What Are We REALLY Looking for in a Letter of Recommendation?

Objectives: The letter of recommendation (LOR) is an important component of a residency application. There is great subjectivity in the interpretation of a letter writer's narrative and many residencies have moved toward standardized LORs (sLOR). We aimed to scrutinize the importance afforded to specific content and applicant attributes in an LOR in hopes of decoding this time-honored process.

Design: A 35-question survey comprised of nonidentifying general questions, and participant evaluation of applicant characteristics and LOR phrases were administered (cross-sectional design). Evaluations were scored both objectively on a 10-point Likert scale and subjectively using a relative ranking.

Setting: Academic, tertiary care center with a large general surgery residency program (Mayo Clinic, Rochester, MN).

Participants: Surgery attendings and general surgery residents (n = 122).

Results: Seventy-two attendings and 50 general surgery residents completed the survey. Faculty ranked strong work ethic/hard working (median rank = 1) and inquisitive/hungry learner (median rank = 3) as the top 2 attributes. "We will plan to recruit this candidate" (median rank = 1.5) and "I give my highest recommendation" (median rank = 2) were the top 2 phrases. Residents valued strong work ethic and collaborative/team player as the top 2 applicant attributes. Seventy-three percent of attendings and 82% of residents agreed that LOR allows the applicant pool to be divided into upper and lower halves. Only 17% of faculty and 18% of residents agreed that an LOR allowed candidate stratification into quartiles.

Conclusions: Elaborating the most favorable applicant characteristics and highly regarded content in an LOR will help truly exceptional candidates obtain letters that make them stand out in the eyes of their evaluators. Since LORs are mostly considered to be able to stratify only upper and lower halves of the applicant pool, it is imperative to move toward LORs which portray superior applicant qualities, and can provide more objective evaluation of a candidate.