The Essential Guide to Letters of Recommendation for EM Residency

Why Letters of Recommendation Matter So Much in Emergency Medicine

Letters of recommendation in emergency medicine residency applications carry exceptional weight. In a high-acuity, team-based specialty where performance under pressure is critical, programs rely heavily on others’ direct observations of you in the Emergency Department (ED) to predict how you will function as a resident.

In most programs, your emergency medicine residency letters of recommendation (EM LORs) are:

• Read closely by both program leadership and selection committee members
• Used to distinguish between applicants with similar test scores and transcripts
• Particularly influential when written on standardized EM-specific forms (SLOEs/“SLOEs-equivalents”)
• Often discussed explicitly during rank meetings

For EM, what the letter says matters—and who says it matters just as much. Understanding how to get strong LOR, who to ask for letters, and how many EM-specific letters you need is crucial to a successful EM match.

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Types of Letters in Emergency Medicine: SLOEs, Non-SLOEs, and Specialty Letters

Emergency medicine has a unique culture and structure around residency letters of recommendation compared with many other specialties. Knowing the types of letters—and which are expected—is the first step.

1. The Standardized Letter of Evaluation (SLOE)

The SLOE (often still called SLOR by some) is the cornerstone of the EM match. It is a structured evaluation developed by CORD (the Council of Residency Directors in Emergency Medicine) specifically for EM residency applicants.

Key features of a SLOE:

• Standardized format: checkboxes and short narratives rather than a long free-text letter
• Completed online, tied to your EM rotation
• Includes:
  • Global assessment (e.g., top 10%, upper third)
  • Comparative rankings versus peers
  • Narrative comments on your strengths and areas for improvement
  • An estimate of where you would be placed on that program’s rank list, if applicable

Program directors consistently report that SLOEs are among the most valuable components of an EM application because they provide apples-to-apples comparison between applicants.

Departmental vs. Individual SLOE

Many EDs will produce one main “departmental SLOE” that reflects the consensus of:

• The clerkship director
• Multiple core faculty
• Sometimes residents who worked with you

Some institutions also allow individual SLOEs written by a single faculty member, but programs generally prioritize:

1. Departmental SLOEs from EM residency programs
2. Individual SLOEs from core EM faculty at residency programs
3. SLOE-like letters from community EM sites or non-residency sites
4. Non-standard letters of recommendation

If your school has its own EM residency or you rotate at an EM residency program, aim for a departmental SLOE from that site.

2. Non-SLOE EM Letters of Recommendation

Not every ED can generate a traditional CORD SLOE (e.g., smaller community sites, non-EM residency sites abroad, or new programs not yet using the system). In those cases, you may receive an EM letter of recommendation in narrative format.

These letters can still be valuable if they:

• Explicitly state that you are being compared to other EM-bound students
• Comment on your performance with EM-specific skills (resuscitation, multitasking, teamwork)
• Include clear, strong language of support for EM residency

Programs know not every applicant will have access to multiple SLOE-producing sites, especially in regions with limited EM rotations. A detailed narrative EM LOR can still help you in the EM match, particularly as a supplement to at least one strong SLOE.

3. Non-EM Specialty Letters

You may also have letters from:

• Internal medicine, surgery, or ICU rotations
• Subspecialty rotations (cardiology, orthopedics, anesthesiology, etc.)
• Research mentors or longitudinal preceptors

For emergency medicine residency, these are supporting letters, not primary decision-makers. They can be useful when they illustrate:

• Work ethic
• Professionalism
• Communication skills
• Longitudinal growth over time

However, they do not replace the need for EM-specific SLOEs or equivalent.

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How Many Letters You Need for Emergency Medicine—and What Kind

Requirements change subtly over time and by program, but some general patterns are consistent.

Typical Letter Requirements for EM Programs

Most emergency medicine residency programs require:

• 3–4 total letters of recommendation in your ERAS application
• Within those, at least 2 EM-specific SLOEs (or SLOE-equivalent letters)

A very common strong configuration is:

• 2 departmental SLOEs from EM residency programs where you rotated
• 1 additional EM letter (SLOE or strong narrative letter from a community EM site)
• Optional: 1 non-EM letter (from IM, surgery, or a mentor who knows you well)

Some highly competitive applicants may submit 3 SLOEs, but more is not always better. Quality and clarity matter more than raw number.

