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After the game: can signaling preferences fix the game? : Emergency medicine news


Match Day, Preference Signaling, EM Jobs


Emergency medicine took a beating in the 2022 game, but it was the best result for our specialty at the most critical inflection point in our history. We needed something to slow the accelerating growth of residency positions. Like the Federal Reserve raising interest rates to cool a high-inflation economy, a few extra games like this will reduce demand for EM training without crashing the system.

Understanding the landscape of the 2023 game is even more important with this game fresh on our minds. Many contentious issues remain as we prepare for the next round of applications, including the decision to offer interviews in person, virtually, or both. The upcoming game will have a new twist, though: preference signaling. This is derived from game theory, a branch of mathematics that analyzes strategies for competitive situations where the outcome of one participant’s choice critically depends on the actions of other participants. Signaling preferences is a formal process for applicants to express a credible interest in a program. Programs can use these signals to gauge credible interest in the face of increased applicant numbers when reviewing applications.

Each residency match applicant is generally allowed to use up to five tokens to signal a higher level of interest in a residency program. Each candidate distributes tokens during the initial phase of the application process before interviews are offered. The requester cannot tell other programs which ones have received their tokens, and the programs are not allowed to request. (The Sodium Sheriff. August 19, 2020;

The first specialties using in-match preference signaling had similar characteristics: they were very competitive and their candidates applied for a substantial percentage of the available programs. As you can imagine, the usual suspects are orthopedics, ENT, dermatology, and urology. These specialties discussed implementing preference signaling in their match before the pandemic, but none did until the 2021 cycle.

Virtual interviews

Internal medicine and general surgery had also implemented preference signage by 2022. These specialties are similar to emergency medicine in the number of applicants and positions available.

Little data is available on the results of using preference signaling in-game. We only have preliminary data from the 2020-2021 otolaryngology game. (West J Emergency Med. 2021;23[1]:72; These results were promising, but it was interesting to see how internal medicine and general surgery, much broader specialties, jumped on the use of preference signaling without much evidence of its benefits. Nevertheless, it will be interesting to review the data from their experiments when they become available.

Why should emergency medicine use preference signaling? It’s likely that the 2023 emergency medicine matchup will be similar to the 2022 matchup, with a lower candidate-to-position ratio than the past two decades. Why add this dimension to an anxiety-provoking process with the supply/demand curve of EM training unlike those of highly competitive specialties? A review of social media posts regarding signaling preferences in other specialties demonstrates a significant amount of grumbling regarding strategy adjustment to maximize the chance of a match in a desired program. (Reddit.

The most obvious reason emergency medicine uses preference signaling is hoarding by prime candidates. Even superstar candidates fear being unmatched in March due to the high stakes of the matching process. This pervasive paranoia is fueled by anecdotes of top candidates who should have easily matched but who instead slipped through the cracks and had to scramble to obtain residency training, usually in another field. (REM. 2021;43[8]:seven; The result is that anxious applicants apply to more programs, and top applicants who apply to 50 programs receive 50 interview offers.

Residency programs, on the other hand, have no idea how many places a candidate is applying for. Virtual interviews eliminate time and money barriers, and the national interview slot pool focuses more on top candidates. I have interviewed hundreds and hundreds of top applicants over the past two decades, fully acknowledging that I could only get two or three each year to choose our program.

Uncharted Waters

At least I know from in-person interviews that the candidate has committed time and money to meeting with me, which limits the number of programs candidates can consider. In virtual interviews, I have no idea how many programs the candidate speaks with or their relative interest in training with us, and I feel like I have to push for them because they are so talented.

The dilemma is that I end up passing on a lot of suitable candidates who are more interested in our program if a superior candidate applies to us without any serious interest.

This issue could be corrected if all programs returned to in-person interviews, but some elements of virtual interviews are likely to remain. It offers some fairness to applicants who cannot afford to travel to the desired program or who may not wish to travel a long distance without a better idea if they fit into the program and its staff.

We can’t predict the near future as COVID is a moving target, and we may find ourselves doing all the virtual interviews again this fall. The 2023 match for emergency medicine will once again navigate uncharted waters. We anticipate a significant drop in the number of applicants, and for the first time will be using preference signaling to control hoarding and prevent programs from skipping suitable applicants who are more likely to match. I hope to be able to write about the success of this strategy next year.

Dr Cookis the director of the emergency medicine residency program at Prisma Health in Columbia, SC. He is also the founder of 3rd Rock Ultrasound ( Friend with him, follow him on Twitter@3rdRockUS, and read his past columns on