Essential Guide to Letters of Recommendation for DO Graduates in Surgery

Why Letters of Recommendation Matter So Much for DO Applicants in General Surgery

For a DO graduate targeting a general surgery residency, letters of recommendation (LORs) are not a formality—they are one of the most powerful parts of your application. In a competitive surgery residency match, program directors rely heavily on letters to:

• Validate your clinical skills and judgment
• Assess your work ethic and professionalism
• Predict how you’ll function on a demanding surgical team
• Understand your performance relative to peers from all medical schools (MD and DO)

As a DO graduate, strong, detailed letters can also help:

• Demonstrate that you perform at or above the level of MD peers
• Counteract any lingering bias or unfamiliarity some programs may have with your school
• Highlight osteopathic strengths—holistic care, communication, and systems-based thinking—in a surgical context

If you’re wondering how to get strong LOR support as a DO applicant, the strategy is not just “work hard and hope for the best.” You can—and should—approach letters in a deliberate, structured way.

This guide will walk you through:

• How many and what types of letters you need
• Exactly who to ask for letters in general surgery
• How to prepare your letter writers so they can write excellent, specific LORs
• Special considerations for DO graduates navigating the osteopathic residency match and ACGME general surgery programs
• Practical templates, timelines, and common pitfalls

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Understanding Letter Requirements for General Surgery (Especially as a DO)

How Many Letters Do General Surgery Programs Want?

Most ACGME general surgery residency programs ask for:

• 3 letters of recommendation, plus
• 1 required Medical Student Performance Evaluation (MSPE, Dean’s Letter)

Many surgery programs will allow up to 4 LORs in ERAS. For a DO graduate applying to a surgery residency match, a good general rule:

• Ideal mix for a DO general surgery applicant:
  • 2 letters from general surgeons (at least 1 from a core or sub-internship rotation)
  • 1 letter from another surgical specialty or surgical intensivist (trauma, SICU, vascular, etc.) or a medicine attending who knows you extremely well
  • Optional 4th: A research mentor, department chair, or program director, if they can write a truly strong letter

Programs frequently state preferences on their websites. Look for wording like:

• “We prefer at least two letters from surgeons”
• “One letter should be from a general surgeon with whom you have worked closely”
• “Chair’s letter from Surgery strongly recommended”

Check each program’s website and ERAS listing early in the spring of your 3rd/4th year so you can plan accordingly.

DO Graduate–Specific Considerations

As a DO graduate, your letters can strategically address:

• Comparability to MD students
  A letter from an MD general surgeon saying you performed “as well as, or better than, our MD students and categorical interns” is powerful.

• Performance in ACGME settings
  If you rotate at an ACGME-affiliated academic center, a strong letter from that setting is especially valuable for the osteopathic residency match and combined ACGME match environment.

• Osteopathic strengths framed for surgery
  For example, a letter might highlight:

  • Your attention to patient-centered communication
  • Your systems-based approach to pre- and post-op care
  • How your DO training improved your holistic management of complex surgical patients

You do not need your letters to overemphasize that you are a DO; instead, focus on performance, reliability, teachability, and team fit.

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Who to Ask for Letters: Building the Right Mix for General Surgery

Choosing who to ask for letters is as important as how well you did on the rotation. In general surgery, hierarchy and reputation matter—but only if the letter writer knows you well.

Ideal Letter Writers for a DO Applying to General Surgery

Aim for a combination of:

1. General Surgery Faculty from a Sub-Internship (Sub-I) or Acting Internship (AI)

   • This is often your most important letter.
   • They can speak to your performance at the level closest to an intern: pre-rounding, writing notes, calling consults, assisting in the OR, ED consults, etc.
   • Preferably at a program or hospital with a residency, ideally at an ACGME institution.

2. General Surgery Clerkship Site Director or Core Rotation Attending

   • Especially valuable if they’ve seen many students over the years and can compare you to a large cohort.
   • Their comments on your growth, resilience, and operative potential carry weight.

3. Chair of Surgery or Program Director (if truly meaningful)

   • Sometimes you’ll have a standardized “Chair’s letter” after a departmental interview or review process.
   • More powerful if the Chair or PD actually worked with you clinically; if not, it’s still helpful but may be more generic.

4. Subspecialty Surgeon (Vascular, Trauma, Surgical Oncology, Bariatrics, Colorectal, etc.)

   • Useful if you spent substantial time on their service and they can comment on your technical skills, clinical reasoning, and OR behavior.

