Are Narrative Letters of Recommendation for Medical Students Interpreted as Intended by Orthopaedic Surgery Residency Programs?

Do Program Directors of Anesthesiology Residency Programs Interpret Narrative Letters of Recommendation as Intended?

Background Letters of recommendation (LORs) are an important part of the application process for medical residency programs with most specialties preferring a narrative format. Given the inherent subjectivity of narrative LORs, the current study sought to determine whether the intended messages of narrative LORs written for applicants to anesthesiology residency programs are accurately interpreted by readers. Methodology Anonymous online surveys were sent via the Qualtrics platform to program directors (PDs) of the Accreditation Council for Graduate Medical Education-accredited anesthesiology residency programs in the Mid-Atlantic region as designated by the Electronic Residency Application Service, which consists of the states of New York, Pennsylvania, and New Jersey. Each PD participant received five surveys, each of which was attached to a de-identified LOR that was written by another PD located at an institution in the same region. Both the letter writer and study participants were asked to score LORs on a Likert-like scale. Participants were additionally asked whether the LORs, if received, would influence their decision to either offer an interview to the applicant or to rank the applicant. Finally, participants were asked to note any specific words or phrases within the LORs that they found to be particularly impactful. Results Overall, 10 of 34, 29.41%, PDs responded to the survey. There was a high correlation between the LOR intent and the respondents' assigned rating (Spearman's rho = 0.7973, p < 0.001). Responses were more accurate for "outstanding and excellent" LORs compared to the lower three categories. Results were unaffected after adjusting for respondents' years of experience as PDs. Additionally, 71.6% indicated that the LORs would influence the decision about offering an interview, and 56.5% stated that the LORs would influence a ranking decision. Conclusions Our results indicate that respondents' perception of LORs correlated strongly with the intent of the writer. Additionally, respondents seemed to value LORs for interview and ranking decisions.

Factors Influencing Medical Interns' Choice of Hospital for Training, Saudi Arabia: A Cross-Sectional Study

Background High-quality, adequately resourced, and strategically oriented medical internship training plays a pivotal role in the continual growth of junior doctors. Evaluating the perspectives of final-year medical students regarding their internship year and their preferred placement is of paramount importance. This study aims to furnish internship programs with valuable insights into interns' perceptions and attitudes toward an optimal internship experience. By doing so, we aim to empower internship programs with the necessary knowledge to enhance their offerings, ensuring they are better tailored to the needs and preparation of future doctors. Objective The objective of this study was to elucidate the primary factors that influence the preferences of medical interns in selecting a hospital for their internship training. Methods In the academic year spanning September 2023 to 2024, a comprehensive cross-sectional study was conducted at three esteemed medical universities in Riyadh, Saudi Arabia. A meticulously crafted questionnaire, consisting of twenty questions was disseminated via various social media platforms, targeting all final-year medical students of the selected medical schools. Overall 241 students actively participated in the survey, their valuable contributions enriching the overall quality and depth of the research findings. Results Among the 241 respondents, 67.22% were male, 83.40% identified as Saudi, and 43.57% hailed from King Saud bin Abdulaziz University for Health Sciences (KSAU-HS). A predominant 94.61% of participants fell within the age group of 22-25 years. Notably, the top four influential factors influencing participants' choice of internship training programs were encouraging consultants (93.80%), the hospital working environment (91.29%), an internship program with effective teamwork (88.38%), and a subspecialty residency program (85.48%). Furthermore, our findings underscored that access to electronic health record (EHR) systems, orientation prior to clinical rotations, and seniors' experiences significantly impact students' decisions when selecting a hospital for rotations. It was also observed that considerations such as the number of on-calls and working hours, salary, location, and extracurricular activities wield a substantial influence over their choices, as indicated by the majority of the surveyed students. Conclusion Given that internship training is one of the most critical stages of medical education, it is recommended to take into account the elements that students believe can influence their hospital choice for conducting their internship. We hope that by acknowledging these aspects, potential approaches to improve and advance hospital training can be formulated in order to provide interns with effective training, a reasonable workload, and a conducive and supportive environment to work in.

The Utility of the Standardized Letter of Recommendation for Orthopedic Surgery Residency Applicants: A Systematic Review

Despite widespread adoption for evaluating residency candidates, few studies have evaluated the orthopedic standardized letter of recommendation (SLOR). A systematic review using PubMed, Embase, and Web of Science was performed in June 2022. Study design and results from SLOR investigations were compiled. Common outcomes studied were summative rank statement scores and SLOR individual domains. Applicants were rated ranked to match or in the top one-third of rank lists in non-normally distributed frequencies. The association of summative rank statement score with match outcome was rarely studied. Applicants' ratings skew positively, the utility is reportedly limited, and influence on match outcome has been inadequately studied. [Orthopedics. 2024;47(1):e1-e5.].

