Applying - Letters of Recommendation

Updated August 2016

Emergency Medicine uses a unique letter writing form, the Standardized Letter of Evaluation (SLOE). This is very different from your standard narrative letter of recommendation. Instead of having three glowing letters extolling your virtues and ignoring your deficiencies, the SLOE compares your performance and candidacy against your peers also applying to EM. As you can imagine, this results in the SLOE being a very informative document to Program Directors considering your application. This makes your letters one of the most important parts of your application, and one of the best ways to enhance your application.  The source and quality of an applicants letters will often make the difference between an interview offer or a rejection.

How many letters do I need?

You will need at least three letters.  Some programs allow the submission of a fourth letter.  The first three should be from someone with whom you have worked clinically.  The fourth is more variable depending on the program.  This can be a good place to include a letter from a research mentor or an advisor.  This can even be from a friend or family member, depending on the programs requirements.  



How many letters should be from EM?
Unlike some other specialties, EM programs are not looking for broad diversity in these letters.  Program Directors would be perfectly happy with all three letters coming from EM faculty.  You can get letters from other specialties, but the more EM the better.


Who should I ask to write letters?
The best letters you can get are SLOE's from Emergency Physicians who write lots of SLOE's and who have worked with you clinically.  Take a look at the SLOE form and it will become clear why it provides better information.  The writer needs to establish their credentials, how they know you, how well you did on their rotation, and then contrast you with other students applying to EM.  The writer also needs to specify how many letters they write.  A SLOE written by someone with a larger sample size of students to compare (more letters written) will have greater credibility.  This letter format, unique to EM, makes our letters more powerful and impactful on your application. The weight other specialties place on third year rotations and board scores, in making interview decisions, is instead placed on your performance in EM.

Your best bet for useful SLOE's is going to be the Clerkship Director of your EM rotations.  Many programs now write a Departmental Letter where the Clerkship Director and Program Director's co-write your letter.  Many feel that these are the most useful letters: the letter writer's know what the letter reader's are going to want.  Other EM faculty can write SLOE's but if they only write a few letters a year they may be better off writing you a more traditional letter.  Any letter from EM faculty, whether a SLOE or a traditional letter, is going to be more useful than letters from other specialties.

Your goal should be to get a letter from each of your EM rotations.  If you do two EM rotations by September (any later than that and the letter may delay your application being complete), you will have two EM SLOE's from Residency Program leadership, and you can add one more letter from wherever.  This is the ideal, but many applicants successfully match with a lesser collection of letters, so don't panic.


Can the SLOE hurt my application?

A common fear many students have once they look at the SLOE form is that the honest assessment asked for in the letter might hurt them: somebody has to be in the "bottom 1/3".  Letter writers are acutely aware of this and have all developed strategies to effectively address this very concern. They often go out of their way to make it clear that they use the entire scale and that students in the "bottom 1/3" are viable candidates for EM training. They will usually provide an explanation of what the student needs to do to succeed.  Work hard, show respect for the staff and compassion for your patients, and listen to the feedback your supervisors give you: your letters will be fine.  


What more can I do to ensure I get a good SLOE?

Maximize Your SLOR is an article I wrote for SAEM on how to get a great letter. Even though the name has changed to the SLOE, the advice still holds.


For more on the SLOE:

40 comments:

  1. Hello, I'm applying to AOA programs this year. My first two letters are regular letters from my EM rotation. No one has done SLOEs there, so they are just regular letters. My first Audition is 8/25 to 9/19. Should I submit and additional non SLOE letter now? Or wait until I get 2 SLOEs?

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    1. First, the usual caveat: I would ask an AOA advisor (my knowledge is much greater on osteopaths making the jump to allopathic programs). The need for SLOE's may be much less than on the allopathic side. You can certainly hold a letter slot for your 8/25 - 9/19 SLOE, as it will be in by October. If you use the two EM letters you have as well, that is a great collection of letters. Don't wait for another SLOE after that. The one will be fine.

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  2. Going off the first Anon comment: I just sent three letters to programs: Two audition SLOEs and a non-EM letter. I am waiting for a final SLOE from my third and recently-ended elective that should be in before October. Since I already submitted the three required letters on ERAS and am comfortable with where I stand - is submitting the fourth one optional?

    (And thanks for the extremely helpful blog.)

    ReplyDelete
    Replies
    1. Some programs will take a fourth letter but it will not be necessary to get your application reviewed. It is still worth getting that letter in as it could make the difference in coming off the wait list.

