Are Narrative Letters of Recommendation for Medical Students Interpreted as Intended by Orthopaedic Surgery Residency Programs?
Authors: Egan Cameron R. , Dashe Jesse , Hussein Amira I. , Tornetta Paul 
Published: February 2021

Abstract

Background
Narrative letters of recommendation are an important component of the residency application process. However, because narrative letters of recommendation are almost always positive, it is unclear whether those reviewing the letters understand the writer’s intended strength of support for a given applicant.

Questions/purposes
(1) Is the perception of letter readers for narrative letters of recommendation consistent with the intention of the letter’s author? (2) Is there inter-reviewer consistency in selection committee members’ perceptions of the narrative letters of recommendation?

Methods
Letter writers who wrote two or more narrative letters of recommendation for applicants to one university-based orthopaedic residency program for the 2014 to 2015 application cycle were sent a survey linked to a specific letter of recommendation they authored to assess the intended meaning regarding the strength of an applicant. A total of 247 unstructured letters of recommendation and accompanying surveys were sent to their authors, and 157 surveys were returned and form the basis of this study (response percentage 64%). The seven core members of the admissions committee (of 22 total reviewers) at a university-based residency program were sent a similar survey regarding their perception of the letter. To answer our research question about whether letter readers’ perceptions about a candidate were consistent with the letter writer’s intention, we used kappa values to determine agreement for survey questions involving discrete variables and Spearman correlation coefficients (SCCs) to determine agreement for survey questions involving continuous variables. To answer our research question regarding inter-reviewer consistency among the seven faculty members, we compared the letter readers’ responses to each survey question using intraclass correlation coefficients (ICCs).

Results
There was a negligible to moderate correlation between the intended and perceived strength of the letters (SCC 0.26 to 0.57), with only one of seven letter readers scoring in the moderate correlation category. When stratifying the applicants into thirds, there was only slight agreement (kappa 0.07 to 0.19) between the writers and reviewers. There were similarly low kappa values for agreement about how the writers and readers felt regarding the candidate matching into their program (kappa 0.14 to 0.30). The ICC for each question among the seven faculty reviewers ranged from poor to moderate (ICC 0.42 to 0.52).

Conclusion
Our results demonstrate that the reader’s perception of narrative letters of recommendation did not correlate well with the letter writer’s intended meaning and was not consistent between letter readers at a single university-based urban orthopaedic surgery residency program.

Clinical Relevance
Given the low correlation between the intended strength of the letter writers and the perceived strength of those letters, we believe that other options such as a slider bar or agreed-upon wording as is used in many dean’s letters may be helpful.