Letters of recommendation (LORs) are a currency in academic medicine, collected and traded in exchange for positions in residency and fellowship. The goal of an LOR is to provide information about the candidate to interested programs, ideally adding data points which cannot be gleaned from other components of the application. Unfortunately, writing LORs is fraught with ethical pitfalls.

When writing LORs, consider the 3 ethical principles of capacity, veracity, and objectivity.¹ Capacity is the most straightforward; do you know this person well enough to write a letter? It requires first-hand knowledge of the skills on which you are commenting. Verbal reports from other faculty, unless attributed to them, should not be included.

Veracity is thornier. Urology, and particularly subspecialties within urology, are very small fields. Word of mouth, or word written in an LOR, carries a lot of weight in residency and fellowship applications, especially if the writer is known to the reader. This makes sticking to the truth, and the whole truth, even more important. Embellishing strengths in an effort to hide inadequacies in the recommended is not fair to the reader, while underplaying positives due to personal clashes unfairly undercuts the recommended’s chances at matching. Expecting programs to “read between the lines” by omitting discussions about certain skills or leaving out key phrases you typically use to distinguish excellent candidates can be misleading. It often feels as though reading LORs is an exercise in translating double-speak; why can’t we just write what we mean to say?

If you truly feel you cannot write a fair letter, the best answer is to decline to write. This can send a very negative message to the applicant’s program if a letter from, say, the chair or program director is absent. In some cases, this may not be the message you want to send; if wavering, stick to the truth.

In many cases you are being asked to write an LOR precisely because the recommended believes you will say nice things; from the outset objectivity is questionable. Knowing this, it is important to focus on the facts when assessing a candidate. And if objectivity has not been undermined enough, recent scholarship has shown LORs introduce unconscious bias, especially along gender lines.² While unconscious bias cannot be completely eradicated, the first step in mitigating its effect is to be aware that it exists. Online tools exist to query an LOR draft to reduce gender bias.³

In an effort to combat many of the snares listed above, some institutions and specialties are moving toward standardized letters. The goal of these is to decrease the narrative, subjective component of the LOR and focus on attributes considered important to the practice of the specialty. Many urology departments have templated letters, listing relevant skills and assigning a superlative (typically from good to outstanding) to the candidate. This allows a more objective comparison of candidates assessed within the same department, and certainly by the same writer.

Emergency medicine has gone one step farther; in 1997 the specialty created the standardized letter of evaluation (SLOE), a templated assessment used across institutions. It has been shown to be easier to write and review, have a higher interrater reliability, provide a greater depth of evaluating the applicant, and be predictive of resident performance on core competencies.⁴ Letters can be coauthored by multiple faculty, thus increasing the exposure of the writers to the recommended and increasing capacity. Targeted questions probe both strengths and weaknesses, allowing a more balanced and truthful picture to develop. Finally, the decreased reliance on narrative facilitates a more objective impression. Perhaps it is time for urology to abandon the static associated with narrative LORs and create a standardized evaluation, thus creating a much more valuable currency for assessment.