      Glad you find it useful. Questions and suggestions are welcome. Good luck!

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  3. Hello, third year here. I was wondering if SLOE's can come from the same program? I go to an osteopathic school and will be attempting both matches. My school allows only 3 maximum rotations in EM, to which I will probably choose 2 MD and 1 DO programs. Could I get an SLOE from a two week peds EM elective at an MD program? Am I correct to assume 3 SLOE's are ideal? I know these are a bombardment of questions, I appreciate the blog.

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  4. 3 SLOE's are great but absolutely NOT required. You will have to ask if they will do a SLOE from your 2 week elective. Many departments will allow more than one letter writer, though it can be hard to find a second writer if they do a departmental letter (a composite by the Clerkship and Program Director's). All you really need is one SLOE from someone who writes a lot of letters. Everything beyond that is a bonus.

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  5. Can a SLOE be written by an EM doctor with whom you rotated in a hospital without an EM residency and/or is not part of a university institution?

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  6. Short answer: yes!

    Longer answer: The SLOE was designed to be used by letter writers who write a lot of letters. It even asks for the number of letters written as one of the questions. Practically speaking this means that a SLOE from a member of a Residency Program carries more weight as that person writes (and reads) more letters than most EM doc's. The letter you describe, by an EM doc not at a residency, is still the second best letter you can get, whether it is a SLOE or written in traditional letter form.

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  7. I am a non-allopathic senior--I went to USUHS and after a transitional internship I have spent the past 7 yrs paying off my military commitment as a general medical officer. I currently work in the urgent care section of an Emergency Department and am sure to have a great LOR from the Department Chief, but it is certainly not a residency program, and, as I'm not currently affiliated with a medical school, rotating at EM programs seems to be a non-starter. Any suggestions on LORs for my application process this year? Would you recommend contacting EM programs asking for mini-rotations to get a good SLOE?

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    1. Folks paying off a military commitment and now seeking EM residency are in a unique set of circumstances, particularly when it comes to letters. You will have a hard time getting a SLOE from a Residency Program for all the reasons you mention, HOWEVER you will not be expected to have them. Your GMO experience will be looked at favorably by many Program Directors. Your letter from your Department Chief will be important and I would also seek LOR's from other emergency physicians who know your clinical work well. Those letters should not be SLOE's as they are probably not frequent letter writers AND that is just fine.

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  8. Hi, I am an IMG, I am currently working as a ED scribe and I have done two 6 month hands-on observerships here in the US, both doctors that I have observed are a part of the faculty, but the ED I rotated in is not a part of the official EM residency program. Can they write me a SLOE or only LOR? Thank you!

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  9. Anyone CAN write a SLOE, however it is intended to be written by faculty in EM training programs. If someone writes many letters each year that SLOE can still be helpful. When a writer only does a few a year the reader will not find the information and assessment as reliable. Letters from EM physicians, even non-SLOE's are still better than letters from other specialties.

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  10. DO student here. My adviser, like you, told me that all EM letters would be great. I have two SLOEs from MD programs assigned to ERAS right now. I read in one of your other articles some programs will not review an application unless there are 3 letters in. Do I assign on ERAS a non-EM LOR now for the sake of completeness? I ask because I am finishing up an AOA away (SLOE expected mid October) and will be wrapping up audition season with an ACGME away in October (SLOE ETA mid November).

    My second question is: if I do use a non EM LOR for application completeness, should I use my AOA SLOE complete mid October or ACGME SLOE complete mid November? The November ACGME SLOE is something I am leaning towards since I received high pass on both my ACGME aways and am hoping for an honors for that rotation (AOA rotation does not grade honors/high pass). However, your input is greatly appreciated.

    Long post, but thank you for the excellent blog Dr. Kellogg.

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  11. Your situation is tricky, and the best option depends on the rest of your application. If you feel there are deficiencies that will prevent you from getting interviews without another EM letter than it could be worthwhile to wait for one of those later SLOE's.
    The problem is that all of the interview spots will be offered by mid-October and you will end up on Wait Lists once your application gets reviewed. This is why I generally advise to go for "complete" (3 LOR's) by October 1st over "perfect" but late.
    The only way stalling your application makes sense is if you won't get interviews based on what is in there already. That is usually not the case.
    Those later rotations can be used as a 4th letter for programs on the fence who allow a 4th. And you can also send that SLOE directly to undecided programs where it may help.

