Essential Guide to Strong Letters of Recommendation for DO Graduates in Peds-Psych Residency

Understanding the Role of Letters of Recommendation in a Peds-Psych Residency Application

As a DO graduate applying to a combined Pediatrics-Psychiatry-Child & Adolescent Psychiatry (often called peds psych residency or triple board) program, your letters of recommendation (LORs) carry particular weight. Programs use them to answer several critical questions:

• Can you thrive in a rigorous, hybrid training environment?
• Do you understand and genuinely want a triple board career path?
• Have you worked closely with physicians who know your clinical abilities and professionalism?
• How do you compare to other applicants—MD and DO—those letter writers have seen?

For DO graduates, high-quality residency letters of recommendation can also help:

• Demonstrate parity with MD peers, especially at historically MD-heavy institutions
• Show that you perform strongly in both pediatrics and psychiatry settings
• Highlight osteopathic strengths: whole-person care, communication skills, empathy, and interprofessional collaboration

In a competitive osteopathic residency match environment where many DO applicants now participate in the single NRMP Match, how to get strong LOR is a strategic question—not just a formality. In peds-psych/triple board, where class sizes are small, a few truly excellent letters can meaningfully shift how your application is perceived.

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How Many Letters You Need and What Types to Aim For

Typical Requirements for Triple Board Programs

Most peds-psych/triple board programs follow standard pediatric or psychiatry guidelines, but you must always verify each program’s website. Common patterns:

• Total letters: 3–4 letters of recommendation
• Required clinical letters:
  • At least 1 pediatrics letter
  • At least 1 psychiatry letter
• Preferred mix for triple board:
  • 1 strong pediatrics letter
  • 1 strong psychiatry letter
  • 1 additional letter from either field (or a related subspecialty, like child neurology, developmental-behavioral pediatrics, or child & adolescent psychiatry)
  • Optional: 1 research or leadership letter, if allowed

For a DO graduate in peds-psych, an ideal set might look like:

1. Pediatrics clerkship or sub-I letter from a core teaching hospital
2. Psychiatry clerkship or sub-I letter, ideally with exposure to children/adolescents
3. Letter from a physician directly involved in combined care, child psych, or complex behavioral pediatrics (if available)
4. Optional research/academic letter (peds, psych, or child psych-focused) if the program accepts a 4th letter

DO-Specific Considerations

For a DO graduate residency application, you’ll also want to:

• Include at least one DO writer if possible, especially if you’re applying to osteopath-friendly institutions or former AOA-accredited programs.
• Demonstrate comfort in MD-dominant environments by also having strong MD letters, particularly from academic centers.
• Consider a letter that references your osteopathic approach (holistic care, mind-body connection, family systems perspective)—this aligns naturally with peds-psych philosophy.

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Who to Ask for Letters: Building the Right Mix of Writers

A central question is who to ask for letters to show the best, most authentic version of yourself as an applicant.

Priority #1: Clinical Supervisors in Pediatrics and Psychiatry

Your core clinical supervisors are your most important letter writers. Look for:

• Attendings who directly observed you seeing patients over time
• Supervisors who can evaluate your independent decision-making
• Physicians who watched you interact with children, families, and multidisciplinary teams

Strong options include:

• Pediatrics:

  • Inpatient pediatric hospitalist
  • Pediatric ward attending on your sub-internship
  • Outpatient general pediatrician with whom you spent a dedicated block
  • NICU or PICU attending (especially if your role was substantial and longitudinal)

• Psychiatry:

  • Inpatient child and adolescent psychiatrist (ideal for triple board)
  • Outpatient child psychiatrist or pediatric consultation-liaison psychiatrist
  • Adult psychiatry attending who can still speak to your suitability for child work and your understanding of lifespan issues

Priority #2: Mentors with Longitudinal Contact

Beyond rotation attendings, consider:

• Faculty mentors from a longitudinal scholarly project in pediatrics, psychiatry, or child mental health
• Faculty advisors who supervised you across multiple courses or experiences
• Directors of longitudinal osteopathic or primary care tracks with strong pediatric or behavioral focus

These writers can speak to your consistency, professionalism, and growth over time.

