Perspectives of program signaling in residency recruitment among surgical and non-surgical applicants

Global Surgical Education - Journal of the Association for Surgical Education · 2026-01-29

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

Journal of surgical education · 2025-06-16

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

medRxiv · 2025-03-18

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

Leadership in Action: Tales From the Trenches

Journal of Surgical Research · 2025-08-29 · 1 citations

Identification and prevalence of growth mindset language in resident feedback

Global Surgical Education - Journal of the Association for Surgical Education · 2025-02-24 · 5 citations

Minimally invasive colorectal cancer surgery: an observational study of medicare advantage and fee-for-service beneficiaries

Surgical Endoscopy · 2024-08-19 · 1 citations

BACKGROUND: Enrollment of Medicare beneficiaries in medicare advantage (MA) plans has been steadily increasing. Prior research has shown differences in healthcare access and outcomes based on Medicare enrollment status. This study sought to compare utilization of minimally invasive colorectal cancer (CRC) surgery and postoperative outcomes between MA and Fee-for-Service (FFS) beneficiaries. METHODS: A retrospective cohort study of beneficiaries ≥ 65.5 years of age enrolled in FFS and MA plans was performed of patients undergoing a CRC resection from 2016 to 2019. The primary outcome was operative approach, defined as minimally invasive (laparoscopic) or open. Secondary outcomes included robotic assistance, hospital length-of-stay, mortality, discharge disposition, and hospital readmission. Using balancing weights, we performed a tapered analysis to examine outcomes with adjustment for potential confounders. RESULTS: MA beneficiaries were less likely to have lymph node (12.9 vs 14.4%, p < 0.001) or distant metastases (15.5% vs 17.0%, p < 0.001), and less likely to receive chemotherapy (6.2% vs 6.7%, p < 0.001), compared to FFS beneficiaries. MA beneficiaries had a higher risk-adjusted likelihood of undergoing laparoscopic CRC resection (OR 1.12 (1.10-1.15), p < 0.001), and similar rates of robotic assistance (OR 1.00 (0.97-1.03), p = 0.912), compared to FFS beneficiaries. There were no differences in risk-adjusted length-of-stay (β coefficient 0.03 (- 0.05-0.10), p = 0.461) or mortality at 30-60-and 90-days (OR 0.99 (0.95-1.04), p = 0.787; OR 1.00 (0.96-1.04), p = 0.815; OR 0.98 (0.95-1.02), p = 0.380). MA beneficiaries had a lower likelihood of non-routine disposition (OR 0.77 (0.75-0.78), p < 0.001) and readmission at 30-60-and 90-days (OR 0.76 (0.73-0.80), p < 0.001; OR 0.78 (0.75-0.81), p < 0.001; OR 0.79 (0.76-0.81), p < 0.001). CONCLUSIONS: MA beneficiaries had less advanced disease at the time of CRC resection and a greater likelihood of undergoing a laparoscopic procedure. MA enrollment is associated with improved health outcomes for elderly beneficiaries undergoing operative treatment for CRC.