What If You Can’t Get Two True SLOEs?

Not every student can rotate at two SLOE-producing institutions. If you are limited, consider this strategy:

1. One departmental SLOE from your home EM site or a visiting EM rotation
2. One SLOE-equivalent EM letter from a community or non-residency EM site
3. One strong non-EM clinical letter (IM, surgery, ICU)
4. One mentor/research/longitudinal letter if it adds unique value

Programs understand structural limitations; what they want to see is at least one robust EM SLOE and additional evidence you function well in clinical environments.

DO, IMG, or Non-Traditional Applicant Considerations

If you are a DO, international medical graduate (IMG), or non-traditional applicant, EM-specific letters become even more critical to:

• Demonstrate that you have real-world EM exposure in the U.S.
• Show you understand the specialty’s demands and culture
• Validate your performance against U.S. EM-bound peers

You should make every effort to secure at least one SLOE, ideally two, by targeting audition rotations (away rotations) at SLOE-producing EM residency programs.

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Who to Ask for Letters: Choosing the Right Authors Strategically

Knowing who to ask for letters is central to crafting a competitive application. The best letters come from people who 1) know you well and 2) are credible voices in EM residency selection.

Priorities for EM SLOEs

For emergency medicine residency specifically, prioritize:

1. Departmental SLOEs from EM residency programs

   • Usually signed by:
     • Clerkship director or site director
     • Program director or assistant PD
     • Sometimes co-signed by an education director
   • These carry the most weight because they represent a consensus departmental opinion.

2. Individual SLOEs from core EM faculty

   • Particularly valuable if:
     • You worked closely with them over multiple shifts
     • They are well-known in EM education (PDs, APDs, clerkship directors, CORD leaders)
   • They must know you well enough to provide specific commentary.

3. Community EM physicians with active ED teaching roles

   • These can be SLOE-like or narrative letters.
   • Particularly useful if:
     • They directly supervised you often
     • They can speak to your ED performance in detail.

If your rotation offers a standard process for a departmental SLOE, you generally do not need to additionally ask individual attendings from that same site for separate SLOEs, unless advised otherwise by your clerkship director.

Selecting Authors for Non-EM Letters

For non-EM letters, choose physicians who can comment meaningfully on:

• Clinical reasoning
• Reliability and punctuality
• Teamwork and communication
• Professionalism and integrity

Examples of strong non-EM letter writers:

• An internal medicine attending who supervised your sub-internship
• A surgical attending from a demanding inpatient rotation
• An ICU attending who saw you manage critically ill patients
• A research mentor with clinical credentials and prolonged contact with you

When deciding who to ask for letters, prioritize depth of relationship and quality of observation over “big names” who barely know you.

Red Flags: Who You Should Avoid Asking

Avoid letters from:

• Faculty who worked with you for only one brief shift and clearly seemed disengaged
• People who may give lukewarm or “faint praise” letters
• Non-physicians (unless exceptionally appropriate, such as PhD mentors for dual-degree candidates, and even then only as supplements)
• Family members or close personal friends, even if they are physicians

If you sense hesitation when you ask someone for a letter, it’s safer to seek another writer.

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How to Earn Strong LORs on Your EM Rotations

Strong residency letters of recommendation begin long before you ask for them; they’re built through your daily performance on rotation. Especially in EM, where SLOEs compare you to peers, small differences in behavior add up.

Core Behaviors that Translate to Strong EM SLOEs

Think about the attributes EM programs value, then demonstrate them consistently:

1. Work Ethic and Initiative

• Arrive early, stay engaged, and offer to see new patients
• Volunteer first for procedures and resuscitations
• Ask, “Is there anything more I can do for the team or this patient?” at the end of each shift

2. Clinical Reasoning and Efficiency

• Present concisely and logically: brief HPI, focused exam, clear assessment, and plan
• Prioritize sick vs. not sick; verbalize your differential and disposition
• Show growth: incorporate feedback into your next patient encounter

3. Communication and Teamwork

• Be respectful to nurses, techs, consultants, custodial staff, and everyone in the ED
• Keep patients updated about wait times and next steps
• Demonstrate calm, clear communication during busy or stressful times

4. Professionalism and Reliability

• Never disappear from the ED without informing your supervising resident/attending
• Own your mistakes; don’t blame others or hide issues
• Document accurately and in a timely fashion when allowed to chart

5. Teachability and Self-Awareness

• Ask for feedback mid-rotation, not only at the end
• Respond visibly to feedback (e.g., “Yesterday you suggested I tighten my presentations; here’s my new condensed structure.”)
• Show humility and curiosity about your knowledge gaps

These habits signal to faculty that you will be a safe, reliable, coachable resident—a theme that will appear explicitly in your SLOEs.

