by Alexandria S. Jo MD, PGY1 at the University of Hawaii Surgery Preliminary Residency Program, future IR Resident at the University of Michigan (starting July 2015).  Please direct any questions/comments to alexandria.s.jo@gmail.com.

Letters of recommendation (LoRs) are one of the most important aspects of your residency application.  Beyond your Step 1 and 2 scores, GPA, research, and extracurricular activities, programs are equally concerned with one pivotal question: “Will I enjoy working with this person?”  Along with your personal statement, a great LoR can tell a more complete, qualitative story about you beyond your ERAS application.  LoRs are uniquely poised to paint a picture of a more well-rounded, amiable, and interesting person—somebody that programs would love to meet.  

As a recent medical school graduate who recently completed the 2013-2014 residency match cycle, I would like to share my experience with all aspiring vascular and interventional radiologists hoping to secure great LoRs.

  • “How many LoRs do I need?”
    • Most radiology programs require 3 LoRs and allow a maximum of 4.  They generally require at least one of them from a radiology faculty.  Review each program’s LoR requirements before assigning your LoRs.  This information can be easily found on their website or ERAS.  Make sure to review the requirements set by your preliminary programs as well, since these may vary. 
  • “Who should I ask for a LoR?”
    • The most important factor when it comes to selecting a letter writer is how well the writer knows you.  Programs are more concerned about the personal nature of the LoR rather than the author’s academic title (e.g. assistant professor vs. associate professor).  A heartfelt letter from a rural physician is more meaningful to a program than a generic letter from a program director that barely got to work with you.
    • Although each program allows a maximum of 4 LoR submissions, you may have an unlimited number of LoRs uploaded onto the Letters of Recommendation Portal (LoRP).   This allows you to assign different cohorts of 4 LoRs to different cohorts of programs.  For instance, you could include LoRs from surgical fields for applying to a surgery preliminary program, and LoRs from medical fields for applying to an internal medicine preliminary program. Given the unlimited number of LoRs allowed for upload, it is not unreasonable to ask for more letters than you plan on using.  
    • A letter from the radiology or interventional radiology department chair at the applicant’s institutions is not usually required. These letters are often more meaningful if you worked closely with them in a research or clinical setting.  That being said, the chair may be well known at the national level and have connections with other chairs or program directors. Thus, it may be in one’s interest to develop a relationship with their home institution’s department chair of radiology or interventional radiology. 
    • When applying to a Interventional Radiology/Diagnostic Radiology (IR/DR) Dual Certificate residency program, it may be helpful to submit a letter from a interventional radiology (IR) faculty member or other procedural-related fields. These include general surgery, surgical subspecialties, and procedural oriented medicine subspecialties (e.g., interventional cardiology, interventional nephrology, etc.).  
    • If you participate in visiting clerkships and feel that you have performed at a high level, be sure to ask your attending for a LoR.  All recommendations from this article also apply to LoRs from visiting clerkships.  In addition, I encourage students to submit LoRs from visiting clerkships held at regions different from their hometown to institutions that are often regionally biased.  For instance, a student from the west coast can increase their chances of an interview invite to an institution located the southeast if they complete a visiting clerkship and receive a great LoR from a southeast institution. Participating in a visiting clerkship that is far away from your home institution can show interviewing institutions that you are willing to travel for your residency.  The letter writer from your visiting clerkship may also have more influence over their region versus a writer from your home institution. 
    • Keep in mind that internal medicine preliminary programs may require at least one letter from an internal medicine physician. By the same token, preliminary surgery programs may require one or more letters from attending surgeons.
  •  “When is the best time to ask for a LoR?”
    • The best time to ask a writer for a LoR is right after your rotation, when things are still fresh.  If you ask for a LoR several months later, the writer may not remember the small but crucial details of your performance.
    • Note that many writers will have multiple students to write for and need ample time to write a great LoR for you.  If it is an option, try to give your writer several weeks to write.
  • “What do I say when asking for a LoR?”
    • When asking for a LoR, you should try to determine two things: 1) how well the letter writer knows you and, 2) if they are willing to write a great, not average, LoR.  Asking in person is highly recommended, but you can also email, write, or call if necessary.
    • Examples:
      • “Do you think that you know me and my potential as an IR well enough to write me a strong LoR?”
      • “Would you be comfortable writing a strong LoR for me?”
    • Don’t be discouraged if the physician indicates that they cannot write you a strong LoR.  It’s better to know that you should look elsewhere than to send a lukewarm LoR as part of your application.
  • “What constitutes a great LoR?”