Enhancing Inclusive Excellence in the Surgical Workforce

Annals of Surgery · 2024-04-25 · 1 citations

RECRUITING A DIVERSE SURGICAL WORKFORCE: THE VISITING CLERKSHIP Recognizing the benefits of a more demographically diverse surgical workforce, the University of Pennsylvania’s (Penn) Department of Surgery implemented a visiting clerkship program (VCP) in 2015 that identified prospective residency applicants who self-identified as ethnically underrepresented in medicine (URiM) as defined by the Association of American Medical Colleges.1–3 This program supplemented existing visiting clerkship opportunities through the Perelman School of Medicine for medical students interested in surgical residencies. The intent of this successful program was to provide equitable access to surgical subinternship experiences for URiM students, which had historically been a challenge. Furthermore, this program aimed to increase the mentorship of URiM applicants in surgical specialties. The VCP was advertised online and at major medical education conferences. Interested rising fourth-year medical students applied to the VCP in their surgical subspecialty of choice during the spring before residency interview season. All rising students, agnostic of sex, race/ethnicity, LGBTQ+ status, socioeconomic status, medical school, or other personal demographics were encouraged to apply. Upon holistic review of the applicants, and with the focus on enhancing demographic diversity, specialties made VCP selection decisions on a rolling basis and completed them by June. VCP application requirements were similar to those for residency applications. Applicants had to submit a curriculum vitae or resume, medical school transcripts, a personal statement, and a letter of support from an attending physician. The letter of support typically came from a surgical attending physician in the specialty to which the applicant applied. Selection processes varied by surgical subspecialty. For some subspecialties, the residency program director alone evaluated applications for acceptance. For others, a VCP selection committee of residents and faculty assisted the program director with applicant selection. Regardless of the process, the selection criteria mirrored residency interview selection criteria to maintain consistency in the caliber of students accepted. Selected students received a stipend for a 4-week visiting clerkship experience at Penn.2,3 They were assigned a faculty and resident mentor, and met with program directors and/or chairs during their time on service. They also participated in social events with visiting students, faculty, and house staff from other specialties, including those from partnering institution, The Children’s Hospital of Philadelphia, to build a community away from home. Together with efforts like conference outreach and holistic review, the VCP is an effective recruitment tool for enhancing the diversity of our surgical trainee workforce. As we initiated these strategies simultaneously, we cannot claim a causal relationship between this VCP and our results as a stand-alone initiative. From 2015 to 2022, the percentage of newly matched URiM interns in our surgical training programs nearly tripled (Fig. 1).4,5 Consequently, one-third of the current complement of surgical trainees at Penn self-identify as URiM. This representation results in a surgical department that better reflects the greater Philadelphia community in which it serves, with hopes of leading to improved patient care experiences and outcomes for all. In addition, improved inclusivity within surgical residency cohorts can groom trainees to be more welcoming and accepting of differing thought processes and cultural behaviors. It is, however, important to stress that surgical leadership and faculty also influence the residency environment, so engagement and commitment to these efforts from these parties is equally critical.FIGURE 1: The University of Pennsylvania’s Department of Surgery categorical intern ethnically URiM match data 2015 to 2022*. % URiM interviewed; % URiM matched. *This includes general surgery, neurosurgery, ophthalmology, orthopedic surgery, otolaryngology, integrated plastic surgery, urology, and integrated vascular surgery categorical residency positions.With the successes at Penn in mind, the authors created a framework for building effective VCPs targeting inclusive excellence. The following Dos and Don’ts should serve as a guide for institutions aiming to enhance the diversity of their surgical trainee workforce: THE DOS Provide a Stipend That is Commensurate With the Cost of Living in Your Locale The costs associated with visiting clerkships can prevent many historically disadvantaged students from applying for them. Institutions should develop standardized stipend amounts for their VCPs informed by the cost of living (lodging and travel) in their respective areas. These stipends should intermittently be re-evaluated to account for inflation. For instance, the starting stipend for Penn VCPs was up to $1500 in 2015 and $2000 in 2022. Stipends are also a strong recruitment tool, as students will likely apply for opportunities that provide funding over those that do not. Have Assigned Faculty and Resident Mentors Who Frequently Check in With the Visiting Student During the Rotation Mentorship is extremely important to ensure residents from diverse backgrounds thrive and is also pivotal for a successful VCP.6 Faculty and resident mentors should help students familiarize themselves with the institution and transition to their sub-intern roles. Faculty mentors should also serve as advocates and check in regularly with service faculty and residents about visiting students’ performances. Resident mentors should more frequently engage with visiting students and serve as a resource for logistics, education, and navigating institutional culture and climate. Residents are also excellent resources for advice related to the residency recruitment process. Their proximate experience with the process is beneficial for imparting advice that will ensure success. Peer mentorship initiatives are growing in popularity and have inherent value.7 Schedule Time for the Visiting Student to Meet With the Specialty’s Program Director and/or Chair VCPs are an opportunity for students to display their strengths for a surgical program and see if the program is a good fit for them. Institutions recognize this and should make every effort to ensure VCP students have face time with the program director of their surgical specialty, at minimum. This face time should be in the form of a one-on-one meeting, akin to a miniature residency interview. Faculty and resident mentors should prime their visiting mentees on this expectation early, so the students can feel adequately prepared. Meeting with the department chair is also encouraged, if scheduling allows. These meetings have the potential to improve VCP students’ visibility and likelihood of matching at their subinternship institution, as they allow for a more complete representation of the students’ abilities and values. Plan Social Gatherings With Other Specialties to Facilitate Networking Between All Visiting Clerkship Program Students Surgical programs with VCPs should cosponsor events for their VCP students, whether formally or informally. Participating faculty and residents are encouraged to attend, keeping in mind that the priority should be ensuring the various visiting students have time to interact and network with each other. These events help reduce anxieties and provide another level of community for VCP students. They also present an opportunity for students to interact more closely with surgical faculty and trainees in a much lower-stress environment. Provide Consistent Feedback and Offer Continued Mentorship at the Rotation’s Completion Faculty and residents who interact with visiting students on service during the VCP should provide them with consistent real-time and intermittent summative feedback. At a minimum, non-mentor faculty and trainees should provide feedback to mentors to review with the students. Furthermore, faculty and/or residents should give summative feedback at two distinct time points during the clerkship. We suggest this feedback happen after 2 weeks and at the end of the rotation to give students a chance to improve upon any deficiencies and hone strengths before their subinternships end. THE DON’TS Do Not Offer Visiting Clerkship Program Positions to Students Who do Not Meet Your Criteria for Residency Selection The goal of the VCP is to provide equitable access to surgical subinternship experiences for students from backgrounds that have been historically overlooked. Students considered for VCP selection should, at minimum, meet the department’s criteria for residency interview selection. This is to ensure that students transition well and have the best chance of success while on their rotations. Aligning VCP selection with residency selection maintains the quality and caliber of students rotating at each institution while allowing broadening access to these programs. Do Not Send Visiting Students to Remote Sites for the Majority of Their Rotation VCP students should conduct the majority of their rotations at the main institution sites. This promotes smoother transitions and gives them face time with more people within the department. This face time gives them the opportunity to demonstrate their clinical acumen, which in turn can develop their networks and attract advocates within the institution. Sending VCP students to remote sites can result in isolation and can interfere with the student’s productivity on service. Do Not Withhold Transparency With Visiting Students About Guaranteeing Residency Interviews An institution can elect not to align their VCP selection metrics with those for their residency interview selection. If this is the case, students selected for VCPs should only be told they will receive a residency interview if it is with 100% certainty. Discrepancies between what an institution says and does about residency interviews can compromise students’ trust and prevent future cohorts of students from applying for VCPs and even residency. Do Not Offer to Follow Up with Visiting Students After Their Rotations and Then Fail to Correspond Mentorship is an important benefit of the VCP. Do not offer to be a mentor for your institution’s program if you do not have the bandwidth to engage with visiting students regularly during their clerkship, as well as after they leave the institution. Long-term mentorship is very important for all students given the inequities many of them face related to access to medical networks and advocates within those networks. CONCLUSIONS VCPs, if implemented thoughtfully, can help build an inclusive and excellent surgical workforce. They provide opportunities for students who otherwise may not have them while still maintaining rigorous selection processes. Improved representation can exist in surgery without compromising quality.

