As you wrap up your end-of-rotation feedback with a student, the student asks hesitantly, “Would you be willing to write me a strong recommendation letter for residency?” Your internal monologue starts to alarm: “Should I say yes? What makes a strong letter? I’ve never done this before! Where do I even start?” This article, next in the Council on Medical Student Education in Pediatrics series on teaching medical students, will help you approach this important task with confidence and skill.

Physicians in a variety of practice settings are tasked with teaching and evaluating students and may be approached to write a letter of recommendation (LOR). Writing an LOR can be a daunting task, especially for those unfamiliar with its expected structure and content. With this article, we provide a framework that any author can use to craft a strong LOR to facilitate a successful application for residency.

LORs are an integral component of residency selection and have been shown to correlate with performance in pediatric internship.1  They provide an opportunity to highlight applicants’ professionalism and adherence to ethical standards, which are qualities important to program directors when selecting applicants to interview.2  In the next few years, US Medical Licensing Examination Step 1 will transition to a pass-fail test, and residency programs may increasingly rely on other aspects of the application, such as the LOR, to identify candidates that are a good match for their programs.3 

Despite their importance, concerns have been raised about the lack of standardization of LORs, including variability in their structure, content, and interpretation by faculty.4,5  One common critique of LORs involves the existence of controversial and unofficial “code words” contained within the letter. For example, “excellent” may be viewed as less favorable than descriptors such as “outstanding” or “one of the best.”6  However, the hierarchy of adjectives is not universal across individuals or institutions. Furthermore, comments intended as positive by letter writers, such as “showed improvement,” can be interpreted negatively by letter readers.7  Therefore, it is important that authors recognize the potential coded language commonly used in LORs to avoid unintentionally harming a student’s application with “insufficient” praise.

A conversation with the student provides valuable insight about the student’s hopes, goals, and strengths. Asking the student about significant clinical encounters, service activities, or life experiences can help define what they would like to highlight about themselves. Review the student’s curriculum vitae (CV) to learn more about their experiences and accomplishments. The themes and narrative stories that arise from their CV and your conversation will help in writing a compelling LOR.

After meeting with the student, if the author does not think they can write a strong, fair, accurate, or timely letter, this should be disclosed to the student. The student should have the opportunity to seek out another letter writer who can honestly and accurately support their application.

Lastly, as you prepare to write your letter, we encourage new letter writers to contact leaders in the undergraduate or graduate educational program. They may be able to provide examples or guidance on the basis of their experience.

To assist letter writers in creating an informative and impactful LOR, we propose the mnemonic “LETTER” as a framework for the important components and their suggested order (see Table 1).

TABLE 1

Structuring an LOR

Key Components of an LORHelpful Questions to AnswerExample
Length and location What is the context of your interaction with the student? I worked with Jenny during the ambulatory portion of her clerkship. In addition to the inpatient responsibilities of that rotation, she worked with me for 3 afternoons each week over the course of 3 weeks in our primary care pediatric practice and assisted in staffing nursery patients after clinic. 
Experience of the student What was the student’s experience while working with you? During the rotation, Jenny functioned in the role of a subintern, independently gathering histories and performing physical examinations under my supervision. Additional responsibilities included providing anticipatory guidance to families. 
Traits of the student What are the student’s unique personal and clinical attributes? Jenny has an outstanding fund of knowledge and can quickly synthesize data to create an accurate assessment and plan. 
Tell a story Share an example to support some of the adjectives you use to describe the student. I was particularly impressed by her ability to handle a busy room with 2 active toddlers and worried parents with many questions. She was able to distract the toddlers with toys and answer the parents’ questions with appropriate confidence. 
Educational summary and professional potential Are there activities or accomplishments from their CV for which you can provide additional context and future application? Jenny’s advocacy experience and community engagement, working to improve access of care to children of recent immigrants demonstrate her dedication to justice. She is poised to have a significant impact on the health and well-being of her patients and community. 
Recap What is your bottom line? I have supervised medical students and residents for the past 5 years and would rank Jenny among the top X% of all students with whom I have worked. I would be excited to have her remain here for residency. 
Key Components of an LORHelpful Questions to AnswerExample
Length and location What is the context of your interaction with the student? I worked with Jenny during the ambulatory portion of her clerkship. In addition to the inpatient responsibilities of that rotation, she worked with me for 3 afternoons each week over the course of 3 weeks in our primary care pediatric practice and assisted in staffing nursery patients after clinic. 
Experience of the student What was the student’s experience while working with you? During the rotation, Jenny functioned in the role of a subintern, independently gathering histories and performing physical examinations under my supervision. Additional responsibilities included providing anticipatory guidance to families. 
Traits of the student What are the student’s unique personal and clinical attributes? Jenny has an outstanding fund of knowledge and can quickly synthesize data to create an accurate assessment and plan. 
Tell a story Share an example to support some of the adjectives you use to describe the student. I was particularly impressed by her ability to handle a busy room with 2 active toddlers and worried parents with many questions. She was able to distract the toddlers with toys and answer the parents’ questions with appropriate confidence. 
Educational summary and professional potential Are there activities or accomplishments from their CV for which you can provide additional context and future application? Jenny’s advocacy experience and community engagement, working to improve access of care to children of recent immigrants demonstrate her dedication to justice. She is poised to have a significant impact on the health and well-being of her patients and community. 
Recap What is your bottom line? I have supervised medical students and residents for the past 5 years and would rank Jenny among the top X% of all students with whom I have worked. I would be excited to have her remain here for residency. 

