The Impact of Preference Signaling on Interview Invitations and Match Outcomes in the 2023 to 2024 Orthopaedic Residency Cycle

Abstract

Background:

Orthopaedic surgery is among the most competitive residency specialties with recent cycles seeing record application volumes and declining match rates. Therefore, the aim of this study was to examine the Electronic Residency Application Service (ERAS) signaling system's impact on interview invitations and outcomes in the 2023 to 2024 orthopaedic surgery residency application cycle, building on data from its inaugural use.

Methods:

Application and interview data were collected from official National Resident Matching Program reports, Association of American Medical Colleges (AAMC) Supplemental ERAS Application Report, and specialty-wide surveys. Statistical findings, including interview distributions and match rates, were extracted from previously published studies and AAMC database.

Results:

The 2023 to 2024 cycle had 1,492 applicants. On average, applicants submitted 86 applications (range: 12-198), with the majority submitting between 70 and 80 applications. Nearly all orthopaedic applicants (∼97%) participated in preference signaling. Applicants received more interview invitations from programs they signaled than from programs not signaled. Signaled programs accounted for the majority (∼79%) of interview offers. Only 19% to 20% of interview offers were extended by programs that applicants did not signal. Of matched applicants, the majority (90%) matched at a program they had signaled, and the remaining (10%) matched at programs, they did not signal. Furthermore, the majority of applicants (63%) who matched were matched at programs where they had completed an away rotation. Although signaling aimed to reduce excessive applications, the overall volume per applicant remained high. While 45% of applicants reported feeling incentivized to apply more selectively, many still submitted broad applications.

Conclusions:

Preference signaling in orthopaedic surgery residency applications has markedly reshaped the match landscape by concentrating interview opportunities and match success predominantly within signaled programs. The authors recommend that medical students strategically research and prioritize programs when signaling, while residency programs should continue refining how they interpret signals to enhance holistic and equitable selection processes.

Background

Orthopaedic surgery remains one of the most competitive residency specialties. In the 2022 match, there were 1,435 applicants for only 875 PGY-1 positions. Match rates have declined, leaving a significant portion of applicants unmatched¹. De Araujo et al. reported that 35.1% of MD applicants failed to match into an orthopaedic residency program in 2022². COVID-19 amplified this trend by enabling virtual interviews and limiting away rotations in 2020 to 2021³. In addition, the shift of the USMLE Step 1 examination to pass/fail removed a key numeric screening tool for programs¹. In the 2022 to 2023 cycle, orthopaedic residency programs received an average of 774 applications each, making holistic reviews increasingly unfeasible⁴. Previously, applicants expressed interest through away rotations, but these opportunities are inconsistent and can create inequities,^5,6. To address this, a formal signaling mechanism was introduced to help normalize competition. Otolaryngology first implemented this in 2020 to 2021, allowing applicants to send 5 “tokens” to preferred programs, a model that has since been adopted in other specialties^7,8.

Applicants who signaled were significantly more likely to receive interviews, with strong support for the system with 91% of program directors favored its continuation^7,9. Following these successes, the Association of American Medical Colleges (AAMC) integrated preference signaling into the Electronic Residency Application Service (ERAS) Application, piloted in 2021 to 2022⁴. In orthopaedic surgery, the Council of Orthopaedic Residency Directors (CORD) of the American Orthopaedic Association (AOA) introduced signaling in the 2022 to 2023 cycle, allotting each applicant 30 signals⁵. Most programs participated, with 91% orthopaedic programs accepting signals in the pilot year⁴. Most applicants used all 30 signals and found the system helpful⁵. Notably, applicants received significantly more interview invitations from programs they signaled than from those they did not¹⁰. In parallel with these early experiences, the AOA Council of Orthopaedic Residency Directors (AOACORD) released guidelines for the 2023 to 2024 and 2024 to 2025 application cycles to standardize preference signaling and away rotations. For 2023 to 2024, AOACORD recommended all programs opt into preference signaling and encouraged applicants to signal their home and subinternship institutions if preferred. The 2024 to 2025 guidelines further limited rotations to 4, maintained universal interview offer days, and clarified that applicants should signal their home program if it was their top choice for residency¹¹. The aim of this study was to analyze the 2023 to 2024 orthopaedic surgery cycle to assess the impact of signaling on interview and match rates.

Methods and Materials

Study Design

This retrospective analysis used 2023 to 2024 National Resident Matching Program (NRMP) and AAMC ERAS reports to evaluate orthopaedic residency positions, applicant behavior, and match outcomes. AOACORD guidelines were reviewed for their role in signaling policy. Additional literature was analyzed to understand interview distributions and applicant strategies.

Outcomes and Definitions

Primary outcomes included interview rates, match results, application behavior, and fill rates. Match outcomes tracked whether applicants matched at signaled programs. Application behavior was defined by the number of applications submitted, while program fill rates reflected the percentage of programs that successfully matched applicants. Signaled programs were those marked through the ERAS supplemental application.

