Authors: Dr. Tom Morrissey MD, Assistant Residency Director at University of Florida – Jacksonville and Dr. Jonathan Wagner, Clerkship Directer at Keck School of Medicine USC

The LOR, SLOR, SLOE, and eSLOE

Over the last twenty years, we as a specialty have moved from the traditional narrative letter of recommendation to the standardized letter of recommendation (SLOR), to the standardized letter of evaluation (SLOE), to its most current form, the electronic standardized letter of evaluation (eSLOE). While the eSLOE now gives us legitimacy with millennials and techies, it also aims to do the following:

1. TRULY standardize all EM letters of recommendation (no more institution specific SLOEs)
2. Ensure proper PDF formatting without loss of information (the 2015-2016 radio button fiasco still haunts many of us)
3. Auto-populate clerkship demographics and data from year-to-year (decrease carpal tunnel syndrome and provide accurate global assessment data from the previous application cycle)

Analogous to the SLOR and the SLOE, the eSLOE is an evaluation, NOT necessarily a recommendation. It aims to keep comments concise and relevant while providing a direct comparison to other EM-bound candidates in the last academic year. In addition, by holding the letter writer accountable for the global assessments that they assign, the hope is that grade inflation is avoided, making the tool truly helpful in the evaluation of applicants for EM residency.

 

How to be an effective eSLOE writer

The narrative section, or “D. Written Comments” as it is titled on the eSLOE, should be viewed as the letter writer’s argument/justification of their assessment of the applicant in the “B. Qualifications for EM” and “C. Global Assessment” sections. While this is likely obvious to many eSLOE authors, and generally adhered to, a large number of letters each year do not give rationale for their assessments. This not only weakens the usefulness of the evaluation, but also potentially hurts applicants chances of matching and diminishes our own reputation as effective letter writers.

The creation of a “Top 10%” and “Top 1/3” eSLOE is easy. Simply check off all “Top 1/3” radio buttons, assign a top tier global assessment and rave about the students positive qualities. Many authors focus on the student’s academic potential, their strong work ethic, how they play well with others in the sandbox/ED, etc. making it clear why a student has earned their positive evaluation. While these letters are helpful to residency directors and their selection committees (and of course fun to write), they should not be the focus of our time and energy. These students generally sell themselves, anyway!

Much more important are illustrative “Middle 1/3” and “Lower 1/3” eSLOEs. These students are almost all very matchable applicants, with high likelihood of success given proper training. These eSLOEs are significantly more difficult to construct as the consequences could be dire for our students (i.e. not matching). As seasoned letter writers who have authored more than 700 EM standardized letters over the last 5 years, we recommend EXPLICITLY stating the reason for their middle to lower third placement. This can be achieved by describing the flaws/challenges in an applicant’s performance and what they could have done to obtain a stronger letter. Alternatively, focusing on how your program does not provide what they will need to truly excel in residency helps readers interpret the letter and gauge the candidate. Below are some techniques that can be quite effective in communicating your reasoning. Here’s a simplified example of each approach:

Flaw in applicant’s performance:

While Applicant A’s clinical and interpersonal scores were that of a Top 1/3 applicant, he performed poorly on his written exam, placing him in our Middle 1/3 category.

What they could have done to obtain a stronger letter:

Had Applicant A shown a bit more independence in his ability to work-up undifferentiated chief complaints, he likely would have received a Top 1/3 designation. Dedicated focus on this aspect of his training will help him excel in the future.

What your program lacks:

While Applicant A has all the skills necessary to be a highly successful EM resident, he needed a bit of encouragement to fully dive into our clinical environment. Therefore, we anticipate that he will reach his full potential in a residency program that provides a bit more supervision than we can provide in our busy county ED.

Seeing a lower ranking on an eSLOE without a cogent explanation is similar to finding a gap year without explanation on an ERAS application: we have NO idea how to interpret this information-and that scares us! Without clear reasoning for an applicant’s middle to lower tier eSLOE placement, we as application evaluators often will assume the worst – that there must be some flaw in the applicants performance that was too horrific to disclose. Conversely, a good explanation can truly help a a non-rock-star applicant. In the vast majority of cases, programs can be quite comfortable remediating certain types of issues (i.e. pulling the wallflower out of their shell, or harnessing a little excessive bravado). Therefore, do not feel as though you are doing your student wrong by being honest – you are helping them find a program that will help them maximize their potential, while upholding your commitment to your colleagues and to the specialty.