Reference Letter for Internal Medicine

[Babybilly]

Hi all, 

I'm CC3 hoping to Internal Medicine. I'm a little worried with respect to reference letters any resident I have talked to has mentioned that one of the letter's must come from 3rd year core rotation. Unfortunately, I did not spend more than week with any of the attendings and I don't think I could get a strong letter from them. 

On the CARMS program descriptions, it recommends a letter from CTU does not specify which year. Will I be okay getting all my letters from 4th year electives?

Any advice would be greatly appreciated.

[RagnarOdinson]

Have never ever heard of this notion that one letter must come from third year. I am pretty anti- third year letters for the simple fact that your performance in 4th year should and probably will be much better and the letter should reflect that. I wouldn't stress at all about not having a letter from third year. Just be smart with your elective choice in 4th year make sure you have a good mix of CTU and subspecialty electives so you'll have plenty of letters to choose from. For what it's worth, I dont know anybody that used a third year letter for IM, unless youre counting like a research supervisor letter and they happened to work with them in 3rd year. 

[pyridoxal-phosphate]

Unfortunately I'm still going through Carms so will have limited insight so hopefully some of the more experienced posters can chime in. 

I too heard this rule of thumb when I was going through 3rd year but I'm not sure how it even spread. For what it's worth I did not ask for a single 3rd year letter for my IM application since I did not believe I was in the position to. I agree with the poster above. If you go to a school that gives a enough 4th year elective weeks to get CTU electives then I think you're fine. I am personally of the opinion that unless you are one of those starchilds (which I am not) 3rd year performance is more or less a write off. 3rd year is incredibly tiring so keep up the good work and focus on learning. 

[bbbbbbb639]

Currently going through CARMS right now and got interviews to all the IM programs I applied to (7). I'm in a three year program and have a reference letter from my early CTU core block as well as reference letter from my later CTU electives and I would say the quality of the references was equivocal. The reference letters were less about actual demonstrated skill, because that will come, but more about commitment to patients and to learning, to pushing yourself to take on higher complexity and reason your way through differentials and management plans, and how you work on a team and get along with peers and fellow residents.

One week is more than enough time to get to know a preceptor enough to ask for a LOR and in IM is oftentimes the only time you'll have given their on-service time. I would recommend asking for a letter from anyone that gives you good feedback at the end of the rotation, and then following up with an email that includes the following information: (1) Memorable cases from our week together (2) What I learned/enjoyed the most (3) Why I want to do IM. If I had any EPAs by residents or other preceptors on the rotation that I felt had strong comments I would sometimes attach those also. Especially in IM preceptors agree to write tons of letters so always err on the side of giving them more information than they need! 

Depending on how the rest of your clerkship goes you may not end up using the reference (or even sending them the LOR through CARMS) but it's better to have to many choices than too few, and I can guarantee you the majority won't even think about writing the LOR until a few weeks before the deadline anyway

[queryradiology]

Unless the program requirement specifically state it, I don't think it's necessary.

However, I disagree that third year letters are inherently weak. I used a third year IM letter for all of my radiology applications (Ottawa requires this or a General Surgery letter) that I know was very strong based on comments by my senior and the attending who wrote the letter. My school has one of the most weeks for electives also. In my third year, I also banked a letter in Pediatrics due to strong performance just in case. I agree with the poster above: it's about learning, patient care and being a good team player.

[Edict]

I have never heard of this before, so it sounds new, which makes me think that it isn't a real requirement. I have heard that at least one of your letters should from a CTU rotation in general. 

Ideally, i do agree that having a letter from your home school, one letter from a CTU program is ideal, I don't think it matters which year its from. I also think that if you have a letter from the school you are applying to that isn't as strong or might be from a sub-specialty rotation use it for that school but you don't have to use it everywhere. 

Try to shuffle your letters around, because people can really get burned if they use a letter at every school that turns out not to be strong. So, if you are pretty sure its a good letter, use it everywhere, but if you have some doubts or are unsure, try to use it at some schools not others. 

I have seen mediocre letters as someone who has sat on a committee and it really can sink your chances, which could be the reason why someone who thought they were competitive doesn't get interviews.  

[jb24]

This is just something perpetuated by medical students. You do not need to use your or even have a third year "core" letter. All you need is good letters, but tbh internal medicine isn't that competitive, you will probably match no problem if you show commitment as a lot of people still use IM as a backup.

Bottom line is use whatever letter is best. Its not like committees have the time to back track to see if you are using a core or elective letter. They won't even know nor do they care.  

In general 4th year letters are better (because you will probably perform better/closer to a resident level), but using a third year letter is fine too as long as they give a good LOR.

[rmorelan]

since carms has not set rules there could easily be someone out there that doesn't think an application which doesn't include a core letter would be "weaker" in some fashion compared to those that do. There could also easily be the reverse - someone that is only interested in evaluating students performance after they have done core clerkship (as it levels the playing field at many schools, any one doing IM as your first block is likely not going to do as well as someone doing it as their last one for instance). There are no standards here and things change by school, and by program. That is what makes all this so messy. 

Thus you are stuck with just getting good letters from people that know you well, and can personally comment on your performance (things like actual examples for instance are way more useful and engaging than generic comments). Since people on your core rotations have a good chance to see you over longer periods of time that may be good options but they are not the only one. 

In your case I would get all the letters from 4th year if you think they will be stronger - and if you can arrange a CTU block somewhere that you know you will be with the same person for some time that would be ideal. I was never afraid to tell the staff you are working with up front your goal will be to get a strong letter at the end of the rotation in part because you have no choice. 

[redbeanbun]

On 2/4/2023 at 4:26 PM, Edict said:

Try to shuffle your letters around, because people can really get burned if they use a letter at every school that turns out not to be strong. So, if you are pretty sure its a good letter, use it everywhere, but if you have some doubts or are unsure, try to use it at some schools not others. 

I haven't heard of using more than three letters and then shuffling around but I can see how that makes sense. If you have more than three letters and they are from preceptors' from different schools (from different traveling electives), would it be advantageous to use a letter that comes from a particular schools' preceptor? 

 

[Edict]

31 minutes ago, redbeanbun said:

I haven't heard of using more than three letters and then shuffling around but I can see how that makes sense. If you have more than three letters and they are from preceptors' from different schools (from different traveling electives), would it be advantageous to use a letter that comes from a particular schools' preceptor? 

 

Usually, yes. Unless you thought you didn't do well there.. but generally speaking if you didn't do well it doesn't matter because they will know anyways. 

[cardio_enjoyer]

Are you talking about UofT? I heard this urban legend as well.

I did not get an interview with UofT IM but I know at least 3 people who did who did not have 3rd year letters.

You should have at least one from CTU though like they suggest.

[No Name Brand]

Agree with above that that is not true - I know of many applying to IM over the years who have gotten many interviews using no 3rd year rotation reference letters. Having CTU staff is important but get them from individuals that know you best and that you think can write you the best letters.