Data Presentation

The results are summarized using descriptive statistics, including means and percentages, to highlight key trends in interview distribution and match outcomes. Tables highlighted key metrics such as the average number of interviews received from signaled versus nonsignaled programs and match rates at signaled institutions.⁴

Ethical Approval

IRB approval was not required due to use of deidentified public data.

Results

Signals Received Per Program

In the 2023 to 2024 cycle, orthopaedic surgery programs received a total of 48,010 signals, with MD applicants contributing 35,637 signals, DO applicants 9,157 signals, and IMG applicants 3,216 signals. The mean number of signals received per program was 252.68 with an average of 4.2 positions per program^4,12,13. These data are summarized in Table I.

TABLE I.

Number of Signals Received By Orthopaedic Surgery Programs From Applicants Varying By Degrees

Degree	ERAS 2024	Mean	Min	Max	SD
DO	9,157	48.19	3	257	66.04
IMG	3,216	16.93	2	72	11.22
MD	35,637	187.56	2	497	111.85
Overall	48,010	252.68	41	542	89.20

Interview Rates Based on Signaling Status

Applicants who signaled a program had a median interview rate of 24.4% and a median interview rate of 0.92% at nonsignaled programs^10,12–14. Applicants secured between 8 to 9 interviews from their 30 signaled programs compared with just 2 to 3 interviews from nonsignaled programs¹⁴. The majority of these nonsignaled interviews came from home programs or programs where the applicant had completed an away rotation.^10,14

Application Volume and Applicant Behavior

One thousand four hundred ninety-two applicants participated in the orthopaedic surgery residency match for 916 PGY-1 positions across 218 programs, maintaining a nearly identical applicant-to-position ratio of 1.63 compared with 1.64 in the prior year, and 99.9% of positions were filled⁴. Application numbers per applicant remained high, with a median of 86 applications submitted¹⁵.

Participation in Signaling

Ninety-seven percent of applicants used at least 1 signal in the 2023 to 2024 cycle⁴. Of the 30 allotted signals, there was an average of 29 to 30 signals used⁷. Furthermore, a majority of applicants (96.7%) used all their signals¹⁶. Program participation was equally high, with nearly all orthopaedic residency programs opting to receive signals (187/199)⁴.

Signaling Strategies

65% of applicants signaled their home program if applicable, while 95 to 96% applicants signaled programs where they completed an away rotation⁴. Conflicting survey results showed 53% and 65% signaling their home program^5,17. The 2024 to 2025 AOACORD guidelines lacked clear direction on signaling home and away programs, leading to diverse approaches, with applicants spreading remaining signals across reach, midtier, and safety programs.

Interview Invitation Outcomes

MD applicants who signaled had the highest median interview rates (24%) compared with DO applicants (5%) and IMG applicants (0%). Applicants who did not signal had a median interview rate of 0%. These data are summarized in Table II.

TABLE II.

Median Interview Rates in Orthopaedic Surgery Varying By Degrees

Degree	Signal (%)	No Signal (%)	N
MD	24	0	1,253
DO	5	0	389
IMG	0	0	163

Signaling led to significant differences in interview outcomes. Applicants received an average of 9.4 interviews from signaled programs and only 2.4 from nonsignaled ones in 2023¹⁴. Most interview invitations (78.7%) came from signaled programs, highlighting the effectiveness of signaling¹⁰. Non-AOA applicants relied on signals for 90% of their interviews, while AOA applicants received 26% from nonsignaled programs¹⁸. Female applicants had a higher interview yield per signal than male applicants (p = 0.006), but no gender difference was found for nonsignaled programs¹⁴.

Match Outcomes

Of the 916 available positions, 915 were filled¹⁵. The overall match rate was 61%, with MD applicants achieving the highest match rate (75%)⁴. MD applicants accounted for all filled orthopaedic residency positions (77%), while DOs comprised 17%¹⁵. The majority of matched applicants (91%) secured a position at a program they had signaled⁵. Compared with the 2022 to 2023 cycle, nearly all applicants matched at a signaled program¹⁹. Survey data confirmed that applicants overwhelmingly matched at 1 of their signaled programs, demonstrating that signaling aligned applicant and program preferences effectively¹⁸. The majority of matched applicants (63%) completed an away rotation at their matched program⁶.

Discussion

Our analysis shows that the ERAS preference signaling program has significantly affected the interview process in orthopaedic surgery, while preserving the specialty's competitiveness. Orthopaedics allows applicants up to 30 signals, the highest among specialties, compared with just 15 for fields such as general surgery. This greater number of signals may make matching at nonsignaled programs more difficult, as not including a program in the top 30 suggests lower interest, reducing the likelihood of an interview offer. Data from the 2023 to 2024 cycle support findings from the inaugural year and provide valuable insights for applicants and residency programs, specialties, and discusses implications and recommendations for future improvements.

Signaling Increases Interviews at Preferred Programs

Before signaling, many qualified applicants were overlooked due to the volume of applications or lack of connections. Allowing applicants to signal interest in 30 programs helps program directors identify and prioritize those who show genuine interest⁷. Tarapore et al. found applicants were nearly 10 times more likely to receive an interview from a signaled program than a nonsignaled one¹⁰. From the program perspective, signaling streamlines the interview process, enabling directors to focus on interested and qualified applicants. Programs often use signals as tiebreakers now¹⁶. With 90% of matches occurring at signaled programs, signaling enhances interview process efficiency^14,20.

