Letters of Recommendation:

How to Rate, Write, and Use Them in Your Evaluation of Applicants

Writing a Letter of Recommendation (LOR):

1. When approached by an applicant to write a LOR, ask the applicant to be specific about the purpose of
the letter, to whom it is to be addressed, how it is to be submitted, and whether or not the applicant
waived their right to see the letter (should be waived). Be honest with the applicant with regards to the
quality of letter if it may not be supportive. For example, “Bob, I will write a letter for you, but I can not
place you in the top third”. The applicant may then select someone else if they want. Also, writers should
generally not write an LOR for a specialty that is not similar to their own (subspecialties are fine, such as
infectious disease writer for a cardiology application). Exceptions may be made for unusual
circumstances, such a lengthy research project where a medicine attending worked with a surgical student
for a long period of time. Lastly, recognize the responsibility to the profession of medicine when writing
this letter. Grossly inaccurate letters that portray a poor candidate as an exceptional one are
unprofessional.

2. In the opening of the LOR, include the reason for the letter (“for application to internal medicine
residency”). Anecdotally, some readers look for comments in the beginning of the LOR that indicate the
writer actually wanted to write the letter because the applicant was high quality (“Mr. Bob Johnson asked
me to write this LOR for his application for internal medicine residency and I enthusiastically agreed”).

3. State whether or not the applicant waived their right to see the letter.

4. Convey a great depth of understanding of the applicant. The reader should believe that the writer had
the opportunity to really get to know the applicant. Always include the context and the length of the
relationship. For example, “I worked with Bob for 4 weeks on the General Medicine Service where he
cared for 10 new patients”. While some statements may be “cut and paste” from previous LORs, specific
examples about the applicant should be frequently included to make the reader believe the LOR isn’t just
generic comments the writer makes about all applicants. Direct quotations from the applicant’s evaluation
are generally helpful. If possible, describe multiple spheres (knowledge, clinical skills, professionalism,
interpersonal skills, etc.) Ensure all comments are “factual, truthful, and made in good faith.” (Wright
2004)

5. Provide a numerical comparison with peers, including a denominator. For instance, state “within the
top 1/3 of students I have worked with in the past 5 years (n=20)”. Do not simply describe the student as
“Excellent” or “Outstanding” without quantification as these words have different meanings at different
institutions. Comment on areas of weakness if appropriate, particularly if there is an explanation. Also,
comment on the applicant’s potential.

6. Provide a clear summary statement. Examples include “I would accept for my program”, “strongly
recommend, without reservations”, or “will be a good resident, but won’t be a star”. Do not give coded
answers that force the reader to attempt to interpret what is actually meant. Think of what comments
would best help the reader of the LOR.

7. Provide medical school affiliation/academic rank of the writer. This should always be included by
writers who are surgeons.

LTC Kent J. DeZee, MD MPH FACP 7 Oct 2011

General Medicine Fellowship Director, USUHS
8. Don’t worry too much about the length of the letter. Anecdotally, some readers will discount shorter
letters. Therefore, writers who typically write short letters for all candidates may wish to include a
comment such as “I limit all of my LORs to one page or less”.

Using LORs in the application process:

1. LORs are generally considered to be important, though there is no clear data that they predict future
performance or discern marginal performance, though top performers may be more professional.
2. No published data on how to use LORs in the context of other data on the applicant, such as board
scores, interview, performance on a rotation at your facility.
3. Anecdotal recommendations:
a. If LORs are absent or there are none from the specialty, this means a poor applicant as
manifested by poor clinical performance (and no one will write them a letter) or the applicant
can’t complete tasks.
b. Look for any concerning phrases.
c. Otherwise, they are all “excellent” and the LOR’s really don’t differentiate the candidates. If
desired, the factors listed above may be used in ranking LORs among different candidates.

Useful References:

Cullen MW, Reed DA, Halvorsen AJ, et. al. Selection Criteria for Internal Medicine Residency
Applicants and Professionalism Ratings During Internship. May Clin Proc 2011;86(3):197-202. [Shows
an association between comparative ratings of students and subsequent professionalism in internship].

Denton GD, Hemmer, PA. Mentoring and Fostering Professionalism in Medical Students: From the
Classroom to Clerkship. In Ende J (ed) Mentoring in Academic Medicine, p 93-5. Philadelphia, PA:ACP
Press 2010. [Perspective of clerkship leadership writing LORs]

DeZee KJ, Thomas MR, Mintz M, Durning SJ. Letters of Recommendation: Rating, Writing, and
Reading by Clerkship Directors of Internal Medicine. Teaching and Learning in Med 2009;21(2) 153-8.
[Recent review of the literature and a survey of a cohort of experienced internal medicine educators]

Friedman RB. Fantasy Land. NEJM 1983:308(11):651-3. [The classic paper]

Greenburg AG, Doyle J, McClure DK. Letters of Recommendation for Surgical Residencies: What they
Say and What They Mean. J Surg Research 1994;56:192-8. [Specific recommendation for surgeons]

Irby DM, Milam S. The Legal Context for Evaluating and Dismissing Medical Students and Residents.
Acad Med 1989;64:639-3. [Advice for negative LORs]

Keim SM, et al. A Standardized Letter of Recommendation for Residency Application. Acad Emerg Med
1999;6(11):1141-6. [Detailed explanation of the EM standardized LOR, the only currently used
standardized LOR]

