Essential Guide to Letters of Recommendation for DO Graduates in Pediatrics

Understanding Letters of Recommendation for DO Graduates in Pediatrics

As a DO graduate applying to a pediatrics residency, your letters of recommendation (LORs) are more than just program requirements—they are one of the most powerful tools you have to stand out in the osteopathic residency match and the broader peds match. For many programs, especially in pediatrics, LORs are the “tie-breaker” when applicants look similar on paper.

This article walks through everything you need to know: who to ask for letters, how to get strong LOR, how many you need, how to choose between pediatric and non-pediatric writers, and specific considerations for DO graduates seeking pediatrics residency positions.

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Why Letters of Recommendation Matter So Much in Pediatrics

Pediatrics is a relationship-driven specialty. Program directors are not just looking for test scores and grades; they want residents who are:

• Compassionate and patient-centered
• Excellent communicators (especially with families)
• Team players who work well with nurses and staff
• Reliable, teachable, and resilient around sick children and worried parents

Letters of recommendation for a pediatrics residency give program directors evidence of these traits from attendings who have worked with you closely. For a DO graduate residency applicant, strong LORs also help:

• Demonstrate your readiness for an ACGME pediatrics residency
• Address any concerns about board scores or COMLEX/USMLE choices
• Show that you can thrive in both osteopathic and allopathic environments
• Highlight your specific path to pediatrics and your commitment to children’s health

In surveys of program directors, LORs consistently rank among the most important factors in offering interviews. For pediatric residencies, narrative comments about your interpersonal skills and work ethic often carry as much weight as your exam scores.

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How Many Letters You Need and What Kind

Most pediatrics residency programs require 3 letters of recommendation, and will accept up to 4 letters in ERAS. A solid strategy for a DO graduate targeting peds is:

• 2–3 letters from pediatricians
  • At least one from a core pediatrics clerkship (ideally inpatient)
  • Another from a sub-internship, acting internship, or away rotation in pediatrics or NICU/PICU, if possible
• 1 letter from another clinical specialty
  • Family medicine, internal medicine, or a subspecialty where you worked closely with children or families (e.g., pediatric neurology, pediatric endocrinology), or
  • A non-peds clinical supervisor who can speak strongly about your clinical maturity and professionalism

If you’re applying broadly (e.g., pediatrics plus a backup specialty), you may need different letter sets tailored to each specialty in ERAS, so plan accordingly.

What About Department or Chair Letters?

Some programs like to see a department chair letter in pediatrics, but it is not universally required. Chair letters can be helpful if:

• Your school’s pediatrics department has a structured chair letter process
• The chair actually knows you or has formally reviewed detailed input from your clinical evaluators
• You’re applying to very academic or competitive pediatrics residency programs

If the chair has never worked with you and the letter will be generic, it is less valuable than a detailed letter from an attending who supervised you directly.

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Who to Ask for Letters: Choosing the Right Writers

One of the most common questions is who to ask for letters. For a DO graduate residency applicant in pediatrics, you want letter writers who can comment in depth on how you function as a future pediatric resident.

Priority Order for Pediatrics Residency Letters

1. Pediatrics Sub-Internship or Acting Internship Attending

   • This is often your strongest pediatrics residency letter.
   • They can speak to how you functioned at a near-intern level:
     • Ownership of patients
     • Efficiency and reliability
     • Ability to handle call or busy inpatient services
   • If you did an away rotation at a program you love, that attending’s letter can carry particular weight in the peds match.

2. Core Pediatrics Clerkship Attending

   • Ideally an inpatient or continuity clinic attending who:
     • Worked directly with you for at least 2–4 weeks
     • Observed your clinical reasoning, note-writing, and communication with families
   • This letter is vital because it demonstrates your genuine interest in pediatrics and your baseline clinical performance.

