The Case of the Late Letter prompted some great discussion around how to properly ask for a letter of reference and what students and preceptors might do when things get down to the wire. As usual, I was extremely impressed by the rich discussion that evolved over the week. We are now proud to present to you the Curated Community Commentary and our two expert opinions. Thank-you again to all our experts and participants for contributing again this week to the ALiEM MEdIC series.
This follow-up post includes
- The responses of our experts, Dr. Alim Pardhan (@alimpardhan) and Dr. Rob Rogers (@EM_Educator).
- A summary of insights from the ALiEM community derived from the blog discussions
- Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities
- SPECIAL FEATURE THIS MONTH: Dr. Rogers provides his commentary in audio format!
By Dr. Alim Pardhan
One of the common challenges faced by senior medical students is who to ask for a reference letter and when/how to go about doing it. Reference letters are an important part of application packages and can add a significant amount of information to the committee when deciding on whom they should invite for interviews and then depending on the process at the program on how to rank candidates.
Polly is in a tough spot. Her application package is due in short order and is hoping to get a reference letter from someone whom she has just worked a shift.
Instinctively many medical students will turn to other medical students for advice, and while this is understandable it may not necessarily provide much insight into the process. It is not inappropriate but there may be other (and more useful) resources that she could turn to. A few examples would include:
- Career Advisor/Center – most medical schools have a resource person to help medical students with career planning. This person will likely be a wealth of knowledge to help guide medial students through the application process
- Medical School Faculty – most of us have been through this process as students and many of us also sit on selection committees so can provide insight and advice
- Program Directors – Most PDs will give information of what they are looking for in reference letters and what types of individuals may be good referees
- Residents – Residents have the advantage of having been through the process more recently and are often more accessible (and less intimidating) than faculty. They may however, have a more limited view than some of the other resources.
Most faculty don’t mind writing reference letters, however it is important to ensure that referees are able to write an accurate and helpful letter. Many faculty will set a minimum number of interactions/time that they have to have spent with a candidate before they are willing to write a letter. This will vary, but in a completely unscientific poll of some of my colleagues for EM it tends to be around 3-4 shifts. Anything less than that and the letter may end up being generic or neutral which can actually be harmful to the candidate.
Other General Tips
- Reference letters should be written by someone who knows the candidate reasonably well. What that means will vary, but in order to helpful the letter should be able to speak to more than a short interaction
- Read the requirements of the program carefully when selecting referees – most will require at least one from someone in the specialty. I usually recommend at least 2, however the others may not need to come from someone in the specialty. In this case a letter from someone who knows you well and can speak to your strengths may be better than someone in the specialty who does not know you as well.Make sure referees know what program you are applying to (so they don’t write you are applying to IM when applying to EM) and can tailor their letter to the program to which you are applying.
- Make sure not to go over the maximum number of letters requested by the program.
- Be direct when asking for reference letters, it is okay to ask if the faculty member is willing to write you a strong reference letter.
- Candidates should send a package to referees including a CV, letter of intent (often your personal statement will work here) as well as whatever they need to submit the letter. If online the information sheet with that information, if hard copy, an addressed, stamped envelope.
- Letters of Reference: how to rate, write and use them in your evaluation of applicants
- Tips for writing letters of recommendation
Expert response 2: The Art of Requesting, Accepting, and Writing Letters
by Dr. Rob Rogers
Dr. Rogers submitted an audio commentary that you can hear below.
To summarize Rob’s fantastic commentary
- Educators have a responsibility to help students with letters, even if the requests are late by either writing or helping the student find someone who can
- Students can turn to websites, blogs, online mentors and onsite mentors for advice about the residency application process
- Students should scope out good letter writers and plan ahead
- Students should ask for letters personally but not directly on shift or while working. Don’t put attendings on the spot, instead ask “can we set up to meet to talk about a letter of recommendation”
- Attendings must be honest about whether they have the time to write letters and about the quality of the letter they will be able to provide.
- Letter writers are accountable to their endorsement. Carefully consider and express your degree of enthusiasm for the candidate. Programs rely on honest evaluations and if every one of your letters suggests the applicant “walks on water” and they show up as an average or below average resident you will lose credibility as a reference.
