The AUA and Society of Academic Urologists (SAU) introduced preference signaling (PS) in a 2021 to 2022 pilot with 5 signals following successful execution in otolaryngology (ear, nose, and throat [ENT]). PS is a standardized system in which a student may send a signal or token to a particular program to demonstrate genuine interest in advance of application review interview selection. The goal of PS is to improve the interview selection process for both applicants and program to provide formal structure to the previous culture of preinterview emails, phone calls, and mentor advocacy in favor of a uniform, equitably assigned, and applicant-directed signal. Programs can use this information to assist in holistic review and interview selection. This attempts to specifically address the underlying bias and inequity that exists in the present informal signaling systems. Network selectivity, differential access to social power, and resource allocation all plague diverse students from achieving a successful match in urology when subjective criteria influence residency recruitment. There is an increasing number of women matching into urology; however, racial and ethnic diversification of the urologic workforce continues to be unsuccessful and discordant with the American patient population.

Subsequently, many subspecialties using the Association of American Medical Colleges’ (AAMC) electronic residency application system (ERAS) participated in an ERAS PS process whereby applicants were provided a structured opportunity to make programs aware of their genuine interest prior to release of interviews. The second cycle of urology PS using 5 signals in the 2022 to 2023 Urology Match showed largely similar outcomes to the 2021 to 2022 pilot. The average signals sent to programs was 18 (range 1 to 61), 48% of signals went to 25% of programs, overall interview rate in 2023 was 13%, signaled interview rate was 52%, and nonsignaled interview rate was 11%; therefore, there was a 4-fold increase in likelihood of interview with a signal. Qualitatively, applicant and program perceptions remained positive about PS, and programs largely incorporated PS into initial application review.

In 2023 to 2023, the SAU board examined the experience of other ERAS specialties such as orthopedics and OB-GYN. Orthopedics elected a large volume signaling program of 30 signals to create value for both programs and applicants. Ortho realized a broader signal distribution as well as a 12% reduction in applications per student in addition to the benefit of an increased interview rate (signaled 23%, nonsignaled 1%, overall 5%). OB-GYN utilized a tiered system and realized a 53% interview rate for gold signaled, 31% for silver signaled, and 5% for nonsignaled.¹ With these data in mind, a positive ortho and OB experience, the plan for 6 other specialties to increase to large volume signals in 2023 to 2024 (ortho, OB-GYN, ENT, anesthesia, dermatology, radiology) and the potential to reduce application volume and allow for holistic review, the SAU/AUA elected to give applicants 30 equally weighted signals in the 2023 to 2024 Urology Match cycle. In addition, the AAMC recommended all participating specialties in ERAS’s PS process signal their most interested programs regardless of whether they are home or away rotations as the most fair and equitable process for all applicants. Therefore, within urology, PS now includes home/away programs as potential signal targets consistent with AAMC recommendations for 2023 to 2024.

In the 2023 to 2024 Urology Match cycle, the average number of signals sent to programs was 103 (range 12-210). Notably, this was associated with 24% reduction in applications per applicant.² Over the past few years, the AAMC, medical school advisors, student leaders, program directors, specialty organizations, and others in the House of Medicine have been emphasizing the need to apply to fewer programs to facilitate holistic review and reduce reliance of programs on filters to screen applications. However, it does appear that large volume preference signaling has also impacted applicant behavior to apply to fewer programs. How this affects diversification of the urology resident workforce remains to be seen. With a significant and meaningful reduction in applications, programs may be better able to focus their limited resources on closer review of applicants who will align with their local and community mission or population. At the present time there are no data in the urology literature to assess if the signal effect of higher likelihood of interview is seen similarly across gender or racial demographics. However, there are data in ENT from a cross-sectional study finding PS was associated with an increased likelihood of interview and that this correlation was robust and present across gender and self-identification as an underrepresented minority.³

Diversification of the urologic workforce is a significant imperative towards health equity outcomes and PS is one component in a complex ecosystem of residency recruitment.