3. Pediatric Subspecialty Attendings

   • NICU, PICU, pediatric cardiology, pediatric hematology-oncology, etc.
   • Particularly strong if:
     • You had a substantial rotation (not just a few days on a consult service)
     • You showed resilience and empathy in high-acuity settings
   • These letters are helpful to show depth and interest in pediatrics, but should supplement, not replace, a solid general pediatrics letter.

4. Non-Pediatrics Clinical Attendings

   • Family Medicine, Internal Medicine, Emergency Medicine, OB, Surgery, etc.
   • Choose those who:
     • Saw you work consistently (2–4 weeks)
     • Can comment specifically on your work ethic, communication, and team skills
   • For example, a Family Medicine attending who supervised your care of many children in clinic can bridge well into pediatrics.

5. Research Mentors (Selective)

   • A research LOR can be helpful if:
     • You have substantial, multi-year involvement in a pediatrics-related project
     • The mentor knows you well and can comment on reliability, initiative, and academic curiosity
   • This should generally be your fourth letter, not a replacement for clinical LORs.

Who to Avoid Asking for Letters

Even if they’re famous or hold titles, avoid letter writers who:

• Barely know you or can’t remember specific patients you cared for
• Only interacted with you for a few days in a large lecture or conference
• Offer to “sign something you write yourself” without meaningful input
• Have a reputation for writing very brief, generic LORs

A strong LOR from a mid-career pediatrician who supervised you closely is far better than a generic two-paragraph chair or dean letter.

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How to Get Strong LOR: Strategy and Timing for DO Applicants

Getting great letters is not passive. As a DO graduate, especially if you’re applying to mostly ACGME pediatrics programs, you want to be proactive and deliberate.

Step 1: Perform Intentionally During Rotations

Before you even think about the letter:

• Show up early, leave late: Arrive prepared, review your patients ahead of rounds, and stay until the work is done.
• Volunteer appropriately: Take initiative—offer to present patients, call consults, or perform procedures when appropriate.
• Demonstrate teachability: Ask thoughtful questions, respond well to feedback, and show visible improvement.
• Be kind and reliable with everyone:
  • Nurses, front desk staff, respiratory therapists, social workers
  • Program directors often ask staff informally about students.

Attendings who see you as mature, humble, and dependable will naturally write stronger pediatrics residency LORs.

Step 2: Identify Potential Letter Writers Early

During each pediatrics or pediatrics-related rotation:

• Notice attendings who:
  • Give you feedback
  • Know your patients
  • Have seen you present multiple times
  • Ask you about your career goals

An attending who has invested in teaching you is more likely to write a personalized, detailed letter.

Toward the middle of a 4-week rotation (or by week 2–3), consider saying:

“Dr. Smith, I’ve really enjoyed working with you and I’m planning to apply to pediatrics residency. If things continue to go well this month, would you feel comfortable writing a strong letter of recommendation for my peds applications?”

This gives you:

• Real-time feedback (they may say “yes” or give you suggestions to improve)
• A sense of whether they’ll be enthusiastic or hesitant

Step 3: Timing Your Requests

For the pediatrics residency and osteopathic residency match cycles:

• Aim to secure commitments for letters by:
  • Late spring / early summer of application year (around May–July)
• Ask for the letter within a week or two after the rotation, while your performance is fresh in their mind.

If you’re taking a gap year or graduating early as a DO graduate, be especially vigilant about time. Don’t wait until the month before ERAS opens.

Step 4: Provide a Letter Writer Packet

Help your letter writers help you. When you ask them (or as a follow-up email) provide:

• Updated CV
• Personal statement draft for pediatrics (even if not final)
• Brief summary of your rotation with them:
  • Dates of rotation
  • What services you were on (inpatient, NICU, clinic, etc.)
• A short bullet list with:
  • Career goals (e.g., general pediatrics, interest in underserved populations, academic peds)
  • Specific attributes they observed that you hope they’ll highlight
• ERAS instructions and deadline:
  • “ERAS opens for programs in September; I hope to have all letters uploaded by [date].”

This packet answers the classic questions about how to get strong LOR: you make it easy for them to write a specific, detailed, and positive letter.