This is actually a pretty common thin that we see in medical education, the “art of asking for a letter”. What is the best way to do it? What are some really bad ways to do it. There’s not a lot of literature on this a lot of what we do is based on how we did it so you can get some good advice or you can get some bad advice. Looking at this scenario, the “case of the late letter”, this actually comes up quite frequently. This person is wondering how to get a letter and considering that there is 10 days left before the deadline for residency applications this is pretty important. The unfortunate thing for medical students is that depending on when they do rotations this could happen to a lot of students. They are going to be in a situation where they might have to grab a last letter or second letter or even a first letter and have very little time to do it.
So the way this case plays out, she ends up asking a friend how she should go about doing this. When you look at the questions for discussion the first question, and it is a good question, is “Polly’s in a tough situation and she asked her friend Mike what she should do, is this appropriate? Where should medical students turn for advice about residency applications?” Unfortunately this happens in a lot of places, students don’t know where to turn or who to ask. I think asking a trusted friend or your spouse or someone that you trust is a good way to do it. Perhaps someone who has been through the process before, just realize you have to digest what they are telling you to do if they are in fact telling you. Don’t just obviously go at it blind and follow they’re advice you have to take it into consideration, maybe ask a couple of people what they think you should do.
The next question is “where should medical students turn for advice about residency applications?” Medical students have a ton of questions about the application process. There are some podcasts, websites and blogs that will answer some of these questions. But for a lot of these questions you may have to go to the program director or some other faculty member or someone in the department where you work. If you are unfortunate enough to work in a place without a department and you don’t have anyone who is really involved in academics or anyone who writes a lot of letters you will have to look outside of your department or outside of your institution and this can be a bit tougher. But there are plenty of people in the FOAM and social media world who are involved in this like Michelle Lin and Nikita Joshi and myself and lots of people who could probably get you to the right place if you or students have questions about how to do this. But this can be a tricky situation for a student because ultimately you do have to ask for advice and you want to make sure you make the right decision.
So she [the attending] is put in a difficult position, how should she respond to Polly’s request? We [educators] have all gotten these requests and I’ve had situations where I’ve had a day to get a letter written. On one hand you feel for the students who are doing their very best, or at least you hope they’re doing their very best, to make the best out of their situation and really get good letters but you have to take into consideration that you have a life as well. You might have things due, a family thing or what if you are out of town when this request comes and you don’t have access to be able to write a letter? There are going to be circumstances where you are going to have to just be honest and say “you know what I don’t have time to crank this letter out in the next however many days or months or whatever it is so this is what I suggest”. I do think, however, that Dr. Marshall and any other physician, anybody in a position to help medical students, we do have a responsibility to help them. Sometimes it is the students fault for not getting to us fast enough, sometimes it isn’t but nonetheless we either have to help them get this letter done or at least point them to someone else who can get it done for them. So it’s a balance when you’ve got this time constraint going on with the “late letter” you’ve got to be careful and I think you owe it to students to be honest whether you have time to do it. If you don’t have time to do it, my recommendation is just be honest that you can’t get this accomplished within this timeframe and make sure that you at least get them to someone who perhaps can or explore the other options with the student about other people they’ve worked with. The worst thing you can do is say, “yeah, I’ll get it done” and then it never gets done. Make sure that you are looking out for their best interests. Be honest, if you don’t think you’ll be able to get it done then don’t say you can get it done. If you’ve got that little voice on your shoulder saying, “do it, do it, do it” just get it done, get the letter done if you truly do believe that you can write a good letter then carve out the time. Just chalk it up to one of those things that we have to put up with sometimes in academics. We sometimes have to do late letters and sometimes spur of the moment things come up and that’s just part of it. Be honest. Be honest with yourself and with the student. You should meet with the student and go over the options. Email is the worst, well not the worst but one of the worst because you can’t read people’s tone, you can’t see facial expressions or know what is going through their mind. Just meet together. Have the student come in and meet with you and go over the options. It’s our job to advocate for students and make sure they are getting what they need.
Now, as far as do’s and don’ts for letter writing and for letter requesting, there are a couple of things that I would mention:
- Plan early: Students who are looking for letters should plan many, many months ahead. They should scope out the landscape to see who writes letters, who knows what they are doing, who are the leadership roles in the department and ask around. You cannot go wrong by asking lots of questions. Scope attendings out at the beginning of a rotation to see who might be a good letter.
