A program director will see hundreds of applications come across his or her desk (or desktop) each season.  Some will jump out immediately but many more will have similar board scores, similar class rankings, and similar lists of extracurriculars (collegiate sports anyone?).  A good letter of recommendation can set your application apart as a direct endorsement from someone the letter reader can identify with.  


What makes a letter good?  

A good letter will be able to help the reader picture what kind of resident you’ll be.  With this in mind, who you ask is very, very important.  Academic faculty who are familiar with the language of recommendation letters are usually a good place to start.  A well-known name in the field can be very impressive.  However, the world of orthopedics is smaller than you think!  Many orthopods have worked together as residents, on committees, or on their golf game and reading an endorsement from a friend definitely changes the whole tone of an application.

Equally important as who writes your letter, is how well they know you.  If they need your CV to remember who you are, they are unlikely to be able to write an exceptional letter touting your suitability for the profession.  Experienced readers can instantly pick out templated letters which send the message that you were forgettable or didn’t have enough time or desire to garner real relationships.

As a former “guesser”, asking for letters of recommendation was really hard for me!  As Dr. Scott Porter, previous program director at Greenville Health System, says,

“You’re asking someone to put their reputation on the line for you.”  

I felt awkward asking that of people in general and to make matters worse, I really didn’t know any orthopedic surgeons that well when letters were due.  This led to a lot of last minute panic and probably one of the weaker aspects of my application.  Don’t let that be your story!  Start the letter of recommendation process ASAP with the first and MOST important part of the process.


1 – Build relationships

Getting that glowing letter of recommendation ideally starts long before application year.  Ryan Holiday, one of my favorite authors puts it this way,

Mentorship, like all relationships, is a process and not an accomplishment.”  

If you think you’re even slightly interested in ortho, seek out the department chair at your school and ask to meet with him or her.  What if you don’t figure it out till later in medical school?  What if your school doesn’t have an orthopedic program chair?  Find chairs of nearby schools.  Attend ortho conferences and approach faculty that participate in student events.  Use vacation time to shadow, use post-call days to set up meetings, in short, hustle.  Not having an established, institutional pathway to an orthopedic mentor is not an excuse to wait until audition season to try to get to know someone fast enough to get a good letter of recommendation.  

Regardless of how close you are to the letter deadline, time is a precious commodity.  Here are some quick tips on how to maximize your time with your potential mentor and letter writer.

Spend time in the clinic.  

Shadowing in the office has double value.  You’ll learn from lots of real life cases and you’ll have downtime to get to know the attending and potential mentor.  The operating room is often exciting but it’s really the office where people get to know you.  That’s when you have time to talk about who you are and to look for common ground.  Beware of being the silent wallflower though.  Be courteous and respectful of course but take some initiative and read about something you saw in office the day before or know you’ll see so you’ve got a topic to ask questions about.

Request feedback.  

Feedback is precious.  People pay so much for it.  Now, remember that you are not just looking for someone to tell you you’re doing a good job. Asking for feedback does several things: gets people to look at you more closely, garners support, and helps you understand where your strengths/weaknesses are.  In order to best take advantage of the former, ask to schedule a time to review your performance.  That way, they have some time to observe and reflect.  If time allows, I would suggest asking for feedback multiple times.  That way, you can implement their advice immediately and get their evaluation on how you’ve changed.  Asking for advice is also a great way to build your relationship!

Keep in touch.  

Keep them posted on your progress and little tidbits that you feel like they may enjoy.  Sometimes, the conversation may seem a little one-sided and awkward but the most likely reason is that they’re just busy!


Two – Ask for a letter

I delusionally wished that one day, someone would recognize how hard I was working and offer to write me a letter.  

“Hey, Emily.  I’ve noticed that you have been reading a lot about ortho and that you’ve been hanging around the office.  I bet you would really like to be an orthopedic surgeon.  How about if I write you a letter of recommendation?” 

– No one ever

Not going to happen.

Be bold.  Be ready for rejection (highly unlikely).  Be brave!  Above all else, just make sure you do it.  Here’s are some key components to include.

Direct Request-

Either via email or in person, you have to start with the request.  While you may worry about a refusal, it’s actually pretty hard for most people to say no.  With that in mind, if you ask someone who doesn’t know you well or doesn’t know how to write letters, you are more likely to get a crappy letter than an all out refusal.  While this will hurt less in the short term and spare your feelings, it would be worse in the long run as it could drop your application to the back of the line.  One suggestion to avoid this problem is to ask openly, “Do you feel comfortable writing a really good letter of recommendation for me?”

Follow up communication –

Once you’ve got the green light, be sure to send all the information that they need to get the letter written and submitted by your deadline (LoRP request form with submission instructions, CV, personal statement.)  A follow up email is a good way to have it all in one place.  Be sure you have the right email address! Be sure you send it right away!

Below is a sample template of a follow up email and then a sample.  Feel free to use it to formulate your own!

Dear [Letter Writer],


¶1 – Express your gratitude for their endorsement.  Why does this letter matter to you?

¶2 – Make it easy for them to make the letter personal.  Tell a story that they will remember that highlights your strengths.  This is also a good place to mention a shared joke or piece of advice they shared with you.

¶3 – Practicalities of the letter.  

  1. When is your deadline?  May be a good idea to set the “deadline” earlier than your actual deadline.  
  2. Mention the resources you’ve attached – CV, personal statement, ERAS LoRP request form.

***I’ve made a quick video on how to upload letters to the LoRP to help guide letter writers who are less familiar with the process.

3. Politely request a copy of your letter.  This will help you select which ones to use if you have more than you need.


Dear Dr. Smith,


Thank you very much for writing me a letter of recommendation.  Orthopedic surgery is what I want to spend the rest of my life practicing and I really appreciate your support.


I have learned so much in the office and in OR with you this past year.  One patient in particular I will never forget: a young lady who was a new patient referred by her PCP with persistent foot pain after a car accident a couple months ago.  She had been diagnosed with a foot sprain and when I started her H&P I wasn’t really sure what to ask.  When she described the bruising on the bottom of her foot after the injury, a lightbulb went off in my head!   You let me order some additional XR’s based on my presentation and sure enough she had a lisfranc injury.  I had read about lisfranc fractures but never seen one in person before and it was really rewarding to get the right diagnosis- even more so because I got to scrub her case later that week!


I’ve attached my CV, personal statement, letter of recommendation portal request form, and the submission instructions.  My target date for letter of recommendation submissions is Wednesday, September 20th.  If you feel comfortable with sending me a copy, I’d love to read it.  However, I’ve gladly waived my right to see it and completely understand if you’d like to keep it private.


Thank you again for taking the time to support my application!

Emily Tan

Three – follow up

In an ideal world, the letter would be submitted soon after.  However, your letter writer may need some gentle nudging!  To help them get the letter in on time, set some dates in your calendar to check that it has been submitted.  If it hasn’t, check in with them and see if there’s another else they need.  It may seem demanding but oftentimes a friendly reminder is very helpful when you’ve got a lot on your plate.  Hopefully by sending timely reminders, you can avoid more stressful emails or phone calls when you’re up against the deadline.   Once the letter is submitted, be sure to send a thank you note!



With an early start, you can avoid the issues I had with my own letters of recommendations.  In comparison to board scores, letters are deemphasized when most people talk about applications.  While they may not be the first thing a reviewer flips to, a really good endorsement can really make your application stand out.  

The work put into getting a solid letter of recommendation is worth it.  The relationships that you build will not only boost your application in the immediate future but will hopefully benefit the rest of your career as an orthopedic surgeon and physician.