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Preference Signaling in the Inaugural Orthopaedic Fellowship Match: A National Survey of Program Directors

A national survey of orthopaedic fellowship program directors reveals that while perceptions of preference signaling vary, it is viewed as a beneficial tool for improving application screening and identifying genuine interest, particularly by programs with higher applicant volumes.

Original authors: Nicholas M Frappa, Colton Evoniuk, Nehaal Siddiqi, Zachary Troiani, Idem Essien, Ellen Lutnick

Published 2026-08-07

📖 5 min read🧠 Deep dive

CC BY 4.0

Original authors: Nicholas M Frappa, Colton Evoniuk, Nehaal Siddiqi, Zachary Troiani, Idem Essien, Ellen Lutnick

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

Imagine the world of medicine as a massive, bustling marketplace where young doctors finish their long training and look for a specialized "master class" to learn a specific skill, like fixing knees or repairing shoulders. This is called a fellowship. For years, these master classes have become incredibly popular, with almost every doctor wanting to join one. But here's the problem: the number of applicants has exploded, creating a chaotic crowd where it's hard for the teachers (Program Directors) to find the students who are truly excited to learn their specific craft.

To solve this, a new tool called "Preference Signaling" was introduced. Think of it like a special, golden ticket. Instead of just sending a generic application to every school, a student gets a limited number of these tickets (10 in this case) to hand directly to the specific schools they really, really want to attend. It's a way for students to say, "I'm not just applying everywhere; I'm serious about you." The big question for the teachers is: Does this golden ticket actually help them sort through the mountain of applications, or does it just add another layer of confusion? This paper dives into the very first time this system was used for orthopaedic fellowships to see if the teachers liked it and how they used it.

The Great Golden Ticket Experiment

In the spring of 2026, orthopaedic fellowship programs across the United States tried out this new "golden ticket" system for the first time. The researchers, a team of curious investigators from the University at Buffalo, decided to ask the people in charge—the Program Directors—what they thought. They sent out a digital survey to 278 directors and coordinators, and 171 of them filled it out completely. It was like asking the head chefs of 171 different cooking schools, "Did this new ingredient help you cook better?"

The Mixed Reactions

The results were a bit like a room full of people voting on a new school rule: opinions were split. When asked if the golden tickets made the application process better, 55% of the directors said, "Yes, it helped!" while 45% said, "Not really."

However, even the skeptics saw some value. A whopping 67% of the directors said they planned to use the system again next year. But here is the twist: 71% of them also said they would still interview students who didn't hand them a golden ticket. It seems the directors didn't want to slam the door on anyone just because they forgot to bring a ticket.

Who Loved the Tickets the Most?

The study found that the usefulness of the golden tickets depended heavily on how crowded the "marketplace" was.

The Busy Schools: Programs that received a huge number of applications (the "high-volume" programs) were the biggest fans. They felt the tickets helped them spot the students who were genuinely interested and made sorting through the pile of applications much easier.
The Specific Specialties: The directors of Adult Reconstruction (fixing hips and knees) and Sports Medicine (fixing athletes' injuries) had the most positive views. About 81% of Adult Reconstruction directors and 77% of Sports Medicine directors said the system improved the process.
The Quieter Schools: In contrast, directors for Foot and Ankle and Shoulder and Elbow fellowships were much less enthusiastic. Only 16% of Foot and Ankle directors and 14% of Shoulder and Elbow directors felt the system helped. For them, the pile of applications wasn't big enough to make the tickets necessary.

How the Numbers Played Out

The researchers crunched the numbers to see what made a director like the system. They found a strong link between the number of applicants and how much the directors liked the signaling.

Programs with more applicants were more likely to say the system improved the process.
They were also more likely to say the tickets were useful for screening applications.
Interestingly, the more applicants a program had, the less likely they were to interview someone who didn't send a ticket. For every 10 additional applicants a program received, their odds of interviewing a non-ticket holder dropped by 12%.

What the Directors Said in Their Own Words

About half of the directors (76 people) wrote extra notes. The quiet schools complained that since they didn't get many applications, the tickets didn't help much—they could just read everyone's application anyway. The busy schools, however, said the tickets were a lifesaver for finding the "real fans" among the thousands of applications. Some directors also mentioned they used the tickets mostly to help decide who to rank at the top, rather than just to decide who to interview.

The Bottom Line

So, did the golden tickets work? The paper suggests that they did, but mostly for the schools that were drowning in applications. For the programs with Adult Reconstruction and Sports Medicine fellowships, the system was a helpful tool to filter the crowd. For the smaller programs, it was less critical.

