Does the experience of the writer affect the evaluative components on the standardized letter of recommendation in emergency medicine?

Assessing Individual Competency Differences Between Third- and Fourth-Year Medical Students Using the National Clinical Assessment Tool for Medical Students in the Emergency Department

Medical students rotating through emergency departments as part of their clinical education are typically evaluated using an on-shift evaluation tool. The National Clinical Assessment Tool for Medical Students in the Emergency Department (NCAT-EM) is the current standard of evaluation for medical students in the emergency department, regardless of level of training. This study aims to evaluate whether the NCAT-EM can detect differences in skill levels between third-year medical students (MS3s) and fourth-year medical students (MS4s) rotating at a level 1 trauma center and teaching institution. These authors hypothesized that MS4s should outperform MS3s across all assessment domains given their additional training. A total of 930 performance evaluations were gathered for MS3 and MS4 rotating between May 2022 and June 2023. There were 321 evaluations of MS3s and 609 evaluations of MS4s. Across the six assessment domains, MS4s had statistically significant higher performances in two domains - namely emergency recognition and management (fully entrustable: 37.4% vs. 23.8% (p = 0.03)) and communication (fully entrustable: 46.2% vs. 33.6% (p = 0.03)). These findings indicate that the use of the NCAT-EM at this institution reliably differentiated between MS3s and MS4s in these two assessment domains. There were trends suggesting MS4s outperform MS3s in the other four domains, which did not rise to the level of statistical significance, but are consistent with prior validation studies of the NCAT.

Confidence of Faculty in Writing Letters of Recommendation for Pediatric Fellowship Applicants

BACKGROUND

The assessment of pediatric residents applying to subspecialty fellowship programs relies on faculty letters of recommendation (LOR). However, it is unclear if pediatric faculty are confident that their LOR are effective.

OBJECTIVE

This study aims to assess the confidence of pediatric faculty in writing an effective LOR for pediatric residents applying to subspecialty fellowship programs.

METHODS

Survey development was conducted using evidence-based best practices. Surveys were distributed via email in 2021 to all full-time pediatric faculty members who taught pediatric residents in a large academic medical center. Categorical values were compared by chi-square test.

RESULTS

Eighty-five out of 150 (57%) faculty members completed the survey. Forty-one percent of participants were very confident that their LOR provided adequate content to assess residents during the application process. Confidence was associated with higher academic rank (p=0.02), frequent contact with residents (p=0.01), and writing >2 LOR in the last five years (p=0.0002). Confident LOR writers were more likely to describe their own background, details about the resident's scholarly activity, and the resident's ability to work as part of a team. Thirty-five percent of respondents reported never considering gender bias when writing LOR, whereas 28% reported always considering gender bias. Eighty-seven percent of respondents reported an interest in receiving LOR writing guidelines.

CONCLUSION

Half of the faculty respondents were not very confident in their ability to write an effective LOR for pediatric residents applying for a fellowship. Faculty development and standardized instructions on writing effective LOR may be helpful both at the institutional and national levels, including the importance of considering gender bias when writing LOR.

Standardized Letter of Recommendation: Can Everyone Be Awesome?

OBJECTIVE

Standardized letters of recommendation (SLOR) are hypothesized to decrease bias and provide consistent domains for evaluation. However, their ability to differentiate among applicants is unknown. The utilization and functionality of SLOR and the impact of SLOR domain rating on matching for colon and rectal surgery (CRS) residency applicants have yet to be assessed.

DESIGN

Descriptive statistics and bivariate analysis were employed. Applicants were categorized into 3 groups; Top-tier(TT): applicants rated 100% Excellent/Very Good; Mid-Tier(MT) applicants rated 80-99% Excellent/Very Good; and Non-Top Tier(NTT) applicants rated <80% Excellent/Very Good.

SETTING

University of Hospitals Cleveland Medical Center.

