Residency Letters Of Recommendation: The Ultimate Guide (with ERAS Samples)


When I reviewed residency applications as a program director, I was always reassured when I read a letter from someone I knew and trusted.

Therefore, because program directors value the opinion and assessments of people with whom you have worked during medical school, and, especially those letters from people within the specialty to which you are applying, ERAS letters of recommendation become one of the most important parts of your residency application.

Knowing from whom to ask for letters, how to ask for them, when to get them, and how to ask is often a major concern for residency applicants.

Below we have answered your most pressing questions about residency letters of recommendation.

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When should I ask for letters of recommendation?

At any time during your medical education, when you identify someone with whom you have rapport and who thinks highly of you ask that person if she would be willing to write you a strong letter of reference in the future. Then be sure to keep in touch with that individual from time to time. Keep the attending updated on your progress and achievements so when it comes time to write your letter she won’t have to play catch up, which will make the letter more sincere.

Assuming you are applying for residency in September, you should request letters by May or June, if possible. However, since many of your key rotations will likely be in June, July, and possible August of your fourth year of medical school, we advise asking those letter writers as soon as you can so they can submit by September 15th.

How should I ask for letters of recommendation?

How you go about asking someone to write a letter depends in part on your relationship with the individual. If an attending offers to write a letter on your behalf and you have had an open dialogue about his doing so, then simply ask him if he would like any supporting documentation. 

Otherwise, it is best to schedule an appointment to meet with the attending. I suggest first requesting this meeting via email. If the email isn’t answered in three to four business day, follow up with a phone call.

You also want to remind your letter write about deadlines since they may not be aware of them.

We suggest you try and personalize your request as much as possible.

Here is a sample email letter request:

Dear Dr. Murray,

I will be applying for residency in otolaryngology this fall and I am writing to ask if you would be willing to write me a letter of reference. I really enjoyed my rotation with you where I learned so much about the practice of ENT both in the OR and in the outpatient setting. This rotation is what really solidified my desire to practice ENT. Since then, I have written one case report and started a research project with Dr. Katz. As we talked about during the rotation, I hope to return to Texas for residency so I can be closer to family. I would be happy to meet or speak with you, whatever is easiest for you. I have attached my CV to this email for your reference. I will be submitting my ERAS application in September and would great appreciate if you could send the letter by then. 

Thank you for your time and consideration.

Krystal Khan, MS IV

During the meeting, it is fair to ask this person openly if he would be willing to write a strong letter on your behalf. You must hope that you will get an honest reply. If you sense any hesitation, walk away. You don’t want any mediocre or poor letters in your profile.

Your job is to make the letter writer’s job as easy as possible. Arrive at the meeting with a folder in hand that has a copy of your CV, your personal statement (if you have already written it), and any information he may need, such as your AAMC number and where the letters should be sent. 

Some attendings may refer you to their administrative assistants, who will let you know what materials are needed for the attending to compose your letter. Every letter writer has his or her own approach to writing letters and therefore each will make different requests regarding the background information they want from you. 

Who should write my letters of recommendation?

Which letters have the most impact when it comes to residency? It depends. If you are applying for orthopaedic surgery, for example, you don’t want to have three letters from non-orthopaedic faculty. When applying to residency, titles matter; a letter from a community doctor will carry less weight than a letter from the chair at a major academic center.

That said, you want to get letters of reference from people who know you well. You want to have a minimum of two letters from people within the specialty to which you are applying and a maximum of four. For very competitive specialties we suggest having at least three letters from with the specialty.

Should I get a letter from a big name in the specialty?

A letter from someone with a “big name” with whom you have never worked won’t be strong. The best letters come from people who know you well and have worked with you directly.

Should I only get letters from within the specialty I am applying for?

Across all specialties, program directors surveyed indicated that letters of reference in the specialty were one of the most important factors in deciding whom to interview. Ideally, we like to see three to four letters from attendings within your specialty and a minimum of two. If you have done research within your speciality, that also “counts” as a specialty letter. There is no  question that when reviewing applications I paid much more attention to letters from within my specialty.

Most influential are letters from clerkship directors, program or associate program directors and chairs within the specialty to which you are applying. Strong letters from department faculty, while they might have less weighty titles, are still valuable.

What makes for a strong residency letter of reference?

The best letters of reference are from people with whom you have worked directly and who know you well. It also helps if your letter writers like you and want to see you succeed. In other words, the strongest letters come from those who believe in you and can offer the strongest endorsements of your candidacy.

How many letters of recommendation should I have?

ERAS allows you to select four letters to be sent to each program and we recommend having at least two of these letters from attendings within the specialty to which you are applying.  Since ERAS allows you to upload multiple letters of reference which you can then assign to programs, it never hurts to ask for more letters than you need in case someone doesn’t come through. You may also have some letters you only want to send to specific programs.

For example, maybe you did a rotation at Brown and asked for a letter from an attending there. But, you don’t think the letter will be as strong as some of your others. So you don’t offend the Brown attending, select that letter to be sent only to Brown and not other programs where you are applying.

How do I nudge my letter writer?

It can get quite awkward if a letter write is late in sending in a letter. Remember, not all letter writers understand the importance of timeliness in this process. I suggest you gently remind the letter writer if they haven’t submitted their letter by September 1st. Ideally, if you see the letter writer in person, mention it to them. Alternatively, send a polite email like the one below:

Dear Dr. Smith,

I hope you are doing well. I am sure you are very busy, but, I wanted to remind you that ERAS applications start getting submitted to programs on September 15th and the ERAS system indicates they have not yet received your letter. If there is anything I can do to help expedite this process or make it easier for you, please let me know. I appreciate your time and consideration.

