Education
Development and Assessment of
Early Utilization of the Standardized
Letter of Recommendation for Use in
the Radiology Residency Match
Caroline W.T. Carrico, MD, FAUR, Ana P. Lourenco, MD, Kedar Jambhekar, MD
Rationale and Objectives: Letters of recommendation are essential for residency applications. Traditionally, narrative letters have been
used. Standardized letters of recommendation (SLOR) have been developed and have benefits to the writer and reader. The goal was to
develop an informative, meaningful, and efficient SLOR for the radiology residency Match and to assess its early use.
Materials and Methods: An Association of University Radiologists (AUR) Research and Education Venture Fund Grant was awarded for
the development of a SLOR for use in the radiology residency Match. Grant recipients developed the letter and modifications were based
on feedback from the Alliance of Medical Student Educators in Radiology (AMSER) SLOR task force and a larger task force including addi-
tional AUR and Association of Program Directors in Radiology (APDR) members. AUR and APDR members were surveyed in 2020 to
assess the radiology SLOR.
Results: The radiology SLOR became available for use in September 2018. It highlights the top six traits or abilities deemed most valued
in a resident candidate and guides the writer to develop a concrete narrative. Top perceived benefits of the Radiology SLOR are ease of
reading and interpretation. Top perceived drawbacks are an impersonal format and concerns regarding program directors ’ perceptions of
the new SLOR. SLOR utilization increased in the second year of availability.
Conclusion: The radiology SLOR was developed and first used in 2018. Its use increased over two years and will likely continue to
increase given the perceived benefits and increasing awareness of the SLOR.
Key Words: Letter; Radiology; Recommendation; Residency; Standardized.
© 2022 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.
INTRODUCTION
L
etters of recommendation are an essential part of the
application for every residency, including radiology.
Traditionally free-form narrative letters of recom-
mendation have been composed and submitted to support
applicants applying to radiology and other medical residency
programs. A standardized letter of recommendation (SLOR)
provides structure and therefore can guide the writer and the
reader, simplifying both letter composition and interpretation
respectively.
BACKGROUND
A strong narrative letter of recommendation provides impor-
tant information. The writer informs the reader of their aca-
demic background and years of experience, as well as the
length and context of the relationship the author has had
with the candidate being recommended. The applicant’s
qualifications for a given residency are described and sup-
ported with specific examples of the applicant’s personal
traits, performance, and skills. The writer may provide insight
into unique aspects of the applicant. The applicant often is
compared to current peers and predecessors and finally, a
global recommendation with a reference range is provided
(1,2).
Unfortunately, not all narrative letters are substantive or
meaningful. Studies of narrative letters have revealed many
drawbacks of these letters (1-5). For example, narrative letters
Acad Radiol 2022; 29:1583–1589
From the Department of Radiology, Duke University Medical Center, Box 3808
Durham, North Carolina, 27710 (C.W.T.C) (C.W.T.C., A.P.L., K.J.); Department
of Diagnostic Imaging, Alpert Medical School of Brown University, Rhode
Island Hospital, Providence, Rhode Island (A.P.L.) (C.W.T.C., A.P.L., K.J.); Uni-
versity of Arkansas for Medical Sciences, Little Rock, Arkansas (K.J.)
(C.W.T.C., A.P.L., K.J.). Received September 14, 2021; revised January 31,
2022; accepted February 3, 2022. Address correspondence to: Caroline W.
T. Carrico, MD, FAUR, Department of Radiology, Duke University School of
Medicine, Box 3808 Duke University Medical Center, Durham, NC 27710 (C.
© 2022 The Association of University Radiologists. Published by Elsevier Inc.
All rights reserved.
https://doi.org/10.1016/j.acra.2022.02.004
1583
often contain excessive praise and flattery (3). They can be
hard to interpret, employing a hierarchy of praise phrasing or
code words that may mean something very specific to the
writer, but may not have that same meaning for different
readers, which may contribute to poor inter- or intra-rater
reliability (3). Narrative letters can be very vague and lack
specific examples of the candidate’s demonstrated abilities, or
redundant, simply restating information found elsewhere in
the application (3). Narrative letters may also contain ele-
ments of gender bias (2,5) and take longer to interpret (1,3).
