Letters of Recommendation (LoRs) have the power to make or break your medical residency application. According to the NRMP® Director Survey, Letters of Recommendation rank #2 among the top 5 most important factors when reviewing a residency candidate’s application.

The strongest Letters of Recommendation are:

1. Recent – Within one year of application
2. Based on US clinical experience (USCE) – USCE is hands-on work with patients completed in a US medical environment. If you do not have USCE, it’s ok to get LoRs from Observerships or Research experience as long as it’s completed in the US. LoRs from the US prove you have exposure to US medical environments and that you have good communication skills. (See information about foreign LoRs below.)
3. Specialty specific – These are LoRs that specifically state your ability in one medical specialty. Ex. “Candidate A would be a great fit for any Family Medicine residency program because…”

Preparing for Letters of Recommendation differs depending on what walk of life you are on. Most residency candidates fit into one of three candidates types:

1. Third or Fourth Year Medical Students – Keep an eye out for potential Letter Writers early on in your clinical rotations. Especially consider people who are practitioners within your potential specialty. BONUS: Asking early means your Letter Writers will be able to get to know you much sooner and more deeply. Make your intentions known right away, and follow up with them every once in awhile to get their feedback.
2. Recent Graduates/First Time Applicants – Those of you who are getting their applications ready right now and realizing you need to tackle LoRs, don’t panic! Think carefully about who you’ve worked with over the years. It might even be a good idea to list them and how well they know you. You don’t have to just ask your direct supervisor, ask anyone who you’ve worked with and knows you. When you know who you want to ask, approach them now and start the conversation.
3. Older Candidates/Re-Applicants – If you haven’t been in the field for a few years, it is advised you complete some extra US clinical experience time to make sure you have an up-to-date reference for your LoR. You can perform fresh rotations through sub-internships, externships, or observerships as a last resort. Please bear in mind, many programs do not count observerships as US clinical experience (USCE). Anything that counts as USCE that you can draw out LoR from will help you in the long run. If you cannot do more USCE, but you are working in the field, think about asking your supervisors in your current employment.

After you have a clear picture of who you will be asking for Letters of Recommendation, the next step is how to actually ask your Letter Writers for the Letter of Recommendation (if you haven’t already in the past). The main goal is to be polite and grateful and to be sure they have everything they need to write a positive letter.

When it’s time to ask for a Letter of Recommendation try to schedule a one-on-one meeting with them. Bring your CV, resume, or anything else that helps highlight your accomplishments, and make sure to run through these items with them. If you can’t meet face-to-face, arrange a phone call or Skype meeting to talk. A simple email asking them for the letter and attaching documents to read won’t cut it!

Some suggested items to offer your Letter Writer are:

• Letter Request Form from ERAS® application
• Your CV or Resume
• Your Personal Statement (if it’s completed to perfection!)
• Information about your chosen program and school
• Bring their attention to the ACGME Core Competencies
• Anything else that can really bring your accomplishments to light

You may also want to discuss:

• Your chosen specialty (this is how you make a letter specialty specific)
• A deadline, they need to know when they need it to be done by
• Whether or not you want it waived
• Any pointers on format or content if they want to know. Don’t give them a template, but a general direction is always helpful

During your discussion with your Letter Writers, be sure to get their feedback on your performance. Ask them if you have exhibited any qualities strong enough to mention such as enthusiasm, confidence, teamwork, dedication, knowledge, or commitment. If anything comes to their mind, ask or provide them with examples of when you demonstrated these traits.

TIP: If you have an idea of what your Letter Writer is saying about you in the letter, you can integrate what they are saying into your Personal Statement to make both your letter and the Personal Statement stronger. For example, if your Letter Writer says you are an exceptional team player, you can mention your teamwork in the Personal Statement with a story about how well you worked with a team of peers. This adds credibility to both documents.

Once you have talked to your Letter Writer, the Letter of Recommendation will need to be submitted. Submission is different whether or not you waive your right to see your LoRs. If you waive your right to see the letter, this means you will not be able to see the LoR before it is submitted. Not waiving means you can review the letter and submit it yourself.

