1. How to Write a Letter of Recommendation
Angela Jackson, MD
Associate Professor of Medicine
Associate Dean for Student Affairs
Emelia J. Benjamin, MD, ScM
Professor of Medicine & Epidemiology
Vice Chair for Faculty Development and Diversity, DOM
1. Access WebROLIC through nrmp.aamc.org, then select Main Match Participant
2. Lots of information about NRMP can be found on the web site by selecting Main Match Guide.

2. Objectives:
Identify the key components of an effective letter of recommendation
Identify common mistakes to avoid
Discuss responsibilities involved in writing a LOR

3. Points to Cover: Purpose of the LOR Getting Started
Letter content and structure
Do’s and Don’ts of letter writing
When to say “no”
Review of examples

4. Limitations of the LOR:
No agreement on expectations
No uniform adjectives
Reliability limited
Limited time observing trainees
Pressure to be overly positive
Still, can be a very useful component of a portfolio

5. Purpose of the LOR:
Provide truthful information about the candidate to assist the reader in selecting the best/appropriate candidate:
Obligation to candidate, reader and patients
Obligation to your own integrity and reputation
Highlight the individual’s qualities in which the reader would be interested

6. Purpose of a LOR: Student: Future resident
Unique or Personal characteristics
Performance description
Future resident

7. Purpose of a LOR: Student: Future resident
Unique or Personal characteristics
Performance description
Future resident
Fund of knowledge
Clinical reasoning
Communication skills
Current functioning
Future potential
Personal qualities
Objective AND Subjective
-Your opinion

8. Getting Started:
How do you get started?

9. Getting Started Meet with the trainee/faculty
Career goals
Purpose of the letter
Review CV, evaluations, your notes
Honestly assess your ability to write a STRONG letter
Define the timeline and due date
Recheck the timeline and due date

10. Letter Content and Structure:
The “Opening”
The “Middle”
The “Summary”

11. Letter Content and Structure:
Opening:
Reason for letter
FERPA
Your qualifications
Context and duration (how you know the student: duration and intensity, role of the student)
Quantify and compare (# trainees you have worked with, ranking of the trainee)

12. Family Educational Rights and Privacy Act of 1974- FERPA
Federal law protects privacy of student education records
Applies to students, but often extended to residents
Students have the right to consent to disclose their “educational record” or not
Most institutions require a waiver

13. Example:
I am writing this letter at the request of Stella Studs, currently a 4th year medical student, who is applying to your internal medicine residency program. I am delighted to enthusiastically support her application. She has waived her right to read this letter. I was Stella’s attending during her four week Internal Medicine subinternship on a busy inpatient service, where she carried 4-6 patients, and admitted up to 8 patients a week. I have served as ward attending twice a year for the past 12 years, and have worked with over 100 students. As such, I feel that I am able to accurately assess her abilities and potential as a house officer.

14. Letter Content and Structure: The “Middle”

15. “The Middle”: Details of the students performance
Address important competencies: FOK, communication, clinical acumen, technical skills
Personal qualities, linked to success in next endeavor
Current accomplishments, linked to future success
Provide specific examples whenever possible

16. “The Middle”: Quantify and compare, if possible
Describe relevant skills
Comment on
Professionalism
Work ethic
Personality
Team work

17. Example:
Stella is among the top 15 of the 100 students that I have worked with to date. Among a group of very strong students, her excellent communication and clinical reasoning skills set her apart, and were at the level of a seasoned intern. This was evidenced by her management of a particularly challenging patient with a new diagnosis of diabetes and severe pneumonia. She…

18. Example:
Stella is an engaging and committed student, well liked by all of the team members. Her patient assessments were appropriately detailed, both written and verbal and her clinical decisions were sound, and appropriately carried out. It is important to add that her fund of knowledge is not accurately reflected by her standardized exam scores. In every clinical situation, it was clear to me that her fund of knowledge exceeded/was on par with that of her fellow students.

19. Letter Content and Structure- The Summary:
Last paragraph:
Summarize overall achievements
Potential
Would you recruit here?
Clear overall recommendation

20. Do’s and Don’ts:
Do’s:

21. Do’s: Set a realistic timeline for yourself
Be honest- responsibility for the reputation of the institution, society, to the student
the student when the LOR has been submitted
Keep it to 1-2 pages, in general
Review some sample letters if new to the game
Highlight something memorable about the student
Use clear, declarative statements and specific examples, rather than flowery generalities

22. Don’ts:

23. Don’ts:
Say yes if you can’t write a helpful letter or meet the deadline
Ask a trainee to write a draft of a LOR
Include criticism – not expected in a LOR (vs. to evaluations, summary assessments)
Assume a word is just a word – SOLID, improved
Underestimate the damage from what you LEAVE OUT

24. When to say “No” and other challenges:

25. Challenges: Not enthusiastic…
Rather than include negative comments, consider omitting comments about weaknesses (organization, FOK, etc.)
If critical skill lacking, mention but frame in a positive light (“I am sure his presentations will improve with continued practice…”)
Tell the student what “temperature letter” you can write
Truthful but POSITIVE – progress made

26. Faculty Letters Features Not Typically in Trainee LORs
Discuss whether “arm’s length” evaluation,
Not mentored, trained, coauthored, or on grant
Emphasize specific unique contributions to field
How changed research or clinical practice
Well cited publications [Google Scholar]
Funding
Service
Teaching & mentoring
Would he/she be promoted at your institution?

27. Be Aware of Racial Bias
African American applicants rated lower than whites
However, asking evaluators to use controlled processing, slowed down their evaluation, led to less bias
Morgan et al., J Appl Soc Psychol. 2013;43:2297. PMID

28. Be Aware of Gender Stereotypes
Men
Women
Letter length
Long
Short
Stand out adjectives
Letters of minimal assurance
Doubt raisers
Accomplishments
Emphasized
Research
Skills and abilities
Career
Diminished
Teaching
Training
Application
Stereotypical adjectives
Ability & Success
Achievement
Grindstone
Compassion
Personal life
Omitted
Commented on
Trix & Psenka Discourse & Society. 2003;14:191.
Schmader, et al. Sex Roles. 2007;57:509. PMID

29. Tip for Reducing Bias Write LOR for candidate & switch the pronouns
If it sounds odd, reconsider
Test for your unconscious biases