To the Editor: Potential Effects of Preference Signaling on International Medical Graduates

I read with interest the study presented by Romanoski and colleagues, in which they reported that the use of preference signaling and geographic location significantly increased an applicant’s chances of receiving a residency interview.¹ However, their study excluded international medical graduates (IMGs). In this letter, we will discuss the unique obstacles faced by IMGs, particularly the barriers to accessing the US residency system.

IMGs often lack access to formal mentorship that provides tailored guidance on how to navigate the US residency application process or how to use signaling effectively. For example, applicants only have a 5% chance of receiving an interview from a non-signaled obstetrics and gynecology program.² IMGs may feel the pressure to spend all of their signals on community programs to increase their likelihood of matching, which may cause their applications to be overlooked by top tier or academic programs. For instance, IMGs who may want to build a career in academia or research may choose to opt out to secure a residency spot. Furthermore, it was reported that program directors often prioritized communications from faculty members or other program directors advocating for applicants that strongly influenced their decisions.³ To date, there is no formal pre-residency training for IMGs that could help them integrate into the system to be better prepared to enter US residency. Consequently, IMGs don’t often have access to US-based faculty members or program directors who may advocate for them.

The adoption of program signaling was a way to improve residency application and selection process that reduced the number of applications per program and total number of applications submitted per applicant.¹ However, recent data indicating minimal interview opportunities from non-signaled programs² suggests that programs may continue to focus on a narrow pool of candidates, potentially jeopardizing efforts to enhance diversity. Signaling, as currently implemented, may serve as an indirect cap on applications and reinforce existing applicant-program dynamics (eg, IMGs applying primarily to community programs, and graduates from top US medical schools applying to prestigious programs). There has been growing discussion around capping the number of interviews, rather than applications, as a means to preserve diversity and support applicants underrepresented in medicine.⁴ As the medical community continues to advocate for greater inclusivity, including the integration of IMGs, it is crucial to understand how recent changes to the residency application process, such as signaling, uniquely impact these applicants.