Letters of Recommendation

The Challenge

Letters of recommendation (LORs) are an essential part of transitioning from residency or fellowship to the next stage of a career. Yet many of us, especially early in our careers, feel uncomfortable asking faculty or mentors for an LOR. The challenge for residents and fellows is to identify faculty who will write informative and supportive letters. The challenge for writers is to write an engaging, truthful letter that provides information not found elsewhere in the application. If the letter cannot augment the candidacy, the prospective writer should decline.

What Is Known

An LOR can confirm information about an applicant's competence, but it is also uniquely able to provide employers with information about an applicant's personal strengths and characteristics that apply to the desired position and in comparison with other applicants.^1–4 Choosing the writer is key. While the academic rank of the writer holds importance, especially for academic positions, the most important attribute is that the writer is knowledgeable and can speak positively about the candidate's integrity, capacity, knowledge, and experience as these attributes apply to the desired position.

Rip Out Action Items

Residents and fellows should:

1. Develop relationships with faculty and mentors who might write letters of recommendation (LORs). Don't assume they “will know you.”

2. Remind LOR writers of specific patients or activities to possibly include in the LOR.

Faculty LOR writers should:

1. Know your candidates, their goals, and why they are seeking the position.

2. Create an LOR template that can be customized and revised.

How You Can Start TODAY

1. Residents and fellows:

   • Create and maintain an up-to-date curriculum vitae (CV).¹ Consider including a cover letter for the specific job and a written job description (if applicable) to orient the letter writer to the position. Include specific instructions for submission of the letter.

   • Think ahead while working with clinical faculty; consider asking about their willingness to write a future LOR.

   • Ask individuals you know will write a credible, positive letter in the timeline needed. Consider specific examples of team and patient interactions for the letter writer to include.

   • Plan ahead and give LOR writers adequate time: a minimum of 4 weeks or more if possible.

2. Faculty LOR writers:

   • Stylistically, write a formal letter on professional stationery/letterhead, with a template similar to the format outlined in the Table. While most LORs follow a similar format, online short-response LOR templates are also common.

   • Include a brief description of your program and/or institution. Save this description as it can be reused.

   • Avoid generalities. Provide details that are relevant to the desired position. Illustrate with examples if possible. Avoid repetition of elements found in the CV unless needed to illustrate a point.

   • Save LORs to modify as needed for future requests.

   • Be honest with the applicant. State if you cannot write a strong LOR.

Table.

Key Letter of Recommendation (LOR) Components

Letter Element	Recommendation	Examples
Introductory paragraph: elements to include	The title of the position under consideration How strongly you recommend this person How you know this person and duration—context of how the relationship developed (eg, review of evaluations, close personal clinical contact, shared committee work)	Highly recommend with no hesitation/reservations I am pleased to support Dr “X” for the position of “Y” I have worked with Dr “X” in the following capacity(ies) . . .
Body of letter: be specific in describing candidate's attributes and abilities	Actions in clinic, research, or education (eg, comments from other attendings, patients, peers, or examples of praiseworthy actions) Professional attributes (eg, exceptional work ethic, trustworthiness, team player, professionalism)2 General intellectual and technical ability, character strengths, motivation, and overall “fitness” for position Place the candidate in context, in terms of your program or other candidates	Dr “X” easily meets all job qualifications … exceeding them in 3 areas I will highlight . . . Dr X's specific strengths are in areas of . . . Compared with other residents at this level . . .
Summary	Include a short summary, typically 1 sentence, of your comments at the end Use modifiers to distinguish level of recommendation Invite further inquiry, for additional information or question	Unreserved highest (versus strongest) recommendation Asset to program Candidate has my support to pursue . . . Please contact me . . .
Signature	Include your professional title(s) and specific contact information
Review	Carefully proof the LOR and review the message from the reference point of the LOR recipient Be alert to inadvertent gender bias3 or other biases

What You Can Do LONG TERM

1. Residents and fellows:

   • Maintain relationships with individuals whom you might ask to write future LORs.

   • Be intentional about choosing mentors from supervisors and peers. Mentors will likely be your most valuable LOR writers when the need arises.

2. Faculty:

   • Make it a point to know more about learners than clinical performance per se. This information will enrich clinical assessments and coaching in the short term, and provide context for future LORs.

   • Build relationships with residents and fellows by considering individual performance assessments more as coaching opportunities, for learning, rather than “grading” opportunities, of learning.⁵