A couple of months ago, I was talking to one of our graduating medical school senior students. He told me that he had applied to 35 different internal medicine residency programs. That may seem like an astoundingly high number but it is not. Over the past 30 years, there has been steady application inflation, that is, senior medical students are applying to more and more residency programs each year. In the 1980’s, residency applications were submitted on paper with each program having a different application template. In the 1990’s, personal computers made it increasingly easy for applicants to generate multiple residency applications. In 2005, the ERAS system (Electronic Residency Application Service) made it easy to apply to a large number of residencies electronically by creating one, single standardized residency application that was accepted by all residency programs. In 2020, residency interviews went virtual making it cheaper and easier for applicants to interview at large numbers of residencies. The result is that students are applying to more residency programs and doing more interviews for residency than ever before.
In 1992, when students applied by filling out paper application forms, the average number of residency applications was 12 per applicant. By 2007, after the introduction of ERAS, that number grew to 30 applications per applicant. Once residency interviews went virtual due to COVID, it grew to an average of 71 applications per applicant in 2021.
Application inflation is harmful to both the applicants and the residency programs. ERAS charges applicants by the number of applications they submit: $11 per application for the first 30 and $30 per application for any applications over 30. For the residency programs, application inflation adds time and expense to read through hundreds or even thousands of applications. This can result in the program wasting the faculty members’ time reviewing applications and virtually interviewing applicants who really have no interest in the residency program. It also can result in residency programs making an initial cut of applicants based on easily quantifiable metrics such as the perceived quality of the applicant’s medical school, their STEP 1 and STEP 2 exam scores, or their rank in their medical school class. These metrics do not always predict how good of a doctor the individual will be after completion of residency, however.
Application inflation has gotten out of control
The Association of American Medical Colleges (AAMC) publishes statistics on the ERAS each year. Data from the 2024 residency match is now available. The graph below shows the number of internal medicine residency applications per applicant since 2019, subcategorized by medical school graduates (MD), osteopathic school graduates (DO), and international medical school graduates (IMG).
The number of residency programs that each applicant applies to also varies by specialty with applicants to highly competitive specialties applying to more programs than less competitive specialties. The graph below shows the average number of residency applications per applicant by specialty in 2024 for medical school graduates (MD) and for all categories of applicants combined (MD, DO, and IMG applicants).
There is a much larger variation in the number of applications that residency programs in each specialty receive. Internal medicine residency programs receive the largest number of applications, averaging 3,165 applications for each internal medicine residency program. This number is so high because internal medicine has the largest total number of applicants each year and has the largest total number of available residency positions.
Applicants do not interview at all residency programs that they apply to. After they submit their application, the residency program will decide whether or not to offer the applicant an interview. Applicants then decide whether or not to interview at each program that offers them an interview. Last year, the median number of interviews per residency applicant was 14 but there was a lot of variation between different specialties.
The solution to application inflation is signaling
Residency applicants can now “signal” their strong interest in a limited number of residency programs as a way of communicating to those programs that they would be more likely to rank the program high on their residency match rank list. Most (but not all) specialties offer program signaling. These program signals are listed on the ERAS application that the applicant fills out in the fall. This allows the residency programs to weed out those applicants who are unlikely to consider their residency program and can help the residency program to prioritize those applicants who are truly interested in the residency program for interviews.
During the COVID pandemic, otolaryngology was the first specialty to offer signaling during the 2021 residency match year. Analysis of ENT match data from that year found that applicants were significantly more likely to receive an interview from signaled programs (58%) versus non-signaled programs (14%). The success of the signaling innovation in ENT in 2021 resulted in signaling rapidly spreading to other specialties.
Each specialty decides if and how many signals will be accepted in the upcoming ERAS applications. Programs can also stratify signals as being “silver” (interest) or “gold” (very high interest). For the upcoming residency application season that begins this fall and will culminate in the 2025 residency match in March 2025, the following are the numbers of signals agreed upon by each specialty.
How will residency programs use signals?
Individual residency programs must publicize how they will use applicant signals in July, prior to students submitting their ERAS applications. The Alliance for Academic Internal Medicine recommends that internal medicine residency programs choose from the following three recommended wordings to communicate how they will use signals:
- “Due to a high volume of applications, we [do not]/ [are very unlikely to] extend interview offers to applicants who do not signal our program.”
- “While we preferentially review applications from those who signal our program, we also consider applicants who do not signal us.“
- “Our program does not consider signals in our interview offer decision-making process and review applicants equally whether or not they have signaled us.”
Because internal medicine residency programs receive thousands of applications, it is anticipated that many programs will opt to only interview applicants who send them a program signal. Residency programs are advised to not use the presence or absence of a signal in devising their rank list but rather to determine which applicants to interview and then create their match rank list after interviews are completed.
