Writing letters of recommendation (LOR) for medical students, residents, and colleagues is an important task that academicians are frequently asked to do. As Roberts and Termuehlen write in their column (1), LOR are “high-stakes” factors and are important both for those who ask one to write them and for those who receive them. LOR are instrumental in advancing one’s career (1), and some believe that they are the optimal criterion for evaluating candidate materials (2). However, writing of LOR is usually not part of any training. Literature on writing LOR is scarce, especially in psychiatry. One usually develops her/his own letter “template” based on seeing an occasional letter written by others, or is helped, in case of letters in support of academic promotion, by questions and rules of the institution asking for such a letter.

As a (probably partial) consequence of this lack of clarity and rules, some (3) have questioned what LOR in residency training really mean. MacLean et al., (3) in their study of members of the American Association of Residency Training Directors in Psychiatry, found that “inconsistency in reporting and interpretation of LOR revealed biases and limited usefulness in decision-making.” They also felt that “letter inflation” makes it difficult to really discriminate among applicants. They (3) found that almost all responders reported some degree of pressure to write a positive letter and that the vast majority never refused to write LOR. Finally, MacLean et al. (3) emphasized the subjectivity of the LOR and a need for changing the culture of writing these letters.

In their column on writing letters of recommendation, Roberts and Termuehlen (1) provide guidance on how to approach LOR writing. They present us with excellent basic suggestions, language, and “tips” for best practices of letter-writing, with all three parties of the professional triangle—seeker, writer, and reader—in mind. This (1) and other publications (2, 3) provide suggestions mostly for LOR for applicants to medical school, residency, and fellowships.

However, there is another “category” of LOR: letters in support of academic promotion. Interestingly, the literature on these letters is even scarcer. I have been able to find only one article (4) discussing more specifically the nature and ethical considerations of LOR to support applications for faculty promotion. Yet, as the authors of this single article (4) note, “Faculty letters, however, may create unique ethical, political, and interpersonal challenges.” They also suggest that “The lure of academic celebrity or the desire of an individual candidate for a flattering letter must not threaten the veracity of the content.” This, similar to the report of MacLean et al. (3) implies possible pressures to write a positive, or inflated, letter. Dealing with this pressure may be quite delicate and challenging. Roberts and Termuehlen (1) suggest that “if a writer finds that he or she cannot in good conscience write a positive letter, rather than simply declining the invitation, he or she may talk with the candidate about realistic career goals, the issues of concern, and what the applicant could do to strengthen his or her candidacy.” This is an excellent suggestion, using honesty in dealing with the LOR (1, 4). However, it does not suggest how to deal with another possible pressure to write a positive letter: possible pressure by the institution asking for an independent evaluation of an applicant for promotion in a form of an LOR. This pressure could be subtle, hardly detectable. In all fairness, it probably does not occur too frequently, but it occurs. There are no data to prove it, but it has happened to me and some of my colleagues (informal inquiry).

As there is no discussion of this phenomenon in the literature, let me provide a scenario description abstracted from my own experiences. The Promotion and Tenure Committee at an academic institution decides to go ahead with the process of promotion of a relatively weak candidate (as there may be various political and individual pressures to pursue it). The institutional rules may require a certain number of LOR by peers, usually those with whom the candidate never worked, and who hold higher academic rank than the applicant. Thus, the committee decides (frequently based on the applicant’s recommendation) who the recommenders should be, and it contacts them. The recommenders receive the letter of request for recommendation with the applicant’s CV and other materials, including the institutional requirements for promotion to a certain academic level. Frequently, the recommender/evaluator knows the applicant or his/her work, although they have never worked together or collaborated on any project. The unspoken expectation (and subtle pressure) is one of a positive LOR. However, as I have suggested, the applicant may be a bit weak and may not even meet the requirements for promotion set by his own institution (or may not meet the criteria at the recommender’s institution—a frequently-asked question). What should one do? The decision should be easier, as the professional and more personal triangle of seeker, writer, and reader described by Roberts and Termuehlen (1) is reduced to a less-personal dyadic relationship of writer and reader. Also, the institution asking for the LOR usually assures the writer of confidentiality of her/his letter. Most frequently, the privately-spoken suggested solution is…. to decline to write the LOR if one cannot write a positive one. It is certainly easier and politically less challenging than writing a laborious evaluation; yet, is it right and ethical? Should the committee keep trying to get positive letters until it gets some? What is the point of writing only “positive” LOR? Don’t we have the responsibility and obligation to the profession and the society to write the “objective” evaluation we are asked for?

I suggest that it is ethical and that it goes directly to the honesty of letter-writing suggested by Roberts and Termuehlen (1) and Larkin and Marco (4) to write an objective, noninflated LOR, rather than refuse to write one because it would not be positive.