5. Research Mentor (preferably surgical)

   • Particularly helpful if you’re applying to more academic or research-heavy general surgery residencies.
   • Only request this letter if they know you well and can speak to persistence, critical thinking, and academic productivity.

Less Ideal—but Sometimes Acceptable—Letter Writers

• Non-surgeon internists or hospitalists

  • Can be helpful if they know you very well and will write a truly exceptional, detailed letter, especially about ICU or perioperative care.
  • Better as your third or fourth letter—not a substitute for surgical letters.

• Residents or Fellows as primary writers

  • Residents and fellows often know you best day-to-day, but they usually cannot be the signing letter writer.
  • However, a strong letter often reflects resident input. When attendings say, “Our senior residents uniformly praised this student,” that’s valuable.

• Community surgeons you shadowed briefly

  • Shadowing is rarely enough for a strong surgery residency match letter.
  • Exception: you worked closely with them over many weeks, actively participated in patient care, and they’re willing to write in depth.

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How to Get Strong LOR: Step-by-Step Strategy for DO Applicants

Step 1: Plan Your Rotations Around LOR Needs

Because letters carry heavy weight, build your 3rd- and 4th-year schedules with LORs in mind:

• Early 4th-year (or late 3rd-year) sub-I in General Surgery

  • Try to schedule a key sub-I at a program you’re strongly interested in before ERAS opens.
  • This allows enough time for a strong letter and gives the faculty a clear view of your capabilities.

• At least one rotation at an academic center

  • Ideally with an ACGME surgery residency.
  • As a DO graduate, this adds credibility and cross-comparison to MD peers.

• If doing away/audition rotations

  • Choose sites strategically where:
    • You’re genuinely interested in training.
    • There’s a track record of DO-friendly support; talk to recent alumni if possible.
    • Faculty are known to be engaged teachers and willing letter writers.

Step 2: Signal Your Interest Early and Clearly

Attendings are more likely to invest time in your letter if they know it matters to you.

On day 1–3 of a rotation, say something like:

“Dr. Smith, I’m a DO student very interested in general surgery and planning to apply this cycle. I’d really appreciate any feedback on how I can improve and be a strong applicant.”

Closer to the midpoint of the rotation:

“I’m hoping to ask a few attendings for letters of recommendation for general surgery. If I continue to perform well, would you feel comfortable considering writing one for me?”

This gives them:

• Notice ahead of time
• Permission to watch you a bit more closely
• An opportunity to give feedback if there are areas to improve before the end

Step 3: Perform Like a Future Surgical Intern

Your day-to-day behavior is what creates the foundation for a strong letter. General surgery attendings typically comment on:

• Work ethic and reliability

  • Are you early for rounds and cases?
  • Do you follow through on tasks?
  • Do you stay engaged until work is truly done?

• Ownership and initiative

  • Do you know your patients inside and out?
  • Do you volunteer to call consults, gather labs, follow up imaging (within your scope)?
  • Do you anticipate the team’s needs?

• Teachable attitude

  • Do you accept feedback and adjust quickly?
  • Do you show humility while still being confident and prepared?

• Operative potential

  • Are you focused and calm in the OR?
  • Do you know the steps of common operations?
  • Are you safe and respectful of the field?

• Professionalism and team dynamics

  • Do residents and staff find you pleasant to work with?
  • Do you communicate clearly and respectfully with nurses and other team members?

If you want a strong LOR, your goal is for your attending to remember you distinctly in a positive way.

Step 4: Ask the Right Way, at the Right Time

Timing is crucial. Ideally:

• Ask 1–2 weeks before the rotation ends, or near the final evaluation meeting.
• Choose attendings who:
  • Saw you frequently
  • Supervised you both clinically and in the OR
  • Have a reputation for mentoring students

How to ask in person:

“Dr. Jones, I’ve really valued working with you this month and I’m applying to general surgery. Based on your experience with me, would you feel comfortable writing a strong letter of recommendation for my surgery residency applications?”

That phrase—“strong letter of recommendation”—is important. It gives the attending an opening to say “I’m not the best person to write your letter” if they can’t endorse you strongly. It’s much better to hear that now than have a lukewarm letter in your file.

