Ultimate Guide to Letters of Recommendation for DO Graduates in Surgery

Understanding the Role of Letters of Recommendation in a Preliminary Surgery Year

For a DO graduate seeking a preliminary surgery residency position, letters of recommendation are not just a box to check—they are often the most powerful part of your application after your board scores and clinical performance. Preliminary surgery spots can be competitive, and programs use residency letters of recommendation to answer a few key questions quickly:

• Can this applicant function safely and reliably as an intern?
• Are they coachable and professional?
• Would I trust this person with my patients at 2 a.m.?
• Do trusted surgeons and educators truly endorse this applicant?

As a DO graduate, you may also be wondering how your background is perceived in the osteopathic residency match environment, especially for surgical fields historically dominated by MD applicants. Strong, targeted letters can go a long way toward neutralizing bias, showcasing your preparation, and highlighting the unique strengths of your osteopathic training.

This guide will walk you step-by-step through:

• Who to ask for letters as a DO applying to prelim surgery residency
• How to get strong LORs that speak to what surgical program directors actually care about
• How to tailor letters for a preliminary surgery year vs. categorical positions or other specialties
• Practical scripts, timelines, and strategies to avoid common pitfalls

---

How Many Letters Do You Need and What Do Programs Expect?

Most programs participating in the NRMP or AOA match for a preliminary surgery year will request 3–4 letters of recommendation. Check each program’s website, but a common pattern is:

• 3 letters required
• 1 additional letter optional (often accepted and sometimes helpful)

For a DO graduate targeting prelim surgery, a strong, balanced LOR portfolio usually looks like this:

1. At least 2 letters from surgeons

   • Preferably, at least one from a general surgeon (not limited to subspecialties).
   • Even better if one is from a core surgery clerkship director, residency program director, or a well-known faculty surgeon.

2. 1 letter that speaks to your overall clinical performance

   • This could be from:
     • An Internal Medicine or ICU attending who saw you on call.
     • A Sub-I (subinternship) director in surgery or another acute-care field.
     • An Osteopathic Manipulative Medicine (OMM) or primary care faculty if they know you very well and can speak to your professionalism, work ethic, and patient rapport.

3. Optional 4th letter (strategic)

   • This can be from:
     • A research mentor in surgery or a surgical subspecialty.
     • A non-surgical attending who knows you extremely well and can vouch for your reliability and integrity.
     • A letter tailored for a backup specialty (e.g., anesthesia, IM) if you’re dual applying, but be careful to assign letters thoughtfully in ERAS.

DO-Specific Considerations

As a DO graduate in the residency match (now unified), you will want to:

• Prioritize ACGME-recognized or allopathic surgical attendings when possible, especially if applying broadly to previously allopathic-heavy programs.
• Do not undervalue strong letters from DO surgeons or DO faculty—these can be excellent, particularly in programs that are DO-friendly or have osteopathic recognition.
• If you rotated at a program where you’re seriously interested in a prelim spot, having a letter from that program’s faculty or PD is extremely valuable.

---

Who to Ask for Letters (and Who Not To)

Choosing who to ask for letters is as important as your personal statement. For a preliminary surgery residency, you want letters that show you:

• Work hard and maintain a positive attitude
• Handle high-stress, acute settings
• Are teachable and responsive to feedback
• Communicate clearly with the team
• Show professionalism and ethical integrity

Best People to Ask

1. Surgery Clerkship Director (Core Surgery Rotation)
Ideal if:

• They directly observed your performance
• They supervised your OR cases or inpatient care
• They know your comparative ranking among students

This letter can confirm you are in the “upper half,” “top 10–20%,” etc., which program directors read as a strong signal.

2. Sub-Internship or Acting Internship Attending (Surgery/ICU/Acute Care)
Your sub-I is where you function closest to an intern. Attending surgeons and senior residents who supervise you can comment on:

• Overnight call performance
• Response to stress and emergencies
• Ownership of patients
• Handoff skills

A letter that begins, “This student functioned at or above the level of an intern…” is extremely powerful.

3. Program Director or Associate Program Director (if you rotated at their site)
If you did an audition or away rotation at a program where you’d be happy to match, this is a top-priority letter. PDs talk to each other. A positive PD letter can open doors beyond that single institution.

4. Surgical Subspecialty Attending (e.g., trauma, vascular, colorectal, plastics)
Helpful when:

• They directly saw your OR work, technical interest, and progression.
• They can speak to how quickly you pick up procedures, suture skills, or sterile technique.
• They saw you in multidisciplinary contexts (consults, ED, ICU).

