Essential Letters of Recommendation Strategies for DO Graduates

Understanding LOR Strategy as a DO Graduate

Letters of recommendation are among the most powerful—and most misunderstood—parts of your residency application. For a DO graduate, they can be especially important in demonstrating your clinical readiness, professionalism, and how you fit into both osteopathic and ACGME-accredited training programs.

In a competitive osteopathic residency match (and increasingly unified match environment), strong letters can:

• Validate your clinical skills and judgment
• Highlight your osteopathic training and OMT skills as assets
• Reassure programs about your ability to succeed in a variety of settings
• Help offset weaker parts of the application (e.g., a below-average COMLEX/USMLE score or a non-traditional path)

This article focuses specifically on letters of recommendation strategies for DO graduates—how many you need, who to ask for letters, how to get strong LOR, and how to maximize their impact across both osteopathic and ACGME programs.

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How Many Letters Do You Need—and What Kind?

Most residency programs require 3 letters of recommendation, plus your MSPE (Dean’s) letter and transcript. Some programs allow or encourage a fourth letter. Always verify on:

• ERAS program descriptions
• Program websites
• FREIDA or AOA/ACGME program listings

Typical Composition for DO Graduate Residency Applications

For the average DO graduate residency applicant:

• 3 letters total is acceptable for most programs
• 4 letters can be useful if:
  • You’re applying in a very competitive specialty
  • You have a dual-interest (e.g., Internal Medicine + FM, EM + IM)
  • You’re using specialty-specific letters for different programs

A strong, balanced LOR set might look like:

1. Specialty-specific letter
   • From an attending in the specialty you’re applying to (e.g., IM, FM, EM, Psych)
2. Additional clinical letter
   • Another attending in your target specialty or a closely related field
3. Osteopathic-focused letter or “big picture” letter
   • From a DO attending, OMM/OPP faculty member, or preceptor who can speak to your osteopathic approach and professionalism
4. (Optional) Sub-internship or audition rotation letter
   • Especially powerful if from a residency site or program leadership

Specialty-Specific Requirements and Nuances

Different specialties have different expectations:

• Primary Care (Family Medicine, Internal Medicine, Pediatrics):

  • 1–2 letters from core rotations (IM/FM/Peds)
  • At least one from a DO if applying primarily to osteopathic residency match programs
  • A letter that emphasizes continuity of care and teamwork is especially valuable

• Emergency Medicine:

  • EM-specific letters (often SLOEs—Standardized Letters of Evaluation)
  • Ideally from an EM rotation in an academic or community program
  • DO graduates should try to obtain at least one SLOE from an ACGME or dually accredited program

• Surgical Specialties:

  • At least 1–2 letters from surgeons in your intended specialty
  • Sub-I or audition rotation letters preferred
  • Technical ability, work ethic, and OR behavior are key dimensions

• Psychiatry, Neurology, PM&R, etc.:

  • At least one letter from the target specialty
  • Another from internal medicine (especially for neurology, PM&R)
  • For DOs, letters that highlight holistic care and communication can stand out

Action Step:
Create a simple table listing:

• Each specialty you’re applying to
• Number and type of letters they recommend
• Which rotations (past or upcoming) can provide those letters

This early planning is crucial to a strong DO graduate residency LOR strategy.

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Who to Ask for Letters—and Who Not To

A frequent question from DO graduates is “Who to ask for letters?” The answer depends on the strength of the relationship and the type of rotation.

