Educators across the continuum of medical education recognize an ongoing crisis in the transition from medical school to residency. The process is very high stakes for applicants; in the past 5 years, fear of going unmatched has fueled a large increase in the average number of programs to which applicants apply (called “application inflation”), despite match rates remaining fairly constant, and quite high, over the same time period. 1, 2 The process is also high stakes for programs, and residency programs may spend disproportionate amounts of time reviewing applications, performing interviews, and recruiting potential residents at the expense of teaching and mentoring current residents. In an attempt to help applicants express their unique qualities and preferences, and to help residency programs identify applicants best suited for, or most interested in, their programs, the American Association of Medical Colleges Electronic Residency Application Service (AAMC ERAS) introduced its Supplemental Application (ERAS-SA) in 2021. In addition to brief questions about personal experiences, ERAS-SA allows applicants to send optional “preference signals.” Applicants may send geographic preference signals by selecting up to 3 preferred geographical regions (out of 9), and/or program preference signals by selecting individual programs of interest. The number of program signals differs for each specialty, from two for Internal Medicine/Psychiatry to 30 for Orthopedic Surgery in 2023. 3 Applicants in Internal Medicine (IM) could send up to five program signals in 2021–2022, and seven in 2022–2023. Uptake of preference signaling has been high; in 2023, the average number of program signals sent by IM applicants was 6.89. 3 There were no statistically significant differences in the average number of signals sent by White and non-White applicants or by male and female applicants. 3 ERAS proposed preference signaling as additional information for programs and cautioned against using signals as strict inclusion or exclusion criteria for interview invitation decisions. Nonetheless, in a survey of program directors (PDs) across all fields, 88% of respondents used program signals as a screening tool before more thorough application review, with 70% of those calling it important or very important. 4

Data-driven insight into the use of preference signaling is essential. IM applicants and programs are an important cohort to investigate because IM offers more positions (9725) to more applicants (14,231) than any other specialty. 5 These programs and applicants are highly diverse, ranging from small community-based hospitals to large researchbased universities, and more applicants who are osteopathic medical students or international medical graduates (IMGs) than other specialties. Two studies published in this issue of the Journal of General Internal Medicine provide important insights into preference signaling in IM.“Internal Medicine Residency Program Directors’ Impressions of the Electronic Residency Application Service Supplemental Application” by Weinstein et al. investigated residency PD views of ERAS-SA during its first year. 6 Most PDs thought that ERAS-SA could improve the interview selection process, with 70% reporting this for program signaling and 53% for geographic signaling. Just over half of PDs (54%) said they would be more likely to invite applicants who signaled their programs, with a smaller percentage for geographic signals (39%). When stratified by program size, the largest programs were more likely to find program-specific preference signaling in ERAS-SA helpful and also more likely to interview applicants who signaled their program …