Is the SLOR in Otolaryngology Residency Applications Contributing to Rural Disparities?

In 2012, the SLOR was introduced by the Otolaryngology Program Directors Organization to objectify and simplify the residency application review and selection process (Laryngoscope. doi: 10.1002/lary.23866). The SLOR contains 12 questions, including 10 scale-based questions, and a section for commentary at the end. Most of the questions focus on an applicant’s knowledge, work ethic, interpersonal skills, research, and relationship with the letter writer.

One question, however, promotes discussion about the goals of our current residency selection process: “Commitment to Academic Medicine— Likelihood of pursuing a research/ academic career after residency.” If comprehensive otolaryngologists are needed to care for rural communities, why is it necessary to consider the likelihood that a residency applicant will pursue an academic career when selecting trainees? Is the SLOR encouraging a selection bias against applicants who desire to practice comprehensive otolaryngology?

Multiple studies have evaluated the SLOR. A retrospective analysis of one application cycle indicated responses to scale-based questions were skewed to reflect higher scores and could not differentiate between candidates (Otolaryngol Head Neck Surg. doi: 10.1177/0194599815623525). Another retrospective study indicated there was no correlation between a letter writer’s perception of an applicant’s commitment to academic medicine and their objective application data, including test scores, research, and other experiences (Laryngoscope. doi: 10.1002/ lary.28054). While the SLOR does appear to reduce review time (Laryngoscope. doi: 10.1002/lary.23866) and reduce writer gender bias (Laryngoscope. doi: 10.1002/lary.26619), the previous findings suggest that the SLOR appears to have limited to no utility in differentiating applicants. Furthermore, no analyses of correlations between SLOR scale scores and resident performance or career selection have been conducted. These findings raise questions regarding the continued use of the SLOR, especially the question of highlighting one career track.

Given that the mean commitment to academic medicine was clustered around the 85th percentile on the SLOR responses (Otolaryngol Head Neck Surg. doi: 10.1177/0194599815623525), applicants and/or letter writers could feel pressured to communicate a desire to pursue academic otolaryngology in order to match. We may also be encouraging students and residents to pursue academics and fellowship training over comprehensive otolaryngology. We should be training some otolaryngologists interested in pursuing fellowships, academics, and expanding the field through research. But the purpose of graduate medical education is to train physicians with diverse interests so that all Americans can be served. Thus, training clinically oriented, comprehensive otolaryngologists is equally important to provide equitable patient care throughout the U.S., particularly for underserved rural regions.