Ideal Letter Writers for DO Graduates

Prioritize letter writers who meet as many of these criteria as possible:

1. They directly supervised your clinical work

   • Attending physicians who observed you seeing patients
   • Preceptors from core or audition rotations
   • Faculty who saw you on wards, in clinic, or in the OR

2. They know you more than superficially

   • Worked with you for at least 2–4 weeks, ideally longer
   • Can recall specific patients, cases, or projects you handled
   • Have seen your growth over time

3. They are in your target specialty (or closely related)

   • For IM: internists, subspecialists, hospitalists
   • For FM: FM attendings, primary care physicians
   • For EM: board-certified EM attendings, especially at sites with residents

4. They are DOs or DO-friendly MDs

   • DO attendings who value your osteopathic background
   • MD faculty familiar with osteopathic graduates and training
   • Especially beneficial if applying to osteopathic residency match programs or DO-heavy institutions

5. They are reliable and responsive

   • Known for submitting letters on time
   • Have a history of working with students and residents

Strategic Considerations for DO Graduate Residency Applications

For a DO graduate, consider this mix:

• At least one letter from a DO physician

  • Helps highlight your osteopathic identity and comfort within osteopathic medicine
  • Especially attractive for osteopathic programs and DO-friendly ACGME programs

• At least one letter from a well-known academic or residency-affiliated site

  • Shows you can function in a teaching environment
  • May carry extra weight because programs know the writer or the institution

• One letter from a rotation with strong continuity or longitudinal experience

  • E.g., a preceptor you worked with regularly over months
  • They can better describe your growth, reliability, and patient relationships

Who NOT to Ask for Residency Letters of Recommendation

Avoid or deprioritize:

• Non-clinical references unless specifically relevant

  • Shadowing experiences (no formal supervision)
  • Purely research mentors (unless you had intense, long-term involvement, or applying heavily research-oriented)
  • Employers from non-medical jobs (unless you need an extra character reference and already have 3 strong clinical letters)

• Anyone who seems hesitant

  • If they hesitate or seem lukewarm when you ask, do not push
  • You want enthusiastic advocates, not neutral or negative voices

• Faculty who barely know you

  • Someone who worked with you for a single day or only peripherally
  • They’ll likely produce a generic, less helpful letter

Red Flag Answer:
If you ask, “Would you be able to write me a strong letter of recommendation?” and they respond with something like, “I can write you a letter,” without specifically saying strong or positive, consider that a warning sign and ask someone else.

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How to Get Strong LOR as a DO Graduate

The strongest letters don’t happen by accident. They are built through deliberate behavior during clinical rotations and thoughtful follow-up.

1. Perform with Letters in Mind

From the first day of a rotation, treat it as an audition for your letter:

• Be consistently prepared
  • Read about your patients the night before
  • Know their meds, labs, imaging, and active problems
• Take initiative
  • Volunteer to present new admissions
  • Offer to follow through on consults or calls
  • Ask to do procedures as appropriate
• Demonstrate osteopathic principles
  • Consider the whole person—bio-psycho-social-spiritual model
  • Ask about function, lifestyle, and environment
  • If appropriate, offer OMT or document your osteopathic reasoning

2. Make Your Goals Clear Early

On day 1–2 of a rotation, let your attending know:

• You are a DO graduate or graduating DO student
• You are applying to X specialty
• You are hoping this rotation might lead to a strong letter if your performance justifies it

This signals to the attending that:

• They should pay extra attention to your performance
• They are expected to observe your progression in more detail

Example script:

“Dr. Smith, I’m a DO student applying to Internal Medicine. I’m really interested in hospitalist medicine and academic IM. I’m hoping to work as hard as I can on this rotation, and if it goes well, I’d be grateful if you might consider writing a strong letter of recommendation for my residency applications.”

3. Ask for Feedback Before Asking for the Letter

About halfway through the rotation:

• Ask for informal feedback:
  • “What can I do to be functioning more like an intern?”
  • “Where could I improve in my presentations or clinical reasoning?”
• Apply that feedback consistently

Near the end of the rotation, you can say:

“Thank you for your feedback earlier this month. I’ve tried to incorporate your suggestions about being more concise in presentations and taking more ownership. Do you feel I’ve improved? If so, would you feel comfortable writing me a strong letter of recommendation for residency?”