Mid-Rotation Check-Ins: Calibrating Your Performance

A powerful, underused tool to improve your letters is the mid-rotation check-in.

Around the halfway point, ask a supervising resident or faculty:

“I’m really interested in emergency medicine and I value your feedback. How do you think I’m doing compared to other EM-bound students at my level? Are there 1–2 concrete things I can work on over the rest of the rotation to improve?”

Listen carefully, adopt the suggestions, and show visible improvement. Many SLOE narratives highlight growth across the month—a strong positive signal.

Case Example: Transforming Feedback into a Strong SLOE

A student is told mid-rotation: “Your presentations are thorough, but too long. Try to be more concise and prioritize the sickest issues.”

By the end of rotation:

• The student consistently presents in 60–90 seconds
• Starts with “sick vs not sick” and major concerns
• Attending comments at the end: “Your presentations have become tight and ED-focused; you’ve clearly worked on this.”

This improvement often gets written into the SLOE as: “Highly receptive to feedback and demonstrated substantial growth over the month,” which program directors love to see.

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The Logistics: When and How to Ask for Letters

Even if you perform exceptionally, poor logistics can weaken your letter strategy. Plan ahead and make the process smooth for your writers.

When to Ask for EM Letters of Recommendation

Ideal timing:

• Ask during the last week of your EM rotation (or near the end of an away rotation)
• Confirm clear timelines:
  • When ERAS opens for uploading
  • When you expect your letters to be submitted (ideally early in the application season)

For SLOEs, many EM rotations have a standard process where everyone automatically receives a SLOE; clarify this at the start:

“For EM-bound students, do you routinely provide a departmental SLOE? Is there anything I can do to facilitate that process?”

How to Ask: Phrasing That Protects You

When asking any writer (EM or non-EM), use language that allows them to decline if they cannot write you a strong letter:

“I’m applying to emergency medicine and I really valued working with you. Do you feel you know me well enough and feel comfortable writing me a strong letter of recommendation for residency?”

If they hesitate or suggest someone else, thank them and move on. A neutral or lukewarm letter can hurt you more than having one less letter.

What to Provide Your Letter Writers

Make it easy for them to write a detailed, positive letter:

• Your CV
• Your personal statement draft (even if not final)
• A brief note summarizing:
  • Why you’re applying to EM
  • What you see as your strengths
  • Any specific moments or patients they may recall from your rotation
• A photo (small, professional headshot) to help them remember you
• Clear deadlines and ERAS instructions

You might include 4–5 bullet points like:

• “Top 1–2 things I hope programs will know about me: …”
• “Specific cases/shifts we shared that really shaped me: …”

These prompts help them recall rich, specific details for their narrative.

Following Up Professionally

If a letter isn’t uploaded by your target date:

1. Wait a reasonable period (1–2 weeks before apps go out).
2. Send a polite reminder email:
   • Thank them again
   • Restate the deadline
   • Offer to provide any additional materials

If there’s still no response and deadlines are close, consider adding an alternate letter writer if possible.

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Common Pitfalls and How to Avoid Them

Several recurring issues can weaken EM applications related to letters. Being proactive can help you sidestep them.

Pitfall 1: Too Few EM-Specific Letters

Problem: Submitting multiple non-EM letters and only one weak EM letter.

Solution:

• Prioritize at least one strong departmental SLOE from an EM residency site
• Strategically schedule rotations early enough in the year (typically by August–September of application season) to ensure you have your SLOE in time
• If your school lacks EM, seek visiting rotations at SLOE-producing sites

Pitfall 2: Late or Missing SLOEs

Problem: Your SLOE isn’t uploaded until well after programs begin reviewing applications.

Solution:

• Clarify timeline expectations with the clerkship director at the start of the rotation
• Politely ask at the end: “When should I expect my SLOE to be uploaded to ERAS?”
• Build in buffer time by scheduling critical EM rotations on the earlier side

Programs understand some SLOEs come a bit later, but you don’t want to be missing all EM letters when applications are first reviewed.