Step 5: Waive Your Right to View the Letter

On ERAS, you’ll be asked if you want to waive your right to view each LOR. Programs strongly prefer that you waive this right because it:

• Signals that the letter is candid and trustworthy
• Avoids any suspicion that the letter might be less than honest

If you’re nervous, remember: if a faculty member seems hesitant or lukewarm about writing a letter, it’s better not to use that person.

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What Makes a Letter “Strong” in the Peds Match?

Understanding what program directors look for can help you choose the right writers and frame your request effectively.

Key Elements of a Strong Pediatrics LOR

1. Specificity

   • Concrete examples:
     • “On her inpatient pediatrics rotation, she independently gathered histories, developed thoughtful differential diagnoses, and consistently followed up on lab results for her patients.”
     • “He comforted a very anxious parent by carefully explaining their child’s asthma action plan in accessible language.”
   • Compare this to generic statements like:
     • “She was a pleasure to work with.”
     • “He did a good job and was always on time.”

2. Clear Endorsement and Ranking

   • Strong letters often explicitly state things like:
     • “Among the top 10% of students I have worked with in the past five years.”
     • “I would rank her in the top tier of our graduating students and would gladly have her as a pediatric resident in our program.”

3. Commentary on Core Pediatric Competencies

   • Communication with children and families
   • Teamwork and respect for nurses and staff
   • Clinical reasoning and adaptability
   • Compassion and emotional maturity in difficult situations
   • Response to feedback and teaching potential

4. Description of Setting and Comparison Group

   • “On our busy inpatient pediatric service admitting 8–10 patients daily…”
   • “Compared with other 4th-year medical students and interns…”

5. Length and Detail

   • Most strong letters are at least 1–1.5 pages, with multiple paragraphs of narrative detail.
   • Very short, half-page letters are often interpreted as lukewarm or impersonal.

Special Considerations for DO Graduates

Program directors are increasingly familiar with DO graduates in pediatrics, but your letters can help clarify and reassure:

• Competitiveness and readiness
  • Writers can comment that you are “fully prepared for the demands of an ACGME pediatrics residency training program.”
• COMLEX vs USMLE
  • If you took COMLEX only, a strong LOR can reassure programs that your clinical performance is excellent regardless of exam type.
• Osteopathic skills
  • If relevant, a letter may mention how your osteopathic training adds value:
    • Holistic, family-centered approach
    • OMM used to help pediatric patients with musculoskeletal complaints or chronic conditions

Subtly but clearly, your letters can signal that you are as capable and ready as any MD applicant—and that your osteopathic background is an asset.

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Common Scenarios and How to Navigate Them

Scenario 1: Limited Access to Pediatric Faculty

If your school or rotations had limited pediatrics exposure:

• Maximize what you do have:
  • Get strong letters from your core pediatrics clerkship and any electives, even if short.
• Use family medicine or internal medicine letters strategically:
  • Ask those attendings to highlight your work with children, adolescents, or families where possible.
• Consider doing an away rotation or audition rotation in pediatrics:
  • Especially at programs or regions where you want to match.
  • This can generate a powerful, current letter directly for pediatrics residency.

Scenario 2: You’re Late Asking for Letters

If ERAS season is near and you still lack letters:

• Prioritize quality over quantity:
  • It’s better to have 3 strong letters than 4 rushed or generic ones.
• Contact attendings you’ve worked closely with (even if it’s been months):
  • Send a polite email:
    • Remind them who you are
    • Attach CV, personal statement, rotation dates, and 1–2 memorable patient cases you worked on together
• Give them a clear deadline:
  • “Programs begin reviewing applications September 15; having your letter by September 1 would be incredibly helpful.”

Scenario 3: You Had a Tough Rotation

If you had a difficult experience or lower evaluation on a pediatrics rotation:

• You do not need to ask that attending for a letter.
• Instead:
  • Seek rotations where you can thrive and rebuild confidence.
  • Use LORs from attendings who can speak to your growth and strengths.
• If a program specifically asks about a weak rotation during interviews, be prepared to discuss:
  • What you learned
  • How you improved on later rotations

Scenario 4: Do You Need All Letters from Pediatrics?

