A primer on writing a narrative letter of recommendation for medical students applying to residency

INTRODUCTION

Letters of recommendation (LORs) are a significant component of the residency application process. ¹ , ² , ³ Historically, standardized exams, clerkship grades, and honor societies, were prioritized. ⁴ However, the shift to holistic review, combined with pass/fail scoring for United States Medical Licensing Examination (USMLE) Step 1, has diminished the rigid, metric‐driven components of the application. ⁵ , ⁶ LORs increasingly factor into the decision making process for interview invitations and rank lists. ⁷ Further, studies have shown LORs to be often biased against women and applicants underrepresented in medicine (UiM). ⁸ While there is guidance on writing standardized LORs, resources for creating a narrative LOR are more limited. ² , ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵

This primer will guide authors on writing narrative LORs for medical students who are applying to residency programs. Recommendations are based on published evidence and the combined experience of the authors. All authors have held positions as advisors and mentors to medical students, residents, fellows, and faculty across four separate academic institutions (e.g., core residency faculty, leadership in undergraduate and graduate medical education, service on medical school admissions committees, residency and fellowship selection committees, and authorship of numerous LORs across all levels of training).

RESPONDING TO A LOR REQUEST

When a student requests a LOR, you may accept or decline with attention to a compassionate reply. If accepting the request, make sure to gather supplemental information, such as instructions for submission and their AMCAS ID, CV, and personal statement. ¹⁶ , ¹⁷ Discuss their goals, strengths and weaknesses, and notable content on the application. Give a realistic timeline to completion and offer that a reminder email near the deadline is welcomed. Providing upfront guidance on the reminder reduces the student's feeling of intimidation that might be inherent in this relationship.

Students should never be asked to write their own letters, so it is important to ensure you have sufficient time to draft the letter by the due date. While students can help clarify or describe experiences to refresh your memory about notable patients during their rotation or their roles and accomplishments in your laboratory, the writing task should remain with the letter writer.

We also caution against writing a narrative LOR for a student with whom you are not familiar or have concerns. We understand that a program director, chair, or clerkship director might be obligated to write a letter and lack the option to decline a request. However, in all scenarios the letter writer should be honest with the student about the anticipated caliber of the LOR, which should help a student decide if they would like to seek an alternate letter writer. For a mandatory letter from the clerkship director, program director, or chair, both the student and the letter writer should discuss positive elements to highlight.

Given the LOR may influence an interview offer or rank list position, we suggest you decline a letter you do not feel comfortable writing, if possible. Declining to write a bad letter is as important as agreeing to write a strong letter. The student will undoubtedly be hurt and worried no matter your rationale. Specify why you are not their best choice to write a letter (e.g., lack of familiarity with the student due to superficial contact; lack of time for a writer due to other competing demands and obligations; lack of confidence in the student's potential). Consider giving specific comments and feedback on how they can improve their performance or demonstrate their strengths going forward.

If you ultimately decide that you are unable to write the letter due to lack of time, familiarity, or confidence in the student, you may offer others to approach. Do not guarantee students that the other potential writer will agree to write the letter unless you have already received confirmation. If possible, facilitate any handoff to the new writer to help ease any stress for the student.

KEY COMPONENTS OF NARRATIVE LORs

The overall goal of the letter writer is to align the content of the letter with the needs of the audience. A letter for residency programs should highlight experiences, values, and ambitions that are desirable by residency leadership. When writing a narrative LOR for residency, nonacademic pursuits and obligations are worth mentioning when best related back to skills needed for success in the targeted role. Any points of disadvantage or challenge, such as lack of extracurricular activities or familial responsibilities, should be discussed ahead with the student to agree upon the best messaging. It is prudent to ensure the letter corresponds to the correct student and that all relevant details are accurate (e.g., student name, AAMC ID number, preferred pronouns, rotations, dates, awards, publications) to avoid any confusion or mistrust in the validity of the letter.

Begin by sharing your notable and relevant credentials. Briefly describe your professional background, roles, and expertise. Quantify your experience by detailing how long you have held your role, how many students you have worked with, and your experience with assessing learners (e.g., “I have served as the clerkship director for the toxicology rotation for the past five years. During that time, I have conducted assessments and written LOR for over 30 students.”).

Next, detail your experience working with and observing the student, including time worked together and in what capacity. A few specific examples of experiences and observations are valuable. Table 1 lists examples of how to describe experiences with and observations of medical students. Identify key themes or attributes and choose examples that demonstrate those characteristics (e.g., compassionate, driven, creative, leader, advocate, or scholarly). You may consider making predictions for future success. For example, you could predict a student will serve as a role model for professionalism or be a future chief resident.

TABLE 1.

General versus specific statements to describe medical student experiences.