Pitfall 3: Over-Emphasis on Prestige vs. Fit

Problem: Choosing letter writers solely based on title or institutional prestige rather than how well they know you.

Solution:

• A letter from a less famous faculty member who supervised you extensively is almost always better than a generic letter from a chair who met you once
• EM program directors are looking for specific, behavior-based descriptions, not name-dropping

Pitfall 4: Ignoring Red Flags in Feedback

Problem: You receive concerning feedback during a rotation but don’t address it, leading to a negative or mediocre SLOE.

Solution:

• Treat mid-rotation critiques as gold; they give you the chance to fix issues before they appear in your letter
• After serious feedback, you might ask: “I really want to improve in this area. Would it be okay if I check back with you in a few shifts to see if you’re seeing progress?”

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Putting It All Together: A Sample Strategy for EM Letters

Below are two illustrative scenarios to show how you might build a strong EM letter portfolio.

Example 1: U.S. MD Student with Home EM Program

• Home EM rotation (June):

  • Goal: departmental SLOE #1
  • Actions: perform strongly, solicit feedback mid-rotation

• Away EM rotation at another academic site (August):

  • Goal: departmental SLOE #2
  • Actions: clarify SLOE process early, ask about timelines

• Sub-internship in Internal Medicine (September):

  • Ask attending who saw you regularly for a non-EM LOR emphasizing reliability, clinical reasoning, and work ethic.

Final letter set:

1. Departmental EM SLOE – home institution
2. Departmental EM SLOE – away rotation
3. Internal Medicine LOR – sub-internship
4. Optional: Longitudinal mentor or research letter (if it adds unique perspective)

Example 2: DO Student without a Home EM Program

• Community EM rotation (May):

  • EM narrative letter or SLOE-equivalent from EM physician who supervised you heavily

• Visiting EM rotation at residency program (July):

  • Departmental SLOE from academic site

• ICU rotation (August):

  • Ask ICU attending for a LOR highlighting managing acutely ill patients, teamwork, and resilience

Final letter set:

1. Academic EM departmental SLOE
2. Community EM narrative LOR (SLOE-equivalent if possible)
3. ICU attending LOR
4. Optional: Research mentor or pre-clinical advisor letter

This still gives programs a clear, EM-focused view of your performance with supporting context from other acute care environments.

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FAQs: Emergency Medicine Letters of Recommendation

1. How many SLOEs do I really need for emergency medicine residency?
Most applicants should aim for two EM SLOEs from residency programs if possible. One solid departmental SLOE is essential; a second from another EM site strengthens your application and shows consistency. A third SLOE is optional and may add value if it brings a distinct perspective, but quality > quantity.

2. Is a narrative EM letter helpful if it’s not on the official SLOE form?
Yes. While standardized SLOEs are preferred, a detailed narrative EM letter can still be very helpful, especially if you have limited access to SLOE-producing institutions. It should clearly compare you to EM-bound peers and comment on ED-specific skills. Programs understand structural differences across institutions.

3. Does it matter if my strongest letter is from a non-EM specialty?
It can still help, but for the EM match, program directors are primarily looking for EM-specific assessments. A glowing letter from internal medicine or surgery is a great supplement, but it will not replace the need for at least one strong EM SLOE. Use non-EM letters to reinforce your professionalism, work ethic, and clinical maturity.

4. What if I had a difficult EM rotation and I’m worried about a bad SLOE?
First, seek direct feedback before the end of the rotation to understand any concerns and try to address them. If you still fear a negative SLOE, speak confidentially with your clerkship director or an advisor. Sometimes they may suggest:

• Obtaining an additional EM rotation and SLOE to demonstrate growth
• Strategically selecting which letters to assign to specific programs
• Providing context in your personal statement or advisor letter if appropriate

Early communication and a clear plan can mitigate the impact of a single challenging rotation.

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Thoughtful planning of your emergency medicine residency letters of recommendation—understanding SLOEs, knowing who to ask for letters, and deliberately shaping your performance on rotation—can substantially strengthen your EM match prospects. Treat every EM shift as an extended audition, and every interaction as a chance to demonstrate the traits your future colleagues are hoping to see.