Mastering Letters of Recommendation for Med-Peds Residency Success

Understanding the Role of Letters of Recommendation in Med-Peds

Letters of recommendation are one of the most influential parts of your Medicine-Pediatrics (Med-Peds) residency application. For many program directors, they sit just behind clinical performance and USMLE/COMLEX scores when deciding whom to interview and how to rank applicants. In a combined specialty like Med-Peds, strong, personalized letters can be the clearest proof that you are ready for the dual demands of internal medicine and pediatrics.

In the context of the medicine pediatrics match, letters serve three main functions:

1. Validate your clinical competence
   They answer questions like:

   • Can you manage complex internal medicine patients safely?
   • Can you care for children and families with confidence and empathy?
   • Do you function at (or above) the level expected of an incoming intern?

2. Describe your “fit” for Med-Peds
   Med-Peds programs need evidence that you understand — and are truly committed to — this combined pathway. Letters that speak to your adaptability between adult and pediatric settings, your enthusiasm for continuity across the lifespan, and your genuine interest in Med-Peds are especially powerful.

3. Differentiate you from other strong applicants
   Many applicants have similar grades and test scores. Letters of recommendation (LORs) provide narrative details, longitudinal observations, and specific examples that highlight what makes you unique.

Because of the combined nature of Med-Peds, the strategy for residency letters of recommendation is a bit different than for categorical internal medicine or pediatrics. This guide will walk you through how to get strong LORs, who to ask for letters, how to manage timing and logistics, and how to maximize the impact of your letters in the medicine pediatrics match.

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How Many Letters Do You Need—and From Whom?

Programs usually require 3–4 letters of recommendation. Always check each program’s website or ERAS listing, but the following structure works well for most Med-Peds applicants:

Core Recommendation Mix for Med-Peds

Aim for:

• 1 letter from Internal Medicine
• 1 letter from Pediatrics
• 1 additional letter from either Med, Peds, or a Med-Peds faculty member
• Optional 4th letter (if a program allows/encourages four) from:
  • A Med-Peds faculty member (ideal)
  • A subspecialist who knows you very well
  • A research mentor closely tied to Med, Peds, or Med-Peds
  • A chief resident or APD–type role co-signer with an attending

In terms of who to ask for letters to create a strong Med-Peds–aligned portfolio:

• At least one letter from a core inpatient rotation (medicine or pediatrics)
• At least one letter from an outpatient or continuity setting, if possible, where your longitudinal patient care and communication skills are visible
• At least one letter that explicitly endorses you for Med-Peds, not just “residency in general”

Ideal Mix Examples

Example: Strong traditional applicant

• Letter 1: Internal Medicine inpatient attending (core clerkship or sub-I)
• Letter 2: Pediatric inpatient or outpatient attending (clerkship or sub-I)
• Letter 3: Med-Peds faculty member (from a Med-Peds clinic or elective)
• Letter 4 (optional): Research mentor in general medicine or pediatrics who supervised a substantial project

Example: Applicant without local Med-Peds program

• Letter 1: Internal Medicine attending
• Letter 2: Pediatrics attending
• Letter 3: Medicine subspecialist (e.g., cardiology, ID) who worked closely with you
  OR a Pediatrics subspecialist (NICU, heme-onc, etc.)
• Letter 4 (optional): Outpatient continuity preceptor who can speak to your long-term patient care skills

Programs understand that not every school has a Med-Peds program. The key is to have attendings who can credibly speak to your performance in both adult and pediatric environments and—when possible—explicitly affirm your suitability for a combined career.

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How to Get Strong LOR: Laying the Groundwork on Rotations

The most important part of obtaining strong residency letters of recommendation is not the request email. It’s what you do months earlier on the wards and in clinic. Strong letters come from strong relationships and memorable performance.

Behaviors That Lead to Powerful Letters

On internal medicine and pediatrics rotations, focus on:

1. Consistency and reliability

   • Show up early, stay engaged, and follow through on every task.
   • Be the person who notices small but important details: pending labs, overdue vaccines, incomplete documentation.

2. Ownership of patient care

   • Know your patients deeply: their history, social context, goals, and concerns.
   • Anticipate needs and next steps for each patient on your roster.
   • Volunteer for challenging patients and complex family meetings when appropriate.

