Is it a red flag if you don't get a LOR from an elective?

[Lactic Folly]

Regarding the top x% -- many letter writers do not use this notation. I have also heard tales of a chairperson who was known to place students in the top 1-2% more often than should have been mathematically possible.

Unfortunately, letters of reference can be extremely variable in the style and degree of generosity in which they are written. The composite of many letters and evaluations does give a better impression as to the overall strength of the student.

However, this is why, particularly in the smaller fields, direct exposure (i.e. electives) as well as letters from people known to the committee (where it's easier to decode info on where the student lies along the continuum) are more influential.

[rogerroger]

People have asked what is important to “impress staff” during clerkship. 
 

This is easy to answer. By far the most important thing is being a person that is enjoyable to be around. Sadly, this answer probably is even more subjective. But it’s so crucial. I don’t care if you have memorized the entire text book and can list every possible differential. It does not matter if on the medical expert role one is operating as a senior resident - IF you seem like a potential colleague who would be a poor addition to our workplace / speciality family there is no way I can write a strong letter.  
 

View this from our perspective. When a staff writes a letter we are putting our names behind a candidate, our own professional reputations. Many of those people who read this letter are people we know personally or professionally. The people reading this letter are colleagues we did residency with, often friends, also the people who trained us, our own mentors, or people we collaborate with on projects or hang out with at conferences etc. It’s very important that a letter reflects reality. Social capital is placed behind these candidates. The last thing we ever want to do is review a candidate in a manner that is misleading, especially around non-medical expert roles. Usually you can teach the medical skills. Much harder to teach work ethic, professionalism and other essential social skills.  I absolutely do not want my colleague to be stuck with someone that will give them grief for 5+ years, I very much want the opposite.   
 

So when I write a letter a big portion of the letter comments on these things. Also I comment on teachability. After professionalism and collegiality this is probably the next most important attribute in a candidate. More important then present medical knowledge by far. How easy a trainee is to teach is a spectrum. The best candidates are able to learn, are self reflective and insightful. Again, picture our perspective. Basically all incoming residents are treated as blank slates in this respect. You got a ton to learn come July 1 as an R1, you are basically expected to be safe and not much else medical expert wise. Teachability determines your actual trajectory throughout residency. So as a letter writer we do not want to recommend a candidate who will be a constant thorn in the side for a program director in this respect. Low maintenance residents are key here.

This is a good segue to another important factor. Generally you want your residents to stay in a program and not migrate out. The reasons for this are for another topic. But just like when you applied to Med school, one of the things we look for is the sense that you know what you are getting into speciality wise. This is where your CV comes into play and where casual conversation is important. Anyone I write a letter for, or sense it is likely they will ask for a letter, I ask questions around this. Usually between cases, or at the end of the day in a casual setting. Why this speciality? What do you like about this job? Any other aspirations or sub-interests within the field etc? You usually can get a pretty good idea where people are at from how they answer these questions. I often comment on a candidates insight into the speciality in this regards in my letter.

So in summary, you want to show your supervisors that you are (1) professional, (2) collegial, (3) teachable, (4) are committed to the speciality,  and (5) know some medical stuff. The degree of importance of each is listed in order above .

Things like research, or potential within the field, unique attributes etc are then used to split hairs between candidates who are equal in respect to the above factors. 
 

I think generally this line of thinking reflects what most file reviewers and reference letter writers are trying to parse out. 
 

Back when I was a clerk on my first rotation, my senior resident said it well. You want to be that Med student that when you are gone, people say, “Where is the Med student today? Oh, s/he is done the rotation? Shame, I wish s/he was still around”.  To be this fella requires different things then what you learned in pre-clerkship.  

 

Edited February 23, 2020 by rogerroger

[Lactic Folly]

Nice post. I am curious - how do you approach being asked to write a strong letter for a student who has spent a good amount of time with you, been interested, always professional and done whatever extra work was asked of them - but you don't feel they were in the upper half? Perhaps they are not as high on the ability to rapidly learn and retain, nor on the domains of self-reflectiveness and insightfulness you mentioned.

