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The Secret Language of Letters of Recommendation

Op-Med is a collection of original articles contributed by Doximity members.

When the heat of summer would break and the first crisp winds roll through, my first reaction used to be to start gathering Halloween decor and sipping on pumpkin-spiced lattes. Although I still enjoy these fall indulgences, it’s no longer my first response to the change in temperature. Now, before I dive into cobwebs and festive treats, I must first enter the letter of recommendation (LoR) season. 

The LoR season is long, spanning from the end of summer until the end of winter, and it comes in two phases. The first is the LoR request-and-submission phase, which usually begins in the summer and ends pretty quickly, as most applicants want to send their packets out as soon as NRMP allows. The second is the review-and-analysis phase, which begins when the first wave of applications are sent to residency programs and lasts until the final round of interviews has finished. This phase involves critically reading LoRs and trying to decipher how the writer honestly felt about the applicant. After all, the opinion of other physicians with a month or more exposure to any particular student is perhaps the highest quality information available about an applicant. If it’s honest. And if you can determine what the physicians are truly trying to say. 

After years of being on both sides of the process, I have come to realize that there is a secret language that goes into letter writing and reviewing. Without this secret language, and sometimes even with it, most of what gets written in these letters is not tremendously useful to the committee reviewing it. I believe most physicians to be nice people, and nice people are hesitant to be honest about the shortcomings of others. However, each residency selection committee has a limited number of slots to fill and is seeking to make the best possible selections for their programs. I am occasionally lucky enough to be reviewing LoRs that read “always punctual,” which generally means, “I have nothing else nice to say.” I once received a letter that stated, “This is a B-/C+ student at best.” No reading between the lines needed there. But the other thousands of LoRs I have reviewed were full of canned phrases that made them difficult to sift through to find the diamonds in the rough.

My experience on both sides of the process has certainly improved the quality of the LoRs I write today. I’ve learned from the pros. With this insider knowledge, I thought I could outsmart the system by creating a ranking system for LoRs using objective numerical values. My aspirations were quickly dashed when I realized that the language of writers varies depending on their circumstances. Comments like, “This student is one of the top 10 students with whom I have ever worked,” normally go a long way. But what do you say if it’s your first year as a teaching attending? Similarly, the classic statement “we are working hard to recruit this student here” is straightforward and obvious in its meaning, but what do attendings who are not affiliated with a residency program say? Even after paying careful attention to language, it seems to me there is no such thing as complete LoR fluency. 

I’ve unfortunately heard the phrase “Letters of recommendation are effectively worthless” more than once, but I’m not ready to give up on them just yet. I am not the only one to feel this way, and several specialties have already moved toward using a Standardized Letter of Assessment (SLOE). However, this specialty-specific LoR process creates issues when students want to apply to more than one specialty, or when faculty are asked to write letters for students who are applying to a field other than their own. At the end of the day, we all want the same information. How much direct experience did the author have working with the student? How did the student perform compared with their peers? Did the author witness any professionalism issues or other barriers to success? What are the applicant’s outstanding features and areas for improvement?

For now, I’ll keep writing and reading LoRs the old-fashioned way. But I do hope that during my career, a universal SLOE emerges, one that simplifies the lives of applicants, writers, and reviewers alike.

What has been your experience with letters of recommendation? Share your thoughts in the comment section.

Dr. Danielle Pigneri is a trauma and acute care surgeon practicing in the Dallas-Fort Worth metroplex. When not working, she enjoys her other job, being a mom to two sweet young children. Dr. Pigneri was a 2022-2023 Doximity Op-Med Fellow, and continues as a 2023-2024 Doximity Op-Med Fellow.

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