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Do gender differences exist in letters of recommendation for gynecology surgical fellowship applicants?

      Objectives

      We aimed to evaluate if there are gender differences in the letters of recommendation (LOR) written for residents applying for gynecology surgical fellowships.

      Materials and Methods

      We analyzed LOR for applicants to urogynecology, gynecology oncology, and minimally invasive gynecology fellowships at a single institution during the 2019-2020 application cycle. The linguistic content of the letters was analyzed for the presence of 4 summary variables and 21-word categories based on previous studies using a validated computerized text analysis software, Linguistic Inquiry, and Word Count. Multivariable analysis using linear mixed models was used to compare letter linguistic characteristics by applicant gender. Concurrently, we performed a qualitative content analysis on a random sample of LOR and compared the frequency of code themes by gender. The mixed-method design was planned a priori to analyze domains that are not captured in the text analysis, for example, surgical skills and leadership.

      Results

      Among 680 letters written for 186 applicants, 124(18.2%) LOR were written for men, and 556 (81.8%) LOR were written for women applicants. Men authored 384(56.5%) LOR. There were no gender differences in the median (interquartile range) number of letters submitted for men and women (4(3-4) v. 4(3-4); p=.18). There were no differences in the least square mean (SE) word counts for LOR written for men and women applicants, 465(20.0) v. 458(9.4) words, p=.74 On multivariable analysis, controlling for USMLE Step2 scores, residency program ranking, and letter writer gender, LOR written for men had higher authentic tone and more risk words (p=.005 and p=.03 respectively) (Figure 1). Whereas LOR written for women contained more communal (relationship-oriented) words (p=.006) compared to LOR for men.
      On the qualitative analysis of a random sample of 340 letters, the most common codes applied were ability and interpersonal traits (Figure 2). Comments about surgical skills and leadership potential were found more in letters for men. In contrast, comments on work ethic were found more in letters written for women.

      Conclusion

      Despite having more risk words, LOR for men had more mentions of surgical skills and leadership compared to LOR for women. These gender differences in LOR written for gynecology fellowship applicants indicate the presence of subtle gender bias.
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