Integrated Cardiothoracic Surgery Residency Applications: Applicant Gender and Recommendation Letter Content

S. Yarlagadda¹, J. J. Han², J. M. Soegaard Ballester³, C. O’brien⁴, J. T. Clapp⁵, M. Cevasco^6
1Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, Princeton, New Jersey ²Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, Philadelphia, Pennsylvania ³Division of General Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States, Philadelphia, Pennsylvania ⁴Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania, Philadelphia, Pennsylvania ⁵Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, Philadelphia, Pennsylvania ⁶Division of Cardiovascular Surgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania

Purpose: Cardiothoracic (CT) surgery remains a heavily male-dominated specialty. Explicit and implicit biases may impact trainee selection, which controls entry into the field. Since letters of recommendation (LORs) can be especially vulnerable to recommender biases, we aimed to qualitatively assess differences in LORs to integrated residency based on applicant gender.

Methods: Among applicants to an integrated CT residency program during a single application cycle, only LORs for applicants who interviewed were selected for inclusion. Invitations to interview were determined by three senior surgeons based on subjective and objective merit criteria. Included letters were pooled by applicant gender. Prior to analysis, all gendered and identifying references in the text—such as names, pronouns, name and location of medical schools, race, age, references to the letter writer’s gender, and mentions of gendered sports—were redacted. Qualitative analysis was conducted, first using modified grounded theory approach to create a codebook. The first several letters were open coded among multiple researchers until the codebook was finalized. Subsequently, two researchers independently coded 20% of transcripts. Interrater reliability was assessed between multiple coders; discrepancies were resolved via group discussion. All transcripts were coded in NVivo.

Results: From the 79 LORs for the 19 applicants selected for inclusion, there were 31 LORs across 8 male applicants and 42 LORs across 11 female applicants. There was no noticeable difference between the frequency of positive attributes assigned to male and female applicants. In both groups, writers highlighted applicants’ leadership through concrete examples or, most often, mentions of future potential. Research accomplishments (mentioned in 60/73 letters) were emphasized more than other academic and social competencies, with no gender-based difference identified. LORs for female applicants tended to be longer, more specific, and to include stronger positive adjectives (e.g., “great” instead of “good”). They also included more mentions of extracurricular activities, invitations for follow-up discussion, and declarations of intent to internally recruit. For male applicants, descriptions of external recognition were almost exclusively via mention of scholarships or research, whereas female applicants were more likely to receive unofficial “grapevine” recognition, such as praise from the letter writer’s colleagues or other persons in positions of authority. Letter writers often attested to male applicants’ understanding of, and commitment to, the long road to becoming a cardiothoracic surgeon. In contrast, female applicants received more varied commentary, including comments about their commitment to proper patient treatment.

Conclusion: Qualitative analysis of LORs for CT integrated residency applicants suggests sincere support of applicants regardless of gender. Letters for male applicants tended to home in on research accolades and career commitment. In comparison, letters for female applicants were longer and more likely to also emphasize compassionate patient care, acknowledge endorsement from other faculty, and mention involvement in extracurricular and athletic endeavors. Future studies may discern whether this phenomenon simply reflects stronger relationships between female applicants and letter writers, or a potentially disadvantageous approach taken by letter writers for female applicants which involves increased reliance on subjective facets of the applicant.

Identify the source of the funding for this research project: University of Pennsylvania Institutional Research Funding for Dr. Marisa Cevasco, Assistant Professor of Surgery