Standardized Letters of Recommendation in Plastic Surgery: The Impact of Gender and Race.

Background: In the last few decades, standardized letters of recommendation have seen increasing popularity among various medical specialties and have been shown to demonstrate score inflation and gender bias in some select specialties. Through analysis of standardized letter of recommendation scoring patterns, this study evaluated the impact of race and gender on performance in standardized letters of recommendation and provides suggestions for programs to optimally interpret standardized letters of recommendation and minimize bias when writing letters of recommendation.

Methods: Available standardized letters of recommendation were those from interviewed applicants to the integrated plastic surgery program between 2015 and 2018 (82 total applicants) and all applicants in the year of 2019 (241 total applicants). Various standardized letters of recommendation component scores were analyzed by demographics of both applicants and letter writers, including descriptive statistics, analysis of variance, t testing, and Fleiss kappa for interrater reliability using SPSS software (IBM, Armonk, N.Y.).

Results: No scoring category had an average score below the eighty-fifth percentile. Male letter writers scored male applicants significantly higher in Overall, Conscientiousness, Self-Initiative, and Academic Performance components, whereas female letter writers scored female applicants higher in Communication and Overall components. In the 2019 cohort, applicants of a minority race received lower scores on average in nine out of 10 categories, a difference that was significant in the Team Player category.

Conclusions: Score inflation pervades standardized letters of recommendation scoring in plastic surgery. Work must be done by letter writers to help mitigate racial and gender biases that influence recommendations for resident selection in plastic surgery.