How to Write a Letter of Recommendation

1. How to Write a Letter of Recommendation Angela Jackson, MD Associate Professor of Medicine Associate Dean for Student Affairs Emelia J. Benjamin, MD, ScM Professor of Medicine & Epidemiology Vice Chair for Faculty Development and Diversity, DOM

2. Objectives: • Identify the key components of an effective letter of recommendation • Identify common mistakes to avoid • Discuss responsibilities involved in writing a LOR

3. 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

4. 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

5. 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

6. Purpose of a LOR: • Student: • Unique or Personal characteristics • Performance description Future resident

7. Purpose of a LOR: • Student: • Unique or Personal characteristics • Performance description Future resident Fund of knowledge Clinical reasoning Communication skills Current functioning Future potential Personal qualities Objective AND Subjective -Your opinion

8. Getting Started: • How do you get started?

9. Getting Started • Meet with the trainee/faculty • Career goals • Purpose of the letter • Review CV, evaluations, your notes • Honestly assess your ability to write a STRONG letter • Define the timeline and due date • Recheck the timeline and due date

10. Letter Content and Structure: • The “Opening” • The “Middle” • The “Summary”

11. Letter Content and Structure: • 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)

12. 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

13. 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.

14. Letter Content and Structure: The “Middle”

15. “The Middle”: • 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

16. “The Middle”: • Quantify and compare, if possible • Describe relevant skills • Comment on • Professionalism • Work ethic • Personality • Team work

17. 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…

18. 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.

19. Letter Content and Structure-The Summary: • Last paragraph: • Summarize overall achievements • Potential • Would you recruit here? • Clear overall recommendation

20. Do’s and Don’ts: • Do’s:

21. 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

22. Don’ts:

23. 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

24. When to say “No” and other challenges:

25. 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

26. 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?

27. 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

28. Be Aware of Gender Stereotypes https://www.aamc.org/members/gfa/faculty_vitae/148590/successful_nominations.html Trix & Psenka Discourse & Society. 2003;14:191. Schmader, et al. Sex Roles. 2007;57:509. PMID 18953419

29. 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