Even for prelim surgery, subspecialty letters are valued as long as they speak to your ability to be an excellent gen surg intern.

5. Internal Medicine, ICU, or EM Attendings (if they know you well)
These letters are especially powerful when they highlight:

• Performance on overnight calls or codes
• Ability to manage complexity and uncertainty
• Strong communication with nursing and allied health staff

For a preliminary surgery year, much of your time will be on off-service rotations (ICU, medicine, ED). Showing you thrive there is a plus.

---

Who Is Less Ideal (and Why)

• Very senior faculty who barely know you
  A big name with a generic letter is weaker than a mid-level faculty member who can provide detailed, specific praise.

• Research-only mentors who never saw you clinically
  This can be a great fourth letter, but not a primary one. Clinical performance is king.

• Non-surgical specialties with no acute care tie-in
  Example: Dermatology or psychiatry, unless they know you extraordinarily well and can highlight professionalism, empathy, and reliability. Use these sparingly and usually not as your primary letters for surgery.

• Family friends or physicians you shadowed only
  These rarely carry much weight unless they later became your clinical supervisor.

If you must choose, prioritize quality of knowledge of your work over title, as long as you still have at least 2 strong surgical letters.

---

How to Get Strong LOR: Timing, Strategy, and Execution

Strong letters are rarely last-minute. As a DO graduate applying to prelim surgery residency, you need a deliberate plan that starts during your clinical years.

Step 1: Plan Backward from Application Deadlines

Typically:

• ERAS opens to applicants in June
• Programs start reviewing in September

Ideal timing:

• Ask for letters during or at the end of each key rotation (especially core surgery, sub-I, ICU).
• Gentle reminders 4–6 weeks before ERAS submission deadlines.
• Final upload ideally by late August or early September.

Step 2: Perform with Intent on Key Rotations

To earn a strong letter, you must first give your attendings something specific to write about. On surgery-related rotations:

• Show up early, pre-round thoroughly, anticipate needs.
• Be proactive in presentations, sign-outs, and note-writing.
• Volunteer for tasks: updating families, calling consults, prepping notes.
• Ask for feedback mid-rotation:
  • “Dr. Smith, I really value your feedback. Are there 1–2 things I could focus on improving for the rest of the rotation? I’m working toward a career in surgery and want to be as prepared as possible.”

This serves two purposes:

1. You genuinely improve.
2. You plant the seed that you are pursuing a surgical path, making a future letter request natural.

Step 3: Ask Clearly and Professionally

When asking for a letter, use a script that both shows respect and gives the attending an easy out if they can’t write you a strong one.

In-person script example:

“Dr. Patel, I’ve really appreciated working with you this month. I’ll be applying for a preliminary surgery residency position as a DO graduate, and I was wondering if you’d feel comfortable writing a strong letter of recommendation on my behalf. You’ve seen me on rounds and in the OR, and I think your perspective would be very valuable to programs.”

The phrase “strong letter of recommendation” gives them permission to decline if they can’t genuinely endorse you—which protects you from lukewarm letters.

Email follow-up (after verbal agreement):

Subject: Letter of Recommendation Request for Preliminary Surgery Residency

Dear Dr. Patel,

Thank you again for agreeing to write a letter of recommendation for my residency applications. As we discussed, I will be applying to prelim general surgery positions.

I am attaching my CV, personal statement draft, and a brief bullet-point summary of the cases and responsibilities I had while on your service. If there are any other materials that would help, please let me know.

The letter can be uploaded directly to ERAS via the link you’ll receive. My AAMC ID is [XXXX]. My goal is to have all letters submitted by [target date].

Thank you again for your mentorship and support.

Best regards,
[Your Name], DO

Step 4: Provide Targeted Support Materials

To help your letter writer craft a detailed narrative, send:

• Updated CV
• Personal statement draft (especially if it explains why you’re applying for a preliminary surgery year)
• A brief one-page highlight sheet:
  • Your career goals (e.g., “ultimately aim for categorical general surgery, but open to transitioning into another field if needed”)
  • Specific patients or cases you worked on with them
  • Concrete examples that show work ethic, resilience, communication
  • Any DO-specific strengths (e.g., manual skills, holistic patient care approach)

You can diplomatically add a short section titled, “Points you might consider including if they align with your experience of me”, such as:

• “Ability to function at an intern level on wards or in the OR”
• “Reliability with patient follow-up and documentation”
• “Teamwork and communication with nurses and other staff”
• “Rapid improvement over the course of the rotation”

This is not telling them what to say; it’s guiding them toward what programs value.