Priority #3: Research, Leadership, and Advocacy Mentors

For triple board, behavioral health, child development, and systems of care are central themes. Strong letters from:

• A research PI on a child development, ADHD, autism, or pediatric mental health project
• A quality improvement mentor in a pediatric ED, inpatient unit, or behavioral clinic
• Faculty overseeing your involvement in child advocacy, school-based health, or community mental health projects

These letters are supplementary but powerful when they tie directly to peds-psych themes.

Who Not to Rely on as Primary Writers

Avoid making any of these your only or primary clinical letters:

• Residents or fellows as sole letter writers (though their input can be incorporated by attendings)
• Faculty who barely worked with you (e.g., a single half-day clinic)
• Non-clinicians (chaplains, social workers, therapists) unless they co-write with a physician who supervised you
• Distant family friends or non-medical professionals, regardless of their status

Their perspectives can be valuable, but in an evidence-driven residency letters of recommendation context, programs weigh attending physician evaluations most heavily.

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How to Get Strong LOR: Concrete Steps Before, During, and After Rotations

Getting an exceptional letter doesn’t start when you email a request; it starts months earlier, with how you conduct yourself clinically and professionally.

Before the Rotation: Set the Stage

1. Clarify your goals.
   Before starting a pediatrics or psychiatry rotation relevant to triple board, ask yourself:

   • What aspects of peds-psych interest me most (autism, trauma, chronic medical illness with comorbid anxiety/depression)?
   • What strengths do I want a future letter to highlight (teamwork, empathy, analytical thinking)?

2. Introduce your aspirations early.
   In the first week, tell your attending:

   • You are a DO graduate (or DO student about to graduate) interested in peds-psych/triple board
   • You hope to earn a letter eventually and want feedback on how to grow into a strong candidate

3. Review competencies and expectations.
   Ask: “What makes a student stand out positively on this service, especially if they’re planning to apply to combined pediatrics-psychiatry?” This frames you as intentional and coachable.

During the Rotation: Behaviors That Lead to Powerful Letters

Focus on consistent, visible behaviors that letter writers can concretely describe.

In Pediatrics settings:

• Take ownership of your patients
  • Pre-round thoroughly; know vitals, I/Os, labs, and overnight events
  • Anticipate questions about growth percentiles, immunizations, and developmental milestones
• Show family-centered communication
  • Sit down when talking to parents
  • Explain plans in developmentally appropriate language to kids
  • Ask about school, sleep, and mental health as part of routine care
• Integrate behavioral and psychosocial factors
  • Screen for social determinants of health
  • Ask about stress, family dynamics, and behavioral concerns

In Psychiatry settings:

• Conduct organized, empathic interviews
  • Develop rapport with both child and caregivers
  • Ask about school, peers, play, and family relationships
• Demonstrate safety awareness
  • Ask clearly and calmly about suicidality, self-harm, aggression
  • Understand basic risk assessment and when to escalate
• Collaborate with the team
  • Communicate clearly with nurses, social workers, therapists, and teachers
  • Be receptive to feedback on interview style and documentation

As a DO applicant, emphasize your osteopathic lens:

• Verbalize how you consider mind-body connections and family systems
• Incorporate holistic questions about nutrition, sleep, physical activity, and stress
• Use OMM/OMT thoughtfully when appropriate in pediatrics (e.g., comfort measures, somatic complaints), while always maintaining safety and evidence-based practice

Asking for the Letter: Timing and Wording

Timing:

• Ask near the end of the rotation, while your performance is fresh in the attending’s mind.
• For away rotations or audition rotations, ask before you leave and confirm the process by which they will upload the letter to ERAS.

How to ask:

Ask in person if possible, then follow with a polite email.

Sample in-person script:

“Dr. Smith, I’ve really valued working with you these past four weeks. I’m applying to combined Pediatrics-Psychiatry-Child & Adolescent Psychiatry (triple board) programs as a DO graduate. Would you feel comfortable writing a strong letter of recommendation for my peds-psych residency application? I’d especially appreciate if you could comment on my work with children and families, and my interest in integrated behavioral healthcare.”

That phrase—“strong letter of recommendation”—gives them a graceful out if they can’t support you strongly.

If they hesitate or seem unsure, thank them and consider asking someone else who can be more enthusiastic.

