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Objective: The primary purpose of this study was to retrospectively analyze letters of recommendation written for medical students applying to orthopedic residency for implicit race and gender bias. The secondary purpose was to determine if the presence of bias was influenced by the gender of the letter writer., Design: This was a retrospective institutional review board (IRB) approved study. All letters of recommendation received in the years 2016 to 2018 were deidentified and analyzed using the Linguistics Inquiry and Word Count (LIWC) 2015 software. Independent variables in our analysis were applicant gender and applicant race. Dependent study variables included the summary and characteristic variables of a letter of recommendation, which are word count, analytic, clout, authenticity, tone, and positive and negative emotion word categories. Separate analyses were completed by gender of the letter writer as well., Setting: Institution: Temple University Hospital, Philadelphia, Pennsylvania., Participants: Medical students applying to Temple University Hospital Orthopaedic Surgery Program from 2016 to 2018. A total of 2113 applicants were included in the study., Results: Female, Asian and underrepresented minority applicants' letters were more likely to have a higher word count. In our subset analysis by gender of letter writer, when the letter writer was male, Asian applicants' letters were more likely to convey analytical thinking and authenticity. When the letter writer was male, male applicants scored higher for authenticity. Letters written by female attendings demonstrated no significant difference for male or female applicants in terms of composite variables or word categories., Conclusions: Our study shows that letters of recommendation for orthopedic surgery residency positions are likely to contain some degree of bias. Further studies are required to fully characterize the degree and magnitude of bias in letters of recommendation and whether the findings of our study are significant enough to contribute to the difference in socioeconomic demographics between orthopedic residents and society at large., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: While dedicated research time (DRT) offers international medical graduates (IMGs) exposure to the US healthcare system and helps boost their residency application, it can lengthen time away from clinical activity. We aimed to determine the value of DRT/protected research time for an IMG applying to general surgeryresidency (GSR)., Design: Cross-sectional survey., Setting: Academic, tertiary care center with a large GSR program (Mayo Clinic, Rochester, MN)., Participants: IMG applicants to our GSR program (2015-2018) and general surgery program directors (PDs) in the United States., Methodology: Separate surveys were emailed to all IMG applicants to our GSR program (2015-2018) and general surgery PDs. Surveys to the applicants focused on the details of DRT spent in the US prior to residency and match outcomes. Surveys to the PDs focused on the importance of different aspects of an IMG applicant's research experience., Results: Applicants: 320 applicants responded of which 148 (46%) applicants spent DRT in the US prior to residency. Among the research group, the median (interquartile range [IQR]) number of first author podium and poster presentations from the DRT were 1 (0-4) and 2 (1-5), respectively. At the time of match application, the median (IQR) number of published manuscripts among the research group was higher than that among the applicant group which did not pursue DRT (5[2-12] vs 1[0-2], p < 0.0001). Pursuing DRT and/or the duration of the research did not affect the match outcomes (p > 0.05)., Program Directors: Seventy-six PDs responded to our survey. A median (IQR) of 2.5 (2-3) publications, and 2 (2-3) presentations per year of DRT were considered "productive." Sixty-three percent of PDs did not recommend IMGs take time off to engage in research; only 54% attributed some importance to an IMG's research experience., Conclusions: DRT does not seem to be associated with better outcomes for IMGs targeting GSR. Most PDs advocate against taking time off after graduation to engage in research activity. Decisions to pursue DRT should be individualized., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The letter of recommendation (LOR) is an important component of a residency application. There is great subjectivity in the interpretation of a letter writer's narrative and many residencies have moved toward standardized LORs (sLOR). We aimed to scrutinize the importance afforded to specific content and applicant attributes in an LOR in hopes of decoding this time-honored process., Design: A 35-question survey comprised of nonidentifying general questions, and participant evaluation of applicant characteristics and LOR phrases were administered (cross-sectional design). Evaluations were scored both objectively on a 10-point Likert scale and subjectively using a relative ranking., Setting: Academic, tertiary care center with a large general surgery residency program (Mayo Clinic, Rochester, MN)., Participants: Surgery attendings and general surgery residents (n = 122)., Results: Seventy-two attendings and 50 general surgery residents completed the survey. Faculty ranked strong work ethic/hard working (median rank = 1) and inquisitive/hungry learner (median rank = 3) as the top 2 attributes. "We will plan to recruit this candidate" (median rank = 1.5) and "I give my highest recommendation" (median rank = 2) were the top 2 phrases. Residents valued strong work ethic and collaborative/team player as the top 2 applicant attributes. Seventy-three percent of attendings and 82% of residents agreed that LOR allows the applicant pool to be divided into upper and lower halves. Only 17% of faculty and 18% of residents agreed that an LOR allowed candidate stratification into quartiles., Conclusions: Elaborating the most favorable applicant characteristics and highly regarded content in an LOR will help truly exceptional candidates obtain letters that make them stand out in the eyes of their evaluators. Since LORs are mostly considered to be able to stratify only upper and lower