---

What Makes a Letter “Strong” for a Prelim Surgery Residency?

Program directors read hundreds of letters. For a prelim surgery year, they’re looking primarily for evidence you will be a safe, dependable intern who is a pleasure (or at least easy) to work with.

High-Impact Elements of a Strong LOR

1. Clear Statement of Support Level
   Program directors quickly scan for lines like:

   • “I give my highest recommendation.”
   • “I would be delighted to have this student as an intern in our program.”
   • “Without hesitation, I recommend [Name] for a preliminary surgery residency position.”

2. Comparative Language
   Standing out requires context:

   • “Top 10% of students I have worked with in the last 10 years.”
   • “Among the best DO students I have supervised in surgery.”
   • “Comparable to our strongest categorical surgery interns.”

3. Specific Clinical Examples
   Examples are more powerful than adjectives. For instance:

   • “On a night when we admitted multiple trauma patients, [Name] stayed late voluntarily, helped with initial evaluations, and followed through on every lab and imaging order without prompting.”
   • “He/she independently looked up each patient’s anatomy and pathology the night before cases and presented clear, concise operative plans.”

4. Descriptions of Core Intern Skills
   For a preliminary surgery spot, letters should highlight:

   • Reliability and punctuality
   • Situational awareness in the OR and wards
   • Ability to accept feedback and improve
   • Teamwork with residents, nurses, and ancillary staff
   • Emotional stability and professionalism under stress

5. Recognition of DO Training Positively
   Subtle but meaningful for DO graduates:

   • “As a DO graduate, [Name] brings a thoughtful, whole-patient perspective to surgical care without losing focus on acute management.”
   • “Their osteopathic background contributes to excellent bedside manner and patient-centered communication.”

Red Flags and Weak Signals

Program directors are wary of:

• Vague phrases without specifics:

  • “Did a good job on the rotation.”
  • “Pleasant to work with.”

• Faint praise without strong endorsement:

  • “I have no reservations about [Name] applying to prelim positions.”
    (This can mean: I also don’t feel strongly positive.)

• Overemphasis on non-clinical traits:

  • If all they talk about is “enthusiasm” or “interest in surgery” without tying it to clinical work, it may read as “not yet proven clinically.”

As you think about how to get strong LOR, your goal is to give your letter writers enough concrete material and positive experiences that their letters naturally include the high-impact elements above.

---

Tailoring Your Letters for a Preliminary Surgery Year as a DO Graduate

A prelim surgery residency is different from a categorical spot. Programs know that:

• Some prelims want to re-apply to categorical general surgery.
• Others will pivot to another field (e.g., anesthesia, radiology, EM).
• All prelims must function at essentially the same level as categorical interns.

Your letters should reflect this reality and support your goals.

1. Make Sure Writers Understand “Preliminary” vs Categorical

Many faculty think mostly in terms of categorical general surgery. When you request a letter, briefly explain:

• “I am primarily applying to preliminary general surgery positions with the goal of [reapplying to categorical surgery / exploring related fields while building a strong clinical foundation].”
• Emphasize that you are fully committed to excelling clinically regardless of whether the year is prelim or categorical.

This helps them tailor their wording appropriately, for example:

“Although [Name] is applying primarily to a preliminary general surgery year, I believe they have the potential to succeed in a categorical surgery program and would not hesitate to have them as part of our team in either capacity.”

2. Highlight Adaptability and Breadth

A prelim year often includes:

• General surgery
• ICU
• ED
• Off-service rotations (e.g., medicine)

Letters that mention your adaptability across these contexts reassures PDs you’ll be valuable on every rotation:

“On our ICU rotation, [Name] quickly learned to manage ventilators, titrate drips under supervision, and communicate effectively with consulting teams. This adaptability will serve them well in a preliminary surgery residency with diverse rotations.”

3. Address Any DO-Related Concerns Indirectly

You do not need your letters to explicitly “defend” you as a DO, but it helps when they show you are on par with allopathic-trained peers:

“[Name]’s performance was indistinguishable from, and in some cases stronger than, the MD seniors on the team.”
“Despite coming from a DO program without a home surgery residency, [Name] proactively sought high-quality clinical and research experiences to prepare for surgical training.”

If you’re from a school with fewer surgical resources, this type of language is especially helpful.

