Essential Guide to Letters of Recommendation for DO Graduates in Med-Peds

Understanding Letters of Recommendation for a DO Applying to Med-Peds

As a DO graduate applying to Medicine-Pediatrics (Med-Peds), your letters of recommendation (LoRs) are one of the most powerful parts of your application. In a competitive medicine pediatrics match, strong letters can:

• Validate your clinical competence across both internal medicine and pediatrics
• Showcase your readiness for a combined specialty
• Reassure programs that you are well-prepared from an osteopathic training background
• Help balance out modest board scores or other application weaknesses

For a DO graduate residency applicant, residency letters of recommendation often matter as much as your personal statement and sometimes more than marginal test score differences. Med-Peds program directors consistently emphasize that well-written, specific, and credible letters can significantly boost an applicant’s rank position.

This guide walks you through exactly who to ask for letters, how to get strong LOR, and how to tailor your letter strategy to the osteopathic residency match and ACGME-accredited Med-Peds programs.

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How Many Letters You Need and What Programs Expect

Most Medicine-Pediatrics residency programs require:

• 3 letters of recommendation (common minimum)
• 4 letters maximum can usually be uploaded in ERAS, with 3–4 assigned to each program

Always verify each program’s website or ERAS listing, but a typical strong strategy for a Med-Peds applicant is:

• 1 letter from an Internal Medicine attending
• 1 letter from a Pediatrics attending
• 1 additional letter from:
  • A Med-Peds physician (ideal if available)
  • Another IM or Peds attending who knows you well
  • A Sub-Internship/Acting Internship supervisor (IM, Peds, or Med-Peds)

For a DO graduate residency applicant, another key consideration is whether programs require or strongly prefer a Department Chair letter (often in internal medicine or pediatrics). This is more common in highly academic or university-based programs.

Typical Med-Peds LOR configurations

Ideal 3-letter set for Med-Peds:

• Letter 1: Med-Peds attending (from a Med-Peds elective or clinic)
• Letter 2: Internal Medicine inpatient attending (sub-I or core clerkship)
• Letter 3: Pediatrics inpatient or outpatient attending

If no Med-Peds attending is available:

• Letter 1: Strong Internal Medicine attending who worked with you closely
• Letter 2: Strong Pediatrics attending who worked with you closely
• Letter 3: Another IM or Peds attending, or a subspecialist (e.g., adolescent medicine, family medicine with inpatient children exposure, hospitalist) who can attest to your Med-Peds-like skills

DO-specific expectations

Most Med-Peds programs are fully integrated ACGME programs and routinely train DO graduates. Still, as a DO graduate:

• Strong, detailed letters help counter any implicit bias some reviewers may still have about osteopathic training
• Letters that explicitly praise your clinical reasoning, documentation, evidence-based practice, and professionalism are especially helpful
• If you have taken USMLE in addition to COMLEX, letters commenting positively on your preparedness for board-level thinking can be helpful, though not required

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Who to Ask for Letters (and Who Not To)

A central question for every applicant is who to ask for letters. For a DO graduate in the osteopathic residency match or ACGME match, the key principle is: choose attendings who know your work well over big names who barely know you.

Priority #1: Clinical attendings in Medicine and Pediatrics

Your most important letters should come from attendings who:

• Directly supervised you in clinical settings (inpatient, outpatient, sub-I, acting internship, or away rotation)
• Observed you taking ownership of patients and functioning near an intern level
• Can speak to:
  • Clinical judgment and reasoning
  • Work ethic and reliability
  • Communication skills with patients and team
  • Ability to manage both adult and pediatric patients (even if the rotation was one side only)
  • Suitability for Med-Peds specifically

High-yield sources for Med-Peds LoRs:

• Med-Peds attendings from combined rotations, continuity clinics, or electives
• Internal Medicine ward attendings (especially from sub-I/AI rotations)
• Pediatrics ward or NICU attendings
• Pediatric or adult hospitalists
• Primary care IM or Peds attendings who worked with you longitudinally

Priority #2: Rotation leaders and sub-I supervisors

Sub-internships (acting internships) are extremely valuable for letters because they simulate intern-level responsibilities.

Ask for letters from:

• Supervisors of your IM or Peds sub-I
• Supervisors on away rotations at Med-Peds programs (these are especially influential if you are applying to that program or similar academic centers)

These letters can directly address your readiness for intern-level responsibilities, which programs strongly value.

Priority #3: Department or Clerkship leadership (if they know you)

Chair, Program Director, or Clerkship Director letters can add institutional weight, but they are only useful if they genuinely know your work. Many “standardized” chair letters are generic and add little value unless:

• The chair actually supervised you clinically
• You did research, QI, or leadership work directly with them
• Your school or certain programs explicitly require a department-level letter

If your school mandates a Chair letter, still ensure your other two letters are from close clinical supervisors.