There are many things to think about when you are deciding whether or not you should waive a LoR.

If you don’t waive:

• You will know exactly what is being submitted
• In knowing the focus of the letter, you can make sure you are sending the right letter to the right program
  • For example, you may have asked the Head of Surgery for an LoR, but they praised your insight in Internal Medicine, so you should send this letter to Internal Medicine programs, not Surgical programs.
• You can see if the letter is negative, incorrect or generic. You want to make sure the Letter Writer did not just use a template
• As stated before, you can use the content from the letter in your Personal Statement
• If you do have access to your Letters of Recommendation, consider signing up with Residency Experts, where you can receive reviews and feedback on your LoRs (complimentary with most of our packages). You can also submit your Letters of Recommendation for editing, ensuring they are written to absolute perfection before you certify your application.

Bear in mind:

• Not waiving can throw up red flags such as a lack of confidence
• The LoR may seem less genuine and reliable because the reviewers know you looked at it

You will have to think carefully if you want the chance to look at the letter, or if you trust your Letter Writer enough to write you an LoR that will be an asset to your residency application.

If you choose to waive your right to see the Letter of Recommendation, your Letter Writers will need to go to the LoR Portal® (LoRP) on the AAMC® website. Make sure you have researched and understand the submission process before you talk to your Letter Writer.

Before submitting, your Letter Writer will need:

1. An AAMC account  
2. The Letter Request Form – Each author will need a Letter Request Form specific to the application you want them to write for. Each form has its own ID number. You will need to generate this on your MyERAS Account and provide your Letter Writer with the correct form.
3. Correct formatting
   1. PDF format
   2. On a letterhead paper
   3. Less than 500 KB
   4. No special characters
   5. Letter signed by Letter Writer

Remember, ONLY the Letter Writer or someone they designate (the designee) can upload LoRs. The designee cannot be someone from your medical school who is affiliated with the medical residency application process. If you do not waive your right to see the Letter of Recommendation, you may submit the letter yourself.

After you have followed up with your Letter Writers to confirm they have submitted the letter or checked your MyERAS Account, don’t forget to send a Thank You card. A handwritten card is more thoughtful than a simple email.

Letters of Recommendation FAQ:

1. I am an IMG. Can I use LoRs from my home country? Technically, yes. Many International Medical Graduates (IMGs) end up needing to use LoRs from their home country. However, LoRs from outside the US hold less weight than LoRs from USCE.
2. Can I use someone from another specialty to write about a different specialty? Absolutely! For example, you can ask an Internist to write you a Letter of Recommendation for Psychiatry. Just make sure you tell them about your specialty preference before they write the letter.  
3. How many Letters of Recommendation do I need? You may assign a minimum of 3 and a maximum of 4 LoRs (ERAS limit) per program. Most programs want to see the minimum amount of LoRs. You may submit any number of LoRs to your MyERAS account.
4. Can I use a specialty specific LoR to apply to another specialty? No! If an LoR is written for one specialty, it is a very bad idea to use it for another specialty. Program Directors like to see passion and dedication for the specialty their program is in, applying with a document for another specialty can be seen as lazy, or even insulting. For example, you would not want to use an Internal Medicine letter to apply to a General Surgery program.

This is just a basic guide to Letters of Recommendation. You can also check out Residency Experts’ helpful tips by reading Your Complete Residency Letter of Recommendation Guide. If you or your Letter Writers have any questions, you can either check out the LoR Portal User Guide on the AAMC website and call 202-862-6264, or call Match A Resident at 858-221-8510.

Sources and Resources:

1. LoR Portal User Guide: https://www.aamc.org/download/286098/data/lorp_ug.pdf
2. ACGME® Core Competencies: http://www.ecfmg.org/echo/acgme-core-competencies.html
3. NRMP Director Survey: https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2020/08/2020-PD-Survey.pdf

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