The recent article by Siddiqi et al provides an early look at family medicine’s first year of program signaling while also revealing deeper structural challenges within the specialty.1 Although the study was limited by a small sample, the findings reflect widespread concerns: unclear guidance for applicants, inconsistent program use of signals, and potential equity disadvantages for international medical graduates (IMGs) compared with US MD applicants who effectively receive a home program signal.
Family medicine has experienced worsening match outcomes, which we believe could improve with clearer signaling guidance for both applicants and programs. In recent matches, approximately 35% of family medicine programs in 2025 and 41% in 2026 entered the Supplemental Offer and Acceptance Program (SOAP), with 15%–16% of all family medicine positions filled through SOAP in each year.2,3 These trends underscore the need for reform. A central issue is that many family medicine programs appear not to incorporate signals as intended into early holistic review, instead relying on long-standing selection practices.4
At the same time, family medicine applicants apply very broadly, averaging 42 applications,5 far above what is necessary to achieve a high likelihood of matching because 8 to 10 contiguous ranks confer a greater than 95% match probability.6 Other specialties have addressed this inefficiency through preference signaling, including tiered systems. Internal medicine, for example, uses three gold and 12 silver signals, enabling applicants to distinguish top choices from strong secondary interest. Despite offering more than twice as many residency positions as family medicine (11,750 in 2025 and 11,632 in 2026), internal medicine achieved substantially higher fill rates (96.8% and 95.2%) compared with family medicine (85% and 83.6%) in those years.2,3 This contrast suggests that a higher-volume, tiered signaling model may better support match efficiency.
Signal concentration further limits family medicine’s current system. Data from the Electronic Residency Application Service show that 10% of family medicine programs received 32% of all signals.7 A single-tier, low-volume approach amplifies clustering, reducing the utility of signals for many programs and disadvantaging applicants without structural advantages.
We propose that family medicine adopt a moderate-volume, two-tier signaling model: two gold and eight silver signals, for a total of 10. This approach could reduce clustering, better identify sincere interest, and promote equity, particularly for IMGs, by expanding signal availability and allowing applicants to differentiate preferences. Ten signals more closely reflect the number of programs with which most family medicine applicants realistically hope to interview, potentially reducing financial and educational burden.
To guide implementation, we recommend a Council of Academic Family Medicine Educational Research Alliance study assessing program directors’ use of signals, changes since early adoption, and receptivity to tiered signaling. Parallel surveys of applicants and advisors are also needed.
We commend the American Academy of Family Physicians Residency Selection Improvement Initiative and urge consideration of tiered signaling as this work continues.8 Tiered signals represent a pragmatic, equity-focused step toward improved alignment, reduced inefficiency, and stronger match performance.
It is time for family medicine to go for the gold.
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