[confusedmedstudent]

@rogerroger Thank you so much for this. I really appreciate it. I understand what you mean about the importance of accuracy in reference letters and the social capital involved for the referees. If someone has agreed to write me a letter, is it safe to assume it'll be a good one? I'm nervous because some preceptors have agreed but I honestly think I am really weak in my knowledge and they were just being nice and didn't want to say no. Also, out of the list you mentioned, I seem to be doing fine for #1-3. All of my preceptors so far have given me positive feedback around these areas. In terms of #4, I came to my specialty of choice a bit late (around November?) and am also interested in family medicine, but no one has asked me about this and I'm not sure what they think about how committed I am. #5 is where I'm very very weak. Sometimes I feel like preceptors are just giving me other good feedback about my personality, professionalism, likability, teachability, "easy/a pleasure to work with", etc. because they have nothing good to say about my clinical knowledge. Just the other day, my preceptor asked me such a BASIC question that I've read about several times and know the answer to, and I couldn't recall it at all. As soon as she said the answer, it came back to me and I was so frustrated because I knew I had read it. This happens a lot. Also, I just feel weak about where I'm at and think I'm very unimpressive. I bought into the whole "clerkship is for you to learn" nonsense - it's an audition. And I've just started to realize that now, and I am worried it's too late for me. :/ 

I got my written evaluation from the elective in question (where I asked my preceptor for a letter and she said no). On the eval she had really nice things to say about  the 1st 3 areas you mentioned. She also said I should keep reading about common conditions, and keep working on developing a DDx and management plans. So, in short, she is saying my knowledge is weak and that's what I've suspected all along, and that's why I didn't get a letter... so does that I am extremely weak, if medical knowledge is the least important but she still didn't want to write a letter for me? No other preceptor has said this to me but I feel like they all know it and are just being nice, but I'm secretly an awful clerk. I am not sure how to improve because I do read around my cases and try to study whenever I can, but I just can't seem to recall anything when it counts. And also I think part of it is that I didn't know until after this elective that you have to tell your preceptor your DDx and plan even if they're busy and they don't ask - so sometimes she didn't ask and I never said anything. I knew some things but never showed that I knew them because I didn't want to be annoying. Have I screwed up too much to redeem myself? 

[confusedmedstudent]

4 hours ago, Lactic Folly said:

Nice post. I am curious - how do you approach being asked to write a strong letter for a student who has spent a good amount of time with you, been interested, always professional and done whatever extra work was asked of them - but you don't feel they were in the upper half? Perhaps they are not as high on the ability to rapidly learn and retain, nor on the domains of self-reflectiveness and insightfulness you mentioned.

I feel like you're describing me and I'm so scared lol

[Lactic Folly]

2 minutes ago, confusedmedstudent said:

I feel like you're describing me and I'm so scared lol

Sorry! Did not mean to make any such implication. I don't know too much about your situation, but could it be that performance anxiety is interfering with your ability to recall information and your confidence in presenting it? Could you put down some of your DDx and plan in writing if that would be an easier way to help you communicate it? I think that preceptors would rather decline to write a letter rather than agree to write a good letter if they know they cannot be supportive.

[confusedmedstudent]

9 minutes ago, Lactic Folly said:

Sorry! Did not mean to make any such implication. I don't know too much about your situation, but could it be that performance anxiety is interfering with your ability to recall information and your confidence in presenting it? Could you put down some of your DDx and plan in writing if that would be an easier way to help you communicate it? I think that preceptors would rather decline to write a letter rather than agree to write a good letter if they know they cannot be supportive.

Hahaha no dont be sorry I know that's not what you meant! Just very relatable LOL

You're right, anxiety is probably part.of the problem. I have been trying to do that recently but my plan is usually wrong because my knowledge is so weak I just need to get better at learning somehow 

[confusedmedstudent]

Bump - sorry I have another question. 

If a preceptor said they could write me a good but not great letter at this time because I'm so early in clerkship, but then said that they think I'm going to be really strong later in clerkship after my core rotation, are they just being nice or do they really think that? Also they asked me to come back and do another elective after my core but I can't due to my schedule, and then they asked me to come work with them in clinic if I have days off here and there. Should I take them up on this? Is it ever possible to get a letter from someone who initially said no?

[Lactic Folly]

If they're making offers to have you work with them more, this sounds like a sincere person who genuinely wants to help you. Someone who just didn't want to write a letter would not have asked you to do further work with them.

[rogerroger]

On 3/3/2020 at 2:57 PM, Lactic Folly said:

If they're making offers to have you work with them more, this sounds like a sincere person who genuinely wants to help you. Someone who just didn't want to write a letter would not have asked you to do further work with them.