PARTICIPANTS

SLORs submitted to a single colorectal surgery residency in 2019 were analyzed RESULTS: A total of 101 applicants were included, 54 (53.5%) of the applicants were male. 75 (74.2%) applicants who applied to our residency matched into a CRS residency, compared to the national rate of 66%. Of the 101 applicants with SLOR, 54 (53.5%) were categorized as TT, 26 (25.7%) as MT, and 21(20.8%) as NTT. The univariable analysis demonstrated a statistically significant difference in research experience (p=0.029) and match status (p=0.01) between applicant tiers. There were no statistically significant differences between applicant-tier and demographics, foreign medical graduates (FMG), H-indices, ABSITE scores, type of residency, preliminary year, completing an unaccredited CRS, and applicants with an additional degree. On multivariable analysis age (OR=0.65; CI=0.48-0.87) and FMG applicants (OR=0.05; CI=0.01-0.44) were inversely associated with successfully matching. Compared to TT applicants, MT (OR=0.07; CI=0.01-0.57) and NTT (OR=0.04; CI=0.01-0.34) applicants were inversely associated with a successful match. Individuals who completed research prior to residency but after medical school was associated with successfully matching (p=0.009).

CONCLUSIONS

The presence of MT and NTT ratings is associated with failure to match and may represent an area of concern for CRS programs rather than a tool to discern differences between candidates.

An Examination of Standardized Letters of Recommendation Rating Scales Among Neurosurgical Residency Candidates During the 2020-2021 Application Cycle

BACKGROUND

Letters of recommendation (LORs) are historically an important, though subjective, component of the neurosurgery residency application process. Standardized LORs (SLORs) were introduced during the 2020 to 2021 application cycle. The intent of SLORs is to allow objective comparison of applicants and to reduce bias.

OBJECTIVE

To examine the utility of SLORs during this application cycle. We hypothesized that "grade inflation" and poor inter-rater reliability, as described by other specialties using SLORs, would limit the utility of SLORs in their current form.

METHODS

This cross-sectional study analyzed all SLORs submitted to a single neurosurgery residency program over the 2020 to 2021 cycle. Data from 7 competency domains and the overall rating were recorded and stratified by academic category of letter writer. Inter-rater reliability was evaluated using Krippendorff's alpha.

RESULTS

One or more SLORs was submitted as part of 298 of 393 applications (76%). Approximately 58.3% of letters written by neurosurgery chairpersons rated a given applicant as being within the top 5% across all competencies. Approximately 44.4% of program director letters similarly rated applicants as amongst the top 5%, while 73.2% and 81.4% of letters by other neurosurgeons and general surgery evaluators, respectively, rated applicants in the top 5%. Inter-rater reliability was poor (<0.33) in all rating categories, including overall (α = 0.18).

CONCLUSION

The utility of the first iteration of SLORs in neurosurgery applications is undermined by significant "grade inflation" and poor inter-rater reliability. Improvements are necessary for SLORs if they are to provide meaningful information in future application cycles.

Characterization of the 2019 Micrographic Surgery and Dermatologic Oncology Standardized Letter of Recommendation

BACKGROUND

Traditional letters of recommendation used for postgraduate medical training applications have multiple limitations, including a lack of clarity, inflated and overly flattering assessments, and low reliability between interpreting faculty. A micrographic surgery and dermatologic oncology (MSDO) standardized letter of recommendation (SLOR) was created to improve the efficiency, validity, and stratification of applicants to dermatology fellowship training programs.

OBJECTIVE

To analyze the MSDO SLOR for trends in grading based on letter-writer and applicant characteristics and to evaluate its ability to demonstrate differences between applicants.

METHODS

Standardized letter of recommendations received by 4 fellowship programs from the 2019 San Francisco Match application cycle were reviewed retrospectively.

RESULTS

Two hundred forty-nine SLORs were analyzed from 140 applicants. Grade inflation and limited variability in scores were evident. Higher scores correlated with the length of the relationships between letter-writers and applicants and with female letter-writer gender. There was no applicant gender or ethnicity bias detected.

CONCLUSION

Despite score inflation, the MSDO SLOR allows for differentiation between fellowship applicants. Future studies are needed to further evaluate the reliability of the SLOR and find ways to improve its content.

Validity Evidence for the Emergency Medicine Standardized Letter of Evaluation

BACKGROUND

The standardized letter of evaluation (SLOE) is the application component that program directors value most when evaluating candidates to interview and rank for emergency medicine (EM) residency. Given its successful implementation, other specialties, including otolaryngology, dermatology, and orthopedics, have adopted similar SLOEs of their own, and more specialties are considering creating one. Unfortunately, for such a significant assessment tool, no study to date has comprehensively examined the validity evidence for the EM SLOE.

