Systematic Review of Gender Differences in Reference Letters for Postgraduate Surgical Training Programs

Objective

This study is the first systematic review to synthesize the literature examining gender bias within reference letters for postgraduate training programs of all surgical disciplines.

Design

MEDLINE, Embase, and CINAHL databases were searched to June 2023 and original studies on gender differences in reference letters were included in a systematic review.

Setting

Surgical postgraduate (residency and fellowship) programs

Participants

n/a

Results

After screening 477 studies, 39 met inclusion criteria and were included in the systematic review. Key gender differences included the greater use of communal terminology for female applicants and increased discussion of male applicants’ leadership skills. There were no consistent gender differences in the use of agentic language or discussions of applicants’ research and teaching skills.

Conclusions

There are gender differences in reference letters written for male and female applicants to postgraduate surgical training programs. Although strides have been made towards improving gender representation in surgery, bias in reference letters may negatively affect female applicants’ success in obtaining postgraduate training positions, which serve as the initial barrier to entering the field of surgery. Awareness of these biases and development of strategies by selections committees and letter writers to mitigate these biases are recommended.