Providing Supporting Materials

Once they agree, immediately send a succinct email including:

• Your CV
• A short personal statement or paragraph on why you’re pursuing triple board
• A brief bullet list of things you hope they might mention, for example:
  • Your performance managing complex pediatric cases with psychosocial components
  • Your communication with children and families
  • Examples where you showed leadership or initiative
  • Any specific time they gave you feedback and you acted on it

For example:

• Worked up several patients with suspected autism/ADHD and discussed differential and community resources
• Took initiative to coordinate family meetings with social work on two complex cases
• Consistently asked about mood, sleep, and school functioning on peds rounds

This doesn’t script their letter, but it jogs their memory and aligns their content with your overall narrative.

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What Makes a Letter “Strong” for Peds-Psych/Triple Board

Programs are not just scanning for “great student, pleasure to work with” statements. They are looking for specific content and themes.

Key Elements of a Powerful Letter

1. Specific behavioral examples
   Strong letters include anecdotes:

   • “She independently gathered a complex trauma history from a 12-year-old patient in a developmentally sensitive way.”
   • “He noticed subtle signs of depression in a teenager admitted for asthma and appropriately escalated concerns.”

2. Comparative language
   Phrases such as:

   • “Among the top 5% of students I have supervised in the last 10 years”
   • “One of the strongest DO graduates I have worked with, comparable to our best MD students”

3. Detail about clinical reasoning

   • Demonstrating you think across systems: medical, psychological, social
   • Integrating pediatric physical findings with psychiatric symptoms

4. Evidence of professionalism and resilience

   • Reliability with follow-through
   • Handling emotionally intense situations (suicidality, child abuse cases, family conflict) with maturity and appropriate boundaries

5. Suitability for a hybrid, longitudinal training path
   Triple board is long (often 5 years) and intensive. Letters that say:

   • “I am confident she will thrive in the rigorous combined pediatric-psychiatric training environment.”
   • “He has the curiosity and emotional stamina to manage complex, chronic pediatric cases with psychiatric comorbidities.”

6. Affirmation of your career direction

   • “Her commitment to working with children with chronic medical and mental health needs is clear and longstanding.”
   • “He has actively sought out opportunities in integrated pediatric-behavioral care and understands what triple board training entails.”

Signals Programs Often Look For in DO Applicants

• Parity with MD peers
  • Letter says you perform at the same (or higher) level compared to MD students and residents
• Strong clinical fundamentals
  • Confident physical exam skills, solid documentation, concise presentations
• Adaptability across settings
  • Able to function in children’s hospitals, psych units, EDs, and outpatient clinics
• Appreciation of osteopathic principles without overreach
  • You use holistic thinking to inform but not replace evidence-based psychiatry and pediatrics

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Common Pitfalls and How to Avoid Them

Pitfall 1: Letters from People Who Don’t Really Know You

Programs can tell when a letter is generic. Avoid:

• Asking a “big name” department chair who barely interacted with you
• Relying on a brief research experience where you were peripheral

Solution:
Choose less “famous” attendings who supervised you day-to-day and can describe you concretely. A specific, detailed letter from a ward attending outweighs a vague note from a national leader who barely remembers you.

Pitfall 2: Only Adult Psychiatry Letters

For triple board, exclusively adult psych letters raise questions:

• Do you truly understand child and adolescent work?
• Have you actually functioned in pediatric or child psych settings?

Solution:
Ensure at least one letter documents your work with children/families. If your child psych exposure is limited, highlight any pediatric consults, adolescent units, or peds-psych interface you experienced.

Pitfall 3: No Explicit Mention of Triple Board

If your letters don’t mention your interest in peds psych residency or triple board, programs may see you as a generic psych or peds applicant.

Solution:
When you request the letter, clearly state:

• You are applying specifically to combined Pediatrics-Psychiatry-Child & Adolescent Psychiatry programs, and
• Ask if the writer can speak to your suitability for training across these domains.

Pitfall 4: Forgetting to Waive Your Right to View Letters

Programs generally expect applicants to waive their right to see letters, signaling that writers can be candid.

Solution:

• When uploading in ERAS, always select the option to waive your right to view.

Pitfall 5: Late or Missing Letters

A strong letter that never gets uploaded helps no one.