Lower priority (use only if they truly know you well)

• Research mentors (unless it’s heavy clinical research with direct patient care and high contact)
• Non-clinical course directors
• Volunteer coordinators with minimal clinical overlap
• Preclinical faculty who never supervised you in patient care

These can be your third or fourth letter only if they can provide rich, specific details and you already have strong IM and Peds letters.

Who not to prioritize

Avoid letters from:

• Residents or fellows acting alone (they cannot officially write the LoR; at best they can co-write with the attending)
• Family friends or physicians you shadowed without substantial direct involvement
• Very short rotations where you were barely observed

Programs are looking for evaluative clinical letters, not just character references.

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How to Get Strong LOR as a DO Med-Peds Applicant

The quality of your letter depends heavily on what your writer has seen you do and how you approach the process. You can’t write your own letter, but you can strongly influence its substance and strength.

Step 1: Perform strategically on key rotations

Target at least:

• One strong IM rotation (preferably sub-I) in your third or early fourth year
• One strong Peds rotation (ward, NICU, or clinic with real responsibility)
• If available, a Med-Peds elective or rotation at a Med-Peds program

On these rotations, deliberately demonstrate qualities programs want:

• Ownership: Arrive early, know every detail about your patients, anticipate plans
• Reliability: Never miss deadlines for notes, orders (within your role), or follow-ups
• Initiative: Offer to present short evidence-based topics or lead family meetings (with supervision)
• Teamwork: Help interns and residents, support co-students, and communicate respectfully with nurses and ancillary staff
• Dual-interest mindset: Ask questions that show you’re thinking about long-term care, transitions of care (peds → adult), and continuity across the lifespan

These behaviors give attendings rich, concrete material to write about.

Step 2: Ask the right question the right way

When you approach someone for a letter, never just say “Can you write me a letter?” Instead ask:

“Do you feel you know my clinical work well enough to write a strong letter of recommendation for Medicine-Pediatrics residency?”

That single word—strong—is important. It gives the attending a graceful exit if they cannot support you enthusiastically. If they hesitate or say something like “I can write you a letter, but I don’t know you very well,” consider asking someone else.

Step 3: Request letters early and clearly

Timeline suggestions:

• Ask at the end of the rotation or within 1–2 weeks, while your performance is fresh in their mind
• For the main medicine pediatrics match cycle, aim to have letters requested by July–August and uploaded by September

When requesting, provide:

• A concise CV or ERAS-generated CV
• Your personal statement draft for Med-Peds (even if not final)
• A short one-page “highlights” sheet, including:
  • Why you’re pursuing Med-Peds
  • Key patients or cases you managed on that rotation
  • Specific moments where you grew or received feedback
  • Any accomplishments they might not know about (research, leadership, service)
• Clear instructions:
  • That you are a DO graduate applying to Med-Peds
  • ERAS submission deadline
  • How to upload via ERAS (you can include the ERAS LoR request form)

You are not telling them what to say; you’re giving them context so they can write a richer and more targeted letter.

Step 4: Highlight your DO background (tactfully)

As a DO graduate residency applicant, your osteopathic training is an asset. Your letter writers can help frame it that way. When you give them your “highlights” sheet, you might mention:

• Your use of osteopathic principles in whole-person care
• Experiences integrating OMT where appropriate (particularly in pediatrics, sports medicine, or chronic pain)
• How your training broadened your approach to systems-based care and preventive medicine

This helps them tie your DO background to characteristics Med-Peds programs value: comprehensive care, adaptability, and patient-centered thinking.

Step 5: Confirm and gently follow up

After your request:

• Send a thank you email within 24 hours confirming your appreciation and timeline
• About 3–4 weeks before ERAS submission, if the letter isn’t in, send a polite reminder, e.g.:

“I just wanted to check in about the letter of recommendation for my Medicine-Pediatrics residency application. ERAS suggests having all materials uploaded by [date]. Please let me know if there’s anything else I can provide. Thank you again—I really appreciate your support.”

If they still haven’t submitted close to the deadline, you need a backup plan (another attending you can ask quickly).

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What Makes a Letter “Strong” for Med-Peds (Especially for DO Graduates)

You cannot see the exact content of your letters (they should be confidential), but you can understand what program directors look for in powerful residency letters of recommendation.

1. Specific, behavioral examples

Strong letters don’t say “Alex was a hard worker.” They say:

• “On our pediatric ward, Alex independently managed eight patients, including a child with new-onset type 1 diabetes. They coordinated care with endocrinology, nutrition, and social work, and led the family education session with minimal supervision.”

Program directors read hundreds of letters; specific narratives stand out.

2. Direct comparison to peers

Strong letters place you in context, such as:

• “Among the approximately 80 third- and fourth-year students I have supervised in the last five years, she ranks in the top 10% in clinical reasoning and professionalism.”

Comparative statements are very powerful, especially if they come from respected faculty.

3. Clear endorsement of Med-Peds fit

Because Med-Peds is a combined specialty, ideal letters address both:

• Your potential as an internist
• Your potential as a pediatrician

Even if the letter writer only supervised you on one side, they can comment on traits that apply across both: curiosity, maturity, patient-centered communication, adaptability between high- and low-acuity settings, etc.

