A perfect match: Pros and cons of preference signaling in dermatology

Abstract

The average United States dermatology applicant submitted almost 60 applications to the Residency Application Service in 2020.1Association of American Medical Colleges. ERAS Statistics 2020.https://www.aamc.org/data-reportsGoogle Scholar The average dermatology program received more than 431 applications.1Association of American Medical Colleges. ERAS Statistics 2020.https://www.aamc.org/data-reportsGoogle Scholar Concerns among program directors include burdensome application volumes and insufficient information regarding applicants' genuine interest in their programs.2Korman A.M. Grant-Kels J.M. Applying to dermatology residency: an ethical approach to an inherently unethical process.Int J Womens Dermatol. 2018; 4: 176-178Crossref PubMed Scopus (5) Google Scholar, 3Salehi P.P. Azizzadeh B. Lee Y.H. Preference signaling for competitive residency programs in the NRMP.J Grad Med Educ. 2019; 11: 733-734Crossref PubMed Scopus (7) Google Scholar, 4Rojek N.W. Shinkai K. Fett N. Dermatology faculty and residents' perspectives on the dermatology residency application process: a nationwide survey.J Am Acad Dermatol. 2018; 79: 157-159Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar In response, program directors sense a duty to pursue “justice” in residency selection processes through preference signaling (PS), a systematic means of providing applicants the ability to evenhandedly indicate interest in programs, while also allowing programs to gauge an applicant's genuine interest. In this way, applicants formally convey interest to a limited number of residency programs to which they apply. One benefit of PS stems from suggested virtues of propriety and transparency. Applicants currently use overt and covert approaches, including direct communication and/or correspondence from advocates (alumnae, department chairs, etc) to demonstrate interest in particular programs.2Korman A.M. Grant-Kels J.M. Applying to dermatology residency: an ethical approach to an inherently unethical process.Int J Womens Dermatol. 2018; 4: 176-178Crossref PubMed Scopus (5) Google Scholar Others seek out costly and already competitive clinical rotations to interface directly. However, assessing objective program preference is difficult because applicants can correspond with multiple programs. The Otolaryngology Program Directors Organization constructed a PS system in which applicants could signal preference to 5 programs for the 2020 to 2021 application cycle.3Salehi P.P. Azizzadeh B. Lee Y.H. Preference signaling for competitive residency programs in the NRMP.J Grad Med Educ. 2019; 11: 733-734Crossref PubMed Scopus (7) Google Scholar This concrete means of conveying interest may conceivably reduce application review burden under the assumption that applicants apply to fewer programs, believing PS may benefit their match chances. Applicants may even benefit from reduced expenses in the residency match process via reduced number of total applications and interviews. Conversely, there are consequential drawbacks regarding PS. Applicants may signal preferences for competitive programs, thus inflating PS values at certain institutions and deflating it at others. Hence, preferences may become interview prerequisites. Alternatively, competitive applicants may signal preferences to less competitive programs to ensure “safety” interviews. This may result in programs receiving PS from applicants who are modestly interested in matching at their programs. Thus, PS may counterintuitively decrease interview opportunities for otherwise qualified applicants. Similarly, questions remain regarding the ideal number of program preference signals allowed per applicant. Numerous preference signals dilute relative values of individual signals. Limited signals restrict the ability of applicants to express interest in suitable programs. While another described benefit of PS assumes reduced total application burden, competitive specialties may not realize application reduction. Lastly, consideration must be given regarding PS regulation. The Otolaryngology Program Directors Organization constructed guidelines prohibiting divulging applicant preferences, questioning applicants on preferences for other programs, and publicizing the number of signals received.5Chang C.W.D. Pletcher S.D. Thorne M.C. Malekzadeh S. Preference Signaling for the Otolaryngology Inteview Market.Laryngoscope. 2020 Oct 6; (Epub ahead of print)https://doi.org/10.1002/lary.29151Crossref Scopus (8) Google Scholar Future regulatory considerations include specifying the extent to which preferences are considered and clarifying how applicants who do not signal preference are reviewed. Idealistically, PS curtails favoritism associated with program-specific “love-letters.” However, concerns persist regarding implementation and regulation of PS, including introducing an unregulated currency and its accompanying bias. The match process already contains PS elements, including rank lists with an applicant-favoring algorithm, and adding complexity to interview selection only confounds the process. Regulating PS is already a concern, calling into question whether it is deployment ready and whether PS is beneficent or even just. Hopefully, the Otolaryngology Program Directors Organization experience will prompt further refinement or abandonment of PS. None disclosed.