LAUSR

Letters of recommendation (LoRs) from neurosurgical faculty shed light on applicants’ personalities and behaviors of those without a neurosurgical program at their home institution. Alongside USMLE Step 1 score, LoRs are the only other factor cited by 100% of program directors in selecting which applicants to interview, ranking it at 4.6/5 importance.1 While LoRs are crucial in interviewee selection, their impact on rank-list position falls behind performance on interview day.1 Accordingly, the goal is to preserve the quality of selected interviewees in the absence of sub-internship LoRs. For certain applicants, outstanding sub-internship performance and strong LoRs are key in securing them an interview invitation; these may include under-represented minorities and those with non-traditional backgrounds. Since objective metrics (eg, board scores) have shown poor correlation with performance in residency,2,3 now, more than ever before, is the time to adopt a wholistic review of applicants’ profiles; this includes close review of performance on third year clinical rotations and involvement in their medical school and local communities. In addition to research LoRs, students should be encouraged to solicit LoRs from non-neurosurgical mentors who can comment on their personal attributes and interpersonal skills.4 Another consideration is how to compare students who have LoRs from pre-COVID-19 sub-internships to those who do not. To level the playing field, one option is to categorically not consider sub-internship letters in determining who merits an interview. Alternatively, a tiered review process could be used where applications are first reviewed without looking at subinternship LoRs, and that these are only consulted (if available) when they may benefit an applicant (ie, when they would otherwise not be invited to interview). Lastly, programs could elect to increase the number of applicants they interview. This comes with added cost to an already costly process for both programs and applicants in terms of time and money.5 A potential solution would be a 2step process wherein a larger pool of applicants is invited to an online screening interview, and a smaller cohort is subsequently invited to the on-site interview day. Some advocate for the use of validated online personality assessment tools as a way to evaluate applicants’ personality, and that these may be superior to LoRs, as they are standardized across applicants and thus, less prone to implicit biases that may be held by letter writers.2