Get Strong Letters of Recommendation for Emergency Medicine Residency

Understanding EM Letters of Recommendation as an MD Graduate

Letters of recommendation are one of the most decisive components of an emergency medicine residency application. For an MD graduate from an allopathic medical school, strong EM-specific letters can significantly influence your place in the allopathic medical school match—especially for a competitive emergency medicine residency.

Program directors consistently rank residency letters of recommendation (LoRs), particularly specialty-specific ones, among the top factors in the EM match. For emergency medicine, the standardized SLOE (Standardized Letter of Evaluation) carries unique weight, but traditional narrative letters still matter, especially for non‑EM rotations, research, or gap years.

This article walks you through, step-by-step, how to get strong LORs for EM, who to ask for letters, how to approach faculty, and how to strategically use letters as an MD graduate applying to emergency medicine.

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Types of Letters for Emergency Medicine Residency

Understanding the different kinds of letters you might submit is crucial before you start asking for them.

1. SLOE (Standardized Letter of Evaluation)

For emergency medicine residency, the SLOE is king.

What is a SLOE?
A SLOE is a structured evaluation form created by EM educators and endorsed by CORD (Council of Residency Directors in EM). It compares you to your peers across multiple domains and includes a global ranking and narrative comments.

Typical SLOE sources:

• Home EM rotation SLOE (from your home institution’s EM residency program, if available)
• Away/audition EM rotation SLOE (from another EM program where you rotated)
• Occasionally, a departmental SLOE (authored by a group of EM faculty rather than a single attending)

Why it matters:
Program directors report weighting SLOEs more heavily than almost any other part of the application because:

• They provide a direct comparison to other EM applicants
• The format makes “grade inflation” more difficult
• Faculty familiar with EM training write them with shared expectations

As an MD graduate applying EM, aim for at least two SLOEs whenever possible—one from your home EM program and one from an away/audition rotation.

2. Traditional Narrative Clinical Letters

You may not have enough SLOEs for all programs or you may be slightly non‑traditional (e.g., taking a research year, or applying after graduation). In these cases, strong narrative letters are very helpful.

Common narrative letter writers:

• Non‑EM core clerkship attendings (e.g., Internal Medicine, Surgery, Pediatrics)
• Subspecialty physicians where you did an elective
• Faculty from a longitudinal clinical experience or continuity clinic
• EM faculty from community sites that do not issue SLOEs (using narrative LoRs instead)

These letters show:

• Consistency of performance across clinical settings
• Professionalism, reliability, and communication skills
• How you function in teams and longitudinal care environments (especially relevant given the ED’s collaboration with multiple services)

3. Academic, Research, and Leadership Letters

Not all strong letters must be clinical, but they should add something unique:

• Research mentors in EM or another specialty
  – Highlight critical thinking, scholarship, grit, and follow-through
• Dean’s letter adjunct or academic advisor
  – Provide a longitudinal perspective, explain context or red flags
• Leadership/advocacy mentors (e.g., student interest group advisor, national EM organization mentor)
  – Emphasize leadership, initiative, advocacy, or education

These are particularly useful if:

• You’re applying to academic‑leaning EM programs
• You have a gap year (e.g., research year) and need to show recent, meaningful engagement
• You need to counterbalance weaker aspects of your application (e.g., marginal Step scores, course remediation, or a leave of absence) by demonstrating growth and resilience

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Who to Ask for Letters – And How to Prioritize

Knowing who to ask for letters of recommendation—and in what order—is central to building a competitive EM match application.

Priority 1: EM Program Leadership and Core Faculty

For an emergency medicine residency, letters from EM attendings carry the greatest weight, especially if they are:

• Program directors (PD) or associate/assistant PDs
• Clerkship or sub‑internship directors
• Core EM faculty deeply involved in resident education

Why these people?