The letter should be concise and ∼1 to 2 pages. A particularly short letter may be misconstrued as a bad letter, despite the accolades it highlights. Similarly, a long letter may lose its impact.

Orient the reader to the depth and capacity in which you worked with the student. Briefly describe your role and the rotation or clinical context in which you worked together. This might include the length of the rotation and a brief description of the clinical setting or patient population. If applicable, highlight your experience supervising or teaching medical students, residents, or other medical trainees. These details allow the reader to understand the rigor of the experience and your familiarity with the student’s skills, behaviors, and knowledge.

Briefly, share the student’s role and responsibilities during the rotation. This may include aspects such as patient load, degree of autonomy, clinical duties, interactions with interprofessional team members, and sensitivity and responsiveness to a diverse patient population.

Discuss unique clinical abilities and personal traits of the student that a CV, test scores, and grades do not capture well. Emphasize in what areas a student excels, such as patient care, medical knowledge, communication skills, teamwork, and self-directed learning. Focusing exclusively on nonclinical attributes like punctuality and enthusiasm may lead some readers to believe that other attributes like knowledge, clinical reasoning, or ability to develop rapport with a patient may be lacking, even if that was not your intent. While describing strengths, take care to avoid personal remarks and comments that may reflect bias. For example, avoid commenting on personal appearance or English fluency. Do not use descriptors that may reinforce stereotypes and be mindful of praising effort rather than accomplishment.8 

Sharing a clinical story that reflects the student’s skill sets will captivate a reader’s attention more than a laundry list of strengths. A story will paint a broader picture of their clinical and communication skills and professional behaviors.

Without repeating the entire CV, describe the student’s contributions, and discuss how they reflect the impact the student will have on their patients and their families, the profession, and society in general. Describe how the student will uniquely contribute to their future training program and the education of their peers.

End the LOR with a summary of highlights of the student and your main message. Summary statements such as “I give my highest recommendation” and “I would recruit this student to stay at our institution/my practice” are statements viewed as most positive by pediatric program directors. Statements including “showed improvement,” “performed at expected level,” and “solid performance” are viewed as most negative.9  If possible, summarize a student’s attributes compared with the average student with whom you have worked. Truthful phrases such as “in the top 10%” or “one of the best in the past 5 years” help others understand your perspective of their attributes and talents. Remember to be honest. Do not undermine students who are outstanding by giving everyone high remarks.

Once a student submits your name as a letter writer, you will receive an e-mail notification from the Electronic Residency Application Service with instructions. These will include the student’s Association of American Medical Colleges identification number, which should be included at the top of the letter. Your final letter should be printed on professional letterhead and include your signature, name and title, and the date. You should include a statement at the bottom of the LOR stating whether the student did or did not waive their right to see the letter. Finally, all letter writers should proofread their letter before submission. Remember, the quality of a letter reflects not only the student but also the writer!

We thank Robert A. Dudas, MD; Michael S. Ryan, MD, MEHP; and Janice L. Hanson, PhD, for their helpful comments and thoughtful reviews of the article.

Drs Pete Devon, Burns, and Hartke conceptualized and drafted this article and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

CV

curriculum vitae

LOR

letter of recommendation

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.