The Role of Gender in Neurosurgical Residency Applicants' Letters of Recommendation

BACKGROUND: Letters of recommendation (LORs) are one of the most important components of the neurosurgical residency application. Studies in other fields and surgical subspecialties have found gender bias. OBJECTIVE: To determine whether neurosurgical LORs contain significant linguistic gendered differences. METHODS: We performed a retrospective review and linguistic analysis of all LORs submitted on behalf of applicants offered an interview invitation to a single neurosurgical residency program at an academic medical center between 2015-2016 and 2018-2019. RESULTS: A total of 599 letters from 156 applicants (120 males and 36 females) were included. Background demographics, including United States Medical Licensing Examination (USMLE) Step 1 score and publications, were not significantly different between applicants. Male faculty authored 93% of all letters. Female faculty were more likely to write letters for female applicants than male applicants (12.1% vs 5.5%, P <.001). Letters for women were significantly longer (334 words vs 277 words, P <.001). Overall, 1754 agentic terms and 854 communal terms were coded. Letters for men contained significantly fewer agentic terms (10.7 vs 13.1, per applicant, P <.01) and communal terms (5.2 vs 6.4, P <.034). This difference, however, is nonsignificant when word count was used as a covariate. Female applicants were more significantly likely to be labeled "Outstanding" (2.4 vs 1.6 mentions per applicant). CONCLUSION: Overall, there are more similarities than differences between genders in LORs for neurosurgical applicants. This finding is at odds with what has previously been reported in most other surgical specialties.