**4. Implicit bias in letters of recommendation and resident evaluations**

Letters of Recommendation (LORs) are important components of the residency and fellowship application process. A survey examining the attitudes of surgical attendings and residents at the Mayo Clinic found that 73% of attendings and 82% of residents believed that LORs effectively stratify applicants into the upper and lower halves of candidates being considered [12]. LORs have been key in the ability to research implicit bias within the surgical field. In this context, implicit bias is the unconscious stereotype that is held against people or certain groups [13]. Though recent research shows an insignificant linguistic difference in LOR between male and female surgical applicants [14, 15], other studies support the existence of detectable inequality in letters written for male and female applicants [16–18]. More specifically, LORs written for women applicants are more likely to contain mentions of physical appearance [16], communal (teamwork, caring, and sympathetic), and caring themes [14, 18]. Moreover, the LORs were shorter for women than for their male counterparts [18]. LORs written in support of men had more mention of achievement and use of superlatives than their female counterparts [18]. For example, when LORs for transplant surgery fellowships were examined, those written for men contained more terminology highlighting competency and leadership [19], whereas females were more likely to be described with communal terms (e.g., friendly) [17]. The different tones, overall length, and word choice in LORs could represent a subtle manifestation of implicit bias, effectively making it more difficult for women to enter and advance within highly competitive fields [18, 20]. Since objective research clearly shows equal surgical skill across genders [7, 8], the observed linguistic disparity within the analyzed subset of LORs could be indicative of a broader issue of implicit bias in the historically male-dominated surgical field [21]. A summary of potential approaches to help address this problem is provided below:

	- Emphasis on actual accomplishments and professional productivity
	- Ensure that various types of academic and professional contributions are clearly defined and treated accordingly

(Source: https://gustavus.edu/committees/concertFiles/media/ faculty\_personnel\_committee/KCEL\_Stategies\_to\_Reduce\_Bias\_in\_Recommendation\_ Letters.pdf)
