Editorial: Recommendation season

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This is the season of recommendation-letter requests.

Residents are just beginning their third year, and as part of the application process for fellowships, they need letters of recommendation from various department faculty. Hopefully, the faculty writing these letters are known in the academic community not for wildly exaggerating their assessments or taking bribes, but rather for their excellent judgment, honesty and fairness by at least some of those receiving the letters. For better or worse, I get a fair share of requests for recommendation letters each year, and I’m sure most of you can relate to the difficulties that can arise.

As outlined in the wonderful commentaries by Robert Thorton,1,3 a professor of economics at Lehigh University in Bethlehem, PA, there are four different circumstances you can find yourself in, and corresponding ways to respond, when handling such requests for letters of recommendation. The easiest, of course, is to be asked to write a letter for an excellent resident you know well and are enthusiastic about. You can craft an unequivocally positive, genuinely enthusiastic letter and have plenty of material and interactions to pull from to reflect your honest and heartfelt opinion of the applicant. Indeed, I have occasionally gone so far as to volunteer to write a support letter without even being asked. (I always assume my residents would want my letter, but maybe there’s a reason they are not asking—a point I should perhaps consider more fully.)

Now, with respect to the second scenario, if you like the resident making the request but have reservations about some aspect of his or her performance (always late, doesn’t check reports, doesn’t bring snacks for the attending, etc.), you have a dilemma. A completely honest letter should include the less-than-stellar attributes, but in today’s world (and for many prior years) any letter that falls short of describing the candidate as less than phenomenal is damning; the frank truth is likely deadly. You can certainly try to smooth over any deficiencies with qualifiers or euphemisms. Nevertheless, writing that the resident is “still finding his or her way” when you really mean “hopelessly lost,” or that he or she “is steadily increasing the speed of interpretations” when you really mean “essentially dead at the workstation” will typically be too transparent to sneak by most fellowship directors.

The only real option in this case is to tell the truth—but not the whole truth. I personally do not favor this approach, which can come back to haunt you. Instead, inform the resident that, unfortunately, you cannot provide as strong a letter as he or she would like. Alternatively—and particularly if true—let the resident know that you do not know him or her well enough because you did not write a paper, consume beer, or climb Mount Everest together. Most residents will probably be OK, if not thrilled, with this response. Just don’t expect any snacks from them in the future.

The third scenario you may find yourself in is that of dealing with a dangerous, clueless, delusional, way-behind-the-knowledge-curve, antagonistic resident who is constantly forlorn about picking radiology as a specialty. The fact that he or she has the temerity to ask for a recommendation proves a lack of self-knowledge or reality recognition. You must turn such people down flat. Do not hesitate. Be firm. Leave quickly after your reply. You may lose a friend (less-than-great residents can still be great friends, especially if they bring snacks). If you feel very guilty, as I would, you may want to plan a more thoughtful, soothing response. Frankly, feeling guilty by giving an unequivocally negative reply is easier on all. I wish such a response could be sent by e-mail. However, that is not appropriate unless the resident originally asked for the recommendation letter electronically—all but ensuring in the first place that they won’t get a recommendation. Do not be tempted to write a very so-so letter and then call the recipient to correct any misunderstanding or misrepresentations you may have made in the letter; i.e., shoot the resident down. The resident will appropriately hate you. Remember: These letters are public domain and lawsuits are possible.

Fourth, if—and only if—you are a master of the written word and know precisely how to “write between the lines,” you may get the opportunity to craft a response that superficially looks like a great letter of recommendation but is actually a fellowship killer. This approach also requires the ultimate reader of the letter to be able to appreciate the double entendre; otherwise, it can backfire and leave you with a reputation for honesty beneath most politicians. Such a letter might include such statements as:1,2

  • You will find that no one would do a better job than Jack Munchkin.
  • You would indeed be lucky to get Dr. Munchkin to work for you.
  • For any task Jack is given, no matter how small, he will be fired with enthusiasm.
  • What Jack can perform is staggering and only a fraction of what he is capable of doing.
  • Particularly when there’s vital work to do, Dr. Munchkin is outstanding.
  • If I were you, I would see to it that Jack gets sweeping responsibilities.

Get the idea?

When I was a member of our Medical School Appointment, Tenure, and Promotion Committee, I would read many recommendations, upwards of 8 or 9 per applicant. I observed that any comment that was, or could be, construed as an applicant’s deficiency was generally given more weight by the committee than were the many positive comments. I believe this problem results from severe compaction of recommendation letters into an extremely narrow range of either “perfect” or “not perfect,” rather than a realistic accounting of the strengths and weaknesses that fellowship applicants and all of us have. It’s like grade inflation in grade school; there has to be a range in the evaluation of an individual to accurately elucidate his or her qualifications and capabilities. That range should be on an analog scale, not 0 or 1.

When all is said and done I think a telephone call, even if the government is listening in, is the best way to succinctly express your real feelings about an applicant. I got a call once from a private practice radiologist asking about hiring my fellow. My response was, “I’d move heaven and earth to keep him here.” He got the job. On the other hand, many years ago an academic practice called to ask about another resident. My response was, “How many body bags are you prepared to buy?” Yes, these are very digital responses, but they leave no room for misinterpretation.

Allow me a final note. This year I received a box of fudge and a box of Godiva chocolates as thank you gifts from two residents for taking the time to write recommendation letters for them. In the best of all worlds, it just goes to show you that endorsements can definitely result in a win-win for residents and their bosses.


  1. Thorton, Robert. How to write a difficult letter of recommendation. Planning for Higher Education. 1994;23:60-62.
  2. Thorton, Robert. Lexicon of ambiguous recommendations. Meadowbrook Press, Deephaven, MN 1998, 38-41.
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Editorial: Recommendation season.  Appl Radiol. 

By Stuart E. Mirvis, MD, FACR| September 05, 2014

About the Author

Stuart E. Mirvis, MD, FACR

Stuart E. Mirvis, MD, FACR

Dr. Mirvis is the Editor-in-Chief of this journal and a Professor of Radiology, Diagnostic Imaging Department, University of Maryland School of Medicine, Baltimore, MD.

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