3. Active learning and feedback-seeking

   • Ask thoughtful, patient-centered questions on rounds.
   • Request mid-rotation feedback and actually act on it.
   • Demonstrate improvement between the first and last week of the rotation.

4. Team contribution and professionalism

   • Support interns and residents; make their work easier, not harder.
   • Maintain composure and kindness in stressful situations.
   • Show respect to nurses, respiratory therapists, case managers, and all staff.

5. Interest in Med-Peds (even on single-discipline services)

   • When appropriate, mention your interest in Med-Peds and continuity across the lifespan.
   • Engage in discussions that bridge adult and pediatric perspectives (e.g., transition of care for adolescents with chronic childhood disease, early risk factors in adults with pediatric conditions).

Concrete Example: Student A vs. Student B

• Student A: Smart, quiet, always present but doesn’t ask for feedback, doesn’t share career goals, and seems to disappear after the rotation ends.
• Student B: Similar test scores, but:
  • Asks mid-rotation, “How can I improve my presentations?”
  • Tells the attending, “I’m planning to apply Med-Peds and would appreciate feedback on skills I should strengthen.”
  • Sends a brief thank-you email and follows up with a question on a topic discussed in rounds.

Even if they perform clinically at the same level, Student B will usually get the stronger, more detailed letter because the attending has a clearer sense of their goals and growth.

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Choosing Letter Writers Strategically

Once you’ve built a track record on rotations, the next step is deciding who to ask for letters. This is where many applicants make preventable mistakes.

Qualities of a Strong Letter Writer

A good letter writer for Med-Peds residency should ideally:

• Have direct, recent clinical supervision of you (within the last 12–18 months)
• Have observed you for at least 3–4 weeks (longer is even better)
• Be able to compare you to other students (“top 1/3,” “outstanding,” “exceptional,” etc.)
• Be willing to comment on both competence and character (work ethic, professionalism, communication)
• Be someone you had a positive rapport with and who knows your goals

Don’t over-prioritize “famous names” if they barely know you. A personalized, specific letter from a well-respected but not world-famous attending is far more valuable than a generic note from a department chair who met you twice.

Balancing Internal Medicine, Pediatrics, and Med-Peds

For the medicine pediatrics match, programs look for evidence that you can thrive in both worlds. When possible:

• Internal Medicine Letter

  • Ideal: from an inpatient sub-internship, ward month, or core clerkship where you took real responsibility.
  • Look for attendings who commented on your clinical reasoning, efficiency, and reliability.

• Pediatrics Letter

  • Ideal: from either inpatient wards or a busy outpatient/general pediatrics clinic.
  • Strong letters highlight empathy with children and families, your ability to explain complex topics to parents, and your adaptability.

• Med-Peds Faculty Letter (if available)

  • This is especially valuable because:
    • They understand the unique demands of Med-Peds training.
    • They can explicitly state that you are a “great fit for Med-Peds.”
    • They can speak to your interest and understanding of a combined career path.

If your institution doesn’t have Med-Peds faculty, consider:

• Faculty who manage transition-age youth (e.g., adolescent medicine, adult congenital heart disease).
• Attendings involved in combined clinics or cross-disciplinary care.

Who Not to Rely on as Primary Letter Writers

Exceptions exist, but generally, avoid using as core clinical letters:

• Letters from non-clinical supervisors (unless it’s a clearly relevant, substantial relationship, such as a multi-year research mentor)
• Letters from older rotations (>2 years ago) unless truly exceptional
• Letters from short electives (1 week) with limited exposure
• Letters where you sense hesitancy or lukewarm enthusiasm from the writer

You can still include such letters as additional (4th) letters if they offer unique insights, but they should not replace your core Med/Peds clinical letters.

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How and When to Ask for Letters

Once you’ve identified your ideal letter writers, the next step is executing a polite, organized, and timely request.

Best Timing for Letter Requests

• For fourth-year core rotations or sub-Is (Med or Peds):
  • Ask near the end of the rotation, ideally during the final week, while your performance is freshest in their mind.
• For earlier rotations or research mentors:
  • It’s fine to ask later, but try to do so by late summer/early fall of your application year (e.g., July–September).

