Message Received? Applicant Insights on Preference Signals in General Surgery Residency Recruitment

OBJECTIVE: We aimed to understand general surgery applicants' experiences with and attitudes toward preference signaling. DESIGN: Qualitative analysis of de-identified transcripts from semi-structured interviews of general surgery residency applicants was performed. SETTING: A general surgery residency program at an academic hospital in the United States. PARTICIPANTS: All applicants to one general surgery residency program in the 2024 to 2025 recruitment cycle were invited to participate. Twenty-seven applicants participated in semi-structured interviews (59% female, 63% MD graduates, 11% DO graduates, 26% international medical school graduates). RESULTS: While applicants decided where to signal differently, applicants noted that they signaled across a range of program competitiveness and made strategic choices based on interest versus likelihood of matching. While applicants highlighted the importance of a good advisor, they noted that disagreements were common between advisors regarding signaling strategies. Applicants additionally noted a disparity in advising for IMG and DO applicants, as their schools often did not have surgery-specific advisors or a track record of matching into surgical specialties. Applicants focused on several signaling pitfalls, including difficulty judging their competitiveness and determining where they would "fit" before their interviews. While applicants did not expect to receive interview offers from non-signaled programs, they found these interviews could go 2 ways: either non-signaled programs were a good fit, or they experienced quasi-adversarial interactions about their potential lack of interest. With respect to future changes, applicants wanted more transparency regarding each program's screening process and felt that signal number changes should be data-driven to ensure applicants receive enough interviews to match. CONCLUSIONS: Applicants had varied experiences with signaling, reporting different allocation strategies and guidance from advisors. Applicants highlighted a need for transparency regarding how applicants should signal and how programs interpret signals. This transparency can break down the hidden curriculum of signaling, improving applicant trust in the recruitment process.