Traditional Letters of Recommendation Need a Rewrite, Say Psychiatry Educators
Abstract
Medical school educators and residency program directors say that a standardized letter of recommendation is a step in the direction of objectivity, fairness, and equity.
The letter of recommendation is a time-honored tool of job seekers everywhere. But in the case of medical students seeking psychiatry residency slots, some educators want to try something new.
Martin Klapheke, M.D., said that the standardized letter of recommendation is modeled in part on the pioneering work of emergency department physicians to make medical student evaluations fairer and more objective.
Last year the membership of the Association of Directors of Medical School Education in Psychiatry (ADMSEP) approved a standardized letter of recommendation, which was developed by the ADMSEP Task Force on Medical School Performance Evaluation, in league with some psychiatry training directors. The standardized letter can be used now.
Task force members say the traditional letter of recommendation has lost its value as a way to assess a student’s prospects as a resident. Often vague and variable in length, quality, and content depending on the author or the extent to which the author really knows the candidate, the traditional letter may be indistinguishable from hundreds of others that training programs receive now that psychiatry’s popularity has increased and students are applying to dozens of programs. Because medical schools are assessed in part on the basis of how many of their students match into training programs, the Medical School Performance Evaluation (MSPE), written by medical school deans, is liable to inflate every student’s prospects as a resident.
“Current letters of recommendation tend to stay quite general—’good student,’ ‘outstanding,’ or ‘will be a good resident’—and may convey very little helpful, specific, or personal information that residency program directors need to know,” said Martin Klapheke, M.D., chair for psychiatry education and director of the psychiatry residency psychotherapy training at the University of Central Florida College of Medicine.
Klapheke and others said that the problem was made more acute when Step 1 of the United States Medical Licensing Exam (USMLE)—which traditionally provided an objective measure of a candidate’s skills and knowledge—was converted to a pass/fail exam in 2021.
In the April 2022 edition of Academic Psychiatry, Klapheke and other members of the ADMSEP task force published the results of a 23-item survey of 70 training directors regarding current measures of medical student performance and their preferences for the future. Forty percent of respondents reported that the most important use of the MSPE is in screening applicants for interviews, and only 26.1% reported that the MSPE in its current form could be trusted to provide a valid and reliable assessment of a student’s medical school performance. Most respondents agreed that in the absence of USMLE Step 1 numerical scores, the existing MSPE format and content requirements should be modified, use a set of ranking categories that are uniform across all medical schools, and be supplemented with additional measures of the student’s character and ability specific to psychiatry.
Standardized Letter Addresses ‘Areas of Growth’ for Candidates
The standardized letter of recommendation for medical students seeking a residency, approved by ADMSEP, asks the author to write a 250-character description of how the author knows the candidate. It then asks the author to write a 500-character description of the candidate for each of two of the following areas: communication/interpersonal skills, interest/passion for psychiatry, teachability (open to and learns from feedback), honesty, and capacity to reflect/self-awareness.
This is to be followed by a 500-character description of the candidate’s clinical skills for each of two of the following five areas: ability to develop rapport with patients, ability to work well in a clinical team, ability to take a psychiatric history, ability to perform a mental status exam, and ability to perform appropriate triage of medical and psychiatric urgent/emergent issues.
The author is asked to describe one characteristic/quality or clinical skill “which may be an area of growth” and to identify one additional item that makes the applicant unique relative to other applicants, such as “sense of duty, teamwork, perseverance, ability to handle adversity.” Finally, the author is directed to summarize the applicant’s preparedness and suitability for a psychiatry residency and to “provide a description of how much guidance this applicant may need as [he or she begins] residency in comparison to their peers.”
“What I particularly like is the section asking for one area of growth in the applicant,” said Sallie De Golia, M.D., residency training director at Stanford University.
She hopes to inculcate a mindset of continual growth in medical education. “Rarely will a [traditional] letter suggest an applicant has any areas where the applicant could grow because they are all awesome and for fear this will reflect poorly on the applicant. But we all have areas for growth.”
Klapheke said the standardized letter of recommendation (see box) is modeled in part on the pioneering work of emergency medicine physicians in working to make medical school performance evaluation fairer and more objective.
Medical school educators and training directors who communicated with Psychiatric News said that the standardized letter is a welcome step in the right direction.
![Photo: “For students, the advantage of [the standardized letter] is that it will likely provide more useful and specific observations about their strengths than would be the case with a traditional letter of recommendation,” said Jeffrey Rakofsky, M.D.](/cms/10.1176/appi.pn.2023.05.5.34/asset/images/medium/jeffrey-rakofsky.jpg "Photo: “For students, the advantage of [the standardized letter] is that it will likely provide more useful and specific observations about their strengths than would be the case with a traditional letter of recommendation,” said Jeffrey Rakofsky, M.D.")
“For students, the advantage of [the standardized letter] is that it will likely provide more useful and specific observations about their strengths than would be the case with a traditional letter of recommendation,” said Jeffrey Rakofsky, M.D.
“For students, the advantage of [the standardized letter] is that it will likely provide more useful and specific observations about their strengths than would be the case with a traditional letter of recommendation,” said Jeffrey Rakofsky, M.D., director of medical student clinical education at Emory University and co-chair of the ADMSEP task force. “The disadvantage would be that it may not be a glowing evaluation. Instead, it would have nuance, addressing strengths and areas for improvement.”
Adam Brenner, M.D., director of training at the University of Texas Southwestern and editor of Academic Psychiatry, said a standardized letter of recommendation would be helpful to both program directors and applicants. “Program directors would be better able to do an efficient holistic review of the application, and applicants would not be as vulnerable to the great differences in length and quality of letters that faculty currently provide.”
Sallie De Golia, M.D., psychiatry residency training director at Stanford and immediate past president of the American Association of Directors of Psychiatric Residency Training Directors, said the standardized letter will help focus the letter writer, particularly on issues that are most relevant to psychiatry, and allow the reader to better compare applicants because authors would be using the same template.
“The letter focuses on applicant characteristics and skills that have been deemed important to becoming an excellent psychiatrist,” she said. “The biggest barrier or obstacle is that it will require letter writers to reflect deeply on the applicant’s qualities and characteristics for whom they are writing the letter and not rely as much on the applicant’s CV for content.”
All of the educators who communicated with Psychiatric News said that the standardized letter can be improved over time as part of an iterative process and as the assessment of candidates evolves.
Rakofsky added that the standardized letter is a step in the direction of fairness and equity. “This is important to graduate medical education because equity matters,” he said. “Matching in a residency sets an applicant on their path to become a psychiatrist with all the benefits that come with this professional identity. The standardized letter offers graduate medical education an opportunity to improve equity for applicants. Poorly written letters in the past may have unfairly biased program directors’ views of the applicants for whom those letters were written. The standardized letter attempts to put everyone on the same level with respect to letter quality.” ■
