When every residency candidate is “the best I ever had”

By Sara Atyia, PharmD

Letters of reference for pharmacy residency tend to almost always be positive. But why? Pharmacy residency programs are receiving an increasing number of applications each year with 5,937 Postgraduate Year One (PGY1) candidates participating in the Match in 2019. This is up from 3,933 PGY1 candidates participating in the Match in 2013. With only 63% of applicants matching in 2019, this increased demand means that a greater number of applications need to be evaluated by residency programs.¹ As a PGY1 resident this year, I have had the opportunity to further scrutinize the application screening process since I am now “on the other side” of the application process. The literature consistently shows that residency program directors consider letters of recommendation and reference as important application factors,² but how do you determine standout candidates from average candidates when most references are overtly positive?

What does ‘Exceeds” mean to you?
Since moving to an electronic application system, pharmacy online residency centralized application service (PhORCAS) has changed how references are submitted. The standard form has transitioned away from the traditional letter format and now forces reference writers to rank candidates as “exceeds,” “appropriate,” “fails to meet,” or “N/A” for several different characteristics and abilities. For those of you who have written a reference, how do you define “exceeds,” and how do you determine when to rate a student as “exceeds”? PhORCAS defines exceeds as “the candidate exceeds what is expected to enter a residency program.” With so many candidates, it is hard to believe that they all exceed what is expected to enter a residency program in every category. I was surprised by how many references used a phrase such as “the top 5% of all students.” They can’t all be exceptional, can they?

Honesty is the Best Policy
As a reference writer, do you worry that rating an applicant as anything but exceptional (or giving the “exceeds” rating) will eliminate them from consideration? Will being honest about an individual’s areas for improvement, however small, be perceived as a red flag since most references are overwhelmingly positive? Honesty is a professional responsibility, but could being completely honest when providing a reference in PhORCAS penalize an applicant?

Evaluating references has become a problem for programs that receive a large number of applications. When every applicant is rated as “exceeds” on almost every category, there is no good way to determine who should be offered an interview based on such an important aspect of the application. A recent study evaluating standardized letters of recommendation for medical residency showed that writers use the lowest categories less than 2% of the time.³ Is that same trend true of pharmacy residency candidate references? If so, what does that mean for programs, applicants, and reference writers?

Something’s Gotta Give
Pharmacy residency programs are now placing less emphasis on references as they take a considerable amount of time to sift through and do not help identify standout candidates.⁴ Is that a mistake? A recent study showed that candidates with references with more standout words (e.g. outstanding, exceptional, etc.) and teach references (e.g. teach, instruct, etc.) were more likely to get an invitation to interview.⁵ Although, no studies, to my knowledge, have been published looking at the impact of references in PhORCAS on application score or applicant ranking. References highlight characteristics that are often difficult to glean from a CV or transcript. Therefore, when writing a reference, writers must balance the fine line of writing an honest reference supporting the candidate and diminishing the credibility of references by overselling an average candidate. From the perspective of someone who has to delineate applicants, it would be helpful if reference writers gave examples of how a candidate exceeds, are specific about characteristics, and honest about areas of improvement. If a candidate truly is exceptional, it will show.

In an ideal world, how can we change the reference process for the better?

Acknowledgements
Thank you to Dr. Jeff Cain for his guidance in preparation of this article.

References
1. ASHP Match | Statistics of the Match. https://natmatch.com/ashprmp/stats.html. Accessed May 5, 2019.

2. Cho JC. Selecting candidates for pharmacy residencies: A national survey of residency program directors. J Clin Pharm Ther. 2018;43(6):844-848. doi:10.1111/jcpt.12723

3. Grall KH, Hiller KM, Stoneking LR. Analysis of the Evaluative Components on the Standard Letter of Recommendation (SLOR) in Emergency Medicine. West J Emerg Med. 2014;15(4):419-423. doi:10.5811/westjem.2014.2.19158

4. Nisly SA, Isaacs AN, Paloucek FP. Fixing letters of “wreck”-ommendation. J Am Coll Clin Pharm. 2018;1(2):119-120. doi:10.1002/jac5.1031

5. McLaughlin MM, Masic D, Gettig JP. Analysis of PGY-1 Pharmacy Resident Candidate Letters of Recommendation at an Academically Affiliated Residency Program. J Pharm Pract. 2018;31(2):145-149. doi:10.1177/0897190017702305

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Sara Atyia is a PGY1 resident at the University of Kentucky HealthCare. She will be completing a PGY2 in critical care at The Ohio State Wexner Medical Center next year. Educational scholarship interests include student affairs and professional development. In her free time, Sara enjoys going to music festivals and concerts, travelling, and staying active.

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Pulses is a scholarly blog supported by a team of pharmacy education scholars.