OBJECTIVE

We summarized the published evidence for validity for the EM SLOE using Messick's framework for validity evidence.

METHODS

A scoping review of the validity evidence of the EM SLOE was performed in 2020. A scoping review was chosen to identify gaps and future directions, and because the heterogeneity of the literature makes a systematic review difficult. Included articles were assigned to an aspect of Messick's framework and determined to provide evidence for or against validity.

RESULTS

There have been 22 articles published relating to validity evidence for the EM SLOE. There is evidence for content validity; however, there is a lack of evidence for internal structure, relation to other variables, and consequences. Additionally, the literature regarding response process demonstrates evidence against validity.

CONCLUSIONS

Overall, there is little published evidence in support of validity for the EM SLOE. Stakeholders need to consider changing the ranking system, improving standardization of clerkships, and further studying relation to other variables to improve validity. This will be important across GME as more specialties adopt a standardized letter.

More Than One-third of Orthopaedic Applicants Are in the Top 10%: The Standardized Letter of Recommendation and Evaluation of Orthopaedic Resident Applicants

BACKGROUND

The American Orthopaedic Association (AOA) released the standardized letter of recommendation (SLOR) form to provide standardized information to evaluators of orthopaedic residency applicants. The SLOR associates numerical data to an applicant's letter of recommendation. However, it remains unclear whether the new letter form effectively distinguishes among orthopaedic applicants, for whom letters are perceived to suffer from "grade inflation." In addition, it is unknown whether letters from more experienced faculty members differ in important ways from those written by less experienced faculty.

QUESTIONS/PURPOSES

(1) What proportion of SLOR recipients were rated in the top 10th percentile and top one-third of the applicant pool? (2) Did letters from program leaders (program directors and department chairs) demonstrate lower aggregate SLOR scores compared with letters written by other faculty members? (3) Did letters from away rotation program leaders demonstrate lower aggregate SLOR scores compared with letters written by faculty at the applicant's home institution?

METHODS

This was a retrospective, single institution study examining 559 applications from the 2018 orthopaedic match. Inclusion criteria were all applications submitted to this residency. Exclusion criteria included all letters without an associated SLOR. In all, 1852 letters were received; of these, 26% (476) were excluded, and 74% (1376) were analyzed for SLOR data. We excluded 12% (169 of 1376) of letters that did not include a final summative score. Program leaders were defined as orthopaedic chairs and program directors. Away rotation letters were defined as letters written by faculty during an applicant's away rotation. Our study questions were answered accounting for each subcategory on the SLOR (scale 1-10) and the final ranking (scale 1-5) to form an aggregated score from the SLOR form for each letter. All SLOR questions were included in the creation of these scores. Correlations between program leaders and other faculty letter writers were assessed using a chi-square test. We considered a 1-point difference on 5-point scales to be a clinically important difference and a 2-point difference on 10-point scales to be clinically important.

RESULTS

We found that 36% (437 of 1207) of the letters we reviewed indicated the candidate was in the top 10th percentile of all applicants evaluated, and 51% (619 of 1207) of the letters we reviewed indicated the candidate was in the top one-third of all applicants evaluated. We found no clinically important difference between program leaders and other faculty members in terms of summative scores on the SLOR (1.9 ± 0.7 versus 1.7 ± 0.7, mean difference -0.2 [95% CI -0.3 to 0.1]; p < 0.001). We also found no clinically important difference between home program letter writers and away program letter writers in terms of the mean summative scores (1.9 ± 0.7 versus 1.7 ± 0.7, mean difference 0.2; p < 0.001).