4. Use at Least One Letter to Highlight Longitudinal Growth

If you have a mentor who has worked with you over multiple years or settings (e.g., preclinical to clinical, or two different rotations), ask them to emphasize your growth trajectory:

“I first met [Name] as a preclinical student and later supervised them on their surgery sub-I. The progression in clinical reasoning, efficiency, and confidence was striking. This upward trajectory suggests they will continue to grow rapidly during a preliminary surgery year.”

Program directors like to see potential as much as current performance, especially for prelim positions.

---

Common Pitfalls and How to Avoid Them

Even strong applicants make mistakes in the LOR process. Being aware of these can save your application.

Pitfall 1: Waiting Too Long to Ask

If you wait months after a rotation ends:

• Attendings may barely remember you.
• The letter is more generic.
• They may decline due to time constraints.

Solution:
Ask near the end of each key rotation when your performance is fresh in their mind. If your application is a year away, you can still ask them to write the letter later but confirm their willingness now.

Pitfall 2: Using the Same Letters for Every Program Without Thinking

For a DO graduate applying to both prelim surgery and other specialties (e.g., prelim surgery plus categorical anesthesiology):

• Sending a letter that screams “future general surgeon” to an anesthesia program can hurt.
• Conversely, a letter that focuses entirely on non-surgical strengths may be less appealing to surgery PDs.

Solution:
Use ERAS to assign letters selectively:

• Prioritize your most surgical letters for prelim surgery programs.
• Consider re-framing your personal statement if dual-applying.
• Where possible, ask at least one faculty member to write a letter that is “surgery-compatible but also highlights broader acute-care strengths” if you’re keeping options open.

Pitfall 3: Overweighting Research Letters

Research letters can be valuable, but for a preliminary surgery year, clinical performance matters far more. A research PI who only saw you in a lab may write:

• “Hard-working.”
• “Detail-oriented.”
• “Team player.”

All good—but not as relevant as:

• “Manages a 10-patient list safely on busy ward days.”
• “Notifies the team early when patients deteriorate.”

Solution:
Use research mentors as supplemental letters, not core ones, unless they also supervised you clinically.

Pitfall 4: Not Waiving Your Right to See the Letter

ERAS will ask if you want to waive your right to view the letter. Program directors interpret a waived letter as:

• More likely to be honest and candid.
• Less influenced by the applicant.

Solution:
Almost always waive your right to read the letter. Non-waived letters may be viewed as less trustworthy.

---

FAQs: Letters of Recommendation for DO Graduates in Preliminary Surgery

1. As a DO graduate, do I need letters specifically from DO surgeons, or are MD attendings better?
You do not need DO letters. The highest priority is who knows you best clinically and can speak in detail about your performance. That said:

• MD letters from ACGME-recognized academic programs may carry extra weight with historically allopathic surgery programs.
• DO letters can be excellent and may be especially valued by DO-friendly or osteopathically recognized programs.
  Aim for 2+ strong surgical letters regardless of the writer’s degree.

---

2. Is it okay to use a letter from a non-surgical specialty for my prelim surgery applications?
Yes, but use it strategically:

• Ideal non-surgical letters come from ICU, EM, or Internal Medicine attendings who saw you handle acutely ill patients, codes, or complex inpatient care.
• These letters are especially helpful to show your versatility on off-service rotations, which are a big part of a preliminary surgery residency.
• Avoid substituting all of your surgical letters with non-surgical ones; you still need at least two strong surgery letters.

---

3. How many letters should I submit if programs say they accept up to four?
In most cases:

• Submit 3 strong letters as your core.
• Add a 4th only if it truly adds something new (e.g., a research mentor who also saw you clinically, or a PD from an away rotation).

Sending four generic letters is not better than three focused, enthusiastic ones. Quality and specificity matter more than quantity.

---

4. What if I had a weaker surgery rotation early on—can I avoid a letter from that site?
You are not obligated to request letters from every site. If you had:

• A stronger performance on a later surgery rotation or sub-I
• Much better rapport with a different attending

Then it is reasonable to build your letter set around your best clinical performances. You can address overall growth and earlier challenges in your personal statement or, if necessary, in an interview—rather than having a lukewarm letter in your file.

---

Strong, well-chosen letters of recommendation can significantly elevate your application as a DO graduate seeking a preliminary surgery year. Focus on being the kind of student that attendings are genuinely excited to recommend, ask the right people at the right time, and provide them with the tools to write detailed, enthusiastic letters that highlight your readiness to function as an outstanding intern.