https://orcid.org/0000-0001-6787-7980
We read the article by Kukulski and Ahn and want to commend the authors on their publication.1 The article encourages stakeholders to consider modifications to the Standardized Letter of Evaluation (SLOE) to improve validity evidence. We would like to further argue that the SLOE cannot accurately assess medical student performance without considering additional barriers that students face within the context of these evaluations. We would like to propose additional modifications to the SLOE to allow for a more equitable review of applicants.
There has been increasing emphasis in medicine to utilize a holistic review of applicants to increase the numbers of individuals from groups that are underrepresented in medicine. Currently, the domains on the SLOE for emergency medicine include items such as commitment to the specialty, ability to develop a differential and plan, and prediction of how much guidance will be needed in residency. There are no areas to address important identifying features that would allow for a more holistic approach, such as identification with the LGBTQ+ community, the presence of disabilities, socioeconomic deprivation, or other markers of adversity.
A major component of the SLOE includes where programs feel an applicant will fall on their rank list and how they compare to other rotating students. However, it is unclear if an equity-centered framework is considered when ranking the students, and it is impossible to do so if markers of adversity are not considered, even less so if they are not collected. All individuals completing the SLOE should be aware if rotating students are from disadvantaged backgrounds or have faced profound hardship, as this may provide a critical lens of equity to clerkship and program directors.
Currently there are calls for the Electronic Residency Application Service to include more of these characteristics, as they have been difficult to tease out during the candidate screening process, but no plan to modify the information made available to residency programs has been announced. The SLOE can serve as an intermediary, making it easier for residency selection committees to incorporate this important data when selecting candidates for interviews and when creating rank lists.
Recently, the Association of American Medical Colleges (AAMC) released recommendations for developing equity-centered learning opportunities within medical schools and residency programs.2 They include incorporating health equity measures in learner assessments. An example of how this could translate to relevant competencies on the SLOE could be, “Applicant understands how socioeconomic factors or physical environment affects patient health outcomes.” These changes would align with the goals of the AAMC and allow programs to recruit more structurally competent physicians.
As versions of the SLOE are being expanded to other specialties, we must be intentional about reflecting our commitment to recruiting not only diverse applicants, but also individuals who understand the social determinants of health that affect our patients. We must apply an equity lens to all data included in the residency application process and be aware of existing bias in measures we consider to be more objective, including the SLOE.
