Overview
Ask early
Provide ammunition
Cover letter
Which specialties should I get letters from?
Account for lost time
Don't over do it

The letter of recommendation can be a great ally for applicants. It gives the admissions committee more than simply a number or a score to get to know you with. Letters of recommendation should be written by those who know you best. The most powerful letters of recommendation will come from faculty members who have known you in clinical situations where you were pushed to perform. Letters describing your clinical abilities as well as your skills in problem solving and teamwork attributes will go a long way in getting doors opened to you during interview season. Avoid letters from occasional preceptors, residents, and fellows. Given the choice between a junior faculty member who knows you well and a senior faculty member who knows you less well, choose the one that knows you better. Letters in which it is obvious that faculty do not know you can do you more harm than good. Remember that you will not likely have the option of having many letters written, and then choosing the best one among them.

Ask early Asking for a letter of recommendation can be like asking someone for a date to the prom. You can't ask the first day of school because the person does not know you well enough, yet you don't want to wait until they've already been asked by someone else. In the case of letters of recommendation, you need to realize that faculty members are busy people, and the sooner you ask, the better. If you ask too late, you may get turned down simply because the faculty member does not have the time, is on vacation, or perhaps on maternity leave! Often, the best time to ask is during the last few days of your rotation. This way you have the opportunity to get a letter from faculty while you are fresh in their mind. In addition, it is generally more convenient at this time for you to hand them a copy of your CV and personal statement (if you have it prepared) instead of tracking them down weeks or months later. Remember also that faculty often have rotating clinical schedules, and may not be easily available later on in the year. Make sure you ask early enough so that the person writing your letter can accurately describe how you performed on the rotation. You may always ask a faculty member to write you a letter early on in the year and change your mind later. For example, you may say, "Dr. X, I am thinking about applying for residency in specialty Y and would like to ask if you would feel comfortable writing me a strong letter of recommendation when it is time for me to apply." This approach accomplishes several goals. First, it secures you a letter of recommendation if you choose to take it later on. If you find three other physicians who will write you stellar letters of recommendations, you may not need to return to ask Dr. X. for his letter. Second, you ask permission in such a way that a physician will feel comfortable backing out of writing you a letter if s/he feels s/he cannot write you a strong letter. Probably the worst kind of letter (besides a negative one) is one that is written half-heartedly or one where the author obviously does not know the applicant well. Never make a faculty member feel obligated to write a letter for you. These kinds of letters may really hurt your application.

You need to provide your letter writers with some ammunition to go to bat for you. Provide your letter writers with a copy of an up to date CV. In addition, if you have finished your personal statement, you should include this as well. If you haven't finished your statement yet, make sure you give your letter writer a cover letter that briefly explains what your chosen specialty is along with some possible career goals you have. The ERAS application program can also print out a cover sheet that you may choose to give your letter writer. If you are unsure of which specialty you will ultimately decide on, you can ask your letter writer to simply recommend you for residency training without explicitly stating your specialty. Or, you can ask your writer to submit slightly different letters of recommendation for one of several specialties. Include a stamped envelope with the designated address (i.e., student affairs office or dean's office.)

In your cover letter you should also give a deadline to your writer This gives them just a hint of pressure to complete the letter and not leave it until too late. If you are asking during the summer, a good deadline to suggest is the first of October if you are in the NRMP match using ERAS. As dean's letters will not be going out until November 1st, you will have a safety net of about a month. The earlier the better! You will find that some programs may offer you an interview well before the dean's letter has been sent. If you are worried that your letter writers are running late, you can gently remind them by sending a thank you letter or card around the time of the deadline to jog their memory. Usually, you can ask your dean's office if letters have been received from a faculty member. Sometimes the dean's office can also give a call to faculty to remind them for you. Be prompt and courteous at all times when communicating with faculty.

At least one, and probably two of your letters should come from people within your chosen specialty Letters need to come from your chosen field explaining why you are a perfect fit for that specialty. Don't feel obligated to get all your letters from within your specialty, but one from a third year clerkship and one from a subinternship within the field would be appropriate. The last letter can be from someone you performed research with, or from a field that is loosely related to your chosen area. For example, it would be acceptable to obtain a letter for pediatrics from an internist. Any good letter from one of the core specialties (internal medicine, pediatrics, surgery, obstetrics and gynecology, etc.) should be fine for most applications.

Account for lost time If you took time off during your medical school career to participate in research or to work, it is customary to have your principal investigator or boss write a letter of recommendation, or at least write a letter that is included in your dean's letter. If you have holes in your schedule that are not accounted for, admissions committees may wonder why someone for whom you did research over a significant period of time didn't take the time to write a letter for you. If you have unexplained gaps in your schooling, they may wonder if you were perhaps in jail between third and fourth year, or involved in something you don't want to mention.

Don't over do it If three letters are required, then five must be better. Wrong. If you have three glowing letters, any additional letters that are even slightly less than glowing will hurt your case. Committee members may wonder why you felt it necessary to obtain extra letters. Perhaps the one extra letter you asked for has a negative comment in it that causes more damage than it is worth. Make sure your primary letters are solid, and don't risk going overboard. If you are approached later on in the year by a faculty member who is particularly enthusiastic about writing you a letter, you may make an exception in this case.