CONCLUSION

In light of these discoveries, programs should examine the data obtained from SLOR forms carefully. SLOR scores skew very positively, which may benefit weaker applicants and harm stronger applicants. Program leaders give summative scores that do not differ substantially from junior faculty, suggesting there is no important difference in grade inflation between these faculty types, and as such, there is no strong need to adjust scores by faculty level. Likewise, away rotation letter writers' summative scores were not substantially different from those of home institution letters writers, indicating that there is no need to adjust scores between these groups either. Based on these findings, we should interpret letters with the understanding that overall there is substantial grade inflation. However, while weight used to be given to letters written by senior faculty members and those obtained on away rotations, we should now examine them equally, rather than trying to adjust them for overly high or low scores.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Reference letters for subspecialty medicine residency positions: are they valuable for decision-making? Results from a Canadian study

BACKGROUND

The letter of recommendation is currently an integral part of applicant selection for residency programs. Internal medicine residents will spend much time and expense completing sub-specialty away electives to obtain a letter of recommendation. The purpose of this study was 1) to examine a large sample of reference letters in order to define essential components of a high-quality letter, and 2) to elucidate the relationship between quality of reference letter and the letter writer.

METHODS

We conducted a two-phase study. In phase one, a large sample of letters of recommendation was examined using an audit tool as a coding framework. A 5-point composite endpoint of high-quality letter components was subsequently developed. In phase two, program director letters were compared to non-program director home institution and non-home institution elective letters based on inclusion of components of the 5-point composite endpoint using Chi square testing.

RESULTS

715 letters were examined (398 non-program director home institution letters, 201 program director letters, and 116 non-home institution elective letters). High-quality letter components were: nature of relationship, duration of relationship, In Training Evaluation Report information, research involvement and comments on areas for improvement. Program director letters had a significantly higher proportion (10.4%) of all 5 high-quality components, compared to 0% in both non-program director home institution letters and elective letters (p < 0.001). A significantly higher proportion of program director letters had 4-5 high-quality components (62.5%) compared to 2% of non-program director home institution letters and 0% of elective letters (p < 0.0001).

CONCLUSIONS

Letters of recommendation from elective rotations are of the poorest quality and such rotations should not be pursued for the sole purpose of obtaining a letter. The low quality of elective letters leads to the recommendation that writers should decline to write them, programs should not require them and trainees should not request them. Program directors write the highest quality letters and should be a resource for faculty development. Clinical supervisors can use the 5-point composite endpoint as a guide when writing letters for applicants.

Evaluating the Standardized Letter of Recommendation Form in Applicants to Orthopaedic Surgery Residency

INTRODUCTION

A standardized letter of recommendation (SLOR) form for orthopaedic surgery residency programs has recently been adopted for use, but it has not been scientifically evaluated. The purpose of this study is to investigate the usefulness of the SLOR form in the selection process.

METHODS

All SLOR forms submitted to our institution over a single application cycle were extracted and analyzed. The United States Medical Licensing Examination Step 1 scores, grades in clinical rotations, Alpha Omega Alpha status, and the number of publications were recorded for each applicant. Correlations were calculated with Spearman rho, and inter-rater reliability was evaluated by calculating intraclass correlation coefficients.

RESULTS

One thousand one hundred thirty-seven SLOR forms were analyzed for 513 applicants. There was substantial rank inflation with the SLOR form; the majority (92%) of applicants were rated as either ranked to match or in the top one-third of their rank list. Objective applicant factors such as grades and Step 1 scores demonstrated a very weak to nonexistent correlation with the summative rank (rho 0.07 to 0.13, P ≤ 0.012). Poor inter-rater reliability was observed with the intraclass correlation coefficient ranging from 0.22 to 0.33 (P < 0.001).

CONCLUSIONS

The usefulness of the SLOR form is limited by the very high ratings observed for all questions, and in particular, the final summative rank. Measures to reduce rank inflation must be implemented to improve the discriminant ability of the SLOR form, and if this cannot be accomplished, perhaps the form should be abandoned.

LEVEL OF EVIDENCE

Level III Retrospective.

The AAMC Standardized Video Interview and the Electronic Standardized Letter of Evaluation in Emergency Medicine: A Comparison of Performance Characteristics

PURPOSE

To compare the performance characteristics of the electronic Standardized Letter of Evaluation (eSLOE), a widely used structured assessment of emergency medicine (EM) residency applicants, and the Association of American Medical Colleges (AAMC) Standardized Video Interview (SVI), a new tool designed by the AAMC to assess interpersonal and communication skills and professionalism knowledge.

METHOD

The authors matched EM residency applicants with valid SVI total scores and completed eSLOEs in the 2018 Match application cycle. They examined correlations and group differences for both tools, United States Medical Licensing Examination (USMLE) Step exam scores, and honor society memberships.

