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HealthApril 15, 2020

How to submit outstanding letters of recommendation for residency

By: Michelle A. Finkel, MD

Several years ago, I advised an accomplished medical student who was applying to plastic surgery residencies. She had everything needed for an excellent residency application: phenomenal clerkship evaluations, top board scores, excellent written materials and multiple first-author publications. When it came time to interview, though, she obtained only a handful of invitations. The institutions she heard from were strong, but we were both surprised her residency application had not received more attention.

Then, at one of her interviews, a faculty member shed some light on the mystery. He told her that although her candidacy was outstanding, one of her letters of recommendation (LORs) was a bit thin. If she was getting fewer invitations than expected, he suggested that this LOR was likely the reason why. The candidate later told me she was confused: If the faculty member she approached felt he could not write her a great letter, why would he write one at all?

(Not to worry: In the end, this student matched to her first-choice program.)

As a former Harvard assistant residency director and current residency admissions consultant, I have seen that middling, misguided or even unfavorable letters can undercut otherwise strong residency applications.

Getting strong residency LORs is particularly difficult because most residency candidates waive their right to see their letters of recommendation. This is meant to ensure that LORs are taken seriously, but it also means that applicants may not know whether their LOR is at the level of quality they need. Despite this conundrum, the approaches outlined below can improve your prospects of procuring strong LORs for residency.

Letters of recommendation for residency: The basics

Fulfilling the LOR requirement is more than a box to mindlessly check off on your to-do list. You want to receive the strongest letter you can from the most influential writer you know. In deciding whom to ask, first remember that you can submit up to four letters through the Electronic Residency Application Service® (ERAS). That said, it is preferable to cull the herd when necessary: better three very strong recommendations than four, if one is weak.

Second, consider your letter writers' specialties. If you're applying in a very competitive field, you will likely need at least two — if not all four — letters from physicians in that field. If you are aiming for a less cutthroat specialty, you will certainly need one letter in your field, but you can choose faculty in related specialties for the other letters. For example, an obstetrics or pediatrics letter would be appropriate for an applicant to family medicine residency.

Finally, if you are applying in more than one field, consider asking your writers for multiple specialty-specific versions of your letter. ERAS allows you to assign different letters to different residency programs.

A letter of recommendation wish list

Beyond the numbers, in choosing the right letter writers, you are aiming to fulfill the following ideal criteria:

1. Senior faculty members with weighty academic titles

Arguably unfair, but when a residency director receives a LOR from an accomplished colleague, the letter will likely be weighed more heavily than one from someone deemed less senior.

2. Faculty members who have spent significant time with you

Choose someone who really knows you and can vouch for your clinical acumen, focus and hardworking nature. Remember, too, that it is OK to gently lead the witness: To improve the content of your letters, even those by faculty who are familiar with your work in the hospital, create a letter of recommendation kit. This may include a brief cover letter highlighting your accomplishments, your curriculum vitae and your board scores.

3. Faculty members who are experienced letter writers

There are brilliant academic physicians who do not understand how to showcase an applicant's strengths. Consider this seriously when you are deciding whom to approach for a letter. You only want players on your team who know the rules of the game.

4. Faculty members who explicitly agree to write you a strong LOR

Do not hesitate to ask potential letter writers if they will write you strong LORs. It may feel embarrassing, but getting a lukewarm endorsement that harms an otherwise robust application is worse. If a faculty member declines or hedges, understand that the attending has in fact done you a huge favor.

While you toil over boards studying and your personal statement, remember that letters of recommendation are critical factors in your residency application. Don't let a weak letter puncture a hole in your otherwise watertight candidacy.

Michelle A. Finkel, MD