The other night, I got a text from a number that I didn’t have saved:

“Hey Brian, I don’t know if you remember me but I was a student who rotated with you last year. I wanted to ask some questions about anesthesia if you have a moment.”

I always end my teaching assignments with the guidance to “feel free to reach out to me for anything along the way,” so this was a welcome solicitation for guidance. And there’s nothing I love more than talking about anesthesia and giving advice. 

We set up a time to chat and connected later that week. This student was a 4th-year medical student compiling his ERAS application, and couldn’t decide between applying to emergency medicine or anesthesia residency programs. I told him everything I knew about my field, and what I knew from friends who had gone into EM. His questions were earnest. It brought me back to my own indecision along the way during medical school, when specialties like ENT and orthopedics had been appealing to me. 

As the conversation was winding down, I asked him, “Charlie, anything else I can do for you?”

“I wanted to know if you’d be able to write me a strong letter of recommendation for my anesthesia application.”

I was taken aback. The phrases “I don’t know if you remember me” and “Can you write me a strong letter…” are totally incongruous. I explained to Charlie that I could write a letter if he needed to check a box and hit a requisite number of letters from a field, but it wouldn’t be strong at all.

I asked him to name some examples of times when he demonstrated strength, good clinical judgment, procedural acumen…

“Is there anything that stands out in your mind where you exhibited excellence? Would there be any material that we could build the letter upon?”

Charlie came up short, describing a difficult case that he might have done, but it was likely with another attending. We were grabbing at straws. And to top it all off, the entire conversation was borne out of a desire to enter a different field.

Sadly, Charlie did not have the luxury of time and went about this entirely the wrong way. What should he have done? Let’s turn back the clock by 18 months to see how he could have landed that strong letter of recommendation.

How to Ask for Strong Letters of Recommendation for Your Residency Application

Develop a strategy early for who will be your ERAS letter writers.

A great folio of letters doesn’t get conjured up by chance. You should have a sense of who will be writing your letters, including close, personal mentors, and attendings in your chosen field. Early on in medical school (first and second year), you can see which relationships develop organically, and who would be able to say great things about you.

After all, you probably don’t know your specialty at this point, and you might not end up using an average letter from an out-of-specialty attending. However, if you have a research mentor with whom you’ve worked hundreds of hours, your relationship is probably worth documenting in a letter of recommendation, regardless of their field.

As you plan your third- and fourth-year clerkships and electives, start to think about who would be able to write you a great letter. Remember, the significance of your relationship trumps the status of their title.

State your intention to receive a letter early in your clinical experience with your intended letter writer.

Attendings are, by nature, busy, and don’t have heaps of time to write letters for a specialty that a student isn’t going into. But if there’s genuine interest, and a decent chance of applying to that specialty, the student should definitely make their intention to solicit a letter known.

On day one of a rotation, I don’t know if a student is here because they are dying to be an anesthesiologist, or if they heard this was an easy rotation where they could leave early every day. Setting the context by telling me you are interested in this specialty and want to walk out of here with a letter of recommendation will certainly improve our experience together. I’ll ask more of you, and give you a chance to deliver. 

Explicitly ask how you can impress them.

Stating your intention to your intended letter writer could look something like this:

“Dr. X, I know it’s early in the rotation, but I’d like to receive a letter of recommendation during this rotation. What can I do to shine? How can I excel on this rotation and earn a solid letter of recommendation?”

Ask for a way to excel, and then deliver tenfold on your promise. If you come to me and tell me you want to shine, I can push you to do so! I can assign topics to read up on, have you give a presentation to the group. I can allow you more liberty to practice somewhat more independently and get a sense of your strengths and weaknesses. I can give you constructive feedback so that you can improve over the course of the rotation. 

Maybe you’ll get asked to give “mini grand rounds” to your eight-person internal medicine team. Take this opportunity and run with it. Master the concept, practice your talk, make handouts…do what it takes to elevate the knowledge of all of your fellow medical students, residents, and attendings on the team. These are the things that get noticed and stand out.

Realize that there is some obligation of your attendings to write a letter if you deserve one.

As I stated earlier, no busy medical professional is twiddling their thumbs waiting for extra work to come their way. But if you are an eager student who has gone out of their way to demonstrate greatness, or at the very least a burning desire to learn and improve, you should not feel sheepish about asking for a letter of recommendation.

Your attendings aren’t just there to collect a paycheck. Their job is to further your education and train the next generation of physicians. Part of that job includes writing letters of recommendation for excellent students. Naturally, some attendings will be more (or less) willing and can produce better (or worse) letters than others. But it shouldn’t be asking for a Herculean task for them to produce a one-page letter about what makes you great.

You’ve got nothing to lose by asking. And your attending is in a teaching role, so writing letters of recommendation for great students is implicit in their job description.

Give the letter writer as little to do as possible.

Just putting out a request for a letter is not enough—it’s hard for anyone, even your esteemed writers, to get going while staring at a blank page. Therefore, you should offer some food for thought to remove any roadblocks your letter writer might face.

If they accept your request, promptly deliver an updated CV, your personal statement, and the ERAS paperwork for them to fill out. Bonus points for offering these via email and printed out. By placing everything into your attendings hands, there is one less excuse for not getting around to your letter.

Don’t wait too long to ask.

Charlie waited for over a year, and neither he nor I could remember anything meaningful about the time we shared. The most I could say was that he was very cordial and did a lot of reading for cases. By taking the above actions, and doing so during the time that we spent together, I could say he was an excellent presenter, had good communication skills, performed at a resident level, and was ambitious and eager. There are so many benefits that could come from asking for ways to shine, but they are only benefits if you truly give all your effort to the task.

I told Charlie to call me if he thought of anything meaningful we could build a letter around. And I’m still waiting to hear back. Learn from Charlie’s mistakes—get that letter now!

Further Reading

• Brainstorming Your ERAS Personal Statement
• How to Choose a Medical Specialty: The Ultimate Guide
• How to Choose a Residency Program: Top Factors to Consider for Your Rank List
• Residency Interview Tips & Tricks: The Ultimate Guide
• Do Residency Programs Rank Everyone They Interview?