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  12. Hello Dr. Kellog,

    Im an MD IMG. I have an SLOE from a rotation I did at at a EM DO residency program from the program director and an MD EM physician LoR from the same rotation. Should I get another SLOE from the same program written by another DO EM physician who I've worked with a lot or ask for an LoR instead. Im finding it very difficult to secure another EM rotation.
    Your input would be much appreciated and thank you for this very helpful blog.

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  13. A SLOE is almost always better than a regular LOR because it asks for comparison to other applicants. Usually the comparison is more valid from someone who writes a lot of letters which is usually Program and Clerkship Directors.
    As for more EM rotations, it has gotten late (october) to complete a rotation and get a letter in that will impact interview offers. Most important right now is to get your letters in so your application gets reviewed.

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  14. Hi Dr. Kellogg,

    Thank you for your blog. I am in a unique situation and am wondering your thoughts. I am in a 3 year accelerated osteopathic program for prior physician assistants. I have several years experience as an EM PA prior to med school. Unfortunately, the schedule for this program is such that I will not be to complete an EM rotation before I apply for the match (earliest would be mid Sept) therefore I likely will not be able to obtain a SLOE. I know that these letters are preferred, however given the circumstances, would regular LORs from my previous attendings be helpful? Is it understandable that I won't have SLOEs? Additionally, do you know of any particular programs that may look favorably upon my previous EM experience as a PA?
    Thank you

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  15. To make sure your application is complete you need to go with letters you have in hand by early October when programs are doing most of their application review and interview offering. You can use a late-arriving SLOE as your fourth letter at the programs that allow four. You can also have it sent directly to the programs you are most interested in but who may be on fence about bringing you in for a late interview.

    It is not uncommon for applicants to have no SLOE's, but it puts you at a disadvantage by making your application difficult to compare to others.

    If you can get that SLOE in by early october, that will make a big difference.

    As for the question of previous experience: most programs will look favorably at having been a PA in EM already.

    ReplyDelete
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    1. Hey man Quick question.

      I'm a 3rd year DO student. I was wondering is it okay to get 2 SLOE's from DO programs, One allopathic SLOE and be able to apply to both ER osteopathic and allopathic match?

      TLDR; DO I need to get two MD SLOE's?

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    2. That would be a perfectly acceptable combination of letters. So long as you have an allopathic letter the allopathic programs will look at you.

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  16. Hi Dr. Kellogg,

    Thank you so much for all your advice from this blog. I was wondering if you could help me with my current situation. Currently, I am scheduled to finish my first EM rotation at my home institution by September 15th. Does this letter have to be in by September 15th for my application to be complete?

    Also, I am unsure as to what I should do with my other letters. Would it be ok to get my 2nd letter from the same EM rotation from one physician? In addition, can my third letter be from family medicine or internal medicine? I also plan on doing an EM externship at the end of September, which could give me another EM letter; however, it probably would not be submitted by mid October. Thanks again for all your help.

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    Replies
    1. A rotation finishing in mid-september will get your letter in early enough. A second letter from that rotation is also okay, and better than waiting too long for a letter from a later rotation. Your third letter can be from another specialty. The rotation ending in october won't get a letter in before early november so you would not want to hold up your application under most circumstances. Some residencies let you submit four letters and you could use this for that fourth spot without delaying review of your application.

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  17. Hello Dr. Kellog,

    Can you please clarify a few things for me. How many SLOE's are required out of my 3 LOR's for my application? Also, it looks like I'll have 2 SLOE's and 1 traditional letter from a family medicine physician. I'll finish up my 3rd EM elective September 16th so should I pull the trigger and submit my application early with 2 SLOE's and one traditional or wait for a 3rd SLOE and apply later on in September? I am trying to maximize my chances for interviews given the fact that I am a US IMG. Thank you for your help ahead of time.

    Respectfully,

    Mark

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  18. Mark - Each program has a different number of "required" SLOE's. Some are fine with just 1. If you have 2 SLOE's from 2 different ED's then almost all programs will seriously consider your application.

    Mid-september is NOT too late for a SLOE that is part of your application. There is plenty of time before serious application review starts (after October 1st) to get the letter in. Any later than September and that should be considered an extra (fourth) letter for those programs that take one.

    As a "non-traditional applicant" (ie anybody who is not a US allopathic senior med student), you are right to do everything you can to have your application complete in early October - that gets the maximum number of eyes on it for review.

