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What can be done about letters of recommendation

Many surgical educators feel that letters of recommendation are not particularly helpful in evaluating applicants or predicting eventual resident performance.

Among the issues are lack of uniformity of content, excessive use of superlatives, reliability—if the writer is not known to the recipient—and more.

Even if the writers are well-known academic surgeons, the degree of their personal knowledge of the applicants is not always clear.

During an extensive Twitter discussion over the weekend, someone mentioned that in an attempt to deal with this problem, emergency medicine had developed a standardized letter of recommendation.

A recent paper from the EM Standardized Letter of Recommendation Task Force shows that there is still work to be done. From the abstract:

For the question on "global assessment," students were scored in the top 10% in 234 of 583 of applications (40.1%), and 485 of 583 (83.2%) of the applicants were ranked above the level of their peers. Similarly, >95% of all applicants were ranked in the top third compared to peers, for all but one section under "qualifications for emergency medicine."

Ive written before that deans letters are more like public relations press releases than accurate assessments of a students performance. You will rarely find negative comments in them. But another recent paper by a group of psychiatrists found that The presence of any negative comments in the deans letter yielded significant correlations with future problems. Further, those applicants with future major problems had significantly more negative comments in the deans letter than did those with future minor problems. Other factors such as USMLE scores, failed courses, letters of recommendation, and interviewer ratings and comments did not predict future problems.

These problems are not new. A 1983 New England Journal opinion piece about recommendation letters entitled "Fantasy Land" is remarkable for its validity even today. Here are a few choice quotes.

Its a land where everyone is "a pleasure to work with," has "excellent initiative," is "enthusiastic and conscientious," and possesses and "above-average fund of knowledge."

No one is ever poor, fair, or average; they are all "very good" or "excellent."

The author, Dr. Richard B. Friedman, said letters of recommendation were useless and advocated doing away with them.

A brief JAMA essay by Dr. Henry Schneiderman in 1988 called for more openness in describing students but acknowledged that negative comments were often "the kiss of death."

He proposed a new system of categorizing medical student performance. Here are just a few examples.



@AmirGharferi suggested this:

"Dr.G, do you feel comfortable writing me a strong letter?"
"No."
"Ok, Ill find someone who is."

That works if the student is aware enough to ask, and the faculty member is honest enough to say no. In my experience, even the most marginal of students can find someone—in addition to the dean, of course—to write a good letter.

I am no longer involved in the process of selecting residents. I have no suggestions.

What is your solution to this problem?

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Should I go to med school

A young man writes

I am thinking about pursuing medicine as a career. However, it is not something that I am entirely sure of because of the changing healthcare landscape.

Suppose I enter medical school at age 26. Four years later I have my MD. Five or six years later I will be done with a surgery residency and two years after that with my fellowship. I will 37-38 years of age with kids, a wife, and most likely a home. My kids will be around 9-11 years of age. In addition, I will be near $250K in debt from medical school because of interest accumulated throughout my residency and fellowship. This is of course not including retirement, car, house, investment, and kids’ college savings.

My friends tell me not to think about it, but if I don’t, I can end up in a position that I don’t want to be in. Even if I pay off my debt at age 50, I still have all those other things to address. And even if I do, when will I enjoy my money? What is perhaps most important though, is the time component. I am essentially giving up my entire life to a profession that will not allow me to transfer laterally to other professions if I choose to. I can be pursuing my other interests in the time that I would be becoming a surgeon such as business or engineering.

Lastly, I grew up in poverty and have no financial assets. It will take me years to accumulate wealth. And once I do (at around age 60), that wealth will be passed down to my children.

Did I miss something? What are your thoughts? 

While rereading and editing your email, I realized you did miss something. Whats missing is enthusiasm for becoming a doctor. You listed several reasons not to go to med school, but nothing about why you want to do it. If you don’t truly love the idea, you will be very unhappy.

I think you need to reassess your future.

For those who want more information, I have written a couple of posts about questions related to this one [links here and here.] The comments on the more recent post are worth reading..

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Real Estate in a Depression by Marc Charles

4:29 PM

Hi Gang:

Ive enclosed a question I received from an entrepreneur recently.

I thought you might like my take.


Question: Marc, whats your take on making money with real estate in the current economy?
M.F. Apple Valley MN

Answer Marc Charles:

In 2004, I mentioned more than a dozen times in my newsletter, blog, speeches and conferences real estate would end badly.

Three conference organizers did not want me back....even though I was the most popular speaker at two of the conferences (according to an attendee poll).

The reason the organizers did not want me back is because I kept talking about a "depression" and real estate collapse (in most areas of the US).

Anyway, that was yesterday....what have you done for me today!

Weve all seen the real estate fiasco...and some people have been devastated by it.

But, the real estate boom (ans BUST) was predictable. If you had eyes to see, you would have known the boom was not going to last.

When I saw a cashier from a local convenience store drive into her triple car garage, which was attached to a $400,000 home, I knew the boom was toast. This was in 2005. The boom lasted another three years, and then kaput!

Almost everyone I knew, 90%+, was bullish on real estate from 2004-2008. The reason everyone was bullish is because in most cases they were making money.

But then the market collapsed....and is still collapsing.

Most people never realize, or refuse to realize, theyre involved in hysteria. But all it takes is simple, common, horse sense. You can also seek wise counsel from someone whos already lived through hysteria or "madness of the crowd". In many cases wise counsel will be twice your age.

Ive made money on real estate. But Ive also avoided major losses. I did not lose one thin dime in real estate from 2004-2009. I was also not underwater with mortgages.

Anyway..enough with the long winded response!

Yes....you can make money on real estate in a Depression. The key is buying at super deep discounts, not being over-anxious about doing deals (or fearful), and paying cash whenever possible.

The problem with most foreclosure properties is finding a clear title, and a property with no liens. But thats another topic.

The days of Fix and Flip are over for now! This market may not recover for 10 years...if ever.

But you can still find incredible deals, offer even less, wait for your terms, and rent the property.

Drop me a note if youd to know about specific markets Im considering.

I hope that helps!

Marc Charles

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