I agree. 

Edited March 9, 2020 by rogerroger

[Haribo7173]

How do reviewers feel about LORs from staff who hasn't supervised you clinically, but who knows you well and can speak about your interest for a field (and you as a person)?

I only ask this because most programs ask for 3 LORs and I wonder how much weight is put into having 3 LORs from 3 supervisors in that specific field. I guess it's always preferable to have a letter from a clinical supervisor regardless of their field (right?) but one shouldn't expect, for example, a neurologist to write about how great you'd be at pediatrics (or I guess they wouldn't do that, and would talk about soft skills, professionalism, etc which hold some weight but not as much weight because they can't speak to your aptitude in the field you're applying to?)

 

[rogerroger]

11 hours ago, Haribo7173 said:

How do reviewers feel about LORs from staff who hasn't supervised you clinically, but who knows you well and can speak about your interest for a field (and you as a person)?

I only ask this because most programs ask for 3 LORs and I wonder how much weight is put into having 3 LORs from 3 supervisors in that specific field. I guess it's always preferable to have a letter from a clinical supervisor regardless of their field (right?) but one shouldn't expect, for example, a neurologist to write about how great you'd be at pediatrics (or I guess they wouldn't do that, and would talk about soft skills, professionalism, etc which hold some weight but not as much weight because they can't speak to your aptitude in the field you're applying to?)

 

Based on my own experience participating in file review several times -  LOR generally fall into this order in terms of weighting, at least for me. 

Authorship of letter from best to least;
 

Person in my speciality I know personally > Person in my speciality I know about but not personally > Person in my speciality I never heard of > Person in other speciality I know personally or have heard about > Person in other speciality I never heard about

Medicine is a small world. If I know the letter writer it lends more weight to their opinion. This is a person I probably already trust on a regular basis or would trust to some degree if the opportunity arose in a professional setting. This subconsciously and consciously influences how a letter is weighted. 
 

I like seeing letters from people in my speciality for two reasons. This is really important. Why? First, they have a horse in the race come reputation of the field and second, they know what the job is about, and who has potential regarding its specific intricacies etc. What makes a great psychiatry candidate might not also make a great emergency medicine candidate and vice-versa and so on.  

This said, a reference letter from someone in another speciality saying the applicant is a clown could easily sink them. Probably not going to take my chances with that applicant.

However, it should be noted that a glowing reference letter from someone in another speciality is certainly not the same as a glowing reference letter from someone I work with or know does my daily job. 
 

Hope that clarifies. 
 

If you read hundreds of apps, the brutal truth is that 80-90% of reference letters are fine but not memorable. Of these memorable letters, about one third are not memorable in a good way if you catch my drift.  

Having a non-memorable letter is fine if the rest of your app is good and solid. There are other parts to the application. But coming across a reference letter from a person you know on a personal level and is glowing is a huge boon to that application. That is memorable and the advice provided naturally weighed differently due to social capital it carries. A glowing letter from a person I know in my speciality is worth 10 times the glowing opinion of someone I never heard of in another speciality. The reference letters are unique in this respect and this is really why they carry value. You can glimpse into the social nitty gritty. No other part of the app is like this. 
 

As for non-clinical stuff in LOR. That’s important. But I also want to hear about clinical stuff. It’s awesome that you might be a great person to spend time with and that you are professional. But I also want to know you are teachable and have an aptitude for the job you are applying for. This is as much a job application as anything else. Having a letter that does not comment on these things greatly limits it’s utility to me as a reviewer. It’s not a red flag per-say, but it’s one less letter where these things could be demonstrated.  So avoid this if possible. 

As an aside, many of these same principles are also at play when you are done residency and looking for a job. You will need reference letters again, and all these principles are once again at play. From here on out, these are the rules of the road to some degree.

 

Edited March 9, 2020 by rogerroger

[DNA Doc]

I'm a staff physician and former residency program director.

I always have a hard time evaluating early clerkship trainees unless they are absolutely stellar - and that's rare. I feel for clerks who have early electives before core rotations, it's not really fair.  The only advice I can offer is to work hard and listen closely to the feedback you get. Ask for feedback if you're not getting it. By the time you get to your later rotations you will be in a much better position.