Post Night Shift Education for Interns: A Pilot Program

Journal of surgical education · 2024-09-20

Medical Student Perceptions of Academic Surgery: Rose-Colored Glasses or Jaded Prism?

Journal of surgical education · 2024-01-04 · 9 citations

OBJECTIVE: Stereotypes of surgeons are pervasive and play a role in medical students' decisions about pursuing a surgical career. This study aimed to determine: (1) how medical students' perceptions of surgery and surgeons changed following exposure to surgery during clerkship rotations; and (2) if gender and racial/ethnic identification played a role in this process. DESIGN, SETTING, AND PARTICIPANTS: In this mixed-method study, clerkship students at one U.S. medical school were asked to anonymously contribute words and phrases that they associated with surgery to an online "word cloud" at the beginning and end of their 12-week surgery clerkship. In addition, an end-of-year, anonymous survey of their perceptions was administered and analyzed using a Grounded Theory approach. RESULTS: Of 154 students invited to complete the online survey, analysis of 24 completed surveys suggested that students believe surgical culture to be toxic, with unfriendly attitudes, strict hierarchy, and lack of work-life balance. Analysis of 678 Word Cloud responses, however, indicated that the frequency of complimentary responses increased following surgery clerkships (25% vs 36%; z = -3.26; p = 0.001), while the proportion of responses describing surgery/surgeons as male-dominated, egotistical, and scary decreased (5% vs 1%, z = 2.86, p = 0.004; 9% vs 4%, z = 2.78, p = 0.005; 3% vs 0.3%, z = 2.56, p = 0.011, respectively). The association between surgeons and being White disappeared entirely. Female students were more likely than male students to state that their perceptions did not change following exposure (40% vs 0%; z = 2.19; p = 0.029). CONCLUSIONS: With exposure to surgery, students' preconceived notions may be positively influenced. However, students continue to hold negative perceptions, and this effect may be stratified by gender identification. Institutions should work to address these perceptions in pre-clerkship years to attract a more diverse pool of future surgeons.

Development of a Machine Learning Model to Identify Colorectal Cancer Stage in Medicare Claims

JCO Clinical Cancer Informatics · 2023-05-01 · 5 citations

PURPOSE: Staging information is essential for colorectal cancer research. Medicare claims are an important source of population-level data but currently lack oncologic stage. We aimed to develop a claims-based model to identify stage at diagnosis in patients with colorectal cancer. METHODS: We included patients age 66 years or older with colorectal cancer in the SEER-Medicare registry. Using patients diagnosed from 2014 to 2016, we developed models (multinomial logistic regression, elastic net regression, and random forest) to classify patients into stage I-II, III, or IV on the basis of demographics, diagnoses, and treatment utilization identified in Medicare claims. Models developed in a training cohort (2014-2016) were applied to a testing cohort (2017), and performance was evaluated using cancer stage listed in the SEER registry as the reference standard. RESULTS: The cohort of patients with 30,543 colorectal cancer included 14,935 (48.9%) patients with stage I-II, 9,203 (30.1%) with stage III, and 6,405 (21%) with stage IV disease. A claims-based model using elastic net regression had a scaled Brier score (SBS) of 0.45 (95% CI, 0.43 to 0.46). Performance was strongest for classifying stage IV (SBS, 0.62; 95% CI, 0.59 to 0.64; sensitivity, 93%; 95% CI, 91 to 94) followed by stage I-II (SBS, 0.45; 95% CI, 0.44 to 0.47; sensitivity, 86%; 95% CI, 85 to 76) and stage III (SBS, 0.32; 95% CI, 0.30 to 0.33; sensitivity, 62%; 95% CI, 61 to 64). CONCLUSION: Machine learning models effectively classified colorectal cancer stage using Medicare claims. These models extend the ability of claims-based research to risk-adjust and stratify by stage.