SLORs have recently been used in the orthopedic surgery
residency Match (6,7), and have been used for many years in
the dermatology (3) and otolaryngology (1,2) Matches. Stan-
dardized letters have been in use for over two decades in the
emergency medicine Match (8).
Comparing the SLOR to narrative letters in dermatology,
Kaffenberger et al. found that the SLOR was faster to inter-
pret than the narrative letter, saving on average one minute
per letter, (p<0.0001), and had higher intra-rater and inter-
rater reliability for determining the applicant’s personality,
work ethic and reliability (p<0.001), had less exaggeration of
positive traits (p<0.0001), and provided two more pieces of
information regarding the status of the author/student rela-
tionship (3). Assessing SLORs in the otolaryngology Match,
Perkins et al. noted that the SLOR took less time to interpret
and to write, averaging less than 5 minutes to write (1). Addi-
tionally, there was higher inter-rater reliability regarding
assessment of the applicant ’s qualifications for otolaryngology,
the author’s global assessment and summary statement, and
for rating the overall letter ranking (1).
A SLOR was developed for use in the emergency medi-
cine residency Match in 1997. A survey of the Council of
Emergency Medicine Residency Directors (CORD) was
published in 2014 (9). One hundred fifty of the 159 program
directors (94.3%) responded to the survey, which speaks to
the value and utility of the standardized letter in the emer-
gency medicine Match. However, respondents noted that
some writers did not follow instructions, some questions
were not answered, and some authors modified the SLOR or
used a longer narrative. Nonetheless, 99.3% supported the
SLOR as an evaluative instrument and 92.7% indicated that
the SLOR was the number one aspect of the application that
they use in making their decision of which applicants to
invite for an interview (9). The SLOR in the emergency
medicine Match has evolved in form and function to become
a Standardized Letter of Evaluation (SLOE) with a required
online electronic format (10).
The goal of this project was to develop a SLOR for use in
the radiology residency Match, with the hope that it would
provide more informative, meaningful, and efficient commu-
nication between letter writers and resident selection teams.
MATERIALS AND METHOD
A Research and Education Venture Fund Grant from the
Association of University Radiologists (AUR) was awarded
to three AUR members in 2017 to develop a SLOR for use
in the radiology residency Match. The SLOR used in otolar-
yngology, dermatology, and emergency medicine were
reviewed and a literature search was performed investigating
the use of SLORs in the medical literature. These SLORs
had some common features which influenced the structure of
the radiology SLOR.
The first draft of the radiology SLOR was reviewed by the
newly formed SLOR Task Force composed of twelve mem-
bers of the Alliance of Medical Student Educators in Radiol-
ogy (AMSER). The revised letter was sent to AUR members
including members of AMSER and the Alliance of Clinical
Educators in Radiology (ACER), as well as to the Association
of Program Directors in Radiology (APDR) members for
additional feedback. Excluding the authors, 79 people from
the membership of the AUR, AMSER, ACER, and APDR
ultimately provided feedback by way of surveys or emails,
which contributed to the sequential revisions of the SLOR.
The final version of the letter was first posted on the AUR
website and was available for use in September of 2018.
Feedback to the developers of the letter was continuously
available via the combined Radiological Society of North
America (RSNA) and AUR reporting feedback email link.
Given the scant feedback from 2018 to 2019, in order to
assess membership awareness of the availability of the SLOR,
its real and potential use, usefulness, and composition, a two-
part survey was created and sent to members of the AUR and
APDR on March 16, 2020. Membership to the APDR can
occur with or without concurrent membership to the AUR.
The first part of the survey was composed of 11 brief ques-
tions that assessed the awareness, use, and usefulness of the
SLOR. The survey taker had the option of ending the survey
at that point. The second part of the survey gave the survey
taker the opportunity to provide suggestions for improve-
ment regarding the composition and elements of the letter.
In this portion, the entire radiology SLOR was printed and
divided into sections. The survey taker had a free text box to
write suggestions for letter modification for each individual
section.
