Essential to getting into a residency program are a few things most medical students will never see. They are the letters of recommendation written on their behalf. What the student can do is choose whom—and how—to ask for them.
Letters of recommendation are a much talked about application step, including myriad fine shadings of advice online, because of the weight they carry. Programs can set an academic cut-off point for entry, but the letters, along with interviews and personal statements are what distinguish between viable candidates.
Foremost in the minds of residency admission decision makers “is the perception that someone would be a good fit with the program and the training environment in which your program exists,” said John Andrews, MD, a former pediatric residency program director, now vice president for the AMA Graduate Medical Innovation initiative. “That's why the personal statement, the letters of reference, the interview are so important because that's, that's where you really get a feel for the person rather than just a reporting of their academic record.”
Every residency program is going to want several letters of recommendation, every student in a clerkship is going to be eyeing prospective letter writers, and every physician who comes in serious contact with those students knows they may be asked to provide them. Even the method used to submit the overwhelming majority of letters is mechanical. The Association of American Medical Colleges’ Electronic Residency Application Service® (ERAS®) site is used to upload letters along with all other application materials.
The system works. About 95 percent of U.S allopathic seniors match into PGY-1 programs. But while getting into any residency program is a success, most students aspire to get into their top choice.
That requires strong performance in clerkships and knowing about the residency program. Research residencies at FREIDA™, the AMA Residency & Fellowship Database®. FREIDA includes information on how many letters a program wants—typically three or four. Check with programs individually about their own, often strict, requirements.
Here are some themes that regularly come up and should be carefully considered.
Focus on the letter’s content more than the writer’s prestige. The most effective letters reflect highly favorable impressions drawn from direct observation of the candidate’s work. A letter drawn largely from a CV is going to carry less weight.
“It's really pretty obvious when a letter is being written by someone just as a formality about a student whom they don't know very well, versus a letter from someone who really seems to have a relationship with a student, understands them well and is advocating for them,” said Dr. Andrews.
Ask outright if a strong recommendation is possible. A strong letter is a highly positive endorsement of the student’s candidacy for training in the specialty. If a physician appears even a bit reluctant about a letter request, it’s best to move on to other prospects. The typical presumption of program directors is that the student will have chosen physicians with the highest opinion of their work, and a critical comment is going to be seen as a red flag.
Provide the letter writer with details and enough time. Give them your CV and statement of interest. What a busy letter writer also needs is time. Secure the commitment to write the letter no later than four to six weeks before it is due.
Permanently waive your right to see the letter. That’s the virtually universal advice to applicants and it’s a built-in ERAS option. Not waiving that right telegraphs a lack of confidence and suggests the candidate is worried about negative comments.
Thank the letter writer. This is probably one of those moments for a hand-written note, but at the very least send an email. Let them know the outcome when you get the news.