RESULTS

The matched sample included 2,884 applicants. SVI score and eSLOE global assessment ratings demonstrated small positive correlations approaching r = 0.20. eSLOE ratings had higher correlations with measures of academic ability (USMLE scores, academic honor society membership) than did SVI scores. Group differences were minimal for the SVI, with scores slightly favoring women (d = -0.21) and US-MD applicants (d = 0.23-0.42). Group differences in eSLOE ratings were small, favoring women over men (approaching d = -0.20) and white applicants over black applicants (approaching d = 0.40).

CONCLUSIONS

Small positive correlations between SVI score and eSLOE global assessment ratings, alongside varying correlations with academic ability indicators, suggest these are complementary tools. Findings suggest the eSLOE is subject to similar sources and degrees of bias as other common assessments; these group differences were not observed with the SVI. Further examination of both tools is necessary to understand their ability to predict clinical performance.

Letters of Recommendation

Letters of recommendation (LORs) are a central element of an applicant's portfolio for the National Resident Matching Program (known as the "Match"). This is especially true when applying to competitive specialties like emergency medicine (EM). LORs convey an applicant's potential for success, and also highlight an applicant's qualities that cannot always be recognized from a curriculum vitae, test scores, or grades. Traditional LORs, also called narrative LORs, are written in prose and are therefore highly subjective. This led to the establishment of a task force by the Council of Emergency Medicine Residency Directors in 1995 to develop a standardized LOR. Revisions of this form are now referred to as a standardized letter of evaluation. These evaluations in this format have proven to increase inter-rater reliability, decrease interpretation time, and standardize the process used by EM faculty to prepare evaluations for EM applicants. In this article, we will discuss LORs; address applicants' concerns, including from whom to request LORs (EM faculty vs. non-EM faculty vs. non-clinical faculty), number of LORs an applicant should include in his or her application materials, the preferred manner of requesting and the timing in which to ask for an LOR, as well as the philosophy behind waiving the right to see the letter.

Use of Standard Guidelines for Department of Medicine Summary Letters

Phenomenon: Fourth-year medical students obtain Department of Medicine (DOM) letters ("Chair" letters) to support their residency applications. Writing and interpreting DOM letters are challenging. There is heterogeneity in the letters that makes it difficult to both write and read these letters.

APPROACH

The purpose of this study is to determine the value of new guidelines developed by a task force of clerkship directors and program directors in internal medicine and assess the implementation of these guidelines. The Clerkship Directors in Internal Medicine performed a cross-sectional survey of internal medicine clerkship directors at U.S. and Canadian medical schools in 2014. In addition, the primary author's institution reviewed 1,347 DOM letters between 2012 and 2014 to assess the implementation of these guidelines.

FINDINGS

The survey response rate was 78%. DOM letter writers reported the guidelines were better, easier to implement, and more compatible with the purpose of DOM letters than previously. Most letter readers reported that letters using the guidelines were more credible. Writers of DOM letters in lower academic ranks rated the letters with guidelines higher in several domains than those in higher academic ranks. Readers of DOM letters in higher academic ranks rated the letters with guidelines higher in several domains than those in lower academic ranks. In the DOM letters examined, the odds of meeting each guideline increased with each additional year. However, for 3 guidelines there was an initial decline in adherence from 2012 to 2013 before increasing again in 2014-the recommended length, clerkship description, and detailed narrative guidelines. Letters solely written by a chair were less likely to incorporate the guidelines. Insights: Clerkship directors often write the DOM letters and identify with the purpose of the guidelines. As writers, lower ranking academic faculty value the guidelines more than higher ranking academic faculty. As readers of DOM letters, higher academic ranking faculty value letters that incorporate the guidelines more than lower academic ranking faculty. DOM letters implemented more guideline criteria since the guidelines were released. If implementing the guidelines, chairs should solicit the help of their clerkship director or educational representative when writing DOM letters. Although many clerkship directors read letters for their residency programs, additional program directors' opinions are needed.

Dear Program Director: Deciphering Letters of Recommendation

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.

Utility of selection methods for specialist medical training: A BEME (best evidence medical education) systematic review: BEME guide no. 45

BACKGROUND

Selection into specialty training is a high-stakes and resource-intensive process. While substantial literature exists on selection into medical schools, and there are individual studies in postgraduate settings, there seems to be paucity of evidence concerning selection systems and the utility of selection tools in postgraduate training environments.