How should applicants use signals?
Applicants who apply to a specialty that does accept program signals should use all of their signals. If a specialty categorizes signals as gold and silver, then the applicant’s top choices should be gold and next choices silver. Because many residency programs are likely to only interview those applicants who send them a program signal, applicants should spread their signals between their “reach” programs and their “safety” programs based on their self-assessment of their competitiveness. Although sending a program signal may increase the likelihood of getting an interview, it does not guarantee an interview; therefore applicants should not waste their signals on residency programs that they are clearly not qualified for.
Applicants should use their signals for residency programs at their home (medical school) institution, institutions that they have done away clinical rotations, and institutions that they have not experienced during their medical school training. If a residency program clearly states that it does not use signaling to decide who to interview, then applicants should not waste a signal on that residency program and instead use it for another residency program.
Applicant geographic preferences
In addition to sending a signal to express interest in a particular residency program, applicants can specify geographic regions that they prefer on the ERAS application. Residency programs may also use these stated geographic preferences in selecting which applicants to offer interviews. Applicants can chose up to 3 of the following U.S. census regions:
- Pacific: AK, CA, HI, OR, WA
- Mountain: AZ, CO, ID, MT, NM, NV, UT, WY
- West North Central: IA, KS, MN, MO, NE, ND, SD
- East North Central: IL, IN, MI, OH, WI
- West South Central: AR, LA, OK, TX
- East South Central: AL, KY, MS, TN
- South Atlantic: DC, DE, FL, GA, MD, NC, PR, SC, VA, WV
- Middle Atlantic: NJ, NY, PA
- New England: CT, ME, MA, NH, RI, VT
Applicants can also express their preference for residency programs located in urban versus rural areas. Like geographic preferences, applicants do not have to specify rural or urban if they have no preference. A sample ERAS application can be found here.
How important are signals to residency program directors?
The AAMC surveyed residency programs directors after the 2024 match to determine what factors are highly considered when deciding whether or not to offer applicants an interview. Overall, the response rate was 28% (1,422 programs). Factors that program directors ranked as important or very important were:
- Step 2 exam results (75%)
- Letters of recommendation (75%)
- Personal statements (74%)
- Medical Student Performance Evaluation (70%)
- Program signals (67%)
- Geographic signals (58%)
- Selected experiences (56%)
- Meaningful experiences (55%)
- Medical school attended (54%)
Factors that fewer than half of residency program directors rated as important or very important included: standardized letters (41%), meaningful experience essay (40%), medical school reputation (38%), focus areas experiences (37%), other impactful experiences essay (37%), key characteristic experiences (34%), total publications (27%), first author publications (25%), rural vs. urban preference signal (25%), Gold Humanism Honor Society (25%), MD vs DO degree (24%), Alpha Omega Alpha membership (23%), and journal reputation of publications (17%).
Of those residency programs that offered gold and silver signals, 69% of program directors considered gold signals as more valuable than silver signals in deciding which applicants to interview. Additionally, 74% of program directors reported that the program signals allowed them to identify applicants that they would otherwise have overlooked.
Next up… interview caps
The inevitable consequence of application inflation is interview inflation. That is, applicants interviewing at more and more residency programs each year. This adds even more cost, especially to the residency program that must dedicate hundreds of hours of uncompensated faculty time to perform the interviews. There is an educational cost to applicants who must take time out of clinical rotations to interview. Additionally, if interviews are performed in-person, there is a cost to the applicant of travel and lodging.
In 2020, ophthalmology instituted a limit of a maximum of 20 interviews permitted per applicant. In subsequent years, this number was decreased to 18 and then 15 interviews per applicant. For 2024, the Alliance for Academic Internal Medicine has recommended a 15 interview cap on the number of interviews each applicant can undertake. This will equal the total gold + silver signals that internal medicine applicants are permitted to utilize.
So, are program signals good or bad?
No medical student wants to be one of the residency applicants in their class that do not match. That can mean taking a year off after medical school in order to try to match the next year, settling for an undesired residency program that did not fill in the regular match, or switching to a different specialty to pursue residency. The ease of the on-line standardized ERAS application plus the advent of virtual interviews brought on by the COVID pandemic has fueled application inflation and interview inflation. Overall, I believe that program signaling is beneficial to both applicants and residency programs.
Because it is so new, program signaling is a work in progress and will undoubtedly evolve in different specialties over the next several years. But the first iterations are good and should help reel in escalating interview costs. Signaling will also cure applicants of the misconception that “more is better” when it comes to residency applications and interviews. The data from the last round of residency interviews suggest that the program signals and the geographic signals are valued highly by residency programs. However, the urban versus rural signals are of considerably less importance.
July 28, 2024
