EP582 - Qualitative Insights from Letter Writers and Program Directors Who Used the Updated Standardized Letter of Recommendation (SLOR) for Colorectal Surgery

ePoster Presenter(s)

• 

  Kayvan Barekatain, MD (he/him/his)

  Resident Physician
  Case Western Reserve University Hospitals
  University Hospitals, Cleveland Medical Center
  Cleveland, OH, United States

  Disclosure information not submitted.

Author(s)

• 

  Emily F. Simon, MD (she/her/hers)

  General Surgery Resident
  University Hospitals Cleveland Medical Center, Department of Surgery
  Cleveland, OH, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.
• SK

  Saher-Zahra Khan, MD

  General Surgery Resident
  University Hospitals Cleveland Medical Center
  South Euclid, OH, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.
• 

  Marnie Abeshouse, MD

  Colon and Rectal Surgery Fellow
  University Hospitals Cleveland Medical Center
  University Hospitals Cleveland Medical Center
  Cleveland, OH, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.
• 

  Kristen Westfall, MD, MPH (she/her/hers)

  Assistant Professor of Surgery
  University Hospitals/Cleveland Medical Center
  Case Western Reserve University
  Cleveland, OH, United States

  Disclosure information not submitted.
• 

  Ronald Charles, MD (he/him/his)

  Assistant Professor of Surgery
  University Hospitals Cleveland Medical Center, Department of Surgery, Division of Colorectal
  Cleveland, OH, United States

  Disclosure information not submitted.
• MC

  Meagan Costedio, MD (she/her/hers)

  Medical Director of Colorectal Surgery
  Ahuja Medical Center of University Hospitals
  Case Western University
  Beachwood, OH, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.
• 

  Michael A. Valente, DO

  Associate Professor of Surgery
  Cleveland Clinic
  cleveland, Ohio, United States

  Disclosure information not submitted.
• JS

  Julia Saraidaridis, MD

  Burlington, MA

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.

Senior Author(s)

• ES

  Emily Steinhagen, MD, FACS, FASCRS

  Associate Professor of Surgery
  University Hospitals Cleveland Medical Center, Department of Surgery, Division of Colorectal
  Cleveland, Ohio, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.

Purpose/Background: The American Program Directors in Colon and Rectal Surgery (APDCRS) implemented a revised standardized letter of recommendation (SLOR) for the 2025-2026 application cycle to enhance fairness, comparability, and distinction between applicants. Key updates included more specific and anchored rating domains, more structured free responses with character counts on specific domains, and a required discussion of a weakness from the list of items in the rating rubric. This qualitative study explores the opinions and impact on program directors (PDs) and letter writers (LWs).

Methods/Interventions: This was a qualitative analysis of responses to open-ended questions included in surveys distributed to LWs and PDs following the 2025-2026 colorectal surgery residency application cycle. Surveys were distributed to all 394 letter writers (LWs) and 74 program directors (PDs); 118 (30%) and 41 (55%) responded, respectively. Responses were analyzed using a combined inductive-deductive approach guided by the RAMP (Relationship, Autonomy, Mastery, Purpose) model of motivation.

Results/Outcomes: 325 open-ended responses (118 LWs, 41 PDs) were analyzed; representative quotes and frequencies are found in Table 1.

Respondents highlighted persistent difficulty distinguishing among applicants and expressed mixed opinions about the weakness question. Both groups viewed the form as a positive, if imperfect, update that requires continued refinement, faculty development, and shared commitment to honest assessment. Many respondents embedded criticism in their responses, expressing frustrations about constraints, difficulty articulating nuance, and ongoing rating inflation.

LWs described a duty to advocate for trainees and conflicting feelings about how to balance an honest assessment with loyalty to applicants and the need to promote them. This led to discomfort in rating or when describing a weakness. PDs emphasized trust in LWs and saw the SLOR as a tool for transparency, though some doubted its ability to counter norms of uniformly high praise.

LWs expressed mixed views regarding autonomy; some felt the form promoted clarity; others found it restrictive. PDs appreciated consistency through anchors but noted inconsistent application by LWs.

Both groups viewed the SLOR as promoting reflection and fairness through explicit standards, though uneven adherence limited its ability to distinguish applicants. They shared a strong belief in the SLOR's overarching purpose: making applicant evaluations more fair, structured, and comparable. PDs frequently emphasized its role in leveling the field, describing it as an "evolution toward accountability." LWs expressed alignment with those goals but noted "tools alone cannot guarantee fairness" without broader systemic interventions. Both groups recognized the SLOR as a step toward equity yet viewed its impact as imperfect.

Conclusion/Discussion: Qualitative comments on the new SLOR suggest a strong shared purpose but differing experiences of autonomy and relational duty. The SLOR promotes fairness but challenges authenticity when the desire to advocate for an applicant conflicts with norms. Persistent difficulty distinguishing among applicants, driven by letter writers' desire to promote them, may not be overcome with a SLOR form alone.

Table 1
Representative Quotes and Frequencies