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Heather Furnas, an adjunct clinical associate professor at Stanford and an aesthetic surgeon, joins us as we delve into the intricate world of recommendation letters, biases in evaluations, and their impact on diverse fields. Heather lends her expertise to unravel the complexities of authenticity, gender disparities, and alternative assessment methods. Discover how these issues resonate across academia, medicine, and beyond. Tune in for an insightful conversation that challenges conventional norms and explores pathways to more equitable evaluation processes.

Heather Furnas is an adjunct clinical associate professor at Stanford and an aesthetic surgeon in Northern California. She co-hosts the Skintuition podcast and can be reached on her website, Heather Furnas, and on Twitter @drheatherfurnas, Instagram @drheatherfurnas, Facebook, and LinkedIn.

She discusses the KevinMD article, “Let’s rethink letters of recommendation.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Heather Furnas. She is an adjunct clinical associate professor at Stanford and an aesthetic surgeon. Her KevinMD article is titled “Let’s rethink letters of recommendation.” Heather, welcome to the show.

Heather Furnas: Thank you so much, Kevin. It is an honor to be on your show.

Kevin Pho: So let’s get into your article a little bit. First off, briefly share your story and journey as a surgeon.

Heather Furnas: I’ve practiced for about 30 years. When I entered the specialty, about 6 percent of all plastic surgeons were women; now we’re about 20 percent. So I’ve seen a lot of change through the years.

Being a woman in surgery wanting a family is hard. It’s always been hard. It’s getting easier, but there are still huge discrepancies and gaps in infertility rates and pregnancy complication rates compared with our male colleagues and their partners, and also women have many fewer children. Now, this is pervasive in medicine. It’s just magnified among surgeons because our hours and our years of training are so long.

Kevin Pho: What are some of the things that the surgical profession is doing to further improve that disparity?

Heather Furnas: Well, the American Board of Medical Specialties in general just opened up the number of weeks that can be used for maternity leave, so that is now six weeks, as opposed to the past, when I was restricted to four weeks. And the American Board of Plastic Surgery actually allows 12 weeks now. It’s 12 weeks spread out over the entire training period, but you can take time off for personal leave without extending your training.

But there are a lot of other things that still need to improve. One common theme, if you look at Facebook chat groups or articles or any sort of venue, is that women are saying, “We need on-site child care that’s available 24/7.” Men are part of this conversation, but it really seems to impact women more.

Kevin Pho: Now, we have a lot of female medical students who listen to this podcast. If they’re considering a career in plastic surgery or a surgical field in general, what kind of questions should they be asking themselves?

Heather Furnas: One would be: What is the program’s makeup? We find that programs with chiefs and chairs who are women tend to be more welcoming to supporting pregnancy. This is something that needs to become standardized.

It does take a certain determination to decide that I am going to have a baby during training. You need support. Unfortunately, now you really need child care, and so a lot of people say that if they have a mother who can come and live nearby, that really helps. But certainly the hours and the years do deter women who would otherwise go into surgery.

Kevin Pho: All right. And speaking of the application process, we’re going to talk about one big facet of that today, and that is the letter of recommendation, or letters of recommendation. So, your KevinMD article is titled “Let’s rethink letters of recommendation.” How did your article come together?

Heather Furnas: Well, I both read and write letters of recommendation, and whenever I read a letter of recommendation, I figure that the words on the paper, or the screen, were written by the person signing that letter. And then I was asked to write a letter of recommendation, and I wrote it, and because this was going to be attached to various applications, I sent in the PDF. And then the letter writer responded a little bit later and had added a few very complimentary paragraphs above my signature, and the letter writer was asking me for approval. So clearly this is not a devious act.

And so I called the letter writer and asked why they had done this, and they said, “Well, this is actually really common practice. Most people say, ‘Can you write this letter? I’ll approve it and sign it.'” And this gave me pause. So I explained why I had misgivings and that there were ethical considerations, but I also realized that a lot of people think this is OK. We offer disclosures with our scholarly articles and our presentations for CME meetings, but we don’t disclose that I actually didn’t write the letter, that the letter writer was the one who wrote the letter.

And so when we’re looking at fairness and bias, we already know that words are used differently in legitimate letters of recommendation for women and underrepresented minorities compared with everyone else. We also know that men are better at negotiating for themselves, and women who do negotiate effectively for themselves tend to be considered unlikable. So any letter that a male writes for himself is likely to be a stronger letter. And so, particularly in the wake of the Supreme Court decision about affirmative action, I think when we’re considering meritocracies, and we consider letter writing to be a part of this meritocracy and fairness, we need to really dissect whether this is building implicit bias into our whole admission process.

Kevin Pho: Now, when you talk to your fellow colleagues, and I know you have an affiliation over at Stanford, what is commonplace when they write their own letters of recommendation? Are they often ghostwritten by the applicant themselves? What is the current trend these days?

Heather Furnas: You know, that’s a good question, because I haven’t actually asked my colleagues. I’ve asked the people asking about letters, and I don’t know if asking would put someone on the spot, so that they would say, “Well, not really. I write them myself.” So, just like I mentioned, I couldn’t find a scholarly article that surveyed people who had the subjects of their letters of recommendation writing the letters.