The survey was distributed on March 16, 2020, before
Match Day. This would usually be a quiet time after program
directors had completed their Match rank lists and before the
matches are announced. Letter readers would have just read
many letters and would likely have many useful ideas to share
at that time. Unfortunately, due to the arrival of the Covid-
19 virus to the United States, this usually quiet time became
very busy with transitions to social distancing and remote
teaching and working. Nonetheless, there were several
responses.
Based on AUR/APDR email data, the survey was sent to
923 people in the AUR and to 112 people in the APDR. Of
the emails sent, 511 (49%) were opened. Eighty-four of the
email recipients, (8%), opened the email and continued to
the survey. The survey link was embedded in the AUR/
APDR email and some likely forwarded the survey to other
radiologists in their department or other at institutions and or
CARRICO ET AL Academic Radiology, Vol 29, No 10, October 2022
1584
accessed the survey outside of the email link given that 91
surveys, presumably completed by 91 different individuals,
were completed and submitted March 16 through June 1,
2020. The survey was unofficially closed on June 1, 2020,
and data was aggregated and sent to the authors for assessment
on June 2, 2020. The link however remained open and
unbeknownst to the authors; a single additional survey was
completed weeks later. The information from that single late
survey response was not included in the survey results that
follow.
RESULTS
The final version of the radiology SLOR has four sections
(Fig 1). Prior to Section 1, there are boxes to indicate
whether the student has waived the right to view the letter.
Section 1: Student and Author Data. This includes applicant
identifiers and author identifiers with contact information and
relevant teaching experience. There are check boxes and free
text options that help to define the nature and duration of
the working relationship of the applicant and the letter
writer.
Section 2: Applicant’s Actions and Traits Demonstrated
Routinely. The top six actions and traits that were deemed
most valued in a candidate for radiology residency are
addressed in Section 2. These are that the student communi-
cates effectively, demonstrates a strong work ethic, exhibits
intellectual curiosity, possesses a strong fund of medical
knowledge, shows leadership, and works well with a team.
The student is then compared to their peers regarding the stu-
dent’s demonstrated qualities and actions in each of these
areas. To do this the writer is asked to rate the student from 0
to 100 percentile for each action and trait. The writer is
instructed to provide a concrete example in the narrative sec-
tion, Section 4, for any rating in the top 10 percent, the 91 to
100 percentile. There is also an option to state that the writer
cannot assess the student regarding any or all of the valued
traits. This instruction, to support high ratings with perfor-
mance examples in the narrative section, is intended to help
create a substantive letter with specific examples of the stu-
dent’s abilities as they were demonstrated in the workplace or
learning center, while simultaneously minimizing praise infla-
tion.
Section 3: Global Assessment. In this section, the author
indicates their overall assessment of the candidate on a 0 to
100 percentile scale. In both Section 2 and Section 3, the let-
ter writer indicates if the student is being compared to all stu-
dents that the writer has ever worked with or to students that
the author had worked with within the last 5 years.
Section 4: Narrative Section. In Section 4, the author is
encouraged to provide concrete examples of the student’s
abilities and traits that were rated in Section 2 and to provide
supportive information that is not found elsewhere in the
application. A 300-word limit is suggested but is not
enforced. The provided text box is expandable.
The AUR Executive Committee and the APDR Board of
Directors approved the use of the Standardized Letter of Rec-
ommendation in 2018. The radiology SLOR and instructions
for its use were officially posted on the AUR website on Sep-
tember 7, 2018. A feedback link was posted on the AUR/
AMSER website for letter users to have a place to send feed-
back and suggestions regarding the SLOR. The link remains
active https://www.aur.org/resources/standardized-letter-
recommendation. Feedback can also be sent directly via email
Recommendation (SLOR).
FEEDBACK AND FOLLOW-UP SURVEY
After receiving feedback in 2018 that the file size was too
large to be accepted by the Electronic Residency Application
Service (ERAS), the format was changed from a PDF to a
modifiable Word document (Fig 1).
The instructions for uploading the letter to ERAS were
modified, and it was confirmed with ERAS personnel that all
letters could be uploaded free of charge by ERAS staff. The
writer simply has to email the letter to ERAS at eraslorporta-
SURVEY RESULTS
The 91 respondents self-identified their departmental role or
roles, as shown in Table 1.