If you are applying in the current cycle:

• Aim to have all letter requests sent by early September (earlier if your school recommends).
• Many programs will start reviewing applications as soon as they are released; late letters can delay full consideration.

Asking in Person vs. Email

In person is best if possible. A simple script:

“I’ve really enjoyed working with you on this rotation, and I’ve learned a lot. I’m applying to Med-Peds residency this year and was wondering if you’d feel comfortable writing me a strong letter of recommendation?”

The phrase “strong letter” gives them an opening to gently decline if they can’t endorse you enthusiastically.

If in-person isn’t feasible, send a concise, professional email.

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What to Provide Your Letter Writers

Make it as easy as possible for your writers to advocate for you. When you request a letter, attach or offer:

1. Updated CV or resume
   Highlight:

   • Clinical honors
   • Research projects and abstracts
   • Teaching/tutoring roles
   • Leadership and service activities

2. Personal statement draft (even if not final)
   This helps them tailor the letter toward your Med-Peds goals and personal narrative.

3. Transcript or grade summary (if appropriate/available)

4. Brief rotation summary
   A short paragraph reminding them:

   • When you worked together and in what capacity
   • A few high-yield patients or experiences you shared
   • Any feedback you received and how you incorporated it

5. Med-Peds–specific talking points (optional but powerful)
   One page (bullet points) with:

   • Your reasons for choosing Med-Peds
   • Key qualities you hope they might comment on (e.g., work ethic, teamwork, clinical reasoning)
   • Any particular achievements on that rotation (e.g., led a family meeting, managed a complex admission, developed a mini-QI project)

6. Deadline and submission instructions

   • Clearly state the date by which you’d like the letter completed (ideally 1–2 weeks before ERAS submission).
   • Provide step-by-step instructions for ERAS (or your matching system) and confirm their email in the system.

Template Email for Requesting a Letter (Med-Peds Focused)

Subject: Letter of Recommendation Request for Med-Peds Residency

Dear Dr. [Last Name],

I hope you’re doing well. I’m applying to Medicine-Pediatrics residency this fall and would be honored if you’d be willing to write a strong letter of recommendation on my behalf.

I truly valued working with you on the [rotation name, dates], particularly [briefly mention one or two memorable cases or experiences]. Your teaching and feedback significantly shaped my growth, and I feel you had a clear view of my clinical skills and my interest in caring for patients across the lifespan.

I’ve attached my CV and a draft of my personal statement, along with a short summary of my work on your service to assist you. ERAS will send you a link with instructions on how to upload the letter; I’m hoping to have all letters submitted by [date].

Please let me know if you’d be comfortable writing a strong letter in support of my Med-Peds residency application, or if there’s any additional information I can provide.

Thank you again for your time and mentorship.

Sincerely,
[Your Name]
[Medical School, Graduation Year]

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Making Your Letters Work for You in the Med-Peds Match

Once your letters are requested, you still have work to do to ensure they are used strategically in the medicine pediatrics match.

Designating Letters in ERAS

In ERAS, you can upload more letters than you send to any single program. This allows you to:

• Customize which letters go to Med-Peds programs vs. categorical Med or Peds programs (if you’re applying to more than one specialty).
• Prioritize Med-Peds–specific or strongly aligned letters for Med-Peds programs.

A typical strategy for Med-Peds programs:

• Must include:

  • 1 Internal Medicine letter
  • 1 Pediatrics letter

• Strongly preferred:

  • 1 Med-Peds faculty letter (if available)
  • 1 additional letter from the strongest supporter (Med, Peds, or research with a clear clinical link)

Coordinating Content (Indirectly)

You cannot write your own letters, but you can shape their focus by:

• Briefly sharing your career goals and what draws you to Med-Peds.
• Highlighting relevant aspects like:
  • Interest in primary care vs. subspecialty
  • Commitment to underserved populations
  • Interest in transitions of care, complex chronic disease, or global health

You might say:

“Because I’m applying to Med-Peds, letters that comment on how I work with both adult and pediatric patients, my adaptability between different clinical environments, and my interest in continuity across the lifespan would be especially helpful.”

This isn’t prescriptive; it just gives your writer a sense of what will be most useful.

