How To Utilize Letters Of Recommendation In Residency Match Applications

What is a Letter of Recommendation?

The letter of recommendation (LOR) serves as a summary of your clinical skills, personal characteristics, and potential as a physician. 

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

Essentially, the letter shows the program director 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.

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?

LORs are becoming an increasingly important part of residency match applications in the USA.

All med students will have objective measures that speak for themselves - ie. YOG, step scores, US and home country clinical experience, research, publications, and other volunteer and work experiences.

However, LORs are more than just a document checking off the rotation as complete, they are a reflection of trust by the physician in charge. They can make or break an application since a strong letter means another physician can vouch for your knowledge or passion or enthusiasm or skills - all of which lead to potentially being a great resident!

Additionally, an LOR can highlight the candidate’s most important accomplishments and focus on his or her strengths, lending a much clearer picture into the applicant's personality and work ethic, 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.

​How do I get the Letter Of Recommendation?

​Approach physicians who are most familiar with your clinical abilities, medical knowledge, work ethic, interpersonal skills with patients, and your ability to work as part of a team.

Program directors hold in high regard letters of recommendation from clerkship directors, high-ranking medical school faculty members, and physicians in your specialty of choice.

You can reach out to the programs in the USA. Sarthi also helps to get hassle-free rotations in many IMG-friendly states, which provide strong letters of recommendation.

Which is the best type of USCE?

Most residency candidates fit into one of three candidate types:

1. Third or Fourth-Year Medical Students – Keep an eye out for potential letter writers early in your career. 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 regularly for feedback.

2. Recent Graduates/First-Time Applicants – Those of you applying this season, and need strong letters,  don’t panic! Think carefully about who you’ve worked with over the years. It might even be a good idea to list them. Start the conversation with anyone who knows you professionally, not only your direct supervisor.
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 to make sure you have an up-to-date reference for your application.

• As a last resort, you can perform fresh rotations through sub-internships, externships, or observerships. 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.

​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 for, and 1 department chair letter. In that case, 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?

• All letters are due by the end of September annually. Ideally, you have all letters ready by July or August so that you are not rushed. If you already asked for a LOR previously, June/July is a good time to reach out again and remind them. Be sure to give them enough time to write the letter (usually 2-3 weeks).
• 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.

​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 LORs

• Waived LORs - Waiving your Letter of Recommendation means you will waive your rights to see the letter. 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
• Unwaived LORs = This means that you uploaded the letter yourself or had access to the letter. These letters do not hold as much value as a waived LOR.

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 an LOR from Observerships or Research experience as long as it’s completed in the US. LORs from the US proves you have exposure to US medical environments and that you have good communication skills.
• Specialty specific – These LORs specify  your ability in one medical specialty. Ex. “Candidate A would be a great fit for any Family Medicine residency program because…”

​Other 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 or snail mail).

​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. Avoid these to strengthen your LOR impact:

• 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
• Using personal letters from family/friends instead of professional letters
• Using all home country LORs instead of US LORs

​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.

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