Which Application Factors Are Associated With Outstanding Performance in Orthopaedic Surgery Residency?

BACKGROUND

Identifying ideal candidates for orthopaedic surgery residency is difficult. Data available for applicant selection are evolving; preclinical grades and the Alpha Omega Alpha (AOA) honors society are being phased out at some medical schools. Similarly, three-digit United States Medical Licensing Examination (USMLE) Step 1 scores have been eliminated. There is renewed interest in improving resident selection to provide a diverse, comprehensive educational opportunity that produces orthopaedic surgeons who are prepared for practice.

QUESTIONS/PURPOSES

We sought to identify whether (1) academic achievements, (2) letters of recommendation, (3) research activity, and (4) miscellaneous factors available on Electronic Residency Application Service (ERAS) applications were associated with outstanding residency performance.

METHODS

Ten faculty members (22% of all full-time faculty) with extensive educational involvement for at least 7 years, whose expertise covered all subspecialty departments at an urban, academic orthopaedic surgery residency program, were given an anonymous survey on the performance of the four most recent classes of residency graduates (24 residents). This survey was developed due to the lack of a validated residency outcomes tool or objective metrics for residency performance. The evaluated criteria were decided upon after discussion by a relatively large group of academic orthopaedic surgeons considering the factors most important for graduating orthopaedic residents. The faculty were selected based on their long-term knowledge of the residency, along with their diversity of specialty and backgrounds; there were no nonresponders. Faculty graded each resident on a scale from 1 to 10 (higher is better) on six criteria: surgical technical skills, research productivity, clinical knowledge, professionalism, personality, and fellowship match. The mean of the faculty ratings made by all faculty for all six criteria was calculated, producing the overall residency performance score. Factors available on each resident's ERAS application were then correlated with their overall residency performance score. Categorical ERAS factors, including AOA status, five or more honors in core clerkships, at least three exceptional letters of recommendation, collegiate athletics participation, expertise with a musical instrument, and research (6-year) track residents, were correlated with overall residency performance score via point biserial analysis. Continuous ERAS factors including USMLE Step 1 and Step 2 scores, number of publications before residency, number of research years before residency, medical school ranking, and number of volunteer experiences were correlated with overall residency performance score via Pearson correlation. USMLE Step 1 three-digit scores were evaluated despite their recent elimination because of their historic importance as a screening tool for residency interviews and for comparison to USMLE Step 2, which retains a three-digit score. Application factors with a p < 0.2 on univariate analysis (five or more honors in core clerkships, at least three exceptional letters of recommendation, research track residents) were included in a stepwise linear regression model with "overall residency performance score" as the outcome variable. All p values < 0.05 were considered significant.

RESULTS

The mean overall residency performance score was 7.9 ± 1.2. Applicants with at least five honors grades in core clerkships had overall residency performance scores 1.2 points greater than those of their peers (95% confidence interval (CI) 0.3 to 2.0; p = 0.01, Cohen ƒ 2 = 0.2, representing a small effect size). ERAS applications including at least three exceptional letters of recommendation were associated with a 0.9-point increase in residency performance (95% CI 0.02 to 1.7; p = 0.046, Cohen ƒ 2 = 0.1, representing a small effect size). Participation in the residency research (6-year) track was associated with a 1-point improvement in residency performance (95% CI 0.1 to 1.9; p = 0.03, Cohen ƒ 2 = 0.2, again, representing a small effect size). Together, these three factors accounted for 53% of the variance in overall residency performance score observed in this study.

CONCLUSION

Past clinical excellence, measured by core clerkship grades and exceptional letters of recommendation, is associated with slightly improved overall orthopaedic residency performance scores. Applicants meeting both criteria who also complete a research track residency may perform substantially better in residency than their counterparts, as these three factors accounted for half of all the variance observed in the current study. Although minimum requirements are necessary, traditionally used screening factors (such as USMLE scores, AOA status, medical school rank, and number of publications) may be of less utility in identifying successful future residents than previously thought.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Orthopaedic surgery residency match trends during COVID-19 pandemic: a cross-sectional study

Orthopaedic surgery is one of the more competitive specialties for medical students to pursue. Students often complete subinternship rotations to demonstrate skill, work ethic, and fit within a program. Away rotations were suspended during the COVID-19 pandemic.