Preference Signaling in General Surgery: A Qualitative Study of Program Director Perspectives.

Objective: Although large-scale surveys have gathered some data on the use of preference signals by general surgery programs, little is known about how program directors (PDs) interpret and apply these signals in practice. This study aims to gather in-depth insights from PDs regarding their perspectives on preference signaling and its impact on the resident selection process.

Design, setting, and participants: Semi-structured, virtual interviews were conducted with 14 PDs, representing a mix of university-based (57.1%), community-based university-affiliated (21.4%), and community-based (21.4%) programs of varying sizes (3-9 residents per year) from all US regions. Interviews explored PDs' perceptions of preference signals, their impact on the selection process, associated benefits/challenges, and recommendations for applicants. Transcripts were de-identified, coded, and analyzed for thematic trends.

Results: Analysis yielded 314 codes and 6 major themes: (1) signals reflect genuine applicant interest; (2) signals help applicants stand out, particularly borderline candidates; (3) signals do not always imply alignment with program values; (4) 5 signals were viewed as meaningful but limited in impact; (5) increasing the number of signals could reduce overapplication and enhance signal utility; and (6) both PD and advisor understanding of signals is evolving. PDs used signals during interview selection but not for postinterview ranking. While signals were useful for mid-tier applicants and helped programs identify unexpected candidates, their absence was not necessarily interpreted as a lack of interest. PDs supported increasing the number of signals, predicting shifts in how signals are used and interpreted.

Conclusions: Preference signaling can support a more intentional and applicant-centric review process, especially for less competitive applicants. However, variability in PDs' use and interpretation of signals poses challenges for equitable advising. As general surgery transitions to 15 signals, further efforts are needed to promote transparency, standardize guidance, and evaluate long-term impact on application behavior and match outcomes.