Solution:

• Request letters at least 4–6 weeks before you need them.
• Send polite reminders 2–3 weeks before ERAS submission deadlines.
• Track receipt in ERAS and have a backup writer in mind if a letter doesn’t come through.

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Strategically Using Letters Across Programs

Tailoring When Possible

While ERAS itself doesn’t allow customizing the letter’s text, you can:

• Select which letters go to which programs
• For example, preponderance of pediatric letters for more peds-heavy triple board programs, or more psych-heavy letters for programs with stronger psychiatry emphasis

If you’re also applying to categorical pediatrics or psychiatry:

• Use your pediatrics-focused letters more heavily for categorical pediatrics
• Use psychiatry letters more heavily for categorical psychiatry
• Keep at least one letter that clearly frames your dual/combined interest for triple board programs

Addressing DO-Specific Concerns Indirectly Through Letters

Some programs may be less familiar with your DO school or prior AOA-accredited setting. Letters can help by:

• Explicitly comparing you favorably to students from well-known MD schools
• Highlighting your performance in environments where MD and DO learners train side-by-side
• Demonstrating that you’ve succeeded in academic or tertiary-care centers

You can gently encourage this by including a bullet in your email to the writer:

• If appropriate, please feel free to compare my performance to both DO and MD students you have worked with, since I’ll be entering the unified NRMP Match.

This cue may help them address an unspoken but real concern for some programs.

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FAQs: Letters of Recommendation for DO Graduates in Peds-Psych/Triple Board

1. How many letters of recommendation do I need for triple board, and how should they be divided between pediatrics and psychiatry?

Most programs require 3 letters, some accept 4. As a DO graduate applying to peds psych residency (triple board), a solid strategy is:

• 1 strong pediatrics letter (ideally from an inpatient or sub-I experience)
• 1 strong psychiatry letter (preferably with child/adolescent exposure)
• 1 additional clinical letter (either peds or psych, or a related area like child neurology or developmental-behavioral pediatrics)
• Optional 4th letter: research or mentorship letter related to child mental health, if programs allow

Always verify each program’s specific requirements on their website or FREIDA entry.

2. Can I use the same letters for categorical pediatrics, psychiatry, and triple board applications?

Yes. ERAS lets you assign different combinations of letters to different programs. Common approach:

• For categorical pediatrics: Use mostly or all pediatrics letters plus one letter that speaks to your broader behavioral/mental health interests.
• For categorical psychiatry: Use psychiatry letters plus at least one letter showing your comfort with medical comorbidities or pediatric populations.
• For triple board: Ensure at least one pediatrics and one psychiatry letter, and ideally a letter that explicitly references your interest in combined peds-psych training.

You do not need to generate completely separate sets of letters, but be strategic in how you assign them.

3. As a DO graduate, do I need a letter from a DO physician, or are MD letters enough?

You don’t have to have a DO letter, but it often helps. Ideal combination:

• At least one letter from a DO, especially if:
  • They directly supervised you clinically, and
  • They can speak to your osteopathic training and holistic approach.
• One or more letters from MD faculty, especially at academic centers, to demonstrate your ability to thrive in mixed or MD-dominant environments.

If you can’t secure a DO letter from a meaningful supervisor, prioritize the strongest, most detailed letters, regardless of degree.

4. What if I’m interested in triple board but haven’t had much formal child psychiatry exposure yet?

Programs know exposure can be limited, especially depending on your school. To compensate:

• Make sure your pediatrics letters highlight your behavioral health screening, communication with children, and work with families.
• Ask your adult psychiatry attendings to describe how you work with younger adults and transitions of care, and to comment on your interest in child/adolescent psychiatry if you discussed it.
• Seek out elective or away rotations in child psychiatry or pediatric consultation-liaison psychiatry before application season if possible, and secure at least one letter from that experience.

Be transparent in your personal statement and interviews about your efforts to gain more child-focused experience and how you intend to build on it in training.

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By approaching your letters of recommendation deliberately—choosing the right writers, performing at a high level on key rotations, and articulating a clear, combined-career vision—you can present yourself as an outstanding DO graduate ready to thrive in a Pediatrics-Psychiatry-Child & Adolescent Psychiatry (triple board) residency. Your letters can become one of the most compelling parts of your application, not just a checkbox.