Trends in utilization of standardized letters of recommendation in the 2021-2022 neurosurgery application process.

OBJECTIVE: Standardized letters of recommendation (SLORs) were introduced during the 2020-2021 neurosurgery residency application cycle, but suffered from poor interrater reliability and grade inflation. Changes were made to the SLOR template and utilization patterns in response to these shortcomings. The authors examined the second year of SLOR utilization. They hypothesized that grade inflation and interrater reliability would be improved from the first iteration. They also hypothesized that increased numbers of letters by single writers would correlate with broader rating distributions. METHODS: This cross-sectional study analyzed all SLORs submitted to a single neurosurgery residency program over the 2021-2022 cycle. Data from 7 competency domains and the overall rating were recorded and stratified by academic category of the letter writer. Interrater reliability was evaluated using Krippendorff's alpha. The frequency of letters written was evaluated using the Kruskal-Wallis H test. RESULTS: Ninety percent of SLORs rated applicants among the top 25%, but there was a significant decrease in the usage of the top 1% and top 2%-5% ratings. Interrater reliability was poor across all competencies. Writers who completed 1 SLOR rated applicants higher and had a narrower range than those who completed multiple SLORs. CONCLUSIONS: Changes in the format and subsequent utilization patterns of SLORs have slightly decreased grade inflation; however, interrater reliability remains poor. The most wide-ranging evaluators submitted the highest number of SLORs, suggesting that future evaluation and usage of SLORs should emphasize letter-writer characteristics and numbers of SLORs written. Overall, SLORs have been well and broadly accepted with subtle improvements in the second year of utilization.