Race- and Gender-Based Differences in Descriptions of Applicants in the Letters of Recommendation for Orthopaedic Surgery Residency

Letters of recommendation (LOR) are an important component of trainee advancement and assessment. Examination of word use in LOR has demonstrated significant differences in how letter writers describe female and male applicants. Given the emphasis on increasing both gender and racial diversity among orthopaedic surgeons, we aimed to study gender and racial differences in LOR for applicants to orthopaedic surgery residencies. METHODS: All applications submitted to a single, academic orthopaedic residency program in 2018 were included. Self-identified gender and race were recorded. The LOR were analyzed via a text analysis software program using previously described categories of communal, agentic, grindstone, ability, and standout words. We examined the relative frequency of word use in letters for (1) male and female applicants and (2) white and underrepresented in orthopaedics (UiO) applicants, with the subgroup analysis based on whether standardized (using the American Orthopaedic Association template) or traditional (narrative) LOR were used. RESULTS: Two thousand six hundred twenty-five LOR were submitted for 730 applicants (79% men). Fifty-nine percent of applicants were self-identified as white, and 34% were self-identified as UiO. In traditional LOR, standout words (odds ratio [OR] 1.07; p = 0.01) were more likely to be used in letters for women compared with men, with no difference in any other word-use category. In standardized LOR, there were no gender-based differences in any word category. In traditional LOR, grindstone words (OR = 0.96; p = 0.02) were more likely to be used in letters for UiO than white applicants, whereas standout words (OR = 1.05; p = 0.04) were more likely to be used in letters for white candidates. In standardized LOR, there were no race-based differences in any word category use. CONCLUSIONS: Small differences were found in the categories of words used to describe male and female candidates and white and UiO candidates. These differences were not present in the standardized LOR compared with traditional LOR. It is possible that the use of standardized LOR may reduce gender- and race-based bias in the narrative assessment of applicants.