The survey asked, “How important is the standardized or
narrative letter of recommendation in determining which
candidates you will invite for an interview?” Eighty-seven
people replied to this question. A letter of recommendation
is: extremely important, main factor (9.2%) moderately
important (39.1%), only important if extreme (27.6%), and
rarely used as a deciding factor (17.2%). Other comments
included that a letter has increased value if the reader knows
the writer, or if the letter declares a strong candidate or hints
at a suboptimal candidate.
Survey takers were asked to speculate on the importance of
the letters of recommendation after the STEP 1 examination
becomes Pass/Fail. Eight-eight people replied indicating that
the importance of the letter would have a marked increase
(26.1%), a moderate increase (50%), would not change
(22.7%), would have a moderate decrease (zero %), or a
marked decrease (1.1%).
Regarding the current use of the SLOR, the survey asked,
“How many radiology SLORs did you receive during this
year’s radiology Match?” This referred to the 2019-2020
Match cycle. They were then asked, “How many radiology
SLORs did you receive during the 2018-2019 Match cycle
(the first year the letter was available)?” 61.4% reported
receiving at least one SLOR the first year it was in use and
that increased to 76.7% for the 2019-2020 Match cycle. The
number of respondents that received 6-25 letters in a year
more than tripled and those that received more than 25
Academic Radiology, Vol 29, No 10, October 2022 RADIOLOGY MATCH STANDARDIZED LETTER OF RECOMMENDATION
1585
Figure 1. Radiology standardized letter of recommendation for use in the radiology residency Match. (Color version of figure is available online.)
CARRICO ET AL Academic Radiology, Vol 29, No 10, October 2022
1586
SLORs more than doubled the second year that the letter was
used (Table 2).
Eighty-eight people answered the question “Did you choose
to use the SLOR when writing letters?” 72% responded that
they never did, 8% used it less than half of the time, 5.7% used it
more than half of the time and 13.6% always used the SLOR.
The main reason offered by the group that stated that they never
used the standardized letter included: 26.4% do not write letters,
12.5% were not aware that the SLOR was available for use,
36.1% did not like the SLOR format, and 29% had a variety of
other reasons, including that they prefer their own template.
None of the 72 respondents that offered reasons for not using
the SLOR selected the option “I had technical difficulty
uploading the SLOR to ERAS”. Sixty percent of the 91 survey
respondents were not aware that SLORs were used in dermatol-
ogy, otolaryngology, orthopedic surgery, and emergency medi-
cine residency Matches.
The survey takers were asked to indicate perceived benefits
and drawbacks to using the SLOR compared to composing a
narrative letter. For both, there were items listed that could
be checked and there was a free text box. Respondents were
asked to check all that apply and to write in benefits and
drawbacks that were not listed in the free text box.
Respondents were asked to indicate perceived benefits of
the radiology SLOR; results are shown in Table 3.
When asked to indicate perceived drawbacks to using the
radiology SLOR responses included that the SLOR has a less
personal format (66%), the writers had concerns about how
the SLOR would be perceived by program directors (38%),
the SLOR is new and untested in radiology (21%), and that
the letter writers did not know the candidates well enough to
give specific examples of the student's traits as requested in
the SLOR (19%).
The second part of the survey gave the survey taker the
opportunity to provide suggestions for improvement regard-
ing the composition and elements of the letter. None of the
respondents continued to section two to suggest structure
modifications.
DISCUSSION
The radiology SLOR is similar to SLORs used in other med-
ical specialties in that it focuses the letter writer to provide
details about their relationship with the applicant, rate the
student on a 0 to 100 percentile scale in specific areas consid-
ered important for success in residency, and to provide a
global assessment. These assessments are substantiated with
specific examples from the letter writer’s interactions with
the student and are detailed in the narrative section.