• They understand EM residency expectations
• Their names and institutions are familiar to selection committees
• They can accurately benchmark you against typical EM residents and applicants

Actionable steps:

• On your EM rotation(s), identify faculty who:
  • Worked with you for multiple shifts
  • Directly supervised your patient care and presentations
  • Provided mid‑rotation or end‑of‑rotation feedback
• Let them know early that you’re pursuing EM and would value their feedback on your competitiveness

Priority 2: Non‑EM Clinical Faculty Who Know You Well

Some MD graduates have less EM exposure or limited access to EM rotations. This is especially true if:

• Your home institution doesn’t have an EM residency
• You changed specialties late
• You completed medical school earlier and are re‑entering the match

In these scenarios, strong non‑EM clinical letters help show:

• Reliable clinical judgment
• Professionalism and teamwork
• Work ethic and consistency across settings

High‑yield non‑EM letter writers:

• Inpatient Internal Medicine attendings (hospitalist or subspecialty)
• Surgery or Trauma surgery attendings (teamwork and pressure tolerance—highly relevant to the ED)
• ICU attendings (critical care skills and composure)
• Pediatric faculty (if you’re emphasizing interest in pediatric EM or broad EM care)

Prioritize attendings who know you well over “big names” who barely worked with you; EM PDs can easily detect generic letters.

Priority 3: Research, Leadership, and Longitudinal Mentors

These letters can be strong “plus” factors if they:

• Are recent (within the last 1–2 years)
• Clearly describe your role and responsibilities
• Support your fit for emergency medicine explicitly

Example high‑impact letter writers:

• A research mentor on an EM‑related project: sepsis, ultrasound, ED workflow, etc.
• Faculty advisor for your EM interest group or national EM organization role
• A longitudinal mentor who can explain your personal growth or a comeback from previous academic difficulties

Who Not to Prioritize

• Letters from relatives, family friends, or non‑physician professionals
  – Even if they know you well, they don’t help programs assess clinical competence.
• Big‑name specialists who barely worked with you
  – A vague two‑paragraph letter from a famous surgeon is weaker than a detailed letter from a mid‑career EM attending who knows your work deeply.
• Very old letters (more than 3 years old)
  – Especially risky for MD graduates out of training; programs want evidence of recent clinical engagement.

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How to Get Strong LORs for Emergency Medicine

Getting letters is easy; getting strong letters takes planning and strategy. Here’s how to approach it step-by-step.

Step 1: Start Planning Early

For an allopathic medical school match, aim to have your main letters ready by the time ERAS opens for submission (typically September).

General timeline for an MD graduate:

• 6–12 months before applying:

  • Map out which rotations will likely provide SLOEs and traditional LoRs.
  • If you’re a graduate doing additional clinical work (e.g., preliminary year, observership, or research), identify supervisors who can observe you closely.

• End of each EM rotation (home + away):

  • Request a SLOE if your site provides them.
  • Confirm who will author or co‑sign the SLOE (clerkship director, PD, group of faculty).

• 2–4 months before ERAS submission:

  • Confirm that letters have been uploaded or ask politely for status updates.

Step 2: Set Yourself Up for a Strong Letter While on Rotation

Your letter begins long before you ask for it.

On your EM rotation:

• Be consistently early for shifts and stay engaged until handoff is complete.
• Seek progressive responsibility:
  • Present more complex patients as the rotation advances
  • Ask to perform procedures when appropriate (with supervision)
• Request mid‑rotation feedback:
  • Ask: “What can I do over the rest of this rotation to be at the level of an EM intern?”
  • Then visibly act on that feedback
• Show EM‑specific behaviors:
  • Comfort with uncertainty and undifferentiated complaints
  • Clear, structured presentations: chief complaint → ED course → focused differential
  • Strong team communication and interprofessional respect (nurses notice—and their feedback often reaches attendings)

Step 3: Ask the Right Way: “Can You Write a Strong Letter?”

When the rotation ends and you’re ready to ask for a letter, your phrasing matters.

Instead of:
“Can you write me a letter of recommendation?”

Use:
“Do you feel you can write me a strong letter of recommendation for emergency medicine residency?”

This gives the faculty member an “out” if they can’t wholeheartedly support you. A lukewarm or faintly positive letter can hurt you more than no letter.

Ask in person if possible, and follow up via email with:

• Your CV
• Personal statement draft (even if not final)
• ERAS ID (when available)
• A brief reminder of specific patients or experiences you shared, to jog their memory
• Logistics (how to upload to ERAS, deadlines, SLOE form links if applicable)

Step 4: Provide Helpful Context to Your Letter Writers

For MD graduates especially—those possibly returning to the match or with non‑linear paths—context is key.

