Thursday 5 July 2012

Importance of Specialty Specific Letters of Recommendation in Residency Application

Letters of recommendation (LOR) are exceptionally important part of the medical residency applicant package. Many IMG applicants seek US letters of recommendation for application to programs. However, given the fact that US LORs are difficult to obtain for those who are not in the system, many applicants have to make do with what they get.

If this were the case, then would it not be ideal to know which specialties prefer LORs from specialty specific referees and which fields are less discerning as far as letters are concerned? To answer this question, data was procured from the program directors survey NRMP 2010, compiled and analyzed for the LOR specific query. The results were tabulated and are represented in Fig 1.
Fig. 1 Relative importance programs place on LORs from specific specialty

The percentage of programs citing specialty specific letters of recommendation was normalized using a min-max formula to nominate a value of one and 0 to the most and least specific respectively. As you can see, Internal medicine and pediatric programs were least concerned about who wrote the letter. On the other hand, IMG friendly programs in psychiatry and family medicine were more critical and wanted more specialty specific LORs. On the higher end of this spectrum were neurology and pathology and emergency medicine was highest at one.

The implication of this is two-fold
  1. If you are applying to pediatrics or internal medicine, it should not matter much as to where your LOR comes from. It could be from a general practitioner, a specialist, a radiologist or even a scientist because these programs did not place much weight on the LOR being specialty specific.
  2. If you are applying to subjects like family medicine, psychiatry, neurology or pathology make sure you have at least 1 or 2 letters or recommendation from physicians who are practicing in that field. Do not use a letters of recommendation exclusively from specialties like cardiologist or internist if you are applying or interested in the above fields.
Keep this advise in mind when you are doing your observership or USCE because the goal of such enterprise is to obtain a stellar letter of recommendation and to make connections who can vouch for your performance and character and ultimately help you obtain an interview. Thus if you focus on obtaining the right kind of letter of recommendation whether you choose to waive it or not, it may make things a little easier for you when it comes to improving your interview chances using the LOR!.
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  1. and what is preferd either waived or un waiver LOR'S? and does that makes any difference with chances of matching ?

    1. It is better to waive the letter if you are confident that the letter content is going to be excellent. more details at

  2. I have a question to ask. I got an Elective opportunity at a community Hospital which have internal medicine residency slots. But my rotations there are in Emergency medicine (1 month) and critical care medicine (1 month). I am interested in applying to internal medicine residency in future. So my question is will this experience in emergency medicine and critical care medicine from a community hospital and the Lors I get from the professors of these departments help me in getting an internal medicine residency. Is there any way E.M and critical care related to internal medicine. Will I get a chance to interact with the professors of internal medicine there, so that it may be to some extent give me a chance to develop connections there which would help me in fetching an interview there in future.

    1) Importance of LOR from a community hospital physician.

    2) Importance of LOR from an Emergency medicine or critical care medicine doctor to get into internal medicine residency.

    3) Do I get a chance to interact with Internal medicine physicians While rotating in the Emergency medicine or Critical care medicine departments and wards?

    4) Will this Elective experience in a community hospital be considered as USCE?

    1. emergency medicine is slightly different that internal medicine in that the problems are more acute and there is usually no long term follow up as you deal with patient in ER and then they get sent somewhere (home, inpatient or vertical discharge) but any experience in my opinion is better than none. Critical care medicine is actually a part of internal medicine so that is good. if the only LOR you are getting is from comm hosp then I would say it is better than home country LOR. IM programs are not that discriminating when it comes to the specialty of the LOR writer so you may still be okay with this. You will get a chance to interact with IM residents and physicians while working in both EM and CCM. This will be considered as USCE although by definition if its only obsie then it is not technically USCE.

  3. which specialty is required for IM preliminary?

    1. IM preliminary is for those who are undecided they want to continue with medicine or do something else. I recommend to not apply to this category as IMG. it is better suited for AMGS who are undecided between surgery and medicine. after a year of prelim, if the program does not/cannot absorb you, you will have problems getting into a PGY2 position

  4. Thanks Droidor for putting up this useful blog.. I have been recently member of the organising committee of a global health summit and i was able to make contact with many eminent doctors like AMA president and ECFMG president and other board members of the ECFMG.. They have mailed me thanking me for my help during the whole summit... I would like to know if i could ask them for LOR??? if yes, what all should i vouch for in the LOR??

    1. you can certainly ask them. If they have the inclination they will be happy to provide you a letter. however, if your contact with them has been very brief they may not be in a position to write a recommendation beyond the capacity in which you interacted with them. its worth a shot, see what comes of it. make sure you document this in your accomplishments and note it on your CV.

  5. Hi
    i am an IMG gradutaed in 2009 and step1 score is 198
    my goal is now only family medicine
    gona start PAID USCE for LORs through a clerkship company for which i have to pay above 8000 USD
    so i am geting 4 LORs in fam medicine but not sure about ACGME criteria
    SO WHAT ARE MY CHANCES if i pass CS in first attempt and CK next year and apply next year for match in family medicine(year of graduation 2009)
    ALSO shoul i ask the private clekship company about LORs ??
    that these are gona be generic or strong and not same old word to word letter
    thanks for help

    1. Hello Dr., In general the consensus is that these paid clerkships are not worth the amount of expense incurred. however, given that you have already committed to this, you should make most of your experience. Be clear and up front about your requirement for a strong letter of recommendation from the attending you will work with. you need to improve on your step 2 score and get very good scores. There is not ACGME criteria for LORs, so you should be fine as long as they are good letters and address your strenghts. There is an article I did on another section about the importance of LORs from referees, univ vs comunnity, Us vs foreign etc. look it up. good luck!

  6. Hi,
    I read your blog post regarding LORs and it's really very interesting. I have some questions regarding it.
    - My USMLE score is 213 on both steps, 1st attempt and interested in Family medicine. Will it be OK if I go to Internist for 1 LOR and ask him to write for FM program? How valid will it be during residency interview? In future, I will go for 2 LOR to some Family practitioner in NY or Chicago. Right now due to tight schedule, I am thinking to go with Internist who is located very near to my home for 1 month and has reasonable rates.
    Hope to hear from you soon,


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