With input from the radiology education community as
detailed above, six important criteria were selected for
TABLE 1. 2020 Survey Respondents. There were 91 Total
Respondents, Some of Which Held More Than 1 Role
Title Number of
Respondents
Residency Program Director 40
Associate or Assistant Program Director 17
Clinical Faculty 29
Clerkship Director 12
Vice Chair for Education 10
Department Chair 2
Research Faculty 2
Former Residency Program Director 1
Former Clerkship Director 1
Medical Student Advisor 1
Director of Medical Student Education 1
Program Administrator 1
Chair of Resident Selection Committee 1
Member of Resident Selection Committee 1
Fellowship Director 1
TABLE 2. SLOR Use 2018-2020. This Table Shows the Num-
ber of Letters That were Reportedly Received by Survey Tak-
ers the First Year the Radiology SLOR was Available (2018-
2019) and the Second Year That the SLOR was Used (2019-
2020) in the Radiology Residency Match
Match Cycle 2018-2019
(n=83)
2019-2020
(n=86)
No letters were received 38.6% 23.3%
Some letters were received 61.4% 76.7%
1-5 letters 48.2% 32.6%
6-10 letters 6% 22.1%
11-25 letters 3.6% 14%
>25 letters 3.6% 8.1%
TABLE 3. Perceived Benefits of the SLOR. Percentage of
Respondents Indicating Each Perceived Benefit of the SLOR
are Shown
Perceived Benefit Percentage of
Respondents
Easier to read 54
Easier to interpret 49
Saves time 43
Easier to write 42
Facilitates rating candidates 38
Greater inter-rater reliability 36
More transparent 30
More concrete examples of strengths 24
More concrete examples of weaknesses 18
More objective 17
Less praise inflation 17
Less grade inflation 11
Limits gender bias 10
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inclusion in the SLOR: 1) communicates effectively, 2) dem-
onstrates a strong work ethic, 3) exhibits intellectual curiosity,
4) possesses a strong fund of medical knowledge, 5) shows
leadership and 6) works well with a team.
The SLOR aims to help both the writer and the reader be
efficient. This is achieved by standardizing the location of
specific information within the letter and by guiding the
writer to produce a robust substantive letter rather than a
string of unsubstantiated superlatives. In the survey, 19% of
the 86 respondents that identified perceived drawbacks to
using the SLOR stated that they do not know the applicants
well enough to use the SLOR. This acknowledges that
unlike narrative letters, the SLOR requires the letter writer
to know the student well enough to rate various skills and
traits and to provide examples of the student’s performance in
the narrative section. This likely produces a more meaningful
letter.
The narrative section has a suggested 300-word limit,
though this is not enforced, as the text box is expandable.
The suggested limit encourages brevity. However, the
expandable text box allows the author to provide rich and
concrete examples of the student’s abilities and traits that
were rated in the top 10%, as well as allowing inclusion of
supportive information not found elsewhere. The writer is
not forced to omit any meaningful and supportive informa-
tion simply because of a word limit. The otolaryngology
SLOR 2014 revision has no word limit in the narrative sec-
tion (11). The dermatology letter limits the writer to 200
words and focuses the author to describe the candidate’s
greatest strength, but additional comments are welcomed
(12). The emergency medicine 2016-2017 letter requests that
authors limit the narrative about the student to 250 words
and has a separate requested 250-word limit narrative section
for the author to describe essential information regarding the
institution and the rotation/course (13).
The main perceived drawbacks for using the radiology
SLOR were the less personal format and that it is untested in
radiology and as such, there is uncertainty as to how the letter
would be received by program directors. However, recall
that 19% expressed that they did not know the candidate
well enough to give specific examples of the student’s traits
and abilities that were supposed to be described in the letter.
Interestingly this directly contradicts the main perceived
drawback which is that the SLOR is thought to be a less per-
sonal format. The format may seem less personal, with lack of
letterhead designs and institutional symbols, but hopefully,
when used correctly, the personal substance will be greater.
To encourage the author to write a letter that genuinely
supports the candidate, the letter writer is not asked to com-
ment on match potential or likely position on the rank list.
The author is not asked to state if they anticipate that the stu-
dent would likely match into the specialty as in the otolaryn-
gology SLOR (11). Similarly, the author is not asked to state
if or roughly, where the student may be ranked for the Match
at the author’s institution as in the emergency medicine
SLOE (13).
