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UPJ INSIGHT Program Directors’ Perspectives on Residency Applications: A Case for Standardized Letters of Recommendation
By: Angeline Johny, MD, Baylor College of Medicine, Houston, Texas; Patrick J. Shenot, MD, Thomas Jefferson College of Medicine, Philadelphia, Pennsylvania; Charles Green, PhD, University of Texas Health Science Center; Leah Chisholm, MD, Vanderbilt School of Medicine, Nashville, Tennessee; Steven Riggs, MD, MBA, FACS, Atrium Health, Charlotte, North Carolina; Stephen V. Jackman, MD, University of Pittsburgh School of Medicine, Pennsylvania; Aqsa A. Khan, MD, Mayo Clinic, Phoenix, Arizona; Peter N. Kolettis, MD, University of Alabama School of Medicine, Birmingham; Brian K. McNeil, MD, MBA, FACS, SUNY Downstate Health Sciences University, Brooklyn, New York; Wesley A. Mayer, MD, Baylor College of Medicine, Houston, Texas | Posted on: 20 May 2024
Johny A, Shenot PJ, Green C, et al. Program directors’ perspectives on residency applications in the post—United States Medical Licensing Examination Step 1 era: a case for standardized letters of recommendation?. Urol Pract. 2024; 11(3):577-584. doi:10.1097/UPJ.0000000000000556
Study Need and Importance
Traditionally, the United States Medical Licensing Examination (USMLE) Step 1 scores were one of the most important metrics in evaluating urology residency applications. However, application evaluation has been impacted by paradigm shifts, including the transition of the USMLE Step 1 score to a pass/fail designation and a progressive loss of other objective metrics such as clerkship grades and class ranking. We assessed current perspectives of urology program directors (PDs) on the relative importance of residency application metrics for both interview selection and predicted clinical performance. The findings are highly relevant for current urology PDs, residency selection committee members, and medical students. These data can be used to improve the application evaluation process and suggest an opportunity for a standardized letter of recommendation (LOR).
What We Found
LORs ranked consistently as the most important parameter with the least heterogenicity among the 89 PD responses, with clerkship grades and USMLE Step 1 score tied as the second most important parameters (Figure). Medical school reputation was consistently ranked as the least important parameter. Female PDs ranked USMLE Step 2 score as less important than male PDs. LORs and clerkship grades were felt to be most predictive of clinical performance.
Limitations
This study includes the inherent selection bias in survey-based data analyses. Although the perspectives of 89 PDs were represented, none were from programs with 5 residents per year. Data collection overlapped with the COVID era of virtual away electives and the transition of the USMLE Step 1 scoring system.
Interpretation for Patient Care
Understanding PDs’ perspectives on application metrics can identify ways to improve our current system. Given the progressive loss of objective parameters, these data provide a rationale for optimizing how LORs are used. Standardizing LORs may offer PDs an additional objective metric to assess students while potentially mitigating bias.
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