The study concludes that while the system is popular and likely to stick around, it isn't a magic wand that replaces all other ways of choosing students. Most directors still plan to interview students who didn't send a ticket, meaning the golden ticket is just one piece of the puzzle, not the whole picture. As the directors get more used to the system, they might change how they use it, but for now, it seems to be a helpful helper for the busiest schools in the orthopaedic world.

Technical Summary: Preference Signaling in the Inaugural Orthopaedic Fellowship Match

Problem Statement
The orthopaedic surgery fellowship landscape has shifted toward near-universal fellowship completion, with selection rates reaching 94% by 2021, the highest among all surgical specialties. This trend has driven a significant increase in application volume and competition, creating challenges for program directors in identifying applicants who are both highly qualified and genuinely interested in specific programs. While preference signaling was successfully implemented in the orthopaedic residency match (2022–2023) to address similar issues, it was introduced to the orthopaedic fellowship application process for the first time during the 2026 cycle via the San Francisco Match. Prior to this study, no published research existed regarding how fellowship program directors perceived or utilized these signals during the application review process.

Methodology
This study employed a prospective, self-completed survey design to evaluate the use of preference signaling during the 2026 orthopaedic fellowship application cycle.

Data Collection: Survey invitations containing a REDCap link were distributed via email to program directors and coordinators of United States-based orthopaedic fellowship programs. Invitations were sourced from publicly available departmental websites and fellowship directories across eight subspecialties: adult reconstruction, foot and ankle, hand, musculoskeletal oncology, pediatric orthopaedics, shoulder and elbow, spine, and sports medicine.
Sampling: Three rounds of invitations were sent between April and June 2026. Of 278 responses, 171 completed surveys with no missing required data were included in the final analysis.
Statistical Analysis: Categorical variables were summarized as frequencies and percentages; continuous variables were reported as means, medians, and ranges. Associations were evaluated using chi-square tests, Fisher-Freeman-Halton exact tests, Mann-Whitney U tests, Kruskal-Wallis tests, and Spearman rank correlations. Univariable and multivariable logistic regression models were used to assess associations between program characteristics (e.g., applicant volume, subspecialty) and attitudinal outcomes. P-values were adjusted using the Benjamini-Hochberg false discovery rate procedure.

Key Contributions
This paper provides the first national characterization of how orthopaedic fellowship program directors incorporate preference signaling into applicant screening, interview selection, and evaluation during its inaugural year. The study quantifies the heterogeneity in director perceptions and identifies specific program characteristics—particularly applicant volume and subspecialty type—that correlate with favorable attitudes toward the signaling mechanism.

Results

General Perceptions: Among the 171 respondents, 55% reported that preference signaling improved the application process, while 45% reported no improvement. Despite mixed views on improvement, 67% anticipated using signaling in the subsequent cycle. However, 71% also anticipated interviewing applicants who did not signal their program.
Utility in Screening: Perceived usefulness varied significantly; 44% rated signaling as important or very important for application screening, whereas 36% rated it as slightly important or not important.
Impact of Applicant Volume: Higher applicant volume was strongly associated with more favorable perceptions. Programs with larger pools reported greater perceived improvement in the process ( $r_b=0.46$ ), greater anticipated future use ( $r_b=0.54$ ), and greater perceived usefulness for screening ( $\rho=0.51$ ). In multivariable analysis, higher applicant volume remained independently associated with anticipated future use and perceived improvement.
Subspecialty Differences: Attitudes varied by subspecialty. Adult reconstruction (81% favorable) and sports medicine (77% favorable) programs reported the most positive attitudes toward signaling. In contrast, foot and ankle (16% favorable) and shoulder and elbow (14% favorable) programs reported the least favorable attitudes.
Interview Selection: Programs with higher applicant volumes were less likely to anticipate interviewing non-signaling applicants. Specifically, the odds of planning to interview non-signaling applicants decreased by 12% for every 10 additional applicants.

Significance and Claims
The authors conclude that program directors' perceptions and use of preference signaling vary substantially across orthopaedic fellowship programs. The study claims that preference signaling appears to provide the greatest perceived benefit for programs with larger applicant pools, where it may assist in identifying applicants with genuine program interest and facilitating the review of large application volumes.

The paper posits that signaling functions primarily as an adjunctive indicator of interest rather than an absolute screening criterion, as the majority of directors still plan to interview non-signaling applicants. The findings suggest that the value of signaling is driven primarily by application volume rather than subspecialty designation alone. The authors note that as familiarity with the process increases, perceptions and usage patterns may evolve. The study acknowledges limitations including potential response bias, the fact that it represents a subset of national programs, and that it evaluates perceptions rather than objective match outcomes.