- The ask :The very worst thing a student can do is just sort of trot along and they know they’ve got to get letters and they scope them out here and there and then they just sort of blurt out during a shift, “would you mind writing me a letter?” So, I think it is okay to ask people personally about writing letters, I think a better way to do it is perhaps to say “hey I’ve worked three shifts with you, I’m just wondering if you’d be willing to meet with me about writing a letter?”. The problem with just coming up to an attending and asking “will you write me a letter?” is that it puts that attending on the spot. The attending might reflexively say “yes” or they might be a bit nervous and reflexively say “no”. It doesn’t give them any time to digest your performance or to let them come up with their own ideas about what kind of letter they could write. It’s just very artificial and happens very abruptly. So one of the things I would recommend would be to just ask if “you would be willing to meet with me about it.” Now if they [the attending] say “oh you know what I would love to write you a letter, you are doing fantastic, I’ll write the letter for you,” then that’s fantastic but just make sure you don’t put them on the spot by saying, “will you do it?’-right in their face. I think that might be a mistake with the wrong attending. I think you might not get the answer you are looking for.
- A personal touch: Now how you handle a letter and if you look at the way that this case plays out, she sends and email with 10 days to go “Thanks for working with me the other day, I had a great shift with you. I am wondering if you could write me a letter for my residency application to Emergency Medicine.” This is a very short email, there is no sense of what’s going through the student’s mind as far as the urgency of this process and I honestly think email is probably not the way to do this. I think the way to do this is personally, explain your situation, explain the couples match. Just lay it out there “Listen, this is coming really late. I’ve realized for x, y, z reasons that I am getting a letter with 10 days to go.” Just lay it out there and I think that meeting personally with people is the way to do this. Email I think can be a big mistake. Some people aren’t that great with email, they might not get back to you. It’s just not good. Then you have to send them a follow up email, another follow up email and another follow up email and emails get lost, then the application season comes along and it just doesn’t go well sometimes.
- Scope the letter writers: The other thing I would add for students, students who seek letters of recommendation, know who writes letters. Know the people in your department or whatever department you are working in. Know the people who write the letters, the program director or the educators, the people who are visible educators in the department. The people maybe with recognizable names in medical education and emergency medicine. Those are the people to go after because they have probably written more letters. Be careful, and it is perfectly appropriate, to use your medical student clerkship director or some other trusted person to scope out who writes a lot of letters. You really don’t want to ask someone who hasn’t written a letter in a couple of years who mistakenly says yes to your last second request during a shift. “Oh yeah, I’d love to write you a letter”- the problem with that is they may not know the language to use in a letter and they also may not know the language they should avoid in writing a letter. For example the word, “solid”. Many people who write letters will use the phrase “Bill is a ‘solid’ student”. Now on the surface that seems like a generic statement, it doesn’t mean very much but some people really don’t like the word ‘solid’. It means ‘average’ to them or it means ‘below average’ to them. If this is a person who has not written many letters they may not know that is a phrase or word maybe they shouldn’t use to avoid any ambiguity in their letter writing so you just have to be careful of that I think.
- Be honest: If you are faculty and you have agreed to write this letter you need to be honest, especially before you have accepted to write this letter. Be honest with the student about what you can and can’t say. If they say “can you write me an excellent letter” and they’re an average student and you don’t think they deserve a top-notch letter I think we probably owe it to students to tell them what kind of letter we are going to be able to write. Where we think they would rank with other medical students. If you had 100 medical students where would they fall? The very top, the middle, the bottom, what have you. So they need to be honest with us but we need to be honest with them when we say “oh yeah I’d love to write you a letter” and it turns out to be a crap letter. We have to let them know what we think we will be able to say.