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  19. Hi
    I am IMG with 4 years of working experience in EM. I am also a member of Royal College of EM (UK). I have 2 questions:

    Can my Instructors (EM Physicians) from India or UK write the SLOE for me?
    How do Program Director/s look at previous experience in EM?

    Thanks
    Appreciate all your time and efforts

    ReplyDelete
    Replies
    1. The SLOE is intended to be written for students, evaluating them and comparing them to their peers. Many reviewers would NOT think it appropriate for your circumstances and would prefer you had more traditional letters from your instructors. For more information about the SLOE: http://www.cordem.org/i4a/pages/index.cfm?pageid=3743

      Previous EM experience is usually seen as a strength. That may be helpful, though it is becoming increasingly difficult to get an EM position for IMG's. Rotations at Academic ED's in the U.S. give you the best possible chance to get both SLOE and interviews.

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  20. Hi Dr. Kellog. I am an IMG and will be applying for ED residency this year. I completed my first ED rotation in Canada which was affiliated with a residency program and has lots of students rotating there. I completed my second ED rotation in the states which was not affiliated with a residency. I am planning on getting two SLOE from the Canadian site and one standard LOR from the american site. Would it be okay for me to get 2 SLOEs from the rotation I did in Canada? Currently, I have the clerkship advisor writing me one and I am planning on getting another one from another faculty member...would that be fine or does having two SLOEs from the same site decrease my chances? Also, does getting SLOE from Canada decrease my chances? Do you advise that I try to find a residency affiliated rotation for sept or oct and try to get a SLOE from there or will these 3 letters plus another letter from one of my other rotations be good enough? Thank you for your help.

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    1. Hi Kristy,
      Having 2 SLOE's from the same site will not hurt your chances, it just does not help as much as having SLOE's from 2 different EM programs.
      The issue with a SLOE from Canada is that few of the U.S. reviewers will know the letter writers. They should trust in their ability to evaluate candidates BUT the personal connection of reading a letter by someone you really know is going to be lost (in most cases). It is likely too late to get a rotation in the US that will provide a SLOE in time for your application to be complete. You do not want to delay your application being reviewable. If a 4th letter could come from an October rotation, that could help. The most important thing to do is to focus your applications on programs with a recent history of taking IMG's and having a back-up plan that is acceptable to you in case you are not able to get enough EM interviews.

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  21. Hi Dr. Kellogg,

    Great blog and quick question. Currently, I am on my last EM elective scheduled to finish at the end of Sept. I have two other SLOE's, one uploaded and assigned from my June rotation, another from August rotation that I expect to be uploaded in a few days. I also have a traditional letter from a family med physician. Given that my rotation finishes at the end of Sept, I don't expect the SLOE till mid Oct, at the earliest. Should I submit my two other SLOE's and the family med letter for a complete letter at the beginning of Oct, or wait till my third SLOE comes out and assign it? It was my understanding that middle of October might be too late, but wanted to clarify. Thanks for your time.

    ReplyDelete
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    1. Given that you already have 2 SLOE's the most beneficial plan is to submit the 3 letters you have. You can designate the 3rd SLOE from this month as your 4th letter for the programs that allow 4. If you only had 1 SLOE than it would be worth holding a spot for that mid-october letter.

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  22. Hey, had a similar question to the one above. Im a DO student that completed 4 ER rotations (1 3rd year, 3 4th year). Of those 4 rotations, 3 have been from DO residencies, and 1 from an ACGME residency. I have already submitted my applications with 3 SLOEs but just recently had another SLOE uploaded from my latest ER rotation. I was wondering if I should upload this latest SLOE? I've heard not uploading a SLOE from an ER rotation has been considered a "red flag" but given I already have 3 with my application, would a 4th even be necessary?

    ReplyDelete
    Replies
    1. In almost any circumstance more SLOE's are better. If one is weak, which you may not know, the weight of all the others will drown it out.
      If you only do 2 rotations then not having a letter from one, especially a home rotation, is a red flag.
      With as many letters as you have it does not really matter if one rotation is not represented. It is unlikely that a reviewer is going to pick up on that as your transcript usually does not include your most recent rotations.

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  23. Hi Dr. Kellogg,

    I want to start off by thanking you for putting up so much valuable information for EM applicants and continuing to be so responsive!

