Letters of recommendation: Nuanced bias or useful affirmation?

Narrative letters of recommendation (NLORs) have become key elements of the application process for residency and fellowship. The potential to inadvertently admit bias into these subjective narratives has become an area of research focus across many disciplines. In the present review, we have highlighted the current data regarding bias in NLORs. We also believe that one of the most effective methods to eliminate bias from written recommendations is to first understand that it exists. Thus, the objective measures that have been taken to identify bias in NLORs are important steps in the right direction. We have presented and reflected on the accrued data on bias in NLORs pertaining to surgical training.