- You are your endorsement: Here’s what I have to say about faculty who write letters. Don’t fall victim to the trap of writing glorious letters about every student you write letters for. “This student walks on water, this student is fantastic, best medical student ever on the planet” and it turns out that residency program who takes them as an applicant ranks them and takes them as a resident and the student doesn’t really do very well. Maybe they are just an outright stinker. You are going to be remembered for that letter, I promise you. You want to be honest with your letters. If you over rate students and they go somewhere, you will be accountable at least in the academic circles as someone who writes overrated letters. At the same time you don’t want to be to critical and lower them in a residency’s ranking. You want to be honest, lay out what they did well and what they need to work on, their energy levels and all of the stuff that they bring to the table. Just be honest. We have to be honest because for faculty your reputation in academics will be on the line if you become someone who is known for writing letters that are not honest. They will not even read your letters or at least they’ll read them and throw them in a stack. This is another one of Rob Rogers letters, he always says “every student walks on water” I really can’t take this for very much. Just be careful as a letter writer.
by Tamara McColl, MD
There was an overwhelming response this month from our on-line community, thus enabling us to generate a comprehensive discussion of reference letters and residency applications, in general. The commentary was analyzed and several key themes emerged which are highlighted below. A member check was performed by co-editors to ensure trustworthiness of the analysis. For simplicity, the content is divided into tips for students and tips for faculty members.
Various perspectives on medical student mentorship were debated. There seemed to be a general consensus that turning to one’s peers was a reasonable and expedient first step. However, many of our ALiEM commenters urged students to approach this style of mentorship with caution when discussing a subject as significant as residency applications.
Several commenters noted that it is often difficult for peers to offer objective advice, particularly on a topic in which they may only possess superficial knowledge. Friends tend to be a great source of emotional support and can help with the many stresses surrounding the application process but aren’t always able to offer the impartial voice of reason. Furthermore, they are also undergoing a similar journey, possess comparable feelings of uncertainty and are making their own speculations regarding the inner workings of the application process. Remember that fear begets fear and anxiety begets anxiety! Might be a wiser choice to turn to an experienced advisor or mentor who will stick to the facts and provide a less biased opinion.
To underscore this point, Dr. Krishan Yadav, Co-Chief Resident of the Ottawa FRCPC emergency program, advised students to seek a mentor who will not shy away from critical feedback.
“I don’t think there’s anything wrong with approaching a friend as long as this isn’t the type of person who avoids being critical. When you’re looking for important advice, it’s essential to get an objective opinion. And so I think a staff mentor may work more effectively.”
Several commenters also recommended seeking out staff mentors, either in emergency medicine or within another specialty. The principle is that these staff physicians have a better understanding of the application process and have developed deeper insights into the necessary steps of becoming a more marketable residency candidate. Moreover, Dr. Bob Connelly, Pediatric Program Director at Queen’s University, reminded us that staff mentors can be powerful advocates for our residency application, as they know the system and the people involved. “Do not underestimate the power of these personal connections!”
Dr. Jan Shoenberger, Residency Director at the Keck School of Medicine at USC, counseled students to utilize the resources available to them, primarily in the form of the Clerkship Director responsible for their EM elective:
“The clerkship director is a key individual to help you navigate the experience. For the most part, they do a good job setting expectations at the beginning of a rotation and during interview season which should include a discussion about obtaining letters of recommendation during or after the rotation.”
Commenters also recognized how important resident mentors are throughout the application process. Residents have all recently completed the same stressful journey and are a wealth of information for future candidates; not only of the do’s and don’ts of residency applications, but also of the various program strengths and weaknesses, fellowship opportunities and collegiality among the group. These are all important topics to explore as you navigate through the final months leading up to the match deadlines. Students can seek out resident advice on shift, in an academic or casual setting or through a more formal mentorship program, which are frequently offered at many universities and organizations such as EMRA, CAEP, and SAEM.
Letter of Reference (LoR)
Who to ask
Many perspectives were offered to help guide students in choosing their referees for residency applications. The number of shifts required prior to asking for an LoR was debated at length. Essentially commenters agreed that this is a grey area and should be handled on a case-by-case basis. There was consensus, however, that in most instances, one shift simply does not provide enough exposure to write a strong recommendation.
Dr. Ross Morton, a nephrologist and medical educator from Queen’s University, reminded us that cognitive biases may play a big role in lasting positive impressions after just one shift with a student:
“While Thorndike’s ‘halo effect’ might be working in Polly’s favor, it is just as likely that Dr. Marshall will be cognizant of being swayed by a ‘good day’ and feel unable to help.”