The reason this is so important is because ultimately our goal in training physicians is about taking care of the patient population. We do know that women, Blacks and Hispanics do better when cared for, in general, by physicians who are women, Blacks and Hispanics. And so that’s where we really ultimately need to look at best outcomes for the patient population.

Kevin Pho: Now, in the application process to residency, just give us a sense of the role of the letter of recommendation.

Heather Furnas: Well, they’re not only used for applications for residency, but on rotations there can be a narrative assessment, and that can determine a grade on a rotation. And there was one study that I hyperlinked in the article that said that people looking at the verbiage felt that there was so much bias that these narratives should be abandoned. And there have been studies that showed that bias, implicit bias, can be reduced by having specific qualities, and then whatever the rating is, the rating should be substantiated with solid evidence.

Kevin Pho: Are there any guidelines to writing letters of recommendation? I don’t write a lot of letters of recommendation. I’m not in an academic institution. But from your standpoint, are there any guidelines regulating this?

Heather Furnas: There are no guidelines that I know of regulating it. I did find some university websites that had advice for structure. There was one university that actually supported having the letter writer be the subject of the letter, because they knew themselves better than anyone else. And it also said that the people who say that they’re honest, well, those are the honest people. But there are plenty of dishonest people signing letters of recommendation, and so it’s an imperfect system, which just underscores why it is so problematic.

Kevin Pho: Now, as someone who writes letters of recommendation, maybe you could share some tips with medical trainees. What are the standard practices? What should they say when they ask for letters of recommendation?

Heather Furnas: I think the one thing, and this is actually some advice, as far as for the letter writer: The letter writer should look for an influential person and get to know that influential person, so then that person would know you well enough to write a letter. Now, that is problematic in that if you are a Nobel Prize laureate, you’re going to have a lot of people just angling to get to know you, and not everybody is.

I think that we in our system should open up consideration, instead of to the position of the person who is writing the letter, to the person who really knows the subject of the letter, whether it’s a sixth-grade teacher or a soccer coach or a teaching assistant, as opposed to some president of a major university.

Kevin Pho: Now, this question has come up on my various physician forums. A lot of doctors actually aren’t taught to write proper letters of recommendation. What are some tips that you could share in terms of writing a strong letter of recommendation, or perhaps some verbiage if the student isn’t as strong on the scale? What are some tips in terms of writing the letter itself?

Heather Furnas: I think there are certain codes, like “I recommend this person without reservation.” There is also a code with a lukewarm letter: “I recommend this person,” period, “I am happy to discuss by phone.” And so it’s not actually saying this is a bad person. I think people may be worried about lawsuits and that type of thing. Some letters are going to be more honest than others, but I think in general, stating the facts as solidly as you know them, stating the good things, you can do that. But when there is that line of hesitancy, “Happy to discuss” or “Please call with any questions,” that’s probably the most significant red flag that there are issues with this person.

Once you get to know the verbiage of somebody, if somebody normally writes warm praise and the letter is “I recommend this person” or “This is a good student” or “a good resident,” the absence of the enthusiasm is code. So each person will have their own code, and probably each university will have a specific code, to be able to read through that. And in and of itself, the fact that it has to be sort of coded makes the whole thing problematic.

Kevin Pho: I was wondering what you thought about the role of generative AI tools like ChatGPT. These are large language models that are being used in terms of generating letters, generating content. Do you see that role influencing letters of recommendation going forward?

Heather Furnas: That’s a very timely question. I think that will be sort of the natural support. And we also know that ChatGPT tends to become quite creative. I’m sure that will improve with time, but there are a lot of facts that come out in assignments to ChatGPT. This is not necessarily a bad thing. If you can tell the AI program, “These are the facts, just make it readable,” then that’s pretty harmless. But when ChatGPT invents things or exaggerates things one way or the other, then that’s where we get into danger.

Kevin Pho: What do you see as the path forward in the evaluative process going forward, whether it’s the rotation or some type of application? How would you like to see these subjective measures being articulated in an application?

Heather Furnas: Well, I think one thing would be to have certain standards, specific qualities, and people writing letters could actually be taught how to evaluate, what things to look for, both positive and negative, so that when you are rating somebody, you can support that rating with specifics, and the person is educated enough to be able to identify what is important and what isn’t.

Oftentimes now, if somebody is a great baseball player and the attending is also a great baseball player, and they’re both men and they dress in the changing room, that’s probably going to be a really strong letter of recommendation, based possibly not exactly on the pertinent qualities that are important to that person’s future. So I think that everybody needs training, and the whole system needs to be updated so that we have benchmarks. Much like we’re moving toward competency-based training, we might want to look at competency-based letters of recommendation.

Kevin Pho: We’re talking to Heather Furnas. She’s an adjunct clinical associate professor at Stanford and an aesthetic surgeon. Her KevinMD article is titled “Let’s rethink letters of recommendation.” Heather, tell us some of your take-home messages that you want to leave with the KevinMD audience.

Heather Furnas: Well, I think whether it is a training structure or letters of recommendation or electronic medical records or whatever you find an issue with, it’s important to ask questions and then consider: Is there a better way? And then speak out. Write to KevinMD.

Kevin Pho: Heather, thank you so much for sharing your time and insight, and thanks again for coming on the show.

Heather Furnas: Great. Thanks so much, Kevin.