Impact on Application Inflation

While signaling aimed to reduce overapplication, the overall volume remained high⁴. Although 40% to 45% of applicants reported applying to fewer programs due to signaling, many still applied broadly out of fear of not matching⁵. The financial burden is significant—applicants applying to 80 programs spent about $1,830 in ERAS fees, compared with $630 for those applying to 40 ⁷. While signaling has not significantly reduced application inflation, it has encouraged more strategic applications⁴. Future interventions, such as interview caps, may be needed²¹.

Equity Considerations

Signaling aimed to improve equity by giving all applicants the same number of signals⁴. The results suggest signaling has contributed to a fairer system, particularly in interview distribution. Female applicants received more interviews per signal than that of male applicants (p = 0.006). In addition, the signaling system allowed applicants without strong institutional connections to express interest in programs that might have overlooked them^3,18. However, away rotations still strongly influenced match outcomes, with 63% of matched applicants securing positions at programs where they completed one¹⁶. DO and IMG applicants face significant challenges, reflected in lower match rates despite equal access to signals. While DO applicants used signals effectively, 128 DO applicants matched in orthopaedics in 2024. Ranson et al. reported 14% of current orthopaedic surgery residents hold a DO degree²². These findings demonstrate the lack of orthopaedic surgery residents and applicants with a DO degree^22,23.

Applicant Strategy and Experience

Signaling adds a strategic layer to the match process, requiring applicants to prerank their top programs⁷. Deckey et al. found that applicants varied in their approach, with some signaling only highly competitive programs, while others spread their signals across reach, target, and safety programs¹⁴. A key takeaway is that signals should be used judiciously. Signaling a home program may be unnecessary if an interview is already likely, and some competitive programs advised against signaling, stating they would interview strong candidates regardless^16,18. Standardized guidance from organizations such as the AOACORD could help clarify best practices. However, applicants who used all 30 signals but still lacked enough interviews expressed frustration⁵. This highlights that while signaling increases visibility, it cannot make up for a weak application.

Program Considerations

Residency programs have largely adopted signaling but continue to refine how they incorporate it into their selection processes⁴. A concern is the potential overconcentration of interviews among signaled applicants, which may lead to strong nonsignaled candidates being overlooked²¹. Programs may need to adjust by considering both signaled and nonsignaled applicants to ensure a balanced interview pool. Reporting the match rate of interviewed applicants could help programs refine their approach⁴.

Comparison With Past Cycles

Comparing the 2023 to 2024 cycle with previous years reveals key differences. Before signaling, applicants lacked a standardized way to express program interest, resulting in an inefficient interview distribution, with some securing excessive interviews while others struggled⁵. Signaling has made the match process more aligned with mutual interest, likely improving interview allocation efficiency, though the overall match rate in orthopaedics has remained stable¹⁵. Future studies could assess whether signaling reduces unmatched applicants with multiple interviews, indicating better interview-to-match conversion rates¹⁸.

Implications of the AOACORD Guidelines

The findings of applicants' reliance on signals and high application volumes align with the AOACORD 2023 to 2024 recommendations, which encouraged universal signaling participation and a 30-signal limit to reduce ‘application inflation’. In 2024 to 2025, AOACORD expanded its recommendations, advising applicants to continue signaling home and subinternship programs and limiting rotations to 4, including home and away. Furthermore, the AOACORD encourages expanded use of electronic Standardized Letter of Recommendation to improve uniformity in communicating applicant qualifications. As more programs adopt these guidelines, it will be important to monitor disparities in match outcomes¹¹.

Limitations

The analysis relies on publicly available data from NRMP, AAMC, and survey-based studies, which may introduce reporting biases or inconsistencies. In addition, while preference signaling has demonstrated a strong correlation with interview invitations and match outcomes, the causality of this relationship cannot be definitively established. Factors such as applicant competitiveness, institutional preferences, and geographic considerations likely influence the effectiveness of signaling. Finally, while signaling aimed to reduce excessive applications, survey data indicate that many applicants still applied broadly, highlighting the need for further research on whether signaling alone can meaningfully affect application inflation in future cycles. A comparison group could not be included in our analysis due to the universal adoption of preference signaling across orthopaedic surgery programs during the application cycle. The extremely limited number of programs that did not participate in signaling lacked similarity in competitiveness or applicant pool to serve as a robust control. Furthermore, year-to-year changes in application trends, interview formats, and policy shifts further hinder the reliability of historical cohorts as a control group.

Conclusion

Preference signaling in orthopaedic surgery residency applications has markedly reshaped the match landscape by concentrating interview opportunities and match success predominantly within signaled programs. The authors recommend that medical students should strategically research and prioritize programs when signaling, while residency programs should continue refining how they interpret signals to enhance holistic and equitable selection processes.