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Dear Program Director: Deciphering Letters of Recommendation. J Grad Med Educ 2018 Jun;10(3):261-266



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Pubmed Central ID




Scopus ID

2-s2.0-85053031688   8 Citations


Background : Letters of recommendation (LORs) are an important part of applications for residency and fellowship programs. Despite anecdotal use of a "code" in LORs, research on program director (PD) perceptions of the value of these documents is sparse.

Objective : We analyzed PD interpretations of LOR components and discriminated between perceived levels of applicant recommendations.

Methods : We conducted a cross-sectional, descriptive study of pediatrics residency and fellowship PDs. We developed a survey asking PDs to rate 3 aspects of LORs: 13 letter features, 10 applicant abilities, and 11 commonly used phrases, using a 5-point Likert scale. The 11 phrases were grouped using principal component analysis. Mean scores of components were analyzed with repeated-measures analysis of variance. Median Likert score differences between groups were analyzed with Mann-Whitney U tests.

Results : Our survey had a 43% response rate (468 of 1079). "I give my highest recommendation" was rated the most positive phrase, while "showed improvement" was rated the most negative. Principal component analysis generated 3 groups of phrases with moderate to strong correlation with each other. The mean Likert score for each group from the PD rating was calculated. Positive phrases had a mean (SD) of 4.4 (0.4), neutral phrases 3.4 (0.5), and negative phrases 2.6 (0.6). There was a significant difference among all 3 pairs of mean scores (all P < .001).

Conclusions : Commonly used phrases in LORs were interpreted consistently by PDs and influenced their impressions of candidates. Key elements of LORs include distinct phrases depicting different degrees of endorsement.

Author List

Saudek K, Saudek D, Treat R, Bartz P, Weigert R, Weisgerber M


Peter J. Bartz MD Professor in the Pediatrics department at Medical College of Wisconsin
David Saudek MD Associate Professor in the Pediatrics department at Medical College of Wisconsin
Robert W. Treat PhD Associate Professor in the Academic Affairs department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Cross-Sectional Studies
Education, Medical, Graduate
Fellowships and Scholarships
Internship and Residency
Personnel Selection
Physician Executives
School Admission Criteria
jenkins-FCD Prod-482 91ad8a360b6da540234915ea01ff80e38bfdb40a