In your email, consider including:

• One paragraph about:
  • Why EM is the right specialty for you
  • What you’re hoping programs will “see” about you through your letters
• A note about:
  • Any aspects of your application you’d like them to address (e.g., “I had an early academic stumble but have performed strongly in recent rotations; if you’ve noticed that trajectory, it would be helpful to mention.”)

Do not script the letter, but you can share:

• Bullet points of what you did on their service
• Specific feedback they gave you that you internalized and acted upon

Step 5: Manage the Logistics Professionally

• Double‑check the exact name under which they should upload (ERAS often uses full legal names).
• Clarify whether:
  • The EM clerkship director will compose a combined SLOE for all rotators.
  • Individual attendings will contribute to a departmental SLOE.
• Send a polite reminder 2–3 weeks before your application submission deadline if the letter is still pending.

Example reminder email:

Dear Dr. Smith,
I hope you’re doing well. I’m touching base regarding the SLOE/letter of recommendation for my emergency medicine residency application. ERAS opens for program review on [date], so if you’re still able to submit by then, I’d greatly appreciate it.
Please let me know if you need any additional information from me.
Best regards,
[Your Name, MD]

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How Many Letters Do You Need—and How to Strategize Them

Most emergency medicine residency programs allow you to upload up to four letters through ERAS. Not all programs require four, but you should aim to fill all available slots with high‑quality letters.

Ideal Letter Mix for an EM Applicant (MD Graduate)

For a standard EM applicant from an allopathic medical school:

1. SLOE #1 – Home EM Program
   • Essential if your school has an EM residency.
2. SLOE #2 – Away EM Rotation
   • Demonstrates performance in a different academic culture / ED environment.
3. Clinical Non‑EM Letter
   • Internal Medicine, Surgery, ICU, or Trauma—whoever best knows your performance.
4. Research/Leadership/Additional Clinical Letter (ideally EM‑related)
   • Use this slot to highlight your unique background (research, advocacy, teaching, etc.)

If you can’t obtain two SLOEs, maximize:

• One strong SLOE from your main EM experience.
• Two or three powerful non‑EM clinical letters that emphasize EM‑relevant skills (triage, teamwork, acuity, critical care).

Special Situations for MD Graduates

1. MD Graduate Re‑Applying to EM or Switching from Another Specialty

If you’ve graduated or previously matched into a different specialty:

• Obtain at least one letter from your current/recent clinical supervisor (e.g., PD, chief of service) to show:
  • You are performing professionally where you are
  • Your skills are current and translatable to EM
• Add:
  • Any EM rotations you can secure (observerships, electives) that might yield SLOEs or narrative EM letters
• Have at least one letter explicitly address:
  • Why you’re switching to EM
  • Your insight into EM’s demands and lifestyle
  • Evidence that the decision is thoughtful and durable

2. MD Graduate with a Gap Year (Research, Family, Personal Health)

Get a letter from:

• The most recent ongoing professional engagement (research PI, volunteer clinical supervisor, etc.)
• Ensure they highlight:
  • Reliability
  • Professional behavior
  • Skills or qualities that reinforce EM fit (problem-solving, teamwork, crisis management)

3. Low Scores or Academic Issues

Letters can’t erase numerical metrics, but they can reframe them.

Ask one trusted mentor to:

• Explicitly acknowledge growth: “Early in training, [Name] struggled with [X], but since that time, I have seen clear improvement in [Y]…”
• Highlight that your current performance is at or above the level of an EM intern.
• Emphasize strengths EM PDs value: adaptability, resilience, and coachability.

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What Makes an EM Letter Truly Strong?

Program directors are looking for evidence, not just adjectives. The best letters of recommendation for MD graduate residency applicants in EM share several characteristics.

Specific Clinical Examples

Stronger:
“On a busy overnight shift, [Name] took primary responsibility for multiple high‑acuity patients, including a trauma activation and two patients requiring critical airway management. They independently developed differential diagnoses, presented succinctly, and incorporated feedback into their plans in real time.”

Weaker:
“[Name] worked hard and was very interested in emergency medicine.”

