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

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 to 2024 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.