1. Keep it a surprise
Your chances of securing a strong and timely LOR are significantly improved when your physician realizes that you’re not there solely for an LOR, so we recommend that you not even hint at wanting an LOR until you’ve earned it. A superb clinical performance over a 4 to 8 week clinical rotation should be the sole reason why your supervising physician would want to recommend you to residency admission committees. Next steps are for a typical 4 week clinical rotation:
2. Start of week 1: Begin earning your LOR
To “earn your LOR”, you should act genuinely interested in the actual experience provided to you by the clinical rotation: start by verbally stating that you have no transportation issues and that you’re available for this rotation 24 hours/day 7 days/week, put away your mobile phones during the rotation, show up early, leave late, be pleasant, communicate effectively, be a team player and do not complain, do not ask for breaks or “when do we leave for lunch”, and avoid every item on the Examples of Resident Trouble column of our 6 ACGME core competencies chart (print this page, memorize the 6 competencies, and refer to this chart 1-2x/day).
3. By end of week 2: Ask for a 5-minute mid-clinical performance feedback
Share the 6 ACGME core competencies chart you printed on week 1 with your supervising attending physician or resident, and ask for an informal, yet brutally honest verbal performance feedback on all 6 competencies. Reassure him/her that this should only take ~3-4 minutes; take notes and make immediate adjustments to your performance as necessary. Do NOT ask for an LOR yet!
4. Week 3: Build the foundation for a strong ACGME core competency based LOR, and that you respect their time
Throughout week 3: Make it a point to have the attending physician or resident who provided you the feedback see your genuine efforts to improve. If you are being evaluated by a resident, then ask the resident to share his/her thoughts about your performance with the attending physician.
By the end of week 3: Ensure that the letter writer (attending physician or program director) is happy with your performance. Let them know that because you know how precious their time is, you’ve begun compiling highlights of your clinical experience based on the 6 ACGME core competencies and the feedbacks you’ve been receiving. Ask the attending if he/she would like to see this by email next week, as you heard from AmeriClerkships that this may help save a significant amount of time in case an attending agrees to write you a letter of recommendation. If the attending says “Yes” or asks you to draft an LOR, then you should take this opportunity to ensure that the content is objective and ACGME core competency based by clicking here to begin drafting this document (or click here for AmeriClerkships professional LOR drafting service immediately) and attend an office hour that same week to discuss the content of this document with Dr. Mizani); if the answer is “No“, then the attending either does not want any help writing an LOR, or he/she has not yet made a decision about recommending you, and you should sign up for the soonest available office hours to discuss with AmeriClerkships.
In preparation for week 4: Thank the attending physician for his/her time and opportunity to be at the clinic, and if you really want to score points (not obligatory at all, but just a recommendation), ask it would be okay to treat his/her office staff to lunch sometime during your final week next week. A lunch from Chipotles will typically not cost more than $7-8/person; a great investment in building bridges for your future!
5. Week 4: Ensure you get a performance based LOR, sooner than later
Start of week 4: Remind your supervising attending to look for an email with the subject: “URGENT: Please evaluate [your first & last name]” in their inbox sent by AmeriClerkships one day after your official clinical block end date. Ask your attending: “On a scale of 1 to 5, 5 being ‘Honors‘ and 1 being ‘Deficient‘, how would you evaluate my clinical performance based on the 6 ACGME core competencies, and were you satisfied with my performance?”
- A rating of 4 or 5 out of 5 or the attending being satisfied with your performance are excellent indicators that the content of an LOR written by this attending will be strong, and you should ask for an LOR (or provide him a draft, based on your conversations during week 3). Surprise the attending and say: “Thank you very much for this amazing opportunity! Now that I know you were satisfied with my performance, may I have your support for this year’s Match and ask that you write me a Letter of Recommendation?” If the answer is “Yes“, and/or the attending agreed to utilize your draft LOR, then thank the attending and say that your draft (either your version of the LOR or the one drafted with the help of AmeriClerkships) was emailed. If the answer is “No” (very unlikely), ask why and sign up for the soonest available office hours to discuss.
- A rating of 1 to 3 out of 5 or the attending NOT being satisfied with your performance are indicators that the content of an LOR written by this attending will be weak or damaging, and will most likely raise red-flags. At this point, you should ask if there was any way that these deficiencies could have been identified earlier, and what you should do to improve moving forward. Also, sign up for the soonest available office hours to discuss.
Thursday of week 4: Ask the attending if there is anything you can do to be able to walk away with your LOR in hand. This conversation will be much easier if the above steps were implemented effectively, especially if you’ve provided the attending with a Clinical Experience Assessment Draft (with the help of AmeriClerkships; read below).
Friday (last day) of week 4: If all goes well, you should be saying your goodbyes to the physician and his/her staff, and be walking away with a fantastic residency-relevant signed LOR in hand.
6. Increase your odds of walking away from each rotation with an ACGME core competency based LOR in hand
Unfortunately now a days, US physicians are stretched thin and they can use all the help they can get to reduce administrative work. To help avoid weeks of potential delays in securing an LOR, maximize your chances of walking away from each clinical rotation with an ACGME core competency-based LOR in hand, using the AmeriClerkships LOR Drafting Service. Make sure that:
- Your supervising attending is okay with you drafting an LOR first, and
- You allow enough time for AmeriClerkships to draft you an LOR (typically 2 to 4 weeks; expedited 1 and 7 day turn around service also available for a fee), and
- Present the draft LOR to your attending by Wednesday or Thursday of your last week, and
- Ask your attending to review the draft and make his/her own changes; if all looks good, to place it on their letterhead, sign and have it ready for you to walk away with it the last day of your clinicals.
Of course we can not guarantee that a physician will sign any document, but taking the above steps can significantly increase your odds of walking away with a true residency relevant LOR in hand.