Essential Guide to Letters of Recommendation for DO Graduate in EM Residency

Understanding the Role of Letters of Recommendation in the EM Match (for DO Graduates)

Letters of recommendation (LORs) can make the difference between a courtesy glance and a serious look from program directors. For a DO graduate pursuing an emergency medicine residency, your letters are especially crucial: they validate your clinical skills, your fit for the specialty, and how you compare to your peers from both DO and MD schools.

In the competitive osteopathic residency match and ACGME EM match environment, strong letters reassure programs that you’re ready for high-acuity, fast-paced work. At the same time, they help counteract any lingering misconceptions about DO training by providing concrete, comparative statements from respected emergency physicians.

This article will walk you through:

• How many and what types of EM letters you need
• How to get strong LORs and who to ask for letters
• How to plan your rotations strategically as a DO graduate
• Common pitfalls to avoid
• Practical scripts, timelines, and tips tailored to emergency medicine

Whether you graduated recently or a few years ago, you can position yourself for success with thoughtful planning and proactive communication.

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How Many Letters of Recommendation Do You Need for EM?

Most EM programs require 3–4 letters of recommendation, with preference for emergency medicine–specific letters. The exact number depends on individual program requirements, but the following structure works well for a DO graduate in the current unified match environment:

Ideal LOR Mix for EM Applicants

1. 2 Emergency Medicine letters from academic or community EM attendings

   • At least one from an EM rotation with a formal evaluation structure (formerly SLOEs; now often termed departmental EM evaluations or EM LORs).
   • Aim for letters that compare you to peers and speak directly to EM-specific competencies.

2. 1 additional EM or core clinical letter

   • Preferably:
     • Another EM attending (especially if you did multiple EM rotations), or
     • A high-acuity field such as ICU or trauma surgery, or
     • A senior medicine or surgery attending who worked with you closely.

3. Optional 4th letter

   • Consider including if:
     • You have a gap in training and want a recent clinical LOR
     • You’re applying very broadly or have red flags on your application
     • You have a letter from a well-known EM educator or department chair

Key Point for DO Graduates:
Because some programs still (consciously or unconsciously) compare DO and MD applicants differently, EM letters are your most powerful equalizer. A department chair or clerkship director saying, “This applicant is in the top 10% of all students I’ve worked with from both MD and DO schools” can carry significant weight in the osteopathic residency match and the broader EM match.

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Who to Ask for Letters – And When to Ask

One of the most common questions is who to ask for letters and how to get strong LOR support from busy attendings. The quality of the letter writer often matters more than their title, but both are important.

Priority Order: Who to Ask for Emergency Medicine Letters

1. EM clerkship director or site director

   • Often writes departmental EM letters or composite letters summarizing evaluations from multiple attendings.
   • Well-known to EM program directors; they know how to write specialty-specific letters that hit the right points.

2. EM department chair or senior faculty in EM

   • Particularly helpful if they’ve seen you clinically or reviewed your evaluations.
   • A chair’s letter can be especially strong when it includes direct comparison to prior students and residents.

3. Core EM attending who worked closely with you

   • Someone who supervised you on multiple shifts, saw you with sick patients, and can comment on your growth.
   • The best letters often come from attendings who saw you on both good days and challenging ones—and watched you respond constructively.

4. Subspecialty EM attendings (to supplement, not replace core EM letters)

   • Toxicology, ultrasound, EMS, etc.—ideal as a fourth letter or when they’ve had extensive interaction with you.

For DO graduates, quality and specificity beat name recognition alone. A detailed letter from a community EM attending who knows you well is usually more valuable than a vague, impersonal letter from a famous academic who barely remembers you.

When to Ask: Ideal Timeline

• Early in your EM rotation (first week):

  • Let your attending/clerkship director know that you are applying to EM and hope to earn a letter.
  • This sets expectations and encourages them to observe you more closely.

• End of the rotation or within 1–2 weeks after:

  • This is the ideal moment to formally ask for a letter, when you’re still fresh in their mind and have a complete performance record.

• At least 4–6 weeks before you need the letter uploaded:

  • Faculty are busy. Respect their time and your own timeline.

For DO graduates who may be juggling COMLEX/USMLE, away rotations, and multiple application systems, build in extra buffer time. Aim to have all writers identified and asked by early August (for a typical late-September ERAS submission).

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How to Get Strong LORs: Strategy, Preparation, and Scripts

Programs don’t just want letters; they want strong, specific letters that:

• Compare you to other EM-bound students
• Comment on your work ethic, clinical reasoning, and communication
• Reflect your readiness for emergency medicine residency
• Confirm that you’ve been evaluated alongside both DO and MD colleagues, where applicable

Step 1: Perform Like You’re Already a Resident

No letter can fix weak clinical performance. During your EM rotations:

• Be early. Stay a bit late.
  • Volunteer for new patients. Offer to do procedures. Ask for feedback at mid-shift and end-of-shift.
• Own your patients.
  • Present clearly, propose plans, and follow up on results without being asked.
• Demonstrate teachability.
  • When corrected, show that you integrate the feedback immediately.