Sincerely, Getmein (999-999-9999)

Can I read my letters?

You should always waive your right to read letters of reference. So, no, you cannot read your letters. If your letter writer sends you the letter to read, then he or she wants you to read it and there is nothing illegal about that!

What if I am asked to write my letter?

We find that more and more attendings are asking applicants to compose letters of reference that they then sign. Why? Attendings are busy and this means they have one less thing to do! Take advantage of this opportunity and write a stellar letter!

How do I thank my letter writers?

We suggest thanking your letter writers after the letter is received and again once you match.

What is the deadline to submit ERAS letters of recommendation?

There is no firm “deadline” for letters to be submitted, but, keep in mind that many programs won’t review your application until all of your letters are received. For this reason, we suggest making sure all of your letters are submitted by September 15th.

Should my letter be addressed to someone specific?

Unless a letter writer is composing a letter for one specific program, the letter should not be addressed to an individual or program.

How do I get a Chair letter if the department chair doesn’t know me?

Many programs and medical schools require that one of your letters be from the chair of the department. If this is the case, we can assure you that the chair has a prescribed way of getting the information she needs to write a strong letter of reference. It is likely she will ask for a CV and personal statement and she may ask other department faculty to chime in or may use excerpts from your clinical evaluations. Remember, your chair wants you to match well and will write a letter that will help guarantee that as much as possible.

Where should my letters be sent?

Your medical school Dean’s office may collect your letters for you. Alternatively, you will log in to MyERAS and download a letter request form (LRF) for each letter writer. The form will have instructions for your letter write about how to upload the letter to the Letter of Reference Portal (LoRP).

If I am applying to more than one specialty does my letter writer need to write more than one letter?

Yes. Each letter should be written for the specialty to which you are applying. Therefore, if you are applying for two specialties, you should notify your letter writers about this so they can compose distinct letters for each and label them differently when uploading them to ERAS.

How do I indicate in ERAS where I want my letters sent?

Before you submit your application you will need to assign letters to individual programs. Be careful with this step especially if you are applying to two specialties or if you are not assigning all letters to all programs.

If I am an IMG, can I have letters sent from doctors in my home country?

You can have letters sent from doctors in your home country, but, unless those doctors have specific connections to residency programs in the United States, they may not be viewed favorably. Letters from U.S. attending physicians, ideally in academic medicine, are the ideal choices.

Sample Letter Of Recommendation

To whom it may concern:

It is with pleasure that I write this letter on behalf of Excellent Student who is applying for residency in surgery. I worked directly with ES for two weeks in March while he was on his core general surgery rotation at the University. During this time, I was an Associate Professor of General Surgery and Clerkship Director for General Surgery. 

ES was always an outstanding student clinically and was well above the expectations of a third year medical student. In our time together, ES cared for numerous patients on the service. Each morning, she would arrive at 5:30 AM, even before the residents and diligently gather information on overnight events, speak with nurses, record laboratory values, and interview patients on her own. Because she was often done with her work before the residents, she then assisted them with any time remaining. During morning rounds, ES always presented her patients in an organized and succinct manner. She paid close attention to details and would often question why his patients had abnormal patterns of laboratory values. She demonstrated an exceptional fund of knowledge that she applied to complex clinical situations. Furthermore, her ability to prioritize problems and create her own plan to address those issues was impressive. ES cared for each of her patients with a rare blend of compassion and sensitivity that is rare for a student her age. She also considered a patient’s family and loved ones when they were present. ES took her role seriously and patients and families often viewed him as “the doctor” rather than a medical student.

In the operating room, I was impressed with ES’s technical skills, ability to know when to step in an assist and when to stay in the background at the ready. Her level of stamina paralleled her curiosity about general surgical techniques. I remember one fairly complex cholecystectomy when the cystic artery was severed and we had to covert to an open procedure. ES expertly assisted during this procedure, staying calm, and the patient did very well. 

Residents on ES’s team remarked at how independent and hard working she was. However, ES also knew when her experience and knowledge limits were met and was not afraid to ask for help. ES was consistently pleasant, personable, easy going and demonstrated great communication skills. Everyone felt that ES was a strong team player, and a professional who would often volunteer to call consults and help with admissions that did not involve her own patients.

Intellectually ES was exceptional. She frequently sought out opportunities to broaden her knowledge base and took an active part in self-directed learning. She read independently on his own patients as well as others and offered to give presentations on various topics. ES presented at our morning conference about cholecystecomy complication and her work was at a resident’s level.

ES consistently impressed me on a daily basis and demonstrated that she is a bright and extremely motivated young woman. I am confident that she will be a tremendous asset to your department and make you proud to have her on your team. I give ES my absolute highest recommendation and consider her to be in the top 5% of students with whom I have worked with in my career. I congratulate the program that is lucky enough to recruit ES. If I can be of any further assistance, please do not hesitate to contact me.

Best regards,
The Doctor

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JESSICA FREEDMAN, M.D., a former medical school and residency admissions officer at the Icahn School of Medicine at Mount Sinai, is the founder and chair of MedEdits Medical Admissions and author of three top-selling books about the medical admissions process that you can find on Amazon.

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