If needed, you can follow up with an email:

Dear Dr. Jones,

Thank you again for the opportunity to work with you on the general surgery service this month. As we discussed, I am applying to general surgery residency this cycle and would be very grateful if you could write a strong letter of recommendation on my behalf.

I have attached my current CV, personal statement draft, and a brief summary of my experiences on the rotation to assist you. I will designate you in ERAS once applications open; you should receive an automatic email with upload instructions.

Please let me know if there is any additional information I can provide.

Sincerely,
[Your Name], DO Candidate

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Setting Your Writers Up for Success: What to Provide and What to Request

What Makes a Letter “Strong” in General Surgery?

Residency letters of recommendation that stand out for general surgery typically have:

1. Specific clinical examples

   • “On our trauma rotation, she took ownership of a critically injured patient, gathered all relevant information, and presented a clear, concise plan at 3 am.”

2. Comparison to peers

   • “In my 10 years of teaching, he is among the top 10% of students I’ve worked with.”
   • “She functioned at the level of an advanced sub-intern or a new PGY-1 by the end of the rotation.”

3. Clear endorsement for the specialty

   • “I recommend him without reservation for general surgery residency.”
   • “I would be delighted to have her as a resident in our own program.”

4. Comments on OR behavior and technical potential

   • “He demonstrated excellent manual dexterity, respect for tissues, and an intuitive understanding of the operative field.”

5. Professionalism and team compatibility

   • “Nurses and residents consistently praised her work ethic and collegiality.”

What to Give Your Letter Writers

When you ask for a letter, make it easy for them to write something specific and accurate. Provide:

• Updated CV

  • Highlight surgical experiences, leadership, research, and any quality improvement projects.

• Personal statement draft (even if not final)

  • This helps them understand your motivation for general surgery and your long-term goals.

• ERAS photo (optional but helpful)

  • Especially if the letter is written months after your rotation.

• Brief “LOR packet” or bullet summary

  • 1–2 pages, optional but very helpful. Include:
    • Rotation dates and site
    • Key clinical experiences (e.g., “First assist on 3 laparoscopic cholecystectomies; managed daily notes on 6–8 post-op patients; frequent ED consults for appendicitis and SBO”)
    • Any specific feedback they gave you and how you acted on it
    • Particular strengths you hope they might mention (e.g., ownership, resilience, patient communication)

You can politely mention a couple of themes that matter in surgery:

“If you feel it’s appropriate, I would be grateful if you could comment on my work ethic, performance in the OR, and ability to function at an intern level on the service.”

Do not script the letter or tell them what to write. Instead, frame it as areas they could highlight if consistent with their experience of you.

Logistics: ERAS and Timing

• ERAS opens for applicants typically in June.
• You can start assigning letter writers as soon as you have their email and they agree to write.
• Target deadline for letter upload:
  • Aim for late August to early September, since many general surgery programs start reviewing as soon as ERAS is released.

To gently keep things on track:

• 3–4 weeks after your initial request:
  • Send a polite reminder with your ERAS ID and deadline.
• 2 weeks before your personal “must submit” date:
  • One more brief, respectful follow-up if the letter is still pending.

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DO Graduate Nuances: Osteopathic Background in a General Surgery Application

Addressing DO vs. MD Perception—Indirectly, Through Performance

You don’t need letters that explicitly defend osteopathic training. Instead, your goal is:

• To have attendings (especially MD surgeons) clearly state that:
  • Your clinical acumen is strong
  • Your performance equals or exceeds that of typical MD students and interns
  • You assimilated quickly into the workflow of an ACGME surgical service

Example phrasing a letter writer might use:

• “Although I do not routinely work with DO students, [Name] quickly demonstrated clinical reasoning, judgment, and operative performance on par with our MD students and interns.”

You can gently encourage this by including a short paragraph in your “LOR packet”:

“As a DO graduate, I’ve had the opportunity to rotate alongside MD students and residents at [Hospital]. I’ve appreciated feedback that my performance is comparable to my MD peers, and I value any comments you feel comfortable including about my ability to function effectively in an ACGME general surgery setting.”

Using Osteopathic Strengths as an Asset

When your letter writer asks about your background or reads your personal statement, you can highlight how DO training reinforces:

• Whole-patient thinking in surgical care

  • Pre- and post-operative optimization
  • Managing comorbidities in a systems-based way

• Communication with patients and families

  • Explaining procedures in accessible language
  • Shared decision-making in high-stakes settings

If this resonates with your attendings, they may reflect it in the letter—giving you a unique edge in the general surgery residency match.