AIM

To explore, analyze and synthesize the evidence related to selection into postgraduate medical specialty training.

METHOD

Core bibliographic databases including PubMed; Ovid Medline; Embase, CINAHL; ERIC and PsycINFO were searched, and a total of 2640 abstracts were retrieved. After removing duplicates and screening against the inclusion criteria, 202 full papers were coded, of which 116 were included.

RESULTS

Gaps in underlying selection frameworks were illuminated. Frameworks defined by locally derived selection criteria, and heavily weighed on academic parameters seem to be giving way to the evidencing of competency-based selection approaches in some settings. Regarding selection tools, we found favorable psychometric evidence for multiple mini-interviews, situational judgment tests and clinical problem-solving tests, although the bulk of evidence was mostly limited to the United Kingdom. The evidence around the robustness of curriculum vitae, letters of recommendation and personal statements was equivocal. The findings on the predictors of past performance were limited to academic criteria with paucity of long-term evaluations. The evidence around nonacademic criteria was inadequate to make an informed judgment.

CONCLUSIONS

While much has been gained in understanding the utility of individual selection methods, though the evidence around many of them is equivocal, the underlying theoretical and conceptual frameworks for designing holistic and equitable selection systems are yet to be developed.

Gender Differences in Language of Standardized Letter of Evaluation Narratives for Emergency Medicine Residency Applicants

OBJECTIVE

While gender differences in language for letters of recommendation have been identified in other fields, no prior studies have evaluated the narrative portion of the emergency medicine (EM) standardized letter of evaluation (SLOE). We aim to examine the differences in language used to describe male and female applicants within the SLOE narrative.

METHODS

Invited applicants to a 4-year academic EM residency program within a single application year with a SLOE were included in the sample. Exclusion criteria were SLOE of applicants from non-Liaison Committee on Medical Education (LCME) schools or first rotation SLOE not available for download. Data were collected on applicant gender, age, rotation grade, Alpha Omega Alpha designation, and medical school rank. The previously validated Linguistic Inquiry and Word Count (LIWC) program was used to analyze frequency of words within categories relevant to letters of recommendation. Descriptive statistics, t-tests, and chi-square tests were employed in analysis.

RESULTS

Of 1,025 applicants within a single application year, 265 were invited to interview; 237 applicants had a first rotation SLOE available for analysis. There were no differences between male and female applicants for baseline characteristics. The median word count per SLOE narrative was 199; within the LIWC dictionary and user-defined categories, words within the categories of affiliation and ability appeared more frequently for female applicants.

CONCLUSIONS

Our results with respect to the SLOE narrative reinforce prior research that letters of recommendation for female applicants highlight communal characteristics of teamwork, helpfulness, and compassion. Contrary to prior research, ability words highlighting intelligence and skill appeared with greater frequency for female applicants. No pervasive differences were found in other word categories. In this sample, the standardized format of the SLOE resulted in letters that were relatively free of gender bias.

Improving the Medical Student Performance Evaluation to Facilitate Resident Selection

The Medical Student Performance Evaluation (MSPE) was introduced as a refinement of the prior "dean's letter" to provide residency program directors with a standardized comprehensive assessment of a medical student's performance throughout medical school. The author argues that, although the MSPE was created with good intentions, many have questioned its efficacy in predicting performance during residency. The author asserts that, despite decades of use and some acknowledged improvement, the MSPE remains a suboptimal tool for informing program directors' decisions about which applicants to interview and rank. In the current approach to MSPEs, there may even be some inherent conflicts of interest that cannot be overcome. In January 2015, an MSPE Task Force was created to review the MSPE over three years and recommend changes to its next iteration. The author believes, however, that expanding this collaborative effort between undergraduate and graduate medical education and other stakeholders could optimize the MSPE's standardization and transparency. The author offers six recommendations for achieving this goal: developing a truly standardized MSPE template; improving faculty accountability in student assessment; enhancing transparency in the MSPE; reconsidering the authorship responsibility of the MSPE; including assessment of compliance with administrative tasks and peer assessments in student evaluations; and embracing milestones for evaluation of medical student performance.

