Whom Should I Ask for a Letter of Recommendation?

Question

When I apply for residency, whom should I ask to write a letter of recommendation? Are these letters really important?

Response from Daniel J. Egan, MD Associate Attending Physician, Department of Emergency Medicine, St. Luke's-Roosevelt Hospital Center, New York, NY

As someone who routinely reviews applications to our residency program, I can tell you that letters of recommendation are very important to a successful match. The initial screening process typically involves board scores, rotation grades, medical school grades, and Dean's letter summary statement. However, after an applicant has made that cut, letters of recommendation play an important role in the evaluation process and truly give insight beyond the standardization in the rest of the application.

Several approaches to letters of recommendation can be taken. The most obvious person to ask for a letter is a mentor who knows you well. If you have worked with a mentor on a research project or have formed a relationship outside of a rotation or the classroom, this person should write a letter on your behalf. Most likely, his or her letter will provide more personal insight about you as an individual and capture the reader's (ie, the interviewer's) attention. I often pull interview questions from these letters to ask about the mentorship or project on which a student worked.

The second most obvious “letter writer” for you should be someone involved in a position of leadership in the clerkship of your specialty choice. Hopefully you have done well in the clerkship of your future specialty, and you will need to have someone from the faculty speak on your behalf. If you do not include a letter from someone in your specialty, it will be a glaring red flag to those of us reading through your application. In fact, some specialties have requirements about a certain number of letters from staff in your specialty. Be sure to find this out. Additionally, some specialties (such as emergency medicine) require a specific form letter; obviously, it is important to make sure you follow these guidelines.

The question becomes, Who should write your letter within a given rotation? A letter from a resident is not an option. A brand-new attending in his or her first year out of residency may also not be the ideal candidate. It may be to your advantage to approach someone who is more senior within the department. Ultimately, the content of the letter is important, but supportive statements from a chair, associate or full professor, or residency director will be taken seriously. Additionally, many of these faculty are nationally known, and the reader next to me may know them personally or by name, giving more credence to the letter.

Faculty members are frequently asked to write letters. People who routinely write letters include the medical student director for a rotation and members of the residency leadership. Those of us reading a letter look for certain phrases and comments. If a faculty member is not familiar with letter writing, he or she may not include these statements and it may be hard for an interview committee to interpret the letter. A medical student clerkship director will also probably include statements or at least a summary from multiple faculty members and give a consensus opinion. One individual faculty member can only speak for himself or herself. Another tip: if you are unsure of a person's opinion of you, avoid asking him or her to write a letter. Clearly, you do not want a “bad” or even mediocre letter in your file.

Some tips for deciding whom to ask:

• Speak to upperclassmen who have completed the rotation. Some faculty members in your school have letter-writing reputations.
• Consider your approach to the faculty member. I have been asked explicitly, “Do you think you would be able to write me a strong letter of support?” Many faculty will tell you that they are not comfortable writing a letter even without this specific question, but it is always hard to say "no" to someone. However, if you deliver this more directed question using the adjective "strong," it gives someone an out to say "no" if they do not think they can write you an adequate letter.
• Ask the residency director at your school for advice. Tell the residency director whom you are considering asking to write letters for you. He or she may steer you in another direction if that faculty member may not be the best option.
• Speak openly with your Dean of Student Affairs. The medical school is acting in your best interest, and the leadership wants students to be successful and match at competitive programs.

One last piece of advice: Ask for your letter as soon as possible after your clerkship, when you are still fresh in the mind of the faculty member. Also, remember that every letter you collect does not ultimately need to be included in your application. Better to have more than you need than not enough.