Look for letter writers who:

• Watched you in crisis scenarios (codes, traumas, resuscitations)
• Observed your communication with nurses, consultants, and families
• Saw your growth from the start to end of the rotation

Comparison to Peers

PDs pay close attention to comparative language and ranking:

• “Top 10% of students I’ve worked with in the last 5 years”
• “Outstanding; I would be happy to have them in our own emergency medicine residency”

In a SLOE, these comparisons are explicit (e.g., global rank list, descriptors like “outstanding,” “excellent,” etc.). In narrative letters, they may be more subtle—but still meaningful.

Clear Support for EM as the Right Fit

Program directors like letters that explicitly connect your strengths to emergency medicine:

• Tolerance for uncertainty and rapid decision-making
• Ability to handle high patient volume without sacrificing safety
• Comfort with patients across all ages and acuities
• Team orientation and interprofessional respect
• Emotional resilience and professionalism under stress

If a letter merely says you’re “a good medical student” without tying that to EM‑specific competencies, it carries less weight.

Internal Consistency with Your Application

Your letters should complement:

• Your personal statement
• Your rotation choices
• Your research/activities list

If your statement emphasizes a passion for community EM and underserved care, but all your letters are from ICU faculty at elite tertiary centers and don’t mention this interest, the narrative feels disjointed. Aim for coherence.

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Putting It All Together: Practical Scenarios

Scenario 1: Traditional MD Graduate, US Allopathic School, Applying Directly into EM

• Rotations:
  • Home EM rotation with SLOE
  • Away EM rotation with SLOE
  • Core IM and Surgery rotations
• Letters:
  • SLOE – Home EM clerkship director
  • SLOE – Away EM site (PD or clerkship director)
  • IM attending letter
  • EM research mentor letter, highlighting scholarship and interest in academic EM

Scenario 2: MD Graduate After a Preliminary Internal Medicine Year, Now Applying to EM

• Rotations:
  • Prelim IM year
  • EM elective during PGY‑1 year (if possible)
• Letters:
  • SLOE from EM elective (even if short, still valuable)
  • Letter from IM program director or chief of service
  • Letter from an inpatient IM attending who supervised you repeatedly
  • Optional: prior EM mentor from medical school who can speak to longstanding EM interest

Scenario 3: MD Graduate with a Research Year After Medical School

• Rotations/Work:
  • One or two EM rotations during M4 (SLOEs)
  • One or two EM‑relevant research projects in gap year
• Letters:
  • SLOE – Home or away EM
  • SLOE – Second EM rotation (if available)
  • Research mentor letter explaining your role, reliability, and EM‑related skills
  • IM or ICU attending letter demonstrating strong clinical skills

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FAQs About EM Letters of Recommendation for MD Graduates

1. How many SLOEs do I actually need for an emergency medicine residency application?

Most EM program directors prefer two SLOEs from EM rotations. If your school doesn’t offer EM or you have limited access, one strong SLOE plus several robust clinical letters can still be competitive. Always check individual program requirements, but when possible, aim for two.

2. Should I choose a big‑name attending who barely knows me or a less famous faculty who worked closely with me?

Choose the faculty who knows you well almost every time. EM match committees can recognize generic, superficial letters, and they will value detailed, specific endorsements over prestige without substance.

3. As an MD graduate re‑entering the match, how recent do my letters need to be?

Ideally, at least one or two letters should be from the past 12–18 months, reflecting your current abilities and professionalism. If you’ve been doing a preliminary year, research, or clinical work, get letters from your current supervisors. You can still submit one strong, older letter if it’s uniquely powerful, but don’t rely solely on distant experiences.

4. Can I see my letters of recommendation before they are sent?

In the ERAS system, letters are intended to be confidential, and most programs expect them to be uploaded directly by the writer. While some faculty might share the content informally, you should not request to edit or rewrite your own letter. Instead, invest your effort in choosing the right writer, performing strongly, and providing helpful background materials.

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Strong letters of recommendation are not an afterthought; they are a central strategy in your emergency medicine residency application as an MD graduate. By targeting the right letter writers, setting yourself up for strong evaluations during rotations, and managing the process professionally, you can significantly strengthen your EM match prospects and present a coherent, compelling picture of yourself as a future emergency physician.