As suggested by Rosenblatt et al, preference signal tokens (PSTs), introduced in 2021, allow dermatology applicants to indicate 3 programs they are interested in interviewing.1,2  For the 2023-2024 application cycle, the Association of Professors of Dermatology (APD) restructured dermatology signaling into a tiered format, with 3 gold and 25 silver PSTs, denoting 3 top programs and 25 of particular interest. One proposed benefit of PSTs is encouraging students to limit their applications to match their allotted PSTs, given the rising number of dermatology applicants and increasing costs of applying. While this could reduce financial and application burden, this restructuring amplifies the opacity regarding PSTs.

With 2 years of signaling data, there is limited evidence indicating how PST restructuring impacts applicants, and effectively nothing indicating how it impacts our most important stakeholders—patients. Dermatology programs each received a mean of 23 PSTs during the 2022-2023 cycle.2  Reviewing dermatology residency program survey data, 21.1% of applicants who signaled were interviewed versus 3.7% of non-signalers.3  Signals from 2021-2022 had less impact on matching; only 19% of matched applicants submitted a PST, while 22.5% of ranked applicants submitted a PST.3  Signals were inequitably distributed across programs in 2022-2023, with roughly 25% (31 of 123) of programs receiving 46% (1305 of 2836) of PSTs.2 

Dermatology programs may expect higher average numbers of PSTs and a more profound impact on likelihood-of-interview in the 2023-2024 cycle. While there are no data on whether program ranking influences quantity of PSTs received, we hypothesize that certain programs will continue to receive the bulk of PSTs. Reviewing such a large pool of applicants with PSTs may disincentivize committees from considering nonsignaling students. One dermatology program has publicized that, due to the increase in PSTs available per applicant, they will not conduct an in-depth review of applicants who do not signal their institution.4  This benefits programs with limited resources to review applications, but applicants should be aware of this before spending money on additional applications. Applicants have a huge financial stake in this process, and transparency would benefit those who cannot afford to apply so broadly.

Without guidance, applicants are analyzing their PST choices beyond just personal preference. Given the competitive nature of matching into dermatology, some may feel forced to strategize based on rank, likelihood of interview with a PST, or whether programs will even review their application without a PST. If the APD and the Association of American Medical Colleges (AAMC) continue to complicate an already confusing strategical process, patient care may be impacted. The criteria for dermatology resident selection determines who cares for future patients—whether we choose residents based on community fit, research abilities, mental aptitude, or their instinct to signal the “right” programs.

Application season is here, with little public information or transparency regarding how programs will utilize PSTs. In the absence of capacity to review applications beyond the number of PSTs programs may receive, applicants should be aware of potential ramifications prior to sending an application without a PST. The AAMC and APD should plan to utilize data from the 2023-2024 Match to hone the PST process for the coming years. This would assist applicants in limiting program lists and reduce application costs while simultaneously encouraging transparency among all stakeholders.

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Rosenblatt
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AAMC Supplemental ERAS 2022-2023 cycle: evaluation of program signaling
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Dirr
MA,
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Zakria
D,
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Dermatology match preference signaling tokens: impact and implications
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4. 
Washington University School of Medicine in St. Louis
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Divison of Dermatology: how to apply
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