Letters of recommendation for your medical clerkships play a vital role in the residency selection process. With the changing academic environment, Step 1 is likely to become a less crucial aspect of the residency application. Step 2, shelves, and clinical experience will also become more important to residency directors. 

The 2018 NRMP Program Director Survey listed Step 1 scores to be the most important factor in selecting applicants for an interview and the 5th most important factor in ranking an applicant during the interview process. LORs followed closely behind at positions 2 and 6, respectively. With Step 1 moving to pass/fail in 2021, this will likely move LORs up to the most important factor in future residency MATCH processes.

1. Why Request a "Strong" LOR?

A key component that is most frequently overlooked by students is to clarify their request for a strong Letter of Recommendation. Many physicians and preceptors are willing to write a letter, or even feel obligated to when confronted by a student. However, that agreement to write the letter doesn’t mean it will properly reflect the learner’s abilities and strengths. By asking in a very specific manner, a learner decreases the chance of receiving a mediocre letter of recommendation.

2. Ask Early

Make it clear on Day 1 that you are seeking a LOR from your preceptor. Waiting a week or two before bringing up this potential request wastes valuable time. Delaying this conversation may prevent a preceptor from being aware of the student’s goals and desired outcomes. It also prevents the student from gaining feedback from the preceptor on how to advance their clinical expertise and stand out from their peers.

3. Understand the Expectations

When discussing expectations with a preceptor, ask what an average student is expected to complete on this rotation and what an exceptional student might do differently. Some physicians have an objective list to follow while others may utilize past experiences and more subjective means. Either way, it greatly benefits the student’s LOR to know this early in the clerkship.

4. Choose the Best Writer for the Job

When able, ask the highest-ranking medical personnel that is familiar with your work. Going to a program director that has never seen you in the clinic before is not likely to be helpful and may even backfire. Simultaneously, asking a resident that knows you well will not provide as strong of a LOR as one from an attending physician. Depending on your clerkship design, there may be very different opportunities when compared with a colleague at another school.

5. Be a Good Person!

This is not a time to be a show-off, know-it-all, or slacker. Make sure to display humility, respect, and professionalism to ALL staff and patients. Residency directors are looking for learners that can interact positively and as a cohesive team within the hospital. Lone guns are not going to make it very well in future healthcare. This professionalism will also be reflected in your LORs!

There are many considerations when planning for your future residency options and your letters of recommendation are going to continue to be an important part of medicine. Planning how to approach these requests ahead of time can go a long way to reducing stress and being better prepared. For more time-honored tips, we recommend the Rounds to Residency podcast!

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