Preparing for Fellowship in Internal Medicine. Steps for Success with a Focus on Pulmonary and/or Critical Care Programs

This paper outlines specific tips for those applying to pulmonary and/or critical care medicine fellowship training in the United States using the PAIR-Match steps: preparation, application, interview, ranking, and match. Preparation for fellowship begins long before the application process with an assessment of one's long-term goals (to the extent that these are known). The cornerstone of the application is the curriculum vitae, which should highlight applicants' pulmonary and critical care-related experiences and scholarly work. Applicants should obtain letters of recommendation from faculty members who know them well and can write a letter that speaks to their strengths in clinical, scholarly, or leadership areas. The personal statement is an opportunity to share experiences not otherwise shared in the application and is an opportunity to explain any breaks in training or performance lapses. When selecting programs to which they will apply, applicants should pay close attention to the areas of education and curriculum, clinical experience, scholarly opportunity, and personal factors. Preparing for interviews should include a review of the program at which one is interviewing and development of relevant questions regarding details of the program. The interview day is the applicant's opportunity to see the "personality" of the program by meeting with the program director, faculty, and current fellows and to assess whether the program is a good fit for their goals. Applicants should only rank those programs they are willing to attend, in order of preference; they should be aware that the match process is binding.

Analysis of the evaluative components on the Standard Letter of Recommendation (SLOR) in Emergency Medicine

INTRODUCTION

The standard letter of recommendation in emergency medicine (SLOR) was developed to standardize the evaluation of applicants, improve inter-rater reliability, and discourage grade inflation. The primary objective of this study was to describe the distribution of categorical variables on the SLOR in order to characterize scoring tendencies of writers.

METHODS

We performed a retrospective review of all SLORs written on behalf of applicants to the three Emergency Medicine residency programs in the University of Arizona Health Network (i.e. the University Campus program, the South Campus program and the Emergency Medicine/Pediatrics combined program) in 2012. All "Qualifications for Emergency Medicine" and "Global Assessment" variables were analyzed.

RESULTS

1457 SLORs were reviewed, representing 26.7% of the total number of Electronic Residency Application Service applicants for the academic year. Letter writers were most likely to use the highest/most desirable category on "Qualifications for EM" variables (50.7%) and to use the second highest category on "Global Assessments" (43.8%). For 4-point scale variables, 91% of all responses were in one of the top two ratings. For 3-point scale variables, 94.6% were in one of the top two ratings. Overall, the lowest/least desirable ratings were used less than 2% of the time.

CONCLUSIONS

SLOR letter writers do not use the full spectrum of categories for each variable proportionately. Despite the attempt to discourage grade inflation, nearly all variable responses on the SLOR are in the top two categories. Writers use the lowest categories less than 2% of the time. Program Directors should consider tendencies of SLOR writers when reviewing SLORs of potential applicants to their programs.

Critical appraisal of emergency medicine education research: the best publications of 2013

OBJECTIVES

The objective was to critically appraise and highlight methodologically superior medical education research articles published in 2013 whose outcomes are pertinent to teaching and education in emergency medicine (EM).

METHODS

A search of the English-language literature in 2013 querying Education Resources Information Center (ERIC), PsychINFO, PubMed, and Scopus identified 251 EM-related studies using hypothesis-testing or observational investigations of educational interventions. Two reviewers independently screened all of the publications and removed articles using established exclusion criteria. Six reviewers then independently scored the remaining 43 publications using either a qualitative a or quantitative scoring system, based on the research methodology of each article. Each scoring system consisted of nine criteria. Selected criteria were based on accepted educational review literature and chosen a priori. Both scoring systems used parallel scoring metrics and have been used previously within this annual review.

RESULTS

Forty-three medical education research papers (37 quantitative and six qualitative studies) met the a priori criteria for inclusion and were reviewed. Six quantitative and one qualitative study were scored and ranked most highly by the reviewers as exemplary and are summarized in this article.

CONCLUSIONS

This annual critical appraisal article aims to promote superior research in EM-related education, by reviewing and highlighting seven of 43 major education research studies, meeting a priori criteria, and published in 2013. Common methodologic pitfalls in the 2013 papers are noted, and current trends in medical education research in EM are discussed.