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Emergency Medicine Letters of Recommendation during COVID

While the COVID-19 pandemic has affected all specialties within medicine and has unfortunately disrupted the academic curriculum of medical students across all four years, the rising fourth year students face particular challenges. Even more so, those applying to Emergency Medicine (EM) are placed in an especially unique situation. The EM application process has a few distinctions from that of other specialities, first being the Standardized Letter of Evaluation (SLOE) which is used in place of a program director letter or other traditional letter of recommendation. In addition, EM applicants traditionally seek out at least one away rotation in order to gain a second or third SLOE letter from a non-home institution. In previous application cycles, these additional letters supplied a breadthe to the evaluation of the applicant’s clinical skills and helped balance out any SLOEs that may have tipped the scales in terms of overly positive or overly negative feedback.

Starting in March, COVID-19 travel restrictions and social distancing guidelines quickly reduced the number of away rotations offered. Concerns for the health and wellness of the applicants, host institutions, and patients also made the decision for limiting visiting students an easy one. However, students must now navigate the application process without the opportunity for audition rotations and non-home SLOE letters.

In response to such changes, multiple organizations came together to write the “Consensus Statement on the 2020-2021 Residency Application Process for US Medical Students Planning Careers in Emergency Medicine in the Main Residency Match” which laid out a few brief recommendations:

1. Ideally, each student will complete one and only one EM rotation, typically at their home institution.

  • No away rotations will be completed unless a student is without a home EM program; institutions with capabilities to take on extra students should do so with the intent to provide an EM rotation for such applicants.

2. Each student is expected to have only one EM clerkship SLOE in their residency application portfolio, typically an institutional SLOE from the site of their single EM rotation.

3. As most students will only have a single SLOE, it will be necessary for residency programs to place greater emphasis on non-EM SLOE letters. We strongly encourage programs to use these non-EM SLOEs to help evaluate candidates’ non-cognitive skills and clinical skills in non-EM rotations.

  • Since, non-EM SLOE Letters of Recommendation (LORs) can be requested, the value of such letters increases.

The Council of Residency Directors (CORD) Advising Students Committee also released a statement to emphasize the weight of non-EM SLOE letters and to bring clarity as to what exactly a non-EM SLOE letter is—a term that is new with this application cycle:

  • Encourage programs to give weight to alternative (non-SLOE) Letters. Examples of alternative LORs include, but are not limited to, orphan SLOEs (a SLOE from a home EM rotation at an institution without an associated residency program), EM sub-specialty SLOEs, or a letter written by an advisor for the instance that a student has been entirely unsuccessful in obtaining an EM rotation. The CORD website contains instructions and a template for writing such SLOEs.

  • Given the increased emphasis that will be placed on non-SLOE letters, letter writers who are not EM physicians should be made aware of the importance of ensuring their letters address knowledge, skills, and behaviors typically seen in the "qualifications for EM" section of SLOES. This can be found on the CORD website.

  • While these statements are informative, they do leave certain questions up for discussion. In particular, when advising students hoping to apply to Emergency Medicine, is there a “preferred speciality” from which a non-EM SLOE letter should be written? Will one hold more weight than the other? To help answer these questions, medical education faculty, program directors, advisors, residents and students took to Twitter to try to come up with a consensus. Here’s what they came up with.

*** Disclaimer we are all Emergency Medicine physicians, so this information is aimed at students applying for Emergency Medicine. While that is true, the information below, is likely relevant to other specialities***

Choose an Attending who can attest to your clinical skills

Consider selecting a letter writer who you’ve worked with for a long period of time or someone with whom you worked closely. If he or she could attest to your medical competency and professionalism-- characteristics that shine through no matter what speciality-- then the quality of the letter trumps the specialty from which it came. Additionally, the consensus statement emphasizes that these letters should provide insight into the candidate’s cognitive and clinical skills. While more specialized fields may be less applicable, arguments could be made that any of the six core rotations would provide foundational clinical skills that would be necessary in EM.

Dr. Elizabeth Swain Rempfer brings up the importance of selecting a faculty member with whom you’ve worked closely.
Dr. Michael Cirone, EM Assistant Residency Director, suggests choosing a letter writer who can specifically comment on your EM qualities.

Choose an Attending who can attest to the EM Qualification SLOE Questions

As per the Consensus Statement Regarding SLOEs and Away Rotations from the CORD Advising Students Committee in Emergency Medicine, it will be important this year to focus on obtaining letters from individuals who can attest to one (or more) of the EM qualification questions normally answered on SLOEs. These questions include:

  • Commitment to Emergency Medicine. Has the applicant carefully thought out this career choice?

  • Work ethic, willingness to assume responsibility.

  • Ability to develop and justify an appropriate differential and a cohesive treatment plan.

  • Ability to work with a team.