This approach:

• Shows maturity
• Reinforces that you value mentorship
• Gives the attending a chance to decline if they don’t feel able to write a strong letter

4. Provide a Helpful Letter Packet

Once they agree to write, make it easy for them:

Include in your email or packet:

• Updated CV
• Personal statement (even if in draft form)
• Transcript and/or list of clinical grades
• COMLEX / USMLE scores (if you’re comfortable sharing)
• A brief paragraph summarizing:
  • Your career goals
  • What you valued most on their rotation
  • Key patient encounters or projects you worked on with them

You can also (carefully) include:

• A short bullet list of points they may consider commenting on, such as:
  • Clinical reasoning and problem-solving
  • Professionalism and work ethic
  • Communication with patients and team members
  • Osteopathic approach or OMT skills (for DO letters)
  • Ability to function at the level of an intern

Do not script the letter for them, but gentle reminders of your contributions are welcomed by most busy faculty.

5. Waive Your Right to View the Letter

In ERAS, you’ll be asked whether you:

• Waive your right to view the letter
• Or retain your right

Programs generally prefer waived letters because they are perceived as:

• More candid
• More trustworthy

As a DO graduate, you want your letters to carry maximal credibility across both osteopathic and ACGME programs—so waiving is usually the best choice unless there is a very specific reason not to.

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Timing, Logistics, and Customization for DO Graduates

Getting strong LOR is only half the battle; the other half is managing logistics so everything arrives on time and is used effectively.

Ideal Timeline for Letters

For a DO graduate entering the upcoming match:

• Third year (or early final year):

  • Identify 3–5 potential letter writers
  • Perform strongly on core rotations (IM, FM, EM, Surgery)
  • Ask for letters soon after completing strong rotations

• Late spring to early summer before ERAS opens:

  • Confirm letter writers and send your packet
  • Follow up with gentle reminders every 3–4 weeks

• By ERAS opening (September):

  • Aim to have at least 3 letters uploaded and assigned to programs
  • You can add a 4th letter later if needed, but don’t delay your application waiting on it

Central Letters vs. Specialty-Specific Letters

You can categorize letters into:

1. General clinical letters

   • Appropriate for almost all specialties
   • Focus on your clinical ability, work ethic, professionalism

2. Specialty-specific letters

   • Tailored to your chosen field (e.g., FM, IM, EM, Psych)
   • Should discuss your fit for that specialty specifically

As a DO graduate:

• Use general clinical letters broadly
• Use specialty-specific letters strategically:
  • Assign IM-focused letters to IM programs
  • FM-focused letters to FM programs, etc.

In ERAS, you can select which letters each program sees, so you can tailor your LOR set without burdening faculty with multiple versions.

DO vs. MD Letter Mix in Your Application

In a unified match environment:

• Programs rarely require letters only from DOs or only from MDs
• But your mix of DO and MD letters sends a subtle signal

For a DO graduate:

• Aim for at least one strong DO letter if possible, especially if:
  • You’re applying to osteopathic-focused programs
  • You want to emphasize your osteopathic identity and OMT skills
• It’s perfectly acceptable—and often beneficial—to have a mix:
  • 1–2 DO letters
  • 1–2 MD letters, particularly from larger academic centers

Following Up Without Being Annoying

Attending physicians are busy. To keep your letters on track:

• Initial request: Provide clear deadlines (earlier than the true ERAS deadline)
• First reminder: 2–3 weeks before your stated deadline
• Second reminder: 1 week before, phrased politely and gratefully
• Final follow-up: After your deadline if not received, consider a brief call via coordinator or clerkship office if appropriate

Sample follow-up email:

“Dear Dr. Jones,
I hope you’re doing well. This is a friendly reminder about my residency letter of recommendation for Internal Medicine, which I had requested for submission by August 15. I truly appreciate your support. Please let me know if there’s any additional information I can provide to make this process easier for you.
Sincerely,
[Your Name], DO Candidate”

If someone doesn’t submit after multiple reminders, do not panic—just ensure you have enough other letters to proceed.

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Common Pitfalls and How DO Graduates Can Avoid Them

Even strong applicants sometimes misuse or mishandle letters of recommendation. Here are common mistakes and how to avoid them.

