Residency Letters of Recommendation: The Best for Success Elise Everett, M.D. Julie Lahiri, M.D. Christa Zehle, M.D.

Workshop objectives: 1. Participants will understand the purpose and importance of Letters of Recommendation (LORs) in the residency application process. 2. Participants will be able to help students identify appropriate faculty from whom they should request LORs. 3. Participants will be able to identify key elements and information needed to write a strong LOR for a medical student applying to residency. 4. The participant will learn how to address declining a LOR request and informing a student if they will need to address challenges in the LOR. 5. The participant will be informed of the timeline for residency applications and when and how to submit a letter.

Importance? A letter of recommendation is one of the most important factors programs use when selecting candidates for interviews and in ranking candidates!

Purpose? Serve as the “expert testimony” that help residency programs make better informed decisions about applicants Convey more than grades and numbers: clinical judgment interpersonal skills professional attributes aptitude for specialty they are pursuing important information not gleaned from ERAS CV technical abilities

Type of Letter? Providing students with a strong letter of recommendation is very important. Students waiving their right to see the LOR is strongly recommended. Ways students might ask? “Can you write me a strong letter of recommendation?” “Do you know me well enough to write a strong letter?” “Would you feel comfortable writing a strong letter?”

Who should write a LOR? Someone who… Knows the student well Is able to describe the applicant’s attributes Has observed the student in a clinical setting Someone who knows the student well Someone who can describe the applicants Fund of knowledge Clinical judgment Interpersonal skills Personal qualities From faculty who have observed a student’s clinical work with the following exceptions: A letter from a faculty research advisor A department chair letter

Who should write a LOR? “Famous” versus “non-Famous” Faculty Programs requirements Specialty versus non-Specialty Faculty . Famous” versus “non-Famous” Faculty “Famous” faculty are those physicians who are well known, in their field or region, or who hold important positions, such as department chair. Helpful, however only if they know you well. If not, it will be obvious and the LOR will carry little weight. Programs may have different requirements Specialty versus non-Specialty Faculty Know the expectations/requirements of the specialty the student is applying in.

What are the main applicant elements you should convey in your LOR?

Elements clinical aptitude personality and professionalism leadership roles and attributes research experience future goals outlying circumstances or things requiring explanation

How do you execute this? Gather information: Meet with the student Review CV and personal statement Request copies of evaluations Request a photo (to jog memory) Ask others! Gather information Meet with the student Details about research , leadership, experience prior to medical school, time off, hardships Understand goals Specific strengths the applicant believes he/she will bring to a residency program Anything specific they want you to focus on? Specialty specific or general LOR Review CV and personal statement Request copies of evaluations Request photo (to jog memory) Ask others!

How do you execute this? Reflect What would a program director like to hear? What would make a great resident? Compare students to others with whom you have worked (top %) Be specific - think of stories that illustrate the student’s strengths

How do you execute this? Opening of letter Body of letter Closing Who you are and what your teaching/advising experience is Nature and length of your relationship with student Body of letter: Clinical performance and fund of knowledge Leadership Research Circumstances that should be elaborated on Personal attributes Closing: Strength of your overall recommendation Reiterate outstanding qualities

Avoid pitfalls! Do not reiterate CV content Not too short (1-2 pages is ideal) Over-generalizations; don’t be too general (i.e., ‘best student I ever had’) Avoid personal remarks (i.e., age, race/ethnicity, marital status, children, physical characteristics, political and religious affiliations, geographic interests, or other personal attributes) Typos / wrong gender/ wrong name

What are potential challenges when writing an LOR?

Challenges Writing many unique letters The average student You are unfamiliar with the student The student has unique challenges; i.e., Academically Personally/professionally Clinical challenges

What are strategies for overcoming these challenges?

Overcoming challenges Meet with the student Share a story about a personal interaction with the applicant Stick to what you can truthfully say about a student Decline -especially if you do not have anything positive to say or cannot write a strong letter of recommendation Or… Inform the student that you will need to discuss challenges that they have Meet with the student Students’ experiences prior to medical school often reflect their specialty choice Discuss academic and curricular/non-curricular activities during medical school Share a story about a personal interaction with the applicant Use examples that relay to characteristics, competencies that are important for a developing resident in your specialty Stick to what you can truthfully say about a student What is left out can sometimes be more telling than what is included

Letter of Recommendation Portal (LoRP) Timeline and Process Letter of Recommendation Portal (LoRP) Enables LoR Authors and/or their designees to upload letters of recommendation (LoRs) to ERAS for distribution to training programs, at the request of applicants. Applicants generate a Letter Request Form (LRF) for each LoR they are requesting and provide the author with the form Authors and/or their designees use the unique Letter ID on each form to upload LoRs for applicants. A designee may not be a member of the hospital in an advising role or a medical school staff member supporting the application process.