No. While pediatrics letters should anchor your application, most programs are happy with:

• 2 letters from pediatrics (core + sub-I/away)
• 1 letter from a non-peds clinical rotation that knows you very well

Your goal is balance: enough pediatrics LORs to show fit for specialty, plus one broader endorsement of your clinical maturity and professionalism.

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Putting It All Together: A Sample LOR Plan for a DO Pediatrics Applicant

Here’s a practical example for a DO graduate applying to the peds match:

M3 Year:

• Core Pediatrics Clerkship (Inpatient + Outpatient)
  • Perform strongly; request verbal feedback near the end.
  • If positive, ask: “Would you feel comfortable writing a strong pediatrics residency LOR for me next year?”

M4 Year:

• Sub-Internship in Inpatient Pediatrics at Home Institution
  • Ask your supervising attending (or site director) for a letter by the final week.
• Away Rotation in Pediatrics or NICU/PICU at a Target Program
  • Request LOR from the attending who worked with you the most and can comment on your performance as if you were an intern.

Additional Letter:

• Family Medicine or Internal Medicine Attending (especially if you saw many children)
  • Ask them to emphasize:
    • Your ability to manage chronic pediatric or adolescent issues
    • Communication with families
    • Team-based care and reliability

This gives you a set of 3–4 high-yield letters:

1. Core pediatrics clerkship attending
2. Sub-I pediatrics attending
3. Away rotation pediatrics/NICU/PICU attending
4. Family or internal medicine attending (optional but useful as a fourth)

You can then assign the best three for each pediatric program through ERAS.

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FAQs: Letters of Recommendation for DO Graduates in Pediatrics

1. Do I need all letters from pediatricians for pediatrics residency?

No. Most pediatrics residency programs are happy if at least two of your letters are from pediatricians (especially core peds and a sub-I/away rotation). A third letter from a non-pediatrics attending who knows you well can be very valuable, particularly if it speaks strongly to your clinical ability, professionalism, and teamwork.

2. As a DO graduate, will my letters be viewed differently than MD applicants’ letters?

Most modern programs evaluate DO and MD applicants side-by-side. For a DO graduate residency applicant, the key is that your letter writers:

• Clearly state your readiness for an ACGME pediatrics residency
• Compare you favorably to other students they’ve taught (MD and DO)
• Emphasize your clinical strengths and professionalism
  If your letters are detailed, specific, and enthusiastic, your DO degree will not be a disadvantage—and may be seen as a strength due to your holistic training.

3. Who to ask for letters if I don’t have a pediatrics sub-internship?

If you lack a formal pediatrics sub-I:

• Use your core pediatrics clerkship attending as your primary pediatrics LOR.
• Add a letter from:
  • A pediatric subspecialty (e.g., pediatric cardiology, PICU) where you worked at least 2–4 weeks, or
  • A family medicine or internal medicine attending with substantial pediatric exposure.
    You can also consider adding a short elective in pediatrics early in M4 to generate another pediatrics-specific letter.

4. How to get strong LOR if I’m not a “top test-taker”?

If your board scores are modest, LORs become even more critical. Focus on:

• Exceptional performance on clinical rotations
• Building strong relationships with faculty and staff
• Asking letter writers to highlight:
  • Your growth over time
  • Clinical reasoning, patient rapport, and work ethic
  • Any specific examples where you handled complex or emotionally challenging cases well

A powerful, specific LOR can reassure program directors that you will be an excellent, reliable pediatric resident, even if your standardized scores are not at the top.

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Thoughtful planning and proactive communication can transform your letters of recommendation from a checkbox into a major strength in your application. As a DO graduate targeting a pediatrics residency, invest in these relationships and processes early—you’ll see the payoff when interview invitations start to arrive.