Pitfall 1: Waiting Too Long to Ask

Issue:

• Attending forgets specific details about your performance
• They may be less enthusiastic or more generic

Solution:

• Ask near the end of the rotation when your work is fresh
• Even if you plan to apply a year later, they can still write and upload when ready

Pitfall 2: Choosing “Big Names” Over People Who Know You

Issue:

• A famous department chair who barely worked with you writes a vague letter
• Programs see generic praise without concrete examples

Solution:

• A mid-level attending or community DO who really knows your work is usually far more powerful than a high-profile but distant name

Pitfall 3: Not Aligning Letters With Specialty

Issue:

• Applying to Psychiatry with three surgery letters
• Applying to EM with no EM letters at all

Solution:

• Ensure at least one letter clearly supports your chosen specialty
• Generalists (IM/FM) are fine if they emphasize traits relevant to your specialty: teamwork, composure under pressure, empathy, etc.

Pitfall 4: Ignoring Your Osteopathic Identity

Issue:

• Application looks identical to an MD’s, with no mention of osteopathic training
• Letters don’t acknowledge your OMT skills or holistic perspective

Solution:

• Ask at least one DO or osteopathically minded physician to:
  • Highlight how your DO training benefits patients
  • Mention OMT use if relevant to the specialty (FM, IM, PM&R, Sports, etc.)
• Use your personal statement and CV to align this message with your letters

Pitfall 5: Overloading Programs With Too Many Letters

Issue:

• Submitting 5–6 letters when programs recommend 3–4
• Adcoms may ignore some or feel you’re unfocused

Solution:

• Stick to 3–4 high-quality, curated letters
• Customize which letters each program receives in ERAS

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FAQs: Letters of Recommendation for DO Graduate Residency Applicants

1. Do I need all of my letters from DOs as a DO graduate?

No. For most programs, a mix of DO and MD letters is perfectly acceptable—and common. As a DO graduate, it’s wise to have at least one strong letter from a DO, especially if:

• You’re applying to osteopathic-focused programs
• You want to highlight OMT or osteopathic philosophy

However, letters from MD attendings at academic centers or well-known programs can also carry significant weight. Focus on who knows you best and can write the strongest letter, not just their initials.

2. Is my application weaker if I don’t have a letter from my chosen specialty?

For most specialties, not having at least one specialty-specific letter will make your application less competitive. Programs want to see:

• Evidence you understand the specialty
• An attending in that field vouching for your fit and potential

If you lack a specialty-specific letter, compensate by:

• Having strong letters from closely related fields
• Making your personal statement and experiences clearly align with that specialty
• Planning for a sub-internship or late rotation that can eventually provide a letter (even if it arrives after ERAS submission, you can sometimes add it later)

3. Can I reuse letters for multiple specialties?

Yes—but with caution. You can absolutely reuse general clinical letters that speak to your:

• Clinical skill
• Professionalism
• Teamwork
• Communication

However, if you’re applying to multiple specialties (e.g., IM and FM, or EM and IM), you should ideally have at least one letter clearly tailored to each specialty. In ERAS, you can choose which letters each program sees, so you can assign:

• IM-focused letters to IM programs
• FM-focused letters to FM programs, etc.

4. How can I tell if a letter is strong or just average if I waived my right to see it?

You won’t see the actual text, but you can infer strength from:

• The enthusiasm when the writer agrees (did they explicitly say “strong” or “excellent”?)
• Their history—students and residents may know who writes strong letters
• Whether programs seem to respond positively (e.g., interview offers from places where the letter writer is known or respected)

This is why it’s so important to ask directly,
“Would you feel comfortable writing me a strong letter of recommendation for residency?”
A hesitant or vague answer is a cue to ask someone else.

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Thoughtful, strategic letters of recommendation can significantly elevate your application in the osteopathic residency match and across ACGME programs. As a DO graduate, lean into your unique strengths—holistic care, OMT when appropriate, and the flexibility to thrive in diverse practice settings—and choose letter writers who can clearly and enthusiastically tell that story on your behalf.