Objective Residency applications rely on traditional letters of recommendation (tLORs) from faculty or mentors to evaluate applicants. However, interpretation of tLORs can be limited by potential biases, overuse of hyperbolic language, and a lack of longitudinal contact. We aimed to assess whether incorporating peer letters of recommendation (pLORs) would add a complementary perspective to the holistic review of an applicant’s attributes and potential.

Design All applicants to a single, university-based general surgery residency program were invited to submit an optional pLOR in the 2023-24 recruitment cycle. Thematic analysis of applicants’ pLORs and tLORs was performed to identify patterns and sentiments.

Setting Large general surgery residency program at a single, tertiary academic center.

Participants Applicants selected for an interview for a general surgery residency program who submitted a pLOR in addition to their tLORs (n=95).

Results Ninety-five applicants (78%) selected for interview submitted a pLOR along with their standard application to the categorical (n=77) and preliminary (n=18) tracks. Peer letter writers knew applicants for an average of 6.14 years (SD 4.7). Thematic analysis identified notable differences in pLORs: 1) peer letter writers more often evaluated applicants across diverse settings (professional and personal) over longer time periods, 2) pLORs placed greater emphasis on the applicants’ impact on others (peers, individuals, patients), and 3) provided more specific, tangible examples of each positive attribute. Lastly, pLORs summative assessments often included personal language while tLORs tended to stratify applicants using percentiles or coded language.

Conclusion Peer letters of recommendation offer a unique, complementary perspective in the holistic residency application review process. Compared with traditional letters, pLORs provide a richer context of an applicant’s impact in a community of their peers, more often providing tangible examples. This perspective is crucial for evaluating applicants as we build diverse and collaborative learning communities each year.

Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

ACGME Core Competencies Professionalism (P), Interpersonal and Communication Skills (ICS)

Highlights

Peer letters of recommendation (pLORs) offer a unique perspective in applicant review

pLOR writers assess applicants across diverse settings over longer time periods

pLORs emphasize applicants’ community impact with tangible, specific examples

tLORs use ranking language, while pLORs include more personal, narrative assessments

pLORs complement tLORs in holistic residency selection and evaluation processes

The authors have declared no competing interest.

This study did not receive any funding

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This study was reviewed and deemed exempt from full review by the Columbia University Institutional Review Board (IRB) under protocol number AAAU9012. In accordance with ethical research guidelines, participant confidentiality was maintained throughout data collection and analysis. No identifiable applicant information was included in the study. This study adheres to the Standards for Reporting Qualitative Research (SRQR) to ensure transparency, rigor, and completeness in reporting.

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