Examples of behaviors that generate strong comments:

• “I’d like to try presenting this next patient in a more structured way. Do you mind giving me feedback afterward?”
• “I noticed last shift we discussed syncope workups. I read up on it; would you mind if I briefly go over my learning points with you?”

Step 2: Ask the Right Question

When it’s time to ask for a letter, don’t just say, “Can you write me a LOR?”

Instead, ask:

“Do you feel you could write a strong letter of recommendation in support of my application to emergency medicine residency?”

This wording gives the faculty member space to decline if they feel they can’t be strongly supportive—protecting you from a lukewarm or neutral letter that can harm your application.

Step 3: Provide a Helpful Packet

To help your letter writer advocate for you:

Include:

• Your CV
• A draft personal statement (even if not final)
• A brief summary of your EM interest and career goals
• A list of programs or regions you’re targeting
• A reminder of specific patients or cases you managed that might be worth mentioning
• Your COMLEX/USMLE scores and brief context if there are anomalies (low score, failure, or gap)

For DO graduates in particular, you can briefly note:

• Your osteopathic background (e.g., OMT interest, holistic care focus)
• Any dual-board aspirations (e.g., plans to sit for COMLEX and USMLE, if applicable)
• How your school structures EM rotations (so they can comment intelligently on your performance relative to peers)

Step 4: Mention Osteopathic Perspective (When Helpful)

Some attendings will naturally highlight your DO training, but you can prompt them (subtly) by including in your materials:

“As a DO graduate, I’ve found that my osteopathic training in whole-person care, communication, and musculoskeletal medicine has been especially helpful in the ED. If you’ve seen examples of that in my work, I’d be grateful if you could mention them.”

This can turn your DO status into a strength rather than something left unaddressed.

Step 5: Clarify Logistics and Deadlines

When you ask, be concrete:

• Confirm which system they’ll use (ERAS, VSLO, etc.)
• Share your target upload date (usually 1–2 weeks before ERAS submission)
• Ask if they prefer a gentle email reminder a week before the deadline

Example script:

“Thank you again for agreeing to write a strong letter. I’m planning to certify and submit my ERAS application around September 20. Would it be okay if I send you a reminder email on September 5 if the letter isn’t yet uploaded?”

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Special Considerations for DO Graduates in the EM Match

As a DO graduate, you’re applying in an environment where the EM match is unified, but backgrounds vary. Here’s how you can use your letters strategically in the osteopathic residency match and beyond.

Highlighting COMLEX and/or USMLE Context

Not every letter writer understands COMLEX scoring or how DO curricula differ. In your materials to your letter writer, you can add:

• A short explanation of your exam pathway (COMLEX only vs COMLEX + USMLE).
• If you took USMLE, how your performance compares to national averages.
• If you did not take USMLE, reassure them about your COMLEX performance and clinical strength so they can speak confidently despite the lack of cross-exam data.

This gives them context to write something like:

“Although this applicant took COMLEX rather than USMLE, their clinical performance in our ED placed them clearly in the top tier of our EM-bound students from both DO and MD programs.”

Addressing Bias Subtly and Positively

You don’t want to harp on bias, but you can help your letter writer frame you as indistinguishable (or superior) in performance to MD peers:

• Suggest they comment explicitly on comparative performance:
  • “Top 10% of all students rotating in our department this year.”
  • “Stronger than many of the MD students we see from nearby academic centers.”

This is especially useful if you’re aiming for programs that historically took more MD applicants.

Bridging Osteopathic and Allopathic Experiences

If you did any of the following, ensure your letter writers know:

• Rotated at both DO and MD-affiliated EM programs
• Participated in multi-institutional EM electives, EMS ride-alongs, or ultrasound rotations
• Worked on an EM-related research project or QI initiative

This allows them to speak to your adaptability across environments—a valuable trait in emergency medicine residency.

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What Programs Look for in EM Letters (and How to Demonstrate It)

Whether you’re applying to a suburban community program or a large academic emergency medicine residency, most EM program directors want to see the same core attributes reflected in your LORs.

Core Traits EM Letters Should Highlight

1. Work Ethic and Reliability

   • Shows up early, stays engaged, reliable follow-through on tasks.
   • Example statement: “I could trust them to manage multiple patients and loop back with me about critical results without prompting.”

2. Clinical Reasoning Under Pressure

   • Can prioritize, triage, and adapt to new data in real time.
   • Example: “When a critical patient arrived, they pivoted smoothly, gathered key information, and proposed an appropriate initial management plan.”

3. Team Communication and Professionalism

   • Communicates respectfully with nurses, consultants, patients, and families.
   • As a DO graduate, your communication training may be a particular strength; attendings can highlight that.

4. Growth Mindset and Response to Feedback

   • Accepts and incorporates feedback rapidly.
   • Example: “After feedback on their presentations early in the rotation, I saw a dramatic improvement over just a few shifts.”

5. Genuinely Passionate Interest in EM

   • Demonstrates curiosity about EM topics and workflow.
   • Reads about cases, follows up with attendings on outcomes, and seeks learning opportunities.

