Preference Signaling in the National Resident Matching Program—Reply

Abstract

To the Editor In their Viewpoint, Salehi et al 1 proposed a "star system" in which otolaryngology residency applicants can indicate particular interest in programs, similar to a "rose-sending system" previously suggested in orthopedic surgery. 2 In the economics literature, these systems are known as preference signaling mechanisms and have been successfully implemented in the American Economic Association (AEA) job market for economics graduate students since 2006. Its rationale, design, and outcomes should inform the current proposal. 3 Residency placement involves 2 phases: information sharing via electronic applications and interviews, then matching the preferences of interviewees and programs. The latter phase is accomplished by an algorithm that the National Resident Matching Program ("the Match") administers. This algorithm was a basis for awarding the 2012 Nobel Prize in Economics to Lloyd Shapley and Alvin Roth. Roth notes that the former phase, however, is congested in that not all interested candidates can be adequately considered. 2 Medical students submit excessive applications, inundating faculty who have limited time to read files. Interviewing is costly for both programs and applicants and thus a scarce opportunity. To avoid unfilled positions in the Match, resource-limited programs must consider at the preinterview stage not simply whether an applicant is attractive, but also whether she is attainable.Signaling can mitigate interview congestion. 2 For example, a strong applicant who has an unexpected geographic preference may choose to signal to an average program in that locale who might otherwise have dismissed the applicant as out of their league. 3 Ensuring a limited number of signals provides credibility. 4 Salehi et al 1 suggested that applicants be allowed to send stars to a maximum of 10 programs, 1 but this is likely too high to be effective. Roth helped design the AEA job market to limit applicants to 2 signals each so that their scarcity provides stronger informative value. 2 Moreover, a limit of 2 signals should reassure applicants that programs would not erroneously infer unattainability from the absence of a signal. After all, about one-third of US MD students match outside of their top 2 ranks. 5 Limited signaling mechanisms are shown to increase the chance of receiving a preferred interview. 3,4 If implemented correctly, signaling may play a valuable role in optimizing the resident selection process.

Preference Signaling for Competitive Residency Programs in the NRMP

“…1 Preference signaling systems have also been proposed in the orthopaedic literature, 4 and successfully implemented since 2006 by the American Economic Association job market for economics graduate students. 5 Such signaling systems have been shown to alleviate interview congestion and increase the odds of applicants receiving preferred interviews, [3][4][5] supporting assertions by Whipple et al…”

“…In fact, Salehi et al previously proposed a preference signaling model-referred to as ''The Star System''-in the Otolaryngology-Head and Neck Surgery (OTO-HNS) literature in 2018. 2,3 Of note, Whipple et al used the 2016 OTO-HNS Match to simulate their computer model. 1 Preference signaling systems have also been proposed in the orthopaedic literature, 4 and successfully implemented since 2006 by the American Economic Association job market for economics graduate students.…”

Otolaryngology Match 2020-21: Survey of Prospective Applicants in the Setting of COVID-19

“…Whether programs decide to simply interview more applicants or employ alternative solutions, such as preference signaling, is yet to be determined. 17,18 While other specialties have encouraged applicants to attend fewer interviews, compliance may be an issue without mechanisms of enforcement. [19][20][21] The major limitation of our study is response bias.…”

Ideas and Innovations to Improve the Otolaryngology–Head and Neck Surgery Residency Application and Selection Process

“…Signaling may also minimize interview congestion and hoarding, which could decrease application costs. 1,55,56 In addition, this system may reward applicants for their interest in specific programs, as programs may employ different screening filters (eg, provide consideration to applicants with lower US Medical Licensing Exam [USMLE] scores) for students who “star” their program. In response to the “Star System,” Chen et al 56 suggested that “if implemented correctly, signaling may play a valuable role in optimizing the resident selection process.” In further support of signaling, a 2019 study created a computer simulation model of the OTO-HNS Match and concluded, “Offering applicants an option to provide program preference improves the practical number of interview invitations.…”

“…Ever since the first editorial by Baroody et al 38 in 2008, many proposals regarding the residency selection process have filled the OTO-HNS literature. 1,6,27,29,55,58 The main catalysts for many of the aforementioned proposals have been to control the rising OTO-HNS applicant volume to relieve the difficulties high-applicant volumes create for programs 12,13,38 and discourage students from broadly applying to programs simply to potentially increase their matching chances—which obscures the programs’ abilities to discern true interest among applicants. 1,6 Moreover, as more than half of OTO-HNS programs use USMLE scores as a screening tool, 41 the recently announced change of the USMLE Step 1 examination to pass/fail scoring furthers the need for residency selection reform.…”