    I am a 4th year DO applicant that has completed 4 audition rotations (2 AOA & 2 ACGME) and my last SLOE was uploaded to ERAS earlier today. So far I have assigned 3/4 because my gut feeling is that the SLOE I received from an AOA rotation in July is not as strong as the others. Although I have not received any red flags from that writer/program, this feeling is based off my perception of the performance from that rotation vs others (e.g. poorer differentials, didn't click as well with attendings/residents). So far I have uploaded the other 3 SLOEs but not the 4th. I understand your philosophy is 'the more EM letters, the better' but I wanted to gauge your thoughts on this unique situation before uploading the last letter.

    Thanks in advance!

    ReplyDelete
    Replies
    1. With 3 other SLOE's you certainly don't need another. Most reviewers will judge a first rotation SLOE differently than one from a later rotation. Most students take a while to adapt to the EM approach and environment. Unless it says something truly negative it is unlikely to hurt you.

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  24. Hi Dr. Kellogg,

    Thank you for so much valuable information for students as well as your reply to every questions!

    I am an IMG and will submit my application next year. I have a short question about the letters: is it true that all the LORs from Emergency faculty should be written in SLOE format? or the traditional letter still works? The reason why I ask this is that I checked the website of CORD (see below) and it reads that "2016-2017: The biggest change for this year is transitioning all of the letters to be completed via the eSLOE website." So, I am a bit confused now...
    BTW, I already have one SLOE from the CD and am going to ask another faculty for another letter during the same ER rotation. The thing is that I am not sure if I should ask a traditional letter or a SLOE?

    Thank you very much!

    http://www.cordem.org/i4a/pages/index.cfm?pageID=3743

    ReplyDelete
    Replies
    1. I am going to have to update this page with the eSLOE changes. The way it is going to work is that eSLOE's will be created by each residency program. Each will have an account and it will keep track of all their data for them. The programs will have the option of letting their individual attendings write eSLOE's as well. But the program may also choose to only have the official "departmental letter" as an eSLOE and have individual faculty write separate letters. There is nothing to stop that faculty member from writing their letter in the SLOE format (the old templates are still around). A SLOE is always going to be better than a narative letter HOWEVER a SLOE that is written like a narrative letter (all positive, nothing constructive, highest ratings in every category) is not going to be trusted UNLESS that person writes a good number of letters each year, with a reasonable distribution, and clearly has some frame of reference for comparison.

      Ask your CD how they are going to handle this in their department - it will be different in each place.

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  25. Hello! MS3 here, with a sort of tight timeline seeing as I attended medical school in the Caribbean. Is it possible to get a SLOE from a Peds ER rotation? I have EM in July and Peds EM in August, hoping to get the SLOEs done before application time. I just wasn't sure if a Peds EM would hold as much weight. Thank you!

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    1. SLOE's from pedi EM rotations is fairly common. The biggest challenge is if those faculty are not frequent letter writers and thus not experienced with contrasting a student with the rest of their applicant peers. The best way to figure out how this is handled is to ask in advance. In general, you would not want your only EM SLOE to be from a pedi EM rotation, but as a 2nd or 3rd, that can be perfectly acceptable.

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  26. Dr. K.

    Regarding SLOEs and application submission timeframe...I have 2 core EM rotations in June and July at a small non-residency hospital (planning on obtaining normal LORs). Then 2 more months EM electives at really solid residency programs - Mid September through mid November (SLOEs).
    I am worried my these SLOEs will come in too late but I was told by a coordinator to apply ASAP in September and then upload SLOEs later when they are in (from the two residency electives) and I should be ok. I was told that it's good to at least have my application submitted and then I can contact the residencies I apply to and let them know I have new SLOEs uploaded. Any advice regarding this situation?

    Thank you for your input!

    ReplyDelete
    Replies
    1. Waiting until late November to have your SLOE's in is going to hurt your application.
      You are limited to 3 or 4 letters per program in ERAS and once they go to the programs you cannot replace them. This means you would need to leave 1 or 2 open spots for letters coming from these later rotations, so your application will not be complete until well into the interview cycle. Programs will be unlikely to offer you an interview and will push your application to the "back of the pile" until it is more complete. Most of the interview spots will be gone by the time your application gets reviewed and you will be trying to get wait list spots for January interviews. It would be really difficult to get enough interviews to comfortably match.
      If there is any way you can move one of your rotation up so that it ends in September or turn one of those community months into an elective at a residency, you will have a SLOE with your application, an EM LOR from the community, and a spot saved for the second EM rotation. That would be okay and would only hurt you at programs that insist on 2 SLOE's from separate rotations (there are very few of those).

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