Chopra Deepti, Joneja Mala, Sandhu Gurjit, Smith Christopher A, Spagnuolo Catherine M, Hookey Lawrence
Department of Medicine, Queen's University, Kingston, ON, Canada.
Departments of Surgery & Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.
BMC Med Educ. 2020 Oct 7;20(1):350. doi: 10.1186/s12909-020-02270-7.
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.
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.
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).
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.
推荐信目前是住院医师培训项目申请人选拔过程中不可或缺的一部分。内科住院医师会花费大量时间和费用完成专科外选修课程以获得一封推荐信。本研究的目的是：1）检查大量推荐信样本，以确定高质量推荐信的基本要素；2）阐明推荐信质量与推荐人之间的关系。
我们进行了一项两阶段研究。在第一阶段，使用一种审核工具作为编码框架检查大量推荐信样本。随后制定了一个包含五个要素的高质量推荐信综合指标。在第二阶段，根据是否包含五点综合指标的要素，使用卡方检验将项目主任的推荐信与非项目主任的本校推荐信以及非本校选修课程推荐信进行比较。
共检查了715封推荐信（398封非项目主任的本校推荐信、201封项目主任推荐信和116封非本校选修课程推荐信）。高质量推荐信的要素包括：关系性质、关系持续时间、培训期间评估报告信息、研究参与情况以及关于改进领域的评论。项目主任的推荐信中，所有五个高质量要素的比例显著更高（10.4%），相比之下，非项目主任的本校推荐信和选修课程推荐信中这一比例均为0%（p < 0.001）。项目主任的推荐信中，有4 - 5个高质量要素的比例显著更高（62.5%），而非项目主任的本校推荐信这一比例为2%，选修课程推荐信为0%（p < 0.0001）。
选修轮转的推荐信质量最差，不应仅仅为了获得推荐信而进行此类轮转。选修课程推荐信质量低，因此建议推荐人拒绝撰写此类推荐信，项目不应要求提供此类推荐信，学员也不应索要此类推荐信。项目主任撰写的推荐信质量最高，应成为师资发展的资源。临床督导在为申请人撰写推荐信时可将五点综合指标作为指导。
