Exploring the Value of Peer Letters of Recommendation in the Holistic Review of Surgery Residency Applications: A Qualitative Study

Abstract Objective Residency applications rely on traditional letters of recommendation ( t LORs) from faculty or mentors to evaluate applicants. However, interpretation of t LORs 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 ( p LORs) 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 p LOR in the 2023-24 recruitment cycle. Thematic analysis of applicants’ p LORs and t LORs 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 p LOR in addition to their t LORs ( n =95). Results Ninety-five applicants (78%) selected for interview submitted a p LOR 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 p LORs: 1) peer letter writers more often evaluated applicants across diverse settings (professional and personal) over longer time periods, 2) p LORs placed greater emphasis on the applicants’ impact on others (peers, individuals, patients), and 3) provided more specific, tangible examples of each positive attribute. Lastly, p LORs summative assessments often included personal language while t LORs 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, p LORs 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 ( p LORs) offer a unique perspective in applicant review p LOR writers assess applicants across diverse settings over longer time periods p LORs emphasize applicants’ community impact with tangible, specific examples t LORs use ranking language, while p LORs include more personal, narrative assessments pLORs complement t LORs in holistic residency selection and evaluation processes