General statements	Specific statements	Rationale
The student was hardworking and contributed to the team.	The student gave 10 weekly presentations on their research to our team of 8.	The specific information allows the reader to understand the manner in which a student was hardworking.
The student demonstrated compassion toward patients.	The student spent 1 h at the bedside with a dying patient, helping them write a goodbye letter to their spouse.	The specific information draws the reader into the degree of compassion and patience a student displayed.
The student worked well with others.	The student managed to organize a new research project, find and apply for two $10,000 grants, lead the trial and data analysis, assemble a team of authors for the manuscript, and write a strong first draft.	The specific information allows the reader to understand the depth in which a student is capable of leading a project and a team.

Provide insight into how you have seen them handle hardship or obstacles and how they respond to feedback. Mention how current or prior experiences have influenced their ability to be a physician. If they took time off, consider describing how they resumed responsibilities on their return. Incorporate and attribute quotations and feedback you have received directly or indirectly about the student as needed, especially if you need to address a topic but lack firsthand experience with the student.

Close the letter by providing an overall assessment of the student's performance (e.g., at the “excellent” or “good” level or in a specific percentile such as top 10th percentile). It is helpful if you can compare the student to their peers (e.g., this student performed at or above the level of their peers). Since these adjectives may have different meanings for different people, you may clarify where a student you describe as outstanding or excellent falls compared to all students you have encountered (e.g., this student is one of the brightest students I have ever mentored.) Words like “solid” or “good” are generally interpreted as less‐than‐ideal adjectives. If relevant, describe your desire to recruit the student as a future resident in your department.

We caution against written mention of unresolved areas for growth. For instance, if a student is consistently late to meetings that would be an area of concern with time management. Ideally, as a mentor or educator you might have identified this concern and given feedback to the student in real time. If the student responded well, you can omit the issues from the letter and future discussions. If the student has not improved, you might mention this issue specifically if a program reaches out to you for further information about performance.

Finally, add a sentence to the end of your letter stating that you are open to discussing the applicant further if needed and your preferred method of contact. This leaves open the door to discuss any ongoing areas of concern that you did not put in writing, which could be misinterpreted. After clarifying with the student about their preference, state that student did or did not waive their right to see the letter.

FORMATTING OF NARRATIVE LORs

While there has been a sporadic shift to standardized letters of evaluation, which have a rigid structure and are used largely by clerkship directors in fields such as emergency medicine and orthopedic surgery, ¹⁸ , ¹⁹ this article is focusing on narrative LOR that are more free‐form and personalized by the author. Narrative letters are open to variation in structure, aesthetic, and length. However, some standard practices exist. Use institutional letterhead when possible. Add your professional address, date of submission, and a tag that lets the reader know what the letter is regarding. Address the letter to a person or committee, such as “Dear Residency Selection Committee.” Sign the letter with your official signature as well as your professional name, title, and contact information. Ideally, the letter should be less than two pages. Figure S1 provides a formatted example of a letter of recommendation for a student.

ADDRESSING BIAS IN LORs

As LORs are subjective, there is room for conscious or unconscious bias. While any aspect of the applicant is vulnerable to bias, much of the published data describes the differential language used between gender and race. For instance, data demonstrate that women and Black applicants receive fewer stand‐out descriptions. ⁸ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ Women applicants are more likely to be described with terms, such as “compassionate,” “lovely,” or “kind.” Data also suggest that women applicants may receive letters that are shorter and contain physical descriptions of them applicants and mention of their partner's profession. ⁸ , ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ One study found women are more likely to have their social status mentioned (such as the occupation of her father or husband) or their leisure activities. ²⁵ In some studies, male applicants are more likely to be described with standout terms like “excellent” or “best.” ²⁰ Male applicants had more instances that mentioned their research. ²⁶ , ²⁷ Vulnerability also exists for candidates UiM. ²¹ , ²⁸ , ²⁹ , ³⁰ , ³¹ When compared to White and Asian applicants, Black applicants are more likely to be described with grindstone terms, such as “competent” or “determined” versus “leader” or “rising star.” ²⁹ In one study, even using defined national guidelines to minimize bias, candidates UiM applicants were still likely to have biased letters. ³¹ Fortunately, there are some data that suggest gender bias is not universally present; however, this literature is not the majority. ³² While most of the solution to bias is early education and thoughtfulness, calculators are available to assess and allow for reduction in gender bias in language. ³³

An additional bias is that not all LOR authors demonstrate the same influence. Letters from clerkship directors, clinical or research faculty, mentors, classroom professors, or project leads carry different weight. Writers who are familiar to the selection committee may be more impactful. Therefore, smaller or less resourced medical schools might provide students less exposure to writers with national recognition.

CONCLUSIONS

The narrative letter of recommendation is open to a variety of styles, lengths, and content. The letter should demonstrate the journey and strengths of a student with concrete examples. A simple structure of highlighting your expertise and position, their experiences, your observations, and predictions of their future will help frame the letter. As letters are written with a subjective lens, awareness of potential bias is critical.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Figure S1.

Landry A, Coates WC, Gottlieb M. A primer on writing a narrative letter of recommendation for medical students applying to residency. AEM Educ Train. 2023;6:e10896. doi: 10.1002/aet2.10896