-19 pandemic creating additional challenges for applicants and programs. To promote an equitable match experience, the American Orthopaedic Association (AOA) introduced a formal preference signaling (PS) system into the 2022–2023 application cycle. PS allows applicants to indicate their heightened interest in specific programs, which improves the likelihood of receiving an interview and ultimately matching at their desired residency program.

Objectives
The objective of this anonymous survey is to assess applicants’ opinions and perspectives toward PS in orthopaedic surgery prior to the 2022–2023 match results. Additionally, we sought to evaluate the signaling strategies being utilized by applicants.

Methods
An anonymous 22-question survey was distributed to applicants of an orthopaedic surgery residency program (34.2 % response rate). Responses were collected after the application submission deadline but before the match lists and results were available. This survey included questions germane to demographics, signal utilization, signaling reasons and strategies, and opinions toward PS. Descriptive statistics were calculated utilizing R (version 4.2.1) and RStudio.

Results
Most respondents (96.1 %) participated in PS, and 96.7 % utilized all 30 signals. Signaling encouraged 24.2 % of applicants to apply to fewer programs. In accordance with guidelines, 83.2 % of respondents signaled each away rotation program; however, only 53 % signaled their home program. Applicants commonly signaled 1–10 “reach” and “safety” programs each. Proximity to Family and Perceived Operative Experience were the most important reasons for signaling, whereas Program Prestige was the least. A program’s social presence and virtual interview option did not influence many applicants’ decisions for signaling. Most applicants believe that the COVID-19 pandemic and pass/fail licensure examinations influenced PS adoption. Sixty-seven of 149 respondents (45 %) claimed that applicants and programs benefit equally from PS, while 41 % believe programs benefit more. Nearly half (40.94 %) knew very little or nothing about PS.

Conclusions
During the inaugural introduction of PS in orthopaedic surgery, nearly every applicant utilized all 30 signals, prioritizing factors like family proximity and perceived operative experience over program prestige. This shift reflects the importance of geographic location and presumed training quality. Despite unfamiliarity toward PS, personalized signaling strategies were implemented, accompanied by a slight decrease in application volumes. The 30 allotted signals in orthopaedic surgery may serve as an informal application cap due to the necessity of signaling a program for an interview invite. However, improved educational efforts are needed to enhance the understanding and maximize the benefits of PS for both applicants and programs.