Wright SM, Ziegelstein RC. Writing More Informative Letters of Reference. J Gen Intern Med
2004;19:588-93. [A more detailed and very informative reference for writing LORs]

LTC Kent J. DeZee, MD MPH FACP 7 Oct 2011

General Medicine Fellowship Director, USUHS
Sample Personal LOR
[Official Letterhead]

Date

To: [The person/committee as directed]

Subject: Letter of Recommendation for Mr. Bob Johnson, ID# 123-45-678

Mr. Bob Johnson asked me to write a letter of recommendation in support of his application for
an Internal Medicine residency and I enthusiastically agreed. Bob waived his right to see this letter. I
came to know Bob during his 6 week long 3rd year internal medicine clerkship in May-June [year]. I am
the associate clerkship director for internal medicine at [X] Medical Center. I also functioned as Bob’s
preceptor for the final three weeks of his internal medicine clerkship. These duties permitted me to
interview every physician that worked with him at our facility, so I believe I can accurately portray his
performance.

Clearly, Bob is in the top third of the 24 3rd year [medical school] students I have seen this
academic year. All of his evaluators agreed that he could function at the sub-intern level if not the intern
level. On several occasions, he was permitted to make all of the management decisions on a patient under
his care. I was particularly impressed with his detailed histories that he presented very clearly. In his
papers, it was obvious that he truly understood the disease processes of his patients. On rounds, he could
routinely offer a reasonable management plan. He also had all the important professional qualities, to
include meticulous work habits, respect for superiors, and being a good team player.

I’d also like to add that I think he is more intelligent than his standardized test scores indicate.
When we reviewed several multiple choice style questions together, it was clear to me that even though
he knew the material, he was not picking the correct answer because he didn’t understand the question
being asked. I gave him some exercises to work on and hopefully his test taking skills will improve.
Please note that in every clinical situation it was readily apparent that his knowledge base exceeded his
peers.

In summary, Bob Johnson is a superb medical student in all aspects. I strongly recommend him
for residency in internal medicine, and would gladly accept him in my own program.

Please note I limit all of my letters of recommendation to one page or less. Please contact me if
you have any questions regarding Bob Johnson. I may be reached as follows: [555-555-5555] or
[first.last@official]

First Last, MD
Job title
Academic rank
Hospital Affiliation

LTC Kent J. DeZee, MD MPH FACP 7 Oct 2011

General Medicine Fellowship Director, USUHS
 Checklist for writing a Personal LOR

Opening paragraph:
 Applicant’s name in the first line
 State the purpose of the letter (e.g. in support of his/her internal medicine residency
application)
 May add a comment such as “I am happy/enthusiastic/excited to write this letter”
 Whether or not he/she waived his/her right to see the letter
 How you came to know him/her (e.g. I was his attending for 4 weeks in Nov 2010)
 Description of the types of observations (e.g. I saw on rounds daily and watched him perform 2
H&Ps)
 If pertinent, list your own experience evaluating applicants like him/her. (e.g. as a residency
program director myself…)

Second paragraph:
 Many details that are specific to him/her to convey a great depth of understanding of the
applicant. Could this LOR have been entirely copied from the last LOR? Hopefully not.
 Multiple spheres (e.g. clinical care, medical knowledge, professionalism, etc.)
 Numerical comparison with peers, including a denominator

Third paragraph (only if needed):

 Explain weaknesses of the applicant. This is probably a good idea if the applicant has
difficulties that will show up elsewhere in the file, such as board scores.

Second to last paragraph:

 Summarize overall findings
 Repeat the unique favorable aspects of the applicant if these aspects are distinctive
 List your recommendation. “I recommend him/her” is weak. “strongly” and “without
reservation” are higher praise. If would accept in your own program, state so. Try to be direct—
“will be a good resident, but not a star. This is not a negative comment.” is acceptable.

Final paragraph:
 Consider statement that all your LORs are short if that is the case
 Provide your contact information…but “if you have additional questions”.

Signature block:
 Name
 Academic rank
 Hospital afflation

General considerations:
 Letterhead used
 Spelling/grammar correct

LTC Kent J. DeZee, MD MPH FACP 7 Oct 2011

General Medicine Fellowship Director, USUHS
 Checklist for writing a Departmental LOR

Opening paragraph:
 Applicant’s name in the first line
 State the purpose of the letter (e.g. “Student X has asked us to write a letter for their application
to XX residency program.”)
 Provide context: describe the clerkship. List qualities such as length, design (longitudinal vs.
block), setting (ward vs. ambulatory vs. both), evaluation method, grading method (criterion vs.
normative).

Subsequent paragraph:
 Grade distribution: provide the student’s grade in context of the grade distribution.
 Describe any mitigating circumstances (illness, psychosocial stressors in general terms) as
appropriate

Subsequent paragraph
 Summarize performance
 Use direct quotes from evaluations
 Balanced and honest performance evaluation. Concerns about performance must be cited and
discussed.
 Use ACGME Core Competencies, if possible, as the audience is GME.
 Extras as appropriate (volunteer work, research)

Last paragraph:
 Summarize overall findings—demonstrated achievement
 Potential-be careful about predicting future
 Make clear overall recommendation. Don’t write in code. Would you trust this student?

Signature block:
 Name
 Academic rank
 Title of author as related to the clerkship/department

General considerations:
 Letterhead used
 Spelling/grammar correct
 All comments factual, truthful, and in good faith

LTC Kent J. DeZee, MD MPH FACP 7 Oct 2011

General Medicine Fellowship Director, USUHS