Explicit statements like:

• “I believe he will excel in a Medicine-Pediatrics residency and would gladly welcome him as a resident in our own program.”

carry significant weight.

4. Addressing DO training positively

For a DO graduate, impactful letters may:

• Describe your clinical performance as on par with or exceeding MD peers
• Comment on your readiness for ACGME-accredited training environments
• Highlight your strengths in communication, holistic assessment, and continuity of care

These reassure any faculty who are less familiar with DO programs or COMLEX that your background is not just equivalent, but valuable.

5. Professional structure and tone

Strong letters are:

• 1–1.5 pages, single-spaced
• Well-organized: introduction, clinical examples, evaluation, overall recommendation
• Free of typos, vague language, or backhanded compliments

Statements like “with further maturity, they may become a capable physician” are red flags. Ask letter writers who are known to be supportive and professional.

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Practical Strategies for Different Applicant Profiles

Every applicant is different. Here are common scenarios for DO Med-Peds applicants and how to adapt your LOR strategy.

Scenario 1: Strong academic record, standard clinical exposure

You have solid COMLEX/USMLE scores, good clerkship grades, and standard IM and Peds rotations.

Strategy:

• Prioritize one IM and one Peds letter from inpatient attendings
• Add a third letter from:
  • Med-Peds attending (if available)
  • Sub-I supervisor (either IM or Peds)
• Ask letter writers to highlight:
  • Your clinical reasoning and independence
  • Your commitment to combined care and transitions of care

Scenario 2: Applying with modest board scores or a red flag

You might have below-average scores, a failed exam attempt, or a rough early rotation.

Strategy:

• Aim for very strong, detailed clinical letters that document your growth and current readiness
• Consider a sub-I late in medical school to show recent strong performance and request a letter from that rotation
• Ask your letter writers (privately) if they are comfortable addressing your progress, for example:
  • “Alex initially struggled with time management but responded very well to feedback. By the end of the rotation, they were performing at the level of a strong intern.”

Programs will weigh consistent, documented improvement heavily.

Scenario 3: Non-traditional or gap year DO graduate

You may be a previous graduate reapplying, or took a research/clinical gap year.

Strategy:

• Obtain at least one recent clinical letter (within 12–18 months) from attending-level supervision
• If you did research or a clinical job, get a letter from that supervisor that highlights:
  • Reliability, teamwork, clinical communication, professionalism
• Combine that with older but strong IM and Peds letters if necessary, but prioritize recency when possible

Scenario 4: Limited access to Med-Peds faculty

Your home institution may not have a Med-Peds program.

Strategy:

• Focus on excellent IM and Peds letters that each speak to your suitability for the combined discipline
• If possible, take an away rotation at a Med-Peds site for both exposure and a letter
• Have your IM and Peds letter writers explicitly state:
  • Your clear interest in Med-Peds
  • How your skills and personality would fit a dual-residency environment

Programs understand these structural limitations; they care more about authentic, strong letters than the specific Med-Peds title.

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Frequently Asked Questions (FAQ)

1. How many letters should I assign to each Med-Peds program?

Most applicants assign 3 letters to each program; some assign 4 if allowed. A reasonable pattern:

• Letter 1: Internal Medicine attending
• Letter 2: Pediatrics attending
• Letter 3: Med-Peds or additional strong IM/Peds letter

Assign your strongest, most Med-Peds-relevant letters consistently across all programs unless a specific program requests something unique (like a Chair letter).

2. Do I need a Med-Peds physician letter to match into Med-Peds?

No. A Med-Peds letter is helpful but not required. Many successful applicants match with:

• 1 IM letter + 1 Peds letter + 1 additional IM/Peds/Chair letter

If you can’t get a Med-Peds letter, make sure your IM and Peds letters explicitly mention your interest in combined training and your suitability for both adult and pediatric care.

3. Is it a disadvantage to be a DO graduate applying to Med-Peds?

DO graduates match into Med-Peds every year and are welcomed by most programs. It is not inherently a disadvantage if:

• Your clinical letters show strong, specific clinical performance
• Your application demonstrates readiness for ACGME environments
• You apply broadly and strategically across a range of programs

Strong residency letters of recommendation that explicitly compare you favorably to MD peers can be very reassuring to committees less familiar with your school.

4. Can I reuse letters if I am reapplying to the medicine pediatrics match?

Yes, but it’s best to:

• Update at least one letter from a more recent clinical or professional experience
• Inform prior letter writers that you are reapplying and ask if they can either:
  • Update the letter (preferred), or
  • Give permission to reuse the existing one

Always check the current ERAS year requirements; you cannot personally “edit” old letters, but writers can upload a revised version.

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Thoughtful planning and proactive communication transform letters from a passive requirement into a real strength of your application. As a DO graduate targeting a med peds residency, invest early in your relationships with IM and Peds attendings, be intentional in how you request letters, and ensure your recommenders understand both your goals and the unique nature of Medicine-Pediatrics training.