Handling Late or Missing Letters

If a letter is delayed:

1. Send a polite reminder 1–2 weeks before your internal deadline.
2. If still not uploaded close to ERAS opening:
   • Consider designating your available letters to ensure your application is not delayed.
   • You can still add an additional letter later; programs may review it if your file is still under consideration.

If a writer ultimately can’t complete a letter, move quickly to request an alternative from another attending who knows you well.

Evaluating Whether to Waive Your Right to See Letters

ERAS allows you to choose whether to waive your right to see your letters. In residency applications, it is standard and strongly recommended to waive this right. Program directors may view non-waived letters as less candid.

If you’re unsure about a writer’s support, address that before officially requesting the letter:

“Would you feel comfortable writing a strong letter of recommendation for me?”

If they hesitate, choose someone else.

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Practical Scenarios and Common Pitfalls

Scenario 1: Limited Pediatrics Exposure Before Application

You’ve had your internal medicine sub-I but no fourth-year pediatric rotations yet. What can you do?

• Use a strong third-year pediatrics clerkship letter.
• Explain in your personal statement and, if needed, in interviews that you have upcoming pediatric sub-Is/electives and are intentionally building your pediatric exposure.
• If possible, ask your dean’s office if your schedule can be adjusted to include an early fourth-year pediatrics experience.

Scenario 2: No Med-Peds Faculty at Your School

You worry that not having a Med-Peds letter will hurt your application.

• Programs understand this limitation; they will not penalize you.
• Make sure at least one letter explicitly describes why you are well-suited for a combined career:
  • Adaptability between patient populations
  • Broad clinical curiosity
  • Commitment to continuity from adolescence into adult life

You can mention in your personal statement and interviews how you sought Med-Peds mentors outside your institution (virtual mentorship, visiting electives, etc.).

Scenario 3: You Had a Rough Rotation

One of your early rotations didn’t go well, but the attending offers a letter.

• Unless you believe the writer ultimately formed a strong, positive impression, decline politely and choose another rotation.
• You can say:

  “Thank you so much for the offer. I really appreciate it. I’m planning to use letters from later rotations that are more directly aligned with my Med-Peds career plans, but I’m very grateful for your mentorship.”

Programs care more about strong recent performance than one early misstep.

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Frequently Asked Questions (FAQ)

1. How many letters should I send to Med-Peds programs?

Most Med-Peds programs accept three to four letters. A good pattern is:

• 1 Internal Medicine letter
• 1 Pediatrics letter
• 1 Med-Peds or additional strong clinical letter (Med or Peds)
• Optional 4th letter from a Med-Peds faculty member or research mentor with a strong clinical perspective

Always check each program’s specific requirements in ERAS or on their website.

2. Is it essential to have a letter from a Med-Peds physician?

It’s very beneficial but not essential. Programs understand that not all schools have Med-Peds programs. A strong combination of internal medicine and pediatrics letters, especially if they clearly endorse you for a combined career, can be just as compelling.

If you can, consider:

• A visiting elective at a Med-Peds site
• Virtual or away rotations with Med-Peds preceptors
• Seeking mentorship through national Med-Peds organizations (e.g., NMPRA)

3. Can a research mentor write one of my letters of recommendation?

Yes, if:

• You had a substantial, long-term research relationship (e.g., 1–2 years).
• They can comment on your work ethic, intellectual curiosity, and reliability.
• Ideally, the research is related to internal medicine, pediatrics, Med-Peds, or population health.

However, research letters should usually be supplemental to core clinical letters, not a replacement for them.

4. How do I know if my letters are “strong” if I can’t read them?

You can’t read them if you waive your rights (which is standard), but you can infer strength based on:

• The writer’s response when you ask if they can write a “strong” letter.
• Their body language and enthusiasm when discussing your performance.
• The depth of your relationship and the feedback they gave you during the rotation.

If an attending seems hesitant or lukewarm, thank them for their time and consider asking someone else.

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Thoughtful planning around your letters of recommendation can significantly strengthen your Med-Peds application. By excelling on rotations, choosing the right letter writers, asking in a professional and timely way, and aligning your letters with your Med-Peds story, you’ll give program directors the clear, compelling evidence they need to feel confident ranking you highly in the medicine pediatrics match.