Uncertainty in Standardized Letter of Evaluation Authorship: A Qualitative Study of Emergency Medicine Faculty.

Background: The standardized letter of evaluation (SLOE) is a cornerstone of emergency medicine (EM) residency selection. While prior research has focused on how SLOEs are interpreted by reviewers, less is known about the considerations and strategies faculty employ when authoring these high-stakes evaluations. Methods: Using a constructivist grounded theory approach, we conducted semi-structured interviews with EM faculty experienced in SLOE authorship between April and October 2025. Interviews were audio-recorded, transcribed, and iteratively analyzed using constant comparative methods and team-based reflexive analysis until thematic sufficiency was achieved. Results: Participants described SLOE authorship as a process of navigating uncertainty arising from the interaction of structural challenges, cultural pressures, and moral tensions. Structurally, authors described difficulty mapping incomplete or imperfect evaluation data onto standardized SLOE items, often requiring interpretive judgment and use of proxies. Culturally, participants reported pressure to calibrate ratings to perceived national norms to avoid disadvantaging students, contributing to grade inflation and narrative justification strategies. Morally, authors experienced tension between transparency and advocacy, balancing honest assessment with concern for learner success and professional credibility. Conclusion: Recognizing uncertainty as a central feature of SLOE authorship underscores the need for improved alignment between clerkship evaluations and SLOE formats, clearer national calibration practices, and faculty development that supports authors in their dual roles as evaluators and mentors. Collectively, these efforts may improve the credibility and consistency of this crucial part of the EM residency application.