    • Most writers are going to write a “good LoR”.  It is very rare for a writer to write you a negative one.  However, a "generic LoR" won’t be of much help to your candidacy either.  LoRs that will truly make a difference are those that delve into the details of your performance and aptitude as a medical student. Try asking for LoRs from those that you worked with extensively and know the best.
    • Programs expect applicants to waive their rights to read their LoRs and most writers will not let you proofread the content of the LoR. Thus you are trusting that the LoRs are of good quality and assigning them to programs blindly.  Note that your dean’s office may prescreen all LoRs and advise you not to send particular LoRs if they feel that the LoR puts you in a bad light. With your dean’s office screening and advising, and some writers allowing you to proofread their LoR, it may be reasonable to ask for more than 4 different LoRs.  With this strategy you can potentially secure stronger LoRs and have a better idea of its content, making it easier to assign them to programs. 
  • “What do I need to give to my writers?”
    • This is all up to you and your writer.  My recommendation is to first ask the writer if they have specific material they would like to receive from you to be able to write an effective letter. If they have no preference you can choose to simply give them the “Letter Request Form” generated through ERAS or provide an extensive packet. 
    • ERAS provides an electronically generated “Letter Request Form” a few months before the application can be submitted.  This form is automatically generated when you enter and confirm the letter-writer information.  It includes information such as the applicant’s name, AAMC ID, Letter ID, and whether or not an applicant has waived their right to view their LoR. The writers need this “Letter Request Form” to properly submit your letter to the dean’s office or upload it directly onto the portal.  Unfortunately, you are not allowed to submit the letter on their behalf.  In the event that the Letter Request Form is not yet available, ask for a LoR right after your rotation and provide them with the “Letter Request Form” later.  The physician may either choose to write and save a LoR as soon as they are asked, or to write the LoR later, when they are provided with the “Letter Request Form”.  Try to stay in touch with them throughout your clerkship years so they can easily recall your performance when they compose your LoR.
    • I opted to provide all of my writers with a packet, because I wanted a comprehensive and diverse set of LoRs that covered all of my qualities.  The packet included:
      • Thank you letter to the writer
        • This could be tailored to your writer, and help remind them about what you valued from your experience with them (and thus, what’s so great about you).
      • CV
      • Most updated Personal Statement
      • Compilation of evaluations from other clerkships
      • Letter Request Form, generated through ERAS
      • Instructions for uploading the LoR into the LoRP
      • Envelope and stamps if the writer chose to mail the LoR into the dean’s office instead. 
    • Strive to have LoRs that emphasize different aspects of you as a medical student (e.g., clinically experiences, research experiences, volunteering experiences, etc.). Ideally, the four LoRs that you assign to programs should be unique and different from one another.  When you request a LoR, you can opt to mention certain qualities that you want your writer to emphasize in your LoR.  For example, your pediatrics attending can emphasize how well you work with patients of all ages and backgrounds. A surgery attending can emphasize your dexterity and post op patient management skills. You can achieve this by reminding them of instances where you demonstrated these qualities in your conversation with them or in your thank you letter.
  • To err is human
    • Letter writers are human and may need reminders to submit your LoR on time.  The dean’s office will provide you with a LoR submission deadline (submission via mail or direct upload onto LoRP).  The dean’s office often screens the LoRs for their students and needs a few days before ERAS application submission becomes available. This deadline is usually a soft deadline and set so that some of your LoRs can be available when ERAS application submission opens.  Note that many writers will have multiple students to write for and will need ample time to write a great LoR for you.  A good time to remind them is about 2-3 weeks prior to the soft deadline.  These gentle reminders are reasonable if you are worried about getting the LoR turned in promptly. An example would be a conversation or email stating, “have you had a chance to look into this yet?”
    • Again, you can choose to add LoRs to ERAS and send additional LoRs to programs even after your application has been submitted. This is possible as long as you haven’t submitted your maximum 4 LoRs.  Thus, if you only have 3 LoRs uploaded by the time the ERAS application submission opens, you should not wait and submit the 3 available LoRs first along with your ERAS application, then submit the last LoR later on. This may be the most likely scenario if you participate in a visiting clerkship during the time ERAS application is open. Some programs heavily rely on LoRs when deciding whom to invite for an interview, so try to have at least a few uploaded by the time ERAS submission opens.  You can submit additional LoRs as long as ERAS remains open but programs generally finish reviewing applications by late December. 
  • Thanking your writers
    • Remember to thank your writers for their effort and for optimizing your application.  Be sure to let them know if an interviewing program comments on how great their LoRs are!  Remain in touch with your writers and let them know where you end up.  You are a product of their great teaching and they will be happy to learn about your future.