Strong letters of recommendation are essential for supporting your residency application and matching well. This article details how to ensure you get great letters of recommendation.

Knowing what constitutes a great letter of recommendation is crucial to obtaining outstanding letters. A strong letter of recommendation clearly conveys knowledge of the medical student, how that student performed and qualities that predict excellent performance in residency. Strong letters of recommendation include the following:

• A statement about how the attending knows the student and his/her ability to evaluate the student’s performance
• An overall summary of the student’s abilities
• A specific evaluation of the student’s performance, often presented using the ACGME’s six core competencies
• A discussion of the student’s attributes that demonstrate why the student will make an excellent resident
• Highlights and characteristics of the student such as work ethic and extracurricular activities such as research or volunteer work. This discussion may include traits that make the student unique or attributes that have enabled the student to overcome hurdles
• A closing paragraph summarizing the student’s performance, including discussion of the student’s strengths

Waive your right to view your letters

You will be asked by your school to sign a Family Educational Rights and Privacy Act (FERPA) statement choosing whether to waive your right to view your letters. You should always waive that right because programs view it as a red flag when an applicant does not waive this right and wonder why the applicant wanted to see the letter or what was omitted. You don’t want any skepticism about your residency application.

Your letter writers

Consider several factors when considering whom to ask for a letter of recommendation. The first involves the specialty to which you are applying. Some specialties such as dermatology or urology will expect that your letters come from physicians in those specialties with whom you have performed clinical work or research. Primary care residencies, such as internal medicine or family medicine, want to see letters from physicians in their specialty but often are open to a letter or two from physicians in another specialty, especially for a rigorous rotation on which you worked closely with that attending.

The second factor to consider is how well an attending knows you. Though it’s nice to have a letter from a department chair, if that person does not know you and your work well, this may come through in the letter. Sometimes an individual will even say something like: “I can’t speak to his/her clinical work, but members of my department were impressed.” A comment like that devalues the letter of recommendation. Find a physician with whom you have worked closely for a reasonable duration of time. This person should be able to provide specific commentary on your clinical skills, work ethic, teamwork and other factors that may predict your performance as a resident.

Consider how a potential letter writer views you and the clinical work you have done. Have you developed a collegial relationship? Has the letter writer directly supervised your clinical work? Has the letter writer provided feedback about how they view your knowledge base and clinical skills? You want to evaluate the situation carefully to get the strongest letters possible. If an attending ever gives unsolicited offer to write you a letter, that is usually a sign you’ll get a strong endorsement.

Evaluate the experience of a potential letter writer. You may have developed a great relationship with an attending who thinks you are great, but if that person is not an experienced letter writer, the letter might not be as strong as it could be or could omit important information. This does not mean you should not approach this individual with a request for a letter, but one useful strategy is to provide guidelines about how to write a strong letter of recommendation. Some medical schools recommend that students do this for every attending. Here’s an example.

Plan ahead

Start thinking about your letters of recommendation early. Make sure that your CV and personal statement are well-developed so that you can provide these to your potential letter writers. To ensure that your letters are written in a timely fashion, start asking for letters around July of your fourth year of medical school.

Schedule a meeting and arrive prepared

When approaching an attending to ask for a letter of recommendation, ask to schedule a short meeting to discuss a letter of recommendation so this important discussion does not occur during a busy day. Having the meeting scheduled allows the attending to consider your performance in advance of the actual request to write the letter.

Provide your CV, personal statement, a signed FERPA statement and instructions for uploading the letter to ERAS. Some medical schools provide specific information or recommendations to give to letter writers. Being prepared demonstrates that you are organized and expedites the completion of your letter of recommendation.

Frame the conversation

When asking for a letter, explain why you enjoyed the rotation, what you learned from the attending and why you are requesting a letter from this individual. Be clear about your specialty choice. Having the wrong specialty on a letter of recommendation can adversely affect your application. Ask the attending if he/she had enough clinical time with you to assess your performance according to the six ACGME core competencies. The most important question to ask is “Do you feel that you can write me a strong letter of recommendation?” You want to do everything you can to ensure that you will be getting a great letter of recommendation while providing the attending the opportunity to honestly tell you if he/she cannot write you a strong letter.

Thank you notes

The attendings who wrote your letters took time out of their busy lives to help you get to the next step in your career. After you match, consider sending thank you notes and let them know where you matched. It’s a nice touch and is a gracious thing to do. These letter writers will be happy to know how you did and perhaps even keep in touch. Paths frequently cross in medicine, so this helps develop your professional relationships.

Ted O’Connell is a family physician and a medical director of a family medicine residency program.

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