How You Can Prompt These Themes

You can’t script your letters, but you can influence what attendings notice by how you behave and what you emphasize:

• At the end of a rotation, ask:

  “Are there particular strengths you’ve noticed that might be worth highlighting in a letter? I’d love to keep building on what’s going well.”

• While providing your CV and personal statement, you might write:

  “If it matches your impression, I’d be grateful if you could comment on my work ethic, team communication, and ability to manage multiple ED patients—these are areas I’ve been intentionally focusing on.”

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Practical Timeline and Strategy for DO Graduates Applying to EM

To maximize your chances in the emergency medicine residency match, plan your letters as part of your broader application strategy.

Ideal Application Timeline (Assuming Traditional Cycle)

Third/Fourth Year (or final clinical year if already graduated):

• January–March:
  • Identify potential EM home rotation and away rotation sites.
  • Talk with your advisor about which programs are DO-friendly and what they expect from letters.
• April–June:
  • Secure EM rotations: 1 home, 1–2 aways if possible.
  • Begin updating your CV and personal statement draft.

Summer (June–August):

• During EM rotations:
  • Communicate expectations early: let attendings know you’re applying to EM.
  • Ask for mid-rotation feedback and implement it.
• End of each rotation:
  • Ask attendings/clerkship directors for strong letters.
  • Provide your packet (CV, statement, goals, exam info).

Early Fall (August–September):

• Confirm that your letters are being uploaded to ERAS.
• Ensure you have:
  • At least 2 EM-specific letters
  • 1 additional clinical letter (EM or ICU/surgery/IM)
• Apply broadly as needed, especially if:
  • You have any academic red flags
  • You are geographically limited
  • You are a DO graduate applying to more competitive academic programs

For DO Graduates Who Already Finished School

If you are a DO who has already graduated (or had a prior unsuccessful match):

• Secure recent U.S. clinical experience in EM or related fields (urgent care with EM-level acuity, ICU, hospitalist).
• Ask for letters from:
  • Supervising physicians in these recent roles
  • Any EM faculty with whom you can arrange an observership or short-term clinical elective
• Make sure letters emphasize:
  • Your clinical currency (you’re up to date)
  • Your professional growth since graduation
  • Your sustained commitment to emergency medicine

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Common Pitfalls and How to Avoid Them

Pitfall 1: Generic, Unspecific Letters

A vague letter (“hardworking, pleasant, team player”) without strong comparative language can hurt more than help.

How to avoid:

• Choose writers who know you well, not just by name.
• Provide specific reminders of cases and behaviors they might reference.

Pitfall 2: Waiting Too Long to Ask

Busy attendings forget details and may delay writing when the rotation is long over.

How to avoid:

• Ask before the last week of your rotation.
• Follow up politely if you haven’t seen the letter uploaded by your agreed date.

Pitfall 3: Too Few EM-Specific Letters

Some DO graduates lean on non-EM letters because they feel more comfortable asking those attendings.

How to avoid:

• Prioritize at least 2 EM letters from your EM rotations.
• Use IM/surgery/ICU letters as supplements, not replacements.

Pitfall 4: Not Addressing Red Flags

If you have a failed exam, a leave of absence, or a previous non-match, silence in your letters can raise unspoken concerns.

How to avoid:

• Briefly explain context in your personal statement or additional application fields.
• Ask at least one trusted attending or advisor to explicitly address your growth and readiness now.

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FAQs: Letters of Recommendation for DO Graduates in Emergency Medicine

1. How many EM-specific letters of recommendation do I really need?

Aim for at least two strong EM-specific letters from faculty who directly observed your performance in the emergency department. Many successful applicants have 2 EM letters + 1 additional clinical letter (EM, ICU, or medicine/surgery). If you have access to more strong EM letters, a 4th can be helpful, but quality always beats quantity.

2. Does it matter if my EM letter writers are DO or MD?

What matters most is how well they know you and how strong the letter is, not their degree. A detailed letter from a DO emergency physician who supervised you closely is just as valuable as one from an MD attending. If your letter writer can comment on your performance relative to both DO and MD students, that comparative perspective is particularly helpful in the EM match.

3. Can I use a non-EM letter (like internal medicine or surgery) for emergency medicine programs?

Yes—but it should supplement, not replace, your EM letters. A strong IM or surgery letter can:

• Highlight your work ethic and clinical reasoning
• Show that you excel in a different but relevant setting

However, EM programs expect to see EM-specific evaluations. Try to have at least 2 EM letters before adding others.

4. What if I didn’t match previously and am reapplying to EM as a DO graduate?

You should:

• Obtain new, recent clinical letters from EM or related fields (ICU, hospitalist, urgent care with high acuity).
• Ask one letter writer (often your advisor or a senior EM faculty member) to address your prior non-match constructively, focusing on how you’ve improved.
• Keep prior strong letters only if they remain clearly relevant and you have permission to reuse them, but prioritize current, updated evaluations that show growth.

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Thoughtfully chosen and strategically planned letters of recommendation can significantly strengthen your emergency medicine residency application as a DO graduate. By performing at your best on EM rotations, asking the right people in the right way, and giving them the tools to advocate effectively, you can translate your osteopathic training into a compelling narrative for program directors across the EM match.