Match Program Signaling in Pain Medicine Fellowship Applications: Association with Interview Outcomes and Implications for a Shrinking Applicant Pipeline.

Abstract

Pain Medicine fellowship programs have reported increasing numbers of unfilled positions in recent match cycles, accompanied by a growing perception that the applicant pipeline is shrinking. In response to concerns regarding application volume and applicant-program fit, the Electronic Residency Application Service® (ERAS) introduced program signaling for the Pain Medicine fellowship in the 2024-2025 application cycle. Of note, Pain Medicine was the first fellowship across all medical specialties to utilize signaling, with further plans by ERAS to expand access to signaling to other fellowships in the future. However, the effectiveness of this intervention in the context of fewer applications to the field remains unclear.To evaluate the association between ERAS program signaling and interview invitation rates in Pain Medicine fellowship applications, and to contextualize signaling outcomes alongside longitudinal National Resident Matching Program® (NRMP) match trends and unfilled positions.Our study integrated data from 3 sources: NRMP Specialties Matching Service reports (2019-2025), Association of American Medical Colleges ERAS signaling dashboards (2024-2025), and a post match survey distributed to all 442 applicants in the 2025 cycle. Primary outcomes included interview invitation rates by signal status and applicant type (MD, DO, international medical graduate [IMG]). Secondary outcomes included match rates at signaled vs nonsignaled programs and applicant perceptions of signaling.Cross-sectional.Sixty-five applicants responded (14.7% response rate), 86.1% matched. Applicants utilized a mean of 4.6 of the 5 available signals. Interview invitation rates were substantially higher for signaled applications than for nonsignaled applications across all applicant types. Among applicants who sent signals, interview rates were 70.3% for MDs, 58.3% for DOs, and 34.1% for IMGs, compared with 39.7%, 32.3%, and 18.0%, respectively, among nonsignaled applications. The signal-associated increase in interview rate was greatest for MD applicants (30.6 percentage points), followed by DOs (26.0 percentage points) and IMGs (16.1 percentage points). Of matched respondents, 70.7% matched at a program they had signaled. Applicant perceptions of signaling were mixed, with 64.1% reporting it as useful and 35.9% reporting it as useless.Program signaling is strongly associated with increased interview invitation rates in Pain Medicine fellowship applications and appears to improve applicant-program alignment, particularly for MD applicants. However, the differential benefits across applicant types raise equity concerns, and signaling cannot address the fundamental workforce changes driving a reduced applicant pool. Sustainable recruitment strategies must extend beyond match optimization to address the structural factors underlying declining interest in Pain Medicine fellowships.

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