How to Write a Letter of Recommendation

Angela Jackson, MDAssociate Professor of Medicine

Associate Dean for Student Affairs

Emelia J. Benjamin, MD, ScMProfessor of Medicine & Epidemiology

Vice Chair for Faculty Development and Diversity, DOM

Objectives:

- Identify the key components of an effective letter of recommendation

- Identify common mistakes to avoid

- Discuss responsibilities involved in writing a LOR

Points to Cover:

– Purpose of the LOR

– Getting Started

– Letter content and structure

– Do’s and Don’ts of letter writing

– When to say “no”

– Review of examples

Limitations of the LOR:

– No agreement on expectations

– No uniform adjectives

– Reliability limited

– Limited time observing trainees

– Pressure to be overly positive

– Still, can be a very useful component of a portfolio

Purpose of the LOR:• Provide truthful information about the

candidate to assist the reader in selecting the best/appropriate candidate:

–Obligation to candidate, reader and patients

–Obligation to your own integrity and reputation

• Highlight the individual’s qualities in which the reader would be interested

Purpose of a LOR:

Student:•Unique or Personal characteristics•Performance description

Future resident

Purpose of a LOR:

Student:•Unique or Personal characteristics•Performance description

Future resident

Fund of knowledgeClinical reasoningCommunication skillsCurrent functioningFuture potential Personal qualities

Objective AND Subjective -Your opinion

Getting Started:

•How do you get started?

Getting Started

1. Meet with the trainee/faculty

- Career goals

- Purpose of the letter

2. Review CV, evaluations, your notes

3. Honestly assess your ability to write a

STRONG letter

4. Define the timeline and due date

5. Recheck the timeline and due date

Letter Content and Structure:

– The “Opening”

– The “Middle”

– The “Summary”

Letter Content and Structure:

1. Opening:

– Reason for letter

– FERPA

– Your qualifications

– Context and duration (how you know the student: duration and intensity, role of the student)

– Quantify and compare (# trainees you have worked with, ranking of the trainee)

Family Educational Rights and Privacy Act of 1974- FERPA

• Federal law protects privacy of student education records

• Applies to students, but often extended to residents

• Students have the right to consent to disclose their “educational record” or not

• Most institutions require a waiver

Example:I am writing this letter at the request of Stella Studs, currently

a 4th year medical student, who is applying to your internal

medicine residency program. I am delighted to

enthusiastically support her application. She has waived her

right to read this letter. I was Stella’s attending during her

four week Internal Medicine subinternship on a busy inpatient

service, where she carried 4-6 patients, and admitted up to 8

patients a week. I have served as ward attending twice a year

for the past 12 years, and have worked with over 100

students. As such, I feel that I am able to accurately assess

her abilities and potential as a house officer.

Letter Content and Structure: The “Middle”

“The Middle”:

2. Details of the students performance

– Address important competencies: FOK, communication, clinical acumen, technical skills

– Personal qualities, linked to success in next endeavor

– Current accomplishments, linked to future success

– Provide specific examples whenever possible

“The Middle”:

– Quantify and compare, if possible

– Describe relevant skills

– Comment on

• Professionalism

• Work ethic

• Personality

• Team work

Example:

Stella is among the top 15 of the 100 students that I have

worked with to date. Among a group of very strong

students, her excellent communication and clinical

reasoning skills set her apart, and were at the level of a

seasoned intern. This was evidenced by her management

of a particularly challenging patient with a new diagnosis

of diabetes and severe pneumonia. She…

Example:

Stella is an engaging and committed student, well liked by

all of the team members. Her patient assessments were

appropriately detailed, both written and verbal and her

clinical decisions were sound, and appropriately carried

out. It is important to add that her fund of knowledge is

not accurately reflected by her standardized exam scores.

In every clinical situation, it was clear to me that her fund

of knowledge exceeded/was on par with that of her fellow

students.

Letter Content and Structure-The Summary:

3. Last paragraph:

– Summarize overall achievements

– Potential

– Would you recruit here?

– Clear overall recommendation

Do’s and Don’ts:

– Do’s:

Do’s:

• Set a realistic timeline for yourself

• Be honest- responsibility for the reputation of the institution, society, to the student

• Email the student when the LOR has been submitted

• Keep it to 1-2 pages, in general

• Review some sample letters if new to the game

• Highlight something memorable about the student

• Use clear, declarative statements and specific examples, rather than flowery generalities

Don’ts:

Don’ts:

• Say yes if you can’t write a helpful letter or meet the deadline

• Ask a trainee to write a draft of a LOR

• Include criticism – not expected in a LOR (vs. to evaluations, summary assessments)

• Assume a word is just a word – SOLID, improved

• Underestimate the damage from what you LEAVE OUT

When to say “No” and other challenges:

Challenges: Not enthusiastic…

• Rather than include negative comments, consider omitting comments about weaknesses (organization, FOK, etc.)

• If critical skill lacking, mention but frame in a positive light (“I am sure his presentations will improve with continued practice…”)

• Tell the student what “temperature letter” you can write

• Truthful but POSITIVE – progress made

Faculty LettersFeatures Not Typically in Trainee LORs

• Discuss whether “arm’s length” evaluation, – Not mentored, trained, coauthored, or on grant

• Emphasize specific unique contributions to field– How changed research or clinical practice– Well cited publications [Google Scholar]

• Funding

• Service

• Teaching & mentoring

• Would he/she be promoted at your institution?

Be Aware of Racial Bias

• African American applicants rated lower than whites

• However, asking evaluators to use controlled processing, slowed down their evaluation, led to less bias

Morgan et al., J Appl Soc Psychol. 2013;43:2297. PMID 91929414

Be Aware of Gender StereotypesMen Women

Letter length Long ShortStand out adjectives Letters of minimal

assuranceDoubt raisers

Accomplishments Emphasized•Research•Skills and abilities•Career

Diminished•Teaching•Training•Application

Stereotypical adjectives

• Ability & Success• Achievement

• Grindstone• Compassion

Personal life Omitted Commented onhttps://www.aamc.org/members/gfa/faculty_vitae/148590/successful_nominations.htmlTrix & Psenka Discourse & Society. 2003;14:191.Schmader, et al. Sex Roles. 2007;57:509. PMID 18953419

Tip for Reducing Bias

• Write LOR for candidate & switch the pronouns– If it sounds odd, reconsider

• https://implicit.harvard.edu/implicit/– Test for your unconscious biases