Dr. Krishan Yadav echoed this opinion, stating: “After just one shift, the only way a strong, quality LoR can be obtained is if the attending is blown away by a potentially ‘star applicant’ and offers to write the letter.”
Commenters acknowledged the difficulty students face when trying to obtain LoR in EM, particularly when they are “late bloomers” and have made the decision to pursue a career in EM late in the game. It is often challenging to fulfill all three reference requirements using emergency staff when scheduled for few EM electives and few shifts with the same preceptor. Dr. Stella Yiu, Emergency Clerkship Director at the University of Ottawa, underscores the importance of the content within the letter and urges students to find referees who know them well over just picking someone for status or for the fact that they happen to be an emergency physician:
“Great letters have to do with the content rather than who writes them. A great letter about your clinical abilities from someone in another discipline is better than an ‘I only worked with them once and they seemed nice’ letter from a specialty-specific faculty.”
Dr. Bob Connelly similarly emphasizes quality over quantity and encourages students to seek out referees who know them well and can thoroughly comment on their abilities. “I have always looked favourably on letters from other specialties as I think it gives a picture of how they (students) perform, even when they don’t think they’re on stage!”
How to ask
When approaching a staff physician for an LoR, commenters agreed that meeting in person was favourable as this method emulates professionalism and offers the student an opportunity to properly assess the situation. One strategy may be to ask for an LoR after an end-of-shift evaluation. This gives the learner the opportunity to carefully analyze the feedback and determine whether this particular staff views them in a positive light and would be likely to provide a strong recommendation. Another option is to ask the preceptor to meet for a coffee where there will be plenty of opportunity to informally discuss the student’s performance, an LoR and even seek advice on program selection, application strategy and research/writing opportunities.
On the other hand, a non-confrontational request provides the staff physician with an opportunity to reflect on the student’s performance and “fit” for EM and may make it easier for them to respectfully decline. Dr. Sarah Luckett-Gatopoulos, a resident from McMaster University, explained that while going through the process as a medical student, she often asked referees for an LoR via email in order to give them an easy ‘out’. She felt that it maybe more difficult for the faculty member to decline the LoR when meeting face-to-face.
The “Press Kit”
Once a student has chosen a referee, it helps if they provide a ‘press kit’ of sorts in which they supply the LoR writer with the tools necessary to construct a comprehensive recommendation. Several commenters advised students to include a photograph, updated CV, letter of intent and a reminder of several cases in which the referee and student worked together. This is an extensive list, but the more tools the student provides, the more informed the referee will be when piecing together the letter.
Too often, the stress of the application process can create an environment in which the main objective for the student when working in the emergency department is to obtain an LoR. Several commenters very insightfully stressed that the focus during the elective period should remain on learning, working hard and creating a positive impression of yourself within the emergency culture. Dr. Nadim Lalani, Assistant Program Director of EM at the University of Saskatchewan, reminded us that, “most medical students do not realize that strong letters are the byproduct, and not the goal.” Very wise words of advice for future EM candidates.
Resources for Students
- CAEP FAQ for Medical Students
- ALiEM EM Match Advice
- BoringEM - CaRMS guide
- Advice for Emergency Medicine Applicants
- SDM – The art of obtaining a stellar letter of recommendation
- EMRA student resources
- Boring EM - Finding a mentor in Emergency Medicine
- AMSA - Finding a mentor in medicine
Tips for Faculty Members
To write or not to write, that it the question
The process of residency selection is certainly a difficult one. There are real limitations in quantifiable metrics in predicting the success of a candidate. One tool that is often heavily relied upon is the subjective interpretation of student performance from our colleagues and peers in the form of a reference letter.
It’s true that most emergency staff work with dozens of students and it’s often the case that a student asks for a letter after only one or two shifts due to scheduling limitations. Dr. Stella Yiu mentioned that her own practice is to have the student request a letter at the beginning of a shift so that she can really focus on their performance in finer detail than she would have otherwise. She also stresses the importance of honest and transparent feedback at the end of this shift. “As faculty, I tell students that their letter will reflect their evaluation at the end of the shift so we are on a similar page in regards to ‘how strong’ the letter would be. It has to be constructive and honest.”