Timeline and Process Letter of Recommendation Portal (LoRP) Guidelines You will need an AAMC account. In order for a letter to be uploaded to the Portal: File must be in a PDF format, cannot exceed 500KB, and cannot be password protected, encrypted and/or contain an electronic signature File name cannot contain spaces or special characters (i.e. hyphens, slashes, period, etc.) Page size must be 8.5 x 11 inches Recommended that letters are written on a professional letterhead and signed by the author Before uploading a letter, carefully review the letter for accuracy and grammatical errors.

Timeline and Process Standard Forms/Letter of Evaluation Programs may request standardized forms/letters in addition to or instead of a narrative letter; if this occurs, both documents should be uploaded as one single PDF file. Otherwise, the standardized form/letter should be uploaded alone.

Timeline and Process Letters may be uploaded once the ERAS season opens in May/June. Students may submit applications around September 15th. A student’s application is considered complete when they have three letters of recommendation. Programs view applications early in the process. To ensure your student receives a fair review, ensure you have your letter of recommendation uploaded prior to the application submission date (preferably by September 1st).

Small group work Review your applicant scenario As a group, think about how you would execute the LOR Do you need additional resources? What should you include in your LOR? Outline a plan for writing this LOR to share with the large group

Large group work Small groups will report back to larger group Discuss your plan for writing this LOR. Discuss the challenges and how to overcome these challenges.

Scenario 1 You have just finished a busy week on the inpatient service. The senior medical student / acting intern asks if you would be willing to write them a strong letter of recommendation for residency in your specialty. The student is in their third week of the rotation and, although you didn’t work with them much or observe them do an H & P, you felt like they did a good job.

Scenario 2 You have been asked to write a letter for an average applicant. How do you write a strong letter for an applicant who is average academically or clinically?

Scenario 3 A medical student asked you to provide a strong letter of recommendation in your specialty on their behalf. The student just completed their acting internship and seemed to struggle more than most students. They showed improvement each week, however, they seemed to perform below the level expected of a senior medical student. Your main concerns are with their clinical judgement and efficiency. They are very nice and interacted well with the team.

Scenario 4 A fourth-year medical student applying into your field asked you to write a strong LOR on their behalf. They failed the USMLE Step 1 and had to retake the exam for which they received a passing score of 198. They did not receive honors in any of their Foundations or Clinical Clerkships due to lower exam scores, per their report. However, clinically all of the residents and faculty with whom they worked report that the student functions at an honors-level, easily assimilates into the team, demonstrates outstanding clinical acumen, functions at the level of an intern in their history taking, physical exam, oral presentations and note- writing, as well as takes ownership and responsibility for their patients. They are extremely hard working, professional, have very strong IPCS; moreover, the patients love them. How do you address their low USMLE Step 1 score in a LOR?

Scenario 5 A fourth-year medical student applying into another field asked you to write an LOR. They have solid Step 1 and 2 board scores (235, 247), received two honors grades in Foundations, and honored the Surgery Clerkship. During their rotation on your clerkship, several residents, nurses, and faculty expressed concerns about their professionalism. They were often late to clinical work, wore headphones and tuned out during group sessions, or left the floor for unclear reasons. They did not seem engaged in your particular field of medicine. When you attempted to discuss this with the student, they accused the residents, nurses, and faculty of discrimination. The student is smart, with strong technical skills, and is interested in anesthesia as a career choice. The student feels like they demonstrated strengths on your rotation with a high shelf score and good comments about their technical skills. They hope you can write a strong letter of recommendation, understanding that the issues raised were not reflective of their abilities, but discriminatory.  How do you address the professionalism issues in writing a LOR for this student?

Resources AAMC Careers in Medicine Website APGO faculty development meeting workshop: Charting an accurate course for a successful journey: how to easily write en pointe letters of recommendation. Star Hampton, M.D., Archana Pradham, M.D.,M.P.H., Samantha Buery-Joyner, M.D. AAMC Careers in Medicine Website Guidelines for Writing Letters of Recommendation; Anita D. Taylor, M.A. Ed., Associate Professor & Director of Career Advising, Oregon Health & Science SOM University California San Francisco http://meded.ucsf.edu/ume/writing- letters-recommendation-residency Guidelines adapted from Gross Davis B. Writing Letters of Recommendation. In: Tools for Teaching (1993). 1st Ed. San Francisco, CA: Jossey-Bass; 1993:407-412.

Thank you! Elise Everett, M.D. Associate Professor of Gynecologic Oncology, Vice Chair for Education Elise.Everett@uvmhealth.org Julie Lahiri, M.D. Associate Professor of Vascular Surgery, Program Director General Surgery Residency at UVM Medical Center Julie.Lahiri@uvmhealth.org Christa Zehle, M.D. Associate Dean for Students & Associate Professor of Pediatrics Christa.Zehle@med.uvm.edu