Letters of Recommendation Should Not Be a Component in Residency Selection

Part II

This post continues yesterday’s. If you have not read Part I, I suggest you read it first.

Adam Cifu

There was a time when, right or wrong, there was a consensus within medicine regarding what kind of person would make a good doctor. It was believed that being a doctor meant you had to remember a great number of obscure things, and so we designed tests that heavily weighted memorization. We restricted medical school to undergraduates who excelled in biology, chemistry, and physics because doctors were also expected to be scientists. If you walk down the halls of medical schools, you can still see the photos of all the upstanding, mostly white, mostly male students who were admitted to medical school under those conditions.¹

Starting about 25 years ago, schools decided that there were new priorities, among them humanism, communication skills, and an orientation towards group performance over personal ambition. Schools also became interested in gender, racial, and ethnic diversity of their classes. Which of these or other factors you cite as being determinative probably has more to do with your politics than with data, but what is clear is that schools decided that science and test scores mattered less than other factors, although exactly what those factors are remain hard to discern and harder to measure.

Over time, unsurprisingly, this evolution moved from the admission process to the medical curriculum itself. Schools abandoned grades and rankings and adopted pass/fail coursework from which rankings could not be created. More recently, in 2020, the Federation of State Medical Boards announced that the first “step” of the United States Medical Licensing Exam would no longer generate a report of a numeric score for residency programs. During the pandemic, some schools decided that they couldn’t be expected to offer grades on clinical clerkships or admit students to academic honor societies. Explanations for this change varied: some schools curtailed rotations out of concern for student safety (although it’s notable that the state of New York graduated its students early so they could join the fight), and others indicated that racial and gender bias made the process of equitably evaluating student performance untenable.

Without taking a stand on any of these decisions, one can admit that the transition away from comparative evaluation has consequences. Medical students, like virtually everyone else, respond to incentives. If they’re graded on knowledge, they will try to know as much as possible. If we decide that doctors don’t need to memorize as much as they used to, drilling on rote memorization is a waste of their time and energy. And some of this is to the good: being able to pencil out metabolic pathways matters a lot if you’re a biochemist, but very little if you’re a primary care physician or neurosurgeon. It’s also fair to say that different kinds of doctors need very different skills, and that technological and systematic changes in what constitutes medical care have huge implications for what medical schools should be teaching and evaluating.

But changing our priorities for what students need to know and what skills they need to demonstrate is not the same thing as declaring that we’re simply not going to consistently evaluate them at all.

What else is a letter of recommendation but the apotheosis of this trend? Any significant reliance on the opinion of the author of a letter of recommendation seems to me to reflect an underlying belief on the part of the people who run medical schools and residency programs that they don’t actually know (or perhaps, on some level, aren’t willing to openly say) what makes a good medical student, and how to tell whether a medical student will make a good resident. Since they can’t or won’t tell you what they think, they’re ok with a student self-selecting three positively biased physicians to take up their flag and declare their worth to the world. Yes, yes, tell me that the letters are only one part of a “holistic evaluation,” but what really does this mean?

To me, it means that you’re ok with bias, so long as it’s your bias.

If the best we can offer our medical students is that the faculty who purport to have taught them how to be doctors promise to write a letter that describes them as among the best medical students of the last 20 years, well, given the price of medical school tuition these days, I guess I can understand why they feel owed that. But I can’t help feeling that it’s less than they deserve.

One last story: one of my other letters came from one of the smartest and bluntest professors at my school. He, too, let me read the letter, which described me as smart, passionate, and, at times, hard to get along with. I expressed concern to him about whether this letter would help me get a position in a good program, honest as it was about both my strengths and my flaws. He looked at me as strangely as the church warden and asked, “Why would you want to train at a program that doesn’t value someone like you?”

Twenty years after he asked me this question, I think it’s time for us to reckon with the answer. I don’t expect perfection of medicine, but I do expect us to acknowledge our weaknesses honestly. If I can’t expect to read a letter of recommendation that contains useful information, I’d honestly rather read none at all.

Wil Van Cleve MD MPH is a practicing anesthesiologist in the Pacific Northwest. The views expressed here reflect his personal opinions and not those of his employer.

1. Unless you are visiting one of the medical schools that pulled all those old class photos down in 2020, of course.