Commenters noted that they are occasionally able to identify an 'all-star' medical student after only one shift but were divided in their decisions to provide a letter after a single exposure. Dr. Michelle Lin offered her insights.
“As an application reader, I’d like to see more of a longitudinal observation period to make sure that they’re not the semi-amazing applicant who was just having a great shift.”
The decision to endorse a candidate through a strong letter can certainly be complex and multifaceted. Our commenters agreed that all too often, we come across generic letters from faculty and wonder why they agreed to write it in the first place! Dr. Nadim Lalani shares his thoughts on the matter. “I feel as though my letter is a reflection on me personally. I owe it to my personal brand NOT to dilute my product (i.e. My word is reliable and consistent).”
An honest approach when asked to write a letter for a mediocre candidate is preferable. Dr. Krishan Yadav comments.
“In my opinion, there is too often a hesitancy to be completely honest with medical trainees about their performance. I don’t think it’s necessarily tactless or wrong to be up front and honest about poor/average performance so long as the criticism is respectful and constructive.”
Constructing a Strong Recommendation
If you ultimately agree to write a strong letter of reference, our commenters devised a few tips to help with the process. Dr. Nadim Lalani remarked that he would typically type out a rough draft of the letter the day he is asked to write it in order to provide fresh examples. Dr. Stella Yiu also recommended providing specific examples to help paint of picture of the candidate’s knowledge, abilities and character.
Several commenters also noted that they find the “press kit” useful and if not provided directly, they will ask for it. Looking over a CV, letter of intent and list of cases you worked together certainly helps with the creative process.
Dr. Elisha Targonsky, a Canadian emergency physician and educator, reminded faculty to discuss the candidate with colleagues to get a better sense of how others perceived the student:
“It is incredibly helpful to speak to other attending doctors who may have worked with the learner to get a sense of how their performance was with another staff. When the response is a clear ‘excellent’ or ‘poor’ then it solidifies any perception that the writer may have for the requesting learner.”
Furthermore, gathering shift evaluations of the student from colleagues helps in a similar fashion and can also provide additional content for the letter itself.
A repeated theme within the online commentary was the need for consistency among letter writers. Not every candidate is a top 5% student, and that’s perfectly acceptable and realistic. “Rankings are helpful but only when they are consistent”, remarked Dr. Sarah Luckett-Gatopoulos. Dr. Stella Yiu furthered this comment by adding, “[I]t’s not as helpful for me unless the letter writer qualifies how many they have trained and seen.”
Dr. Bob Connelly reminded faculty of a very simple concept, which is often forgotten. “Grammatical errors, run on sentences and letters with little substance are surprisingly frequent.” Make sure to either look over the final product yourself or have a colleague proofread it for you. These letters are important and influence the outcome of the candidate’s application; so it’s worth the second read!
Finally, Dr. Franny Crawford, an emergency physician from Queen’s University, underscored that being asked to write an LoR is itself a high compliment and demonstrates that the learner thinks highly of you as an educator and clinician. “Like myself, many see writing letters as an honour, a privilege and a responsibility.” Being asked to endorse a strong EM candidate is certainly something to be proud of!
Food for Thought
A few interesting points were brought up by Dr. Teresa Chan and Eve Purdy regarding the structure of the clerkship curriculum in many medical schools. Eve had mentioned that due to the implemented longitudinal integrated clerkship (LIC), she actually spent 5 months of her clerkship period in the family medicine setting and, as a result, one of her perceived strongest letters is from a general practitioner.
Dr. Chan provided some thought-provoking discussion regarding the potential unintended consequences of these new systems with regards to career planning. She felt that although this LIC may be beneficial from an educational standpoint, it results in fewer hours spent pursuing the student’s area of interest; consequences of which may include fewer opportunities for face-time within the department and increased difficulty obtaining LoR from specialty-specific faculty.
“The irony, though, is that perhaps we should be throwing the Flexnarian model out the window, and starting med students with integrated med sciences and LIC at the same time in preclerkship - freeing up time later in the curriculum for early streaming and specialization. I think the whole letter-cramming game is just another symptom of a broken system.”
Resources for Attendings
MEdIC Series Case and Responses for Download
Download the case (245 kb PDF)
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