What is a Letter of Recommendation (LOR)?
Letters of recommendation play a crucial role in your residency Match application. While things like test scores are pretty standard across the board, these letters of Recommendation can highlight what makes you stand out as a future doctor.

Essentially, they give program directors a deeper look into your clinical skills, personal traits, and potential as a physician. Despite being just one aspect of your application, they can significantly influence how you're viewed as an International Medical Graduate.

Letters of Recommendation (LORs) have the power to make or break your medical residency application. These can significantly enhance an IMG's chances of being accepted into a residency program.
So... How Important Are Letters Of Recommendation?
The letter of recommendation (LOR) is becoming an increasingly important part of residency match applications in the USA.

Why, you may ask?

All med students indeed have objective measures that speak for themselves Scores, US e clinical experience, research and number of volunteer/research/work experience, etc.

But The Letter Of Recommendation is more than just a document stating that you did your rotation, it is a reflection of trust by the physician in charge. It is what can make or break an application since a strong Letter means someone found you extremely helpful or passionate or enthusiastic or maybe just some other quality that would make you a great resident.

Additionally, a Letter Of Recommendation can highlight the candidate’s most important accomplishments and focus on his or her strengths, lending a much clearer picture of what the applicant is actually like, behind test scores and extracurricular activities. 

It is important to ensure that your letters of recommendation achieve their intended purpose to demonstrate to programs that you have both the professional and personal qualities to succeed as a resident and, later, as a practicing physician.​

“A strong/effective letter of recommendation depends
​on choosing your letter writers wisely."

How do I get the Letter Of Recommendation?
Approach physicians who are most familiar with clinical abilities, medical knowledge, work ethic, interpersonal skills with patients, and your ability to work as part of a team.

Program directors may hold in high regard letters of Recommendation from clerkship directors, high-ranking medical school faculty members, and physicians in the specialty to which you are applying. 

You can reach out to the programs in the USA or check the video for FREE USCE click here to check the list. Sarthi also helps to get hassle-free rotation in many IMG-friendly states, which provides strong letters of recommendation.
Which is the best type of USCE?
Most residency candidates fit into one of three candidate types:
  • 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 a while to get their feedback.
  • Recent Graduates/First-Time Applicants – Those of you who are getting your applications ready right now and realizing you need to tackle a Letter Of Recommendation, 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 and start the conversation.
  • 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 Letter Of Recommendation.
    • As a last resort, you can perform fresh rotations through sub-internships, externships, or observerships. Please bear in mind, that many programs do not count observerships as US clinical experience (USCE). Anything that counts as USCE that you can draw out a Letter Of Recommendation 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.
Click here to read more about the types of USCE.
How to ask for a Letter Of Recommendation?
  • When asking for a Letter Of Recommendation, try to do it face to face and ask specifically if they would be willing to write you a “strong letter” of support. Also, ask them what they would need from you (CV, PS, etc).

  • It is helpful to provide letter-writers with a succinct cover letter or bulleted list that states what you’d like them to cover. Even if you know them well, this can help guide the letter and emphasize aspects of your CV or application.
How many letters of Recommendation do I need?
Ideally, IMGs should have 3-4 letters of Recommendation. However, when it comes time to submit your letters, don’t just upload the max allowed (4) for every program. Check on program sites prior and upload what programs require. For example,  some specialties may specifically say they only want 3 total letters, 2 from the specialty that you are applying to and one department chair letter, so sending 4 letters may look like you didn’t take the time to visit their website and learn about the program.

When to ask for a Letter Of Recommendation?
  • You should have your letter of recommendation by July before your application cycle. If you already asked them for a Letter Of Recommendation previously, this can be a time for you to touch base with them again and confirm this.
  • If you are starting a clinical rotation and know that one of your objectives is to identify and impress a doctor so that they would be willing to write you a Letter Of Recommendation, then this is something you can bring up with them during the rotation (closer to the end), regardless of what month it is.
  • Ideally, you want your letters finished and uploaded by the time you submit your application in mid-September (but it’s not a big deal if the timing is slightly off). Therefore, you need to make sure you give your Letter Of Recommendation writers enough time to write a letter after asking them (ie at least ~2-3 weeks)
Types of Letter Of Recommendations and which is best for residency?
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
There are two types of Letter Of Recommendations
  • Waived Letter Of Recommendation - Waiving your Letter Of Recommendation means you will waive your rights to see the Letter Of Recommendation. This would essentially mean your letter writer has not shown you the letter and you are not aware of the content of the letter. This will make the letter more candid hence more reliable for the program
  • Generic Letter Of Recommendation - This is written in generic terms not much information is provided on this.​
​The strongest Letters of Recommendation are:
  • Recent – Within one year of application
  • 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 a Letter Of Recommendation from Observerships or Research experience as long as it’s completed in the US. Letter Of Recommendation from the US proves you have exposure to US medical environments and that you have good communication skills. (See information about foreign letters of Recommendation below.)
  • Specialty specific – These are letters of Recommendation that specifically state your ability in one medical specialty. Ex. “Candidate A would be a great fit for any Family Medicine residency program because…”
Tips for Letters of Recommendations
  • Your dean’s letter (MSPE) does not count as one of your letters of Recommendation.
  • Send your Letter Of Recommendation writer a thank you note (can be a simple email, snail mail, etc)
Common Mistakes to Avoid
When it comes to letters of recommendation, there are some common mistakes that applicants make that can negatively impact their application. Here are a few things to avoid:
  • Asking for letters from individuals who do not know you well
  • Waiting until the last minute to ask for letters
  • Not providing enough information to your letter writers
  • Not following up or expressing gratitude to your letter writers
  • By avoiding these mistakes, you can ensure that your letters of recommendation are strong and effective.
Conclusion
Letters of recommendation play a crucial role in the residency match application process. They provide insight into your character, work ethic, potential, and knowledge of the US medical system as a future physician.

By starting early, choosing the right Physician/Attending/Writer, providing relevant information, and avoiding common mistakes, you can secure strong and effective letters of recommendation that will help you stand out in the competitive world of US residency Match application.


Written By
Swati Chauhan
Team USMLESarthi

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