  • Ability to communicate a caring nature to patients

Applicants should consider a letter writer who can speak to these questions and should be willing to share these questions with their writer. It may be of benefit if you specifically request that they touch upon EM-valued skill sets, especially for writers who are new to the SLOE format or in a specialty outside of EM.

Dr. Eric Blazar, EM Clerkship Director, brings up these specific EM Qualification questions, including your ability to communicate a caring nature to patients!

Dr. Sree Natesan, EM Assistant Program Director, agrees, and points out the importance of letters that touch on work ethic, willingness to assume responsibility and ability to develop and justify an appropriate differential and a cohesive treatment plan.

Dr. Kristy Schwartz, EM Assistant Program Director, agrees, and suggests to specifically ask your letter writers to touch on EM traits!

Dr. Edward Lew recommends finding letter writers who can specifically comment on your strengths.

Choose an Attending in a speciality with crossover

Many specialities have significant crossover with Emergency Medicine. The skill sets required to succeed on different clerkships can be relevant and easily reflected in one’s LOR for EM. Additionally, a successful Emergency Medicine physician must have a wide breadth of knowledge in order to manage conditions that span across all specialties-- from a nursemaid’s elbow to pre-eclampsia. The “Jack-of-all-trades” stereotype regarding EM, allows for an EM bound applicant to choose from a variety of specialties to highlight certain skills. EM program and clerkship directors echo similar sentiments, stating that a well-rounded performance in non-EM rotations will be important.

Dr. Meenal Sharkey, EM Clerkship Director, brings up certain specialties with EM crossover.

Dr. Cassandra Bradby, EM Program Director, recommends you focus on getting letters from core rotations.

Dr. Laryssa Patti, EM Clerkship Director, provides us with a ranking of author specialities.

Dr. Edward Lew points out some strategy around author speciality.

Dr. Abra Fant, EM Program Director, brings up some specialities that might be worth avoiding, due to minimal patient interaction.

Dr. Andy Little, EM Associate Program Director, points out how specialties with the most cross over then to be the specialities we consult the most!

Choose an author with experience writing and reading letters

Most EM SLOEs are written as a group SLOE authored by program leadership including PD, CD, & APD. For your non-EM SLOE, after you have considered the above characteristics, it is also worth considering asking letter writers who have experience writing and reading LORs. CDs, PDs, APD and fellowship directors experience reading and writing a range of LORs, which has attuned them to the language and characteristics that other program leaders are looking for while reading.

Dr. Wendy Coates, Emergency Medicine Professor and Director for Medical Education, brings up the importance of finding balance between name recognition and personalized assessment.

Dr. Cassandra Bradby, EM Program Director, also points out the importance of choosing someone who knows you- not just the biggest name.

Take home points

For students: Develop a plan/strategy for your LORs

Give advanced notice to your chosen letter writers. Despite the changes to the ERAS timeline, not only is advanced notice polite, but it also allows the writer more time to navigate any challenges. CORD will be releasing guidelines for non-EM letter writers regarding the specific format that the emergency medicine community will be looking for on these non-EM-SLOEs.

Dr. Brian Barbas mentions that it will be helpful to let your letter writers know in advance about these upcoming guidelines so that they do not have to re-write your letter.

Be willing to discuss what your goals are with your letter writer. It may be of benefit if you can emphasize why you chose them to write your letter, and express to them what attributes you hope they can attest to after your time working together. This non-EM SLOE process is new for everyone, both within and outside of Emergency Medicine, so don’t be afraid to ask questions or get clarification from your advisors as the application season nears.

For letter writers

Dr. Cullen Hegarty reminds us that CORD’s letter template for the non-EM SLOE will be released within the coming weeks. If EM-bound students have already asked for letters of recommendation, ask for clarification about the format for the letter. Students may be unaware of the template or its upcoming release date.

If you are a practicing EM physician at an institution without an EM residency program, review the CORD guidance on completing a SLOE: The Standardized Letter of Evaluation (SLOE) for Non-EM Residency Faculty

Lastly, per CORD, the SLOE letter was intended to “provide a global perspective on an applicant’s candidacy for training by providing meaningful comparisons to peers applying for training in emergency medicine.” By comparing the applicant to their peers in tiers of thirds, the SLOE allows programs to better discriminate between applicant’s abilities. However, for EM-SLOEs and non-EM SLOEs alike, the written comments section should be completed with every effort to prevent gender bias. UCSF’s website has a “checklist” for writing a letter without gender bias including tips to avoid gendered language and letter-length discrepancies.



Elizabeth Swain Rempfer, MD is an Emergency Medicine, and recent Medical Student who applied to Emergency Medicine.

Brian Barbas, MD is a Clerkship Director for Emergency Medicine and EM Interest Group Advisor.

Lexie Mannix, MD is an Assistant Clerkship Director and Assistant Program Director for Emergency Medicine.

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