halves of the applicant pool, it is imperative to move toward LORs which portray superior applicant qualities, and can provide more objective evaluation of a candidate., (Copyright © 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The selection of high-quality applicants is critical to the future of surgery. However, it is unclear if current practices meet industry criteria of a successful selection system, as measured by administrative efficiency and performance and attrition of those selected., Methods: We performed a modified systematic review process to gain an understanding of current selection processes, remediation practices, and attrition rates in surgery residency training programs in the United States. We also conducted semistructured interviews with local residency program directors and coordinators to obtain a specific snapshot of the amount of time and resources dedicated to these activities in various sized programs. The associated financial costs of these activities are also presented., Results: The administrative costs for current residency selection processes are substantial, ranging from $45,000 to $148,000 for each program per year. Approximately 30% of residents require at least 1 remediation intervention, costing programs $3400 to $5300 per episode, and typically involve concerns around nontechnical skills. Attrition rates range from 20% to 40%., Conclusions: This review suggests that additional methodologies may allow surgery residency programs to identify best-fit candidates more efficiently and effectively, while also decreasing remediation and attrition rates. Possible solutions include incorporation of structured interviews, personality inventories, and situational judgment tests. Resources dedicated to current interview practices, remediation efforts, and attrition management can be redirected to support these methodologies. By applying the science of selection and assessment to the recruitment process, programs may be able to make more data-driven decisions to identify candidates who will be successful at their institution., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The number of surgical applicants to "independent" plastic surgery programs has drastically decreased. However, the competitiveness of recent applicants relative to previous years has not been assessed. The purpose of this study was to analyze the characteristics of recent "independent" applicants and to obtain their preferences regarding the match., Methods: A 25-question survey was distributed to 97 applicants of the 2012 "independent" match. The survey consisted of questions regarding demographics, academic qualifications, interview results, match results, program characteristic preferences, interview preferences, and future career plans., Results: A total of 62 applicants responded; 71% male, 82% US medical graduates, 94% general surgery residents, and 76% in university programs. Three-quarters had ≥2 publications and 29% in plastic surgery journals. Applicants most commonly attended 11 to 13 interviews, and 31% got their top choice. Mean rank list position matched was 2.7. Out of 10 program selection criteria, overall training quality and geographic location were most important to applicants. Difficulty of on-call responsibilities and research opportunities were least important. Applicants interested in university-based practice had a significantly higher interest in research (p = 0.003). Most prefer one-on-one interviews with 5 sessions being ideal. Two-thirds would prefer regional coordination of interviews. Half were undecided about fellowship, and most were undecided about subspecialty of greatest interest. University-affiliated (39%) and university-based (33%) were the most commonly envisioned future practices., Conclusion: The profile of "independent" plastic surgery applicants has not changed much in recent years. When selecting a program, applicants are looking for the best overall operative training above all else with little regard for difficulty of on-call responsibilities or ability to do research. Applicants are still very moldable in their preference of future career plans with the majority possessing an early interest in academic-related practices., (Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: To train surgeons effectively, it is important to understand how they are learning. The Kolb Learning Style Inventory (LSI) is based on the theory of experiential learning, which divides the learning cycle into 4 stages: active experimentation (AE), abstract conceptualization (AC), concrete experience, and reflective observation. The purpose of this investigation was to assess the learning styles of orthopedic residents, faculty, and applicants at an east-coast residency program., Methods: A total of 90 Kolb LSI, Version 3.1 surveys, and demographic questionnaires were distributed to all residency applicants, residents, and faculty at an academic program. Data collected included age, sex, type of medical school (MD or DO), foreign medical graduate status, and either year since college graduation, postgraduate year level (residents only), or years since completion of residency (faculty only). Seventy-one completed Kolb LSI surveys (14 residents, 14 faculty members, and 43 applicants) were recorded and analyzed for statistical significance., Results: The most prevalent learning style among all participants was converging (53.5%), followed by accommodating (18.3%), diverging (18.3%), and assimilating (9.9%) (p = 0.13). The applicant and resident groups demonstrated a high tendency toward AE followed by AC. The faculty group demonstrated a high tendency toward AC followed by AE. None of the 24 subjects who were 26 years or under had assimilating learning styles, in significant contrast to the 12% of 27- to 30-year-olds and 18% of 31 and older group (p < 0.01)., Conclusions: The majority of applicants, residents, and faculty in the orthopedic residency program were "convergers." The converging learning style involves problem solving and decision making, with the practical application of ideas and the use of hypothetical-deductive reasoning. Learning through AE decreased with age, whereas learning through AC increased., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)