Gender bias in reference letters for residency and academic medicine: a systematic review

Abstract

Reference letters play an important role for both postgraduate residency applications and medical faculty hiring processes. This study seeks to characterise the ways in which gender bias may manifest in the language of reference letters in academic medicine. In particular, we conducted a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched Embase, MEDLINE and PsycINFO from database inception to July 2020 for original studies that assessed gendered language in medical reference letters for residency applications and medical faculty hiring. A total of 16 studies, involving 12 738 letters of recommendation written for 7074 applicants, were included. A total of 32% of applicants were women. There were significant differences in how women were described in reference letters. A total of 64% (7/11) studies found a significant difference in gendered adjectives between men and women. Among the 7 studies, a total of 86% (6/7) noted that women applicants were more likely to be described using communal adjectives, such as “delightful” or “compassionate”, while men applicants were more likely to be described using agentic adjectives, such as “leader” or “exceptional”. Several studies noted that reference letters for women applicants had more frequent use of doubt raisers and mentions of applicant personal life and/or physical appearance. Only one study assessed the outcome of gendered language on application success, noting a higher residency match rate for men applicants. Reference letters within medicine and medical education exhibit language discrepancies between men and women applicants, which may contribute to gender bias against women in medicine.

Equity, diversity, and inclusion in the emergency medicine workforce: benefits, barriers, and strategies

“…Additional disparities in pay, promotion, and leadership opportunities based on gender, race, and ethnicity have been documented both within EM and academia more generally. For example, women in EM are consistently paid less than men, whether salaried or fee-for-service; women and URM are promoted at slower and lower rates than white men even after adjusting for tenure status, degree, and National Institutes of Health funding status; and women are 52% less likely than men to advance to senior healthcare leadership positions despite controlling for age, experience, education, and training [2,3,6].…”

“…In addition, letters written for women more frequent mentioned physical appearance and personal life and contained more doubt raisers. Finally, gendered language in reference letters was associated with preferential matching of men to a residency program [6]. The impact of gender bias persists throughout the academic faculty trajectory and is manifest in the wage gap, fewer invitations to present at rounds and conferences, differential introduction of speakers (women by first name, men by formal title), slower and lower rates of promotion, and fewer opportunities for leadership [2,3,5].…”

Seeking justice, equity, diversity and inclusion in pediatric nephrology

“…The medical field, and pediatrics specifically, is not immune to implicit bias in its many forms, be it gender bias, racial-ethnic bias, or others. Reference letters within medicine and medical education exhibit language discrepancies between men and women applicants with women applicants more likely to be described using communal adjectives, such as “delightful” or “compassionate”, while men applicants more likely to be described using agentic adjectives, such as “leader” or “exceptional” ( 58 ). Implicit racial bias among medical school admissions committee members have been implicated in recruitment of less diverse classes ( 59 ), while gender bias has been implicated in lower rates of promoting women to leadership roles ( 60 ).…”

Building a RAFFT: Impact of a professional development program for women faculty and residents in emergency medicine

“…[5][6][7][8] Women in academic EM are paid significantly less, but work more clinical hours than their male colleagues 9,10 and are more prone to gender discrimination. 11 Women trainees in EM are even more vulnerable to bias, with robust data reflecting differences in selection and matriculation, [12][13][14][15] faculty and nursing evaluation of performance, [16][17][18] patient perception, 19 and attrition. 20 In light of such data, there is a growing recognition of the need for support for women in academic medicine.…”