Bias in Letters of Recommendation

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The institution of academic medicine revolves around review and evaluation. At each stage of the process during training, and even attendingship, letters of recommendation are crucial and have the power to curtail or boost a medical career. Often, they can provide valuable insight into the character, capacity, and potential of a candidate and occasionally, they lead reviewers to hypothesize about possible concerns. The strength of a letter of recommendation is that it allows a reviewer to acquaint themselves with the candidate through the words of someone who has firsthand experience working with the candidate. The personal nature of the letter is also it’s weakness, in that it is susceptible to bias on the part of the letter writer. As professionals in academic medicine, we all write countless letters for hopeful candidates, and we too will be at the mercy of others to write (hopefully glowing) letters about us. This should be motivating enough for us to be actively engaged in the process of eliminating bias in letters of recommendation. Moreover, it is the right thing to do.

So, I challenge you to look over a letter of recommendation you wrote within the last year. Do you notice any biases, perhaps related to the trainee’s gender or racial identity? Maybe you look it over and think, wow, I only wrote great things! How can this be biased?

 

1.  Are letters of recommendation biased? Are yours?

All of us navigate the world with implicit biases that are our minds’ way of creating (maladaptive) heuristics. This is a well-documented phenomenon with multiple articles published on this in science and medicine!(1-2) Among many medical and academic fields, historically, male applicants received stronger letters of recommendation with more agentic descriptors (that portray independence, such as “ambitious”, “visionary” versus women who are described with more communal descriptors which illustrate interpersonal skills such as “compassionate”, “caring”).(3)  Disparities in letter writing persist today; in Dr. Viglianti’s 2020 paper, she found that underrepresented in medicine and Asian applicants for PCCM fellowship, received comparatively shorter and less supportive letters.(4

 

2.  So, our letters are biased. What we can we do about it?

A.  Use standout descriptions that endorse that the applicant is the best fit for the job (superlatives, not adjectives that connote the bare minimum).(5)

        • For example, “outstanding”, “extraordinary”, “exceptional” versus “dependable”, “reliable”

B.  Meet with the student/resident/fellow to review goals for the letter and to hear their story. The more you get to know them outside of the limited clinical contact, the better you can tell their story and convey your enthusiastic support; It makes for a more holistic letter writing process.(6)

C.  Focus on specific accomplishments, not just effort made while on service. Cite specific examples.(5)

D.  Avoid strictly describing someone with gender stereotypes. Selection committees may back candidates with more “masculine” adjectives.

        • For example, women may be described as “nurturing”, “dedicated” versus men who may be described as “assertive”, “decisive”.(5)

E.  No need to mention personal life (eg, marital status, children, physical characteristics) unless you think it is vital to the story, and if so, discuss with the candidate first. Use surnames and titles in your letter.(5)

F.  Make sure to reference research publications and accomplishments in the letter.(5)

 

3.  What does the future hold?

A.  In good news, the tides are changing and we’re starting to see female applicants with longer letters with more “grindstone, positive agentic, research, ability, and outstanding adjectives” compared with males.(4)

B.  You can try this program: https://www.tomforth.co.uk/genderbias/ as a first pass to check for gender bias in writing.

C.  Congratulations, now that you’ve read this, you may be more aware and liable to review your letter for bias. The more awareness you have, the better mentors, sponsors and educators you can be.

 

Letters of recommendation provide a personal perspective on the candidate in a way that other parts of the portfolio do not capture. We are in positions of power as educators and have the privilege of writing a letter of recommendation that will influence someone’s career. Now that you’ve taken time to read up on how bias can creep into your letter writing, I hope you feel empowered to use these tools to combat bias in your letter writing. Let’s just hope anyone writing a letter for us is reading this too!

 

References:
  1. Carnes M, Sheridan J, Fine E, Lee YG, Filut A, Topp S. Engaging faculty in a workshop intervention on overcoming the influence of implicit bias. J Clin Transl Sci. 2021 Jun 8;5(1):e135. doi: 10.1017/cts.2021.796. PMID: 34367679; PMCID: PMC8327611. (Breaking the Bias Habit® workshop)
  2. Neil Zhang, Sarah Blissett, David Anderson, Patricia O'Sullivan, Atif Qasim; Race and Gender Bias in Internal Medicine Program Director Letters of Recommendation. J Grad Med Educ 1 June 2021; 13 (3): 335–344. doi: https://doi.org/10.4300/JGME-D-20-00929.1
  3. Schmader T, Whitehead J, Wysocki VH. A Linguistic Comparison of Letters of Recommendation for Male and Female Chemistry and Biochemistry Job Applicants. Sex Roles. 2007;57(7-8):509-514. doi: 10.1007/s11199-007-9291-4. PMID: 18953419; PMCID: PMC2572075.
  4. Viglianti EM, Sheffield V, Choudhuri I, Goldberg R, Vita A, Byrd KM, Oliverio AL. Gendered Language in Letters of Recommendation for Applicants to Pulmonary Critical Care Fellowships. ATS Sch. 2022 Aug 22;3(3):413-424. doi: 10.34197/ats-scholar.2022-0004OC. PMID: 36312806; PMCID: PMC9590447.
  5. https://csw.arizona.edu/sites/default/files/avoiding_gender_bias_in_letter_of_reference_writing.pdf
  6. PLoS Comput Biol 17(2): e1008656. https://doi.org/10.1371/journal.pcbi.1008656

 

Additional Resources:

https://app.box.com/s/w2zihrmmcgksofcfehjk10b3x2x6zylh

https://app.box.com/s/8570mbu4g3dag0vqf5joalb9gzm4ft5g

 

Debasree Banerjee, MD is an attending physician in pulmonary and critical care medicine at Brown University. She is the Diversity, Equity and Inclusion (DEI) Director for her division and is a member of several DEI working groups in Brown medicine. Her focus is on anti-bias education and health disparities.

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