Seventy-six of the radiology SLOR survey respondents
speculated that letters of recommendation would have a
marked (50%) or moderate (26%) increase in importance after
the STEP 1 examination becomes Pass/Fail. Some schools do
not have uniformly tiered grading but rather limit some
grades to Pass/Fail (14,15). As fewer objective assessments are
available, resident selection committees may place greater
weight on letters of recommendation when choosing candi-
dates to interview and select for residency.
The radiology SLOR is relatively new. Emails to the AUR
and APDR members have been sent prior to each Match sea-
son beginning in September of 2018 to inform and remind
members that the SLOR is available for use. Nonetheless, in
the 2020 SLOR survey, of the 72 respondents that answered
the questions that asked why they did not use the radiology
SLOR when writing letters for the radiology Match, 12.5%
said that they did not know that the letter was available for
use. The recent Covid-19 pandemic and lack of in-person
national meetings have limited the opportunities for the
SLOR to be discussed in large forums and in small groups.
This publication, workshops, and discussion panels at future
meetings and continued email campaigns will be useful to
increase awareness and likely increase subsequent use. Addi-
tionally, 60% of the 91 survey respondents stated that they
were not aware that SLORs were used in dermatology, oto-
laryngology, orthopedic surgery, and emergency medicine
residency Matches. Recognition of the building trend in the
use of SLORs may also increase the use and acceptance of the
radiology SLOR.
There is a great opportunity for research and development
regarding the radiology SLOR. Studies should be performed
to assess the time required for composition and interpretation,
inter-reader reliability, gender-related issues, grade, and praise
inflation, the utility of the format for inducing the letter
writer to add details and information not found elsewhere in
the application, and the correlation of the interpretation of
the letter with interview and rank lists.
A repeat survey of the AUR and APDR membership is
planned for early 2023. This will be used to gather feedback
to determine what portions of the SLOR should be modified
and how.
In the future, a national committee could curate feedback
and update the SLOR as recruiting practices change, modify
the accessibility and ease of use of the SLOR, and develop a
variety of SLORs. A variety of SLORs could be developed
including 1) a specific letter for the interventional radiology
residency Match, 2) a Group Letter to be filled out by a clerk-
ship director, chairman, and or program director that summa-
rizes input from many faculty, or two or three faculty could
compose a consensus letter, 3) a letter for the non-radiologists
physician to compose, or 4) fellowship letters.
Limitations of this study include the relatively low numbers
of survey respondents. Additional formative feedback from a
larger number of radiology educators could lead to further
substantive changes to the SLOR, which could improve its
functionality. Similarly, the novelty of the letter and limited
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early utilization makes it difficult to ascertain any tangible
improvements it may provide to the recruitment process.
Future studies will be important to assess this. In addition,
continued education about the SLOR’s existence will be
important to increasing its use. This will require discussion at
national meetings, publications such as this one, as well as
social media and email campaigns to increase awareness of the
letter's existence and potential benefits of its utilization.
CONCLUSIONS
The SLOR was developed through research funding support
by an AUR Venture Fund Grant and was first available for
use in September 2018. While the use of the radiology
SLOR increased during the first two years, more needs to be
done to increase use and awareness. Many remain unaware
that the radiology SLOR is available and that other medical
specialties have used standardized letters in the Match for
years or decades. As the utilization of the SLOR increases,
further research to evaluate its effectiveness in comparison to
narrative letters will help inform future modifications to opti-
mize its utility. Artificial intelligence and deep learning may
facilitate this research. Lastly, the SLOR’s importance in the
residency selection process will likely increase significantly, as
some schools reduce or eliminate tiered grading and the
USMLE STEP 1 examination shifts to a binary pass/fail
exam.
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2017 and by Jennifer S Jackson via email with CWT Carrico in 2021.
14. McDuff SG, McDuff D, Farace JA, et al. Evaluating a grading change at
UCSD school of medicine: pass/fail grading is associated with
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15. Reed DA, Shanafelt TD, Satele DW, et al. Relationship of pass/fail grad-
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Academic Radiology, Vol 29, No 10, October 2022 RADIOLOGY MATCH STANDARDIZED LETTER OF RECOMMENDATION