Osteopathic Residency Match and ACGME Programs

In the unified ACGME era, most general surgery programs are now under a single accreditation system, but some may still be more familiar with:

• Local DO schools
• Specific osteopathic hospitals or systems

If you rotate at DO-friendly sites, those surgeons’ letters can:

• Signal: “We know DO students well, and this one is excellent even among that group.”
• Provide reassuring commentary on your ability to thrive in a busy surgical residency, regardless of degree.

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Common Pitfalls and How to Avoid Them

Pitfall 1: Choosing “Big Names” Who Barely Know You

A short, generic letter from a famous chair is less helpful than a detailed letter from an associate professor or core faculty who truly knows you.

Avoid:

• Letters that read like, “I met [Student] briefly on service and found them to be pleasant and enthusiastic.” That will not help you stand out.

Choose:

• Faculty who supervised your clinical work and OR performance, even if they’re “only” assistant professors or community surgeons in residency-affiliated hospitals.

Pitfall 2: Waiting Too Long to Request Letters

If you wait several months after a rotation:

• The attending may not remember details about your performance.
• The letter becomes more generic and less powerful.

Try to:

• Request the letter within 1–2 weeks of finishing the rotation.
• If you need to wait (e.g., waiting for ERAS access), at least send a thank-you email and ask if they’d be open to writing a letter later.

Pitfall 3: Not Clarifying That You Need a “Strong” Letter

If you don’t explicitly ask for a “strong letter,” you may end up with:

• Neutral or lukewarm LORs that subtly harm your application.

By asking:

“Would you feel comfortable writing a strong letter of recommendation for my general surgery residency applications?”

You give the writer a graceful way to decline if they can’t endorse you strongly.

Pitfall 4: Ignoring Program-Specific Requirements

Some general surgery programs have unique expectations, such as:

• A Chair’s letter from Surgery
• A letter from a trauma or acute care surgeon
• A limit on the number or type of letters

Always:

• Read each program’s website and ERAS entry carefully.
• Adjust your letter assignments accordingly.

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FAQs: Letters of Recommendation for DO Graduates in General Surgery

1. How many letters of recommendation do I actually need for general surgery?

Most programs want 3 letters of recommendation plus the MSPE. As a DO graduate in general surgery, a strong strategy is:

• 2 letters from general surgeons (preferably from core and sub-I rotations)
• 1 additional letter from a surgical subspecialist, ICU/trauma attending, or a non-surgical mentor who knows you extremely well

If ERAS allows, a 4th letter can be from a research mentor or Chair, but only if it’s genuinely strong and specific.

2. Is it bad if not all my letters are from MDs as a DO graduate?

Not necessarily. Programs care much more about quality and specificity than about the degree of your letter writer. A mix can work well:

• DO surgeons (especially at osteopathic-friendly programs) can speak to your growth and reliability.
• MD surgeons at ACGME institutions can offer powerful cross-comparisons to MD peers.

Aim for at least one letter from an MD general surgeon at an ACGME-affiliated site if possible, as this can be reassuring for more traditional academic programs.

3. What if I didn’t “click” with any attendings on my surgery rotation?

You still have options:

• Ask residents which attendings are known for working closely with students and consider scheduling a sub-I or elective with them.
• On your next surgery-related rotation, signal your interest early, ask for feedback often, and actively seek out responsibility so attendings get to know you.
• If necessary, a strong letter from a medicine ICU or trauma service attending who saw you function like a near-intern may still be very helpful.

You can also supplement with a research mentor or program director letter if they know your work ethic and commitment to surgery well.

4. Can I see or edit my letters? Should I waive my right to view them?

In ERAS, you will be asked whether to waive your right to view each letter. Most program directors expect applicants to waive this right, as it:

• Signals that the letter is more likely to be candid and unbiased.
• Reflects standard practice in residency applications.

You generally should not ask to see or edit your letters. Instead:

• Provide a thorough CV, personal statement, and summary of your work.
• Trust that your attendings will use that information appropriately.

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Well-crafted, detailed, and strategically chosen letters of recommendation can significantly elevate your application as a DO graduate pursuing a general surgery residency. If you perform like a future intern, choose the right writers, and support them with clear information and timelines, your LORs will speak powerfully on your behalf in the surgery residency match.