Letters of Recommendation: A Pharmacy Residency Program's Perspective

In speaking with my colleagues, letters of recommendation are by far the most-valued component of the application packet. While the curriculum vitae (CV) and letter of intent are also important, the recommendation letters are more direct, less biased, and usually a better assessment of the candidate’s qualifications.

With that much riding on the letters of recommendation, it is vital that candidates strategically choose whom they ask to write their letters.

(I must stress that I work in an academic medical center that provides traditional PGY1 clinical hospital residency experiences and a PGY2 residency in infectious diseases. Therefore, the following suggestions may not apply to fellowship, community residency, or job applications.)

Most residencies accredited by the American Society of Health-System Pharmacists (ASHP) require that you submit all your application materials through the Pharmacy Online Residency Centralized Application Service (PhORCAS) system. This limits your letters of recommendation to 3 references, who are required to use the standard PhORCAS form. Fewer residencies are requesting traditional “letters” of recommendation.

Even though 3 recommendations is the standard, it may be beneficial to ask 4 or 5 individuals to write letters of recommendation for you, in case one or 2 are unable or unwilling to do so. You read that correctly: some preceptors, mentors, and colleagues may not want to write letters or recommendations.

Reasons for this include:

• They may be uncomfortable doing so.
• They may never have written a letter of recommendation before.
• They may feel unqualified because they either haven’t observed you in a supervisor role or feel their relationship with you is not optimal to write a letter.
• They may not be able to write a positive letter.

When you finally have a list of those who you would like to ask for letters of recommendation, it is important to determine whether they will be able to write favorable ones. As residency programs are becoming more competitive, you want to be presented in the most favorable yet truthful light possible.

It is entirely acceptable to ask whether they would be willing to write you a letter, and whether that letter would be a good or strong recommendation. If they say no, thank them regardless and move on to the next person.

Before we get into who are some good individuals to ask for recommendation letters, there are a few courtesies I expect from students and residents:

1. Provide adequate time.

Good, thoughtful letters of recommendation take time to construct. Ideally, you should approach the individual about a month before the first deadline.

While this may fall before the ASHP Midyear Clinical Meeting, and you may still be deciding upon your final list of prospective programs, this at least gives advance notice to the letter writers. They may be taking time off for the holidays, they may have other job responsibilities, or they may be writing letters for several individuals.

Personally, I like to have time to pull up student and resident reviews to remind myself of what types of projects they completed and what types of critiques and compliments they received. This can result in a much more personal recommendation.

2. Include a program list.

Once you have decided upon your final list of programs (ideally, this should be 2 weeks before the first deadline), create a quick Word document or e-mail that lists all the program names, residency director name and contact information, application deadlines, and method of recommendation. This last part will most likely be via PhORCAS, but some programs may require a direct e-mail to the program director.

3. Provide your CV and/or letter of intent.

You want your letters of recommendation to be personal. The writers are vouching for your credibility and deservedness for a residency spot, so you want them to be able to point to specific examples that highlight your qualities.

If you are asking one of your first rotation preceptors to write you a letter of recommendation, you want to keep them updated of your subsequent rotations, projects, and experiences. Again, you may want to ask the writer what additional information he or she would need to write a strong recommendation. Some may prefer a quick meeting to discuss goals in person.

Now that you’ve got the basics of a letter of recommendation, and you understand the weight placed on these documents, it’s time to break down who you can ask to write them, and hear my opinion of how those writers impact a clinical, inpatient residency program.

A good recommendation letter can speak to your strengths, comment on improvements to your weaknesses, and highlight key characteristics that would suite a potential resident. You want to cater your letter to the type of program you are targeting.

If you are targeting ambulatory programs, seek out preceptors and employers in similar environments. If you are targeting inpatient, clinical programs, seek out preceptors and faculty members in clinical, academic positions.

Most importantly, you want someone who actually knows who you are.

Each of the following individuals have pros and cons. It is up to you to decide which 3 writers are best for you:

1. Employers

Asking an employer or supervisor to write a letter of recommendation can be a good thing. It shows that you had initiative enough to acquire a job and maintain it while achieving good grades.

Your employers have probably known you longer than your 4- to 6-week rotation preceptor has, so they can speak to your maturity, dependability, and work ethic. However, I caution you to think if the employer can speak to your clinical abilities.

Most residencies are much more concerned with your clinical knowledge, patient evaluations, and formal presentations than your ability to show up to work on time, ring up patients at the register, or correctly refill automated dispensing cabinets. It is much more impactful if your employer can comment on your ability to counsel patients on their medications, interact with providers regarding prescription discrepancies, and highlight examples of you taking the lead on projects.

2. Faculty Members

Faculty members can comment on your clinical knowledge—the crux of residency training. They may have had you for several classes, so they may be able to talk about your growth over the years or how you thrived through the rigorous coursework.

Because some pharmacy classes are growing in student body size, it is in your best interest to make sure that the faculty members you approach for letters of recommendation know you more than just “student who complained about question 4 on the exam.”

Have you worked with them on a project or activity? Are they an advisor to a club you are actively involved in? Have you had them on rotation? Better yet, one you did well on?

The key here is that you want a faculty member who knows you well enough to write a personalized recommendation letter. One pro of asking faculty members is that most have completed residencies of their own, so they know the demands of the programs and can be a good judge of whether you can handle the stress.

3. Rotation Preceptors

A preceptor you had in a rotation similar to the setting you are applying to can be a good idea. Just make sure you did well on the rotation.

Students and residents may feel pressured to ask their “clinical” preceptor(s) to write a recommendation for them, but it is much more important to ask someone who saw you perform at your peak. That said, if you feel you did well on a rotation (look to your final grade and evaluation as a hint), then by all means ask the preceptor for a recommendation.

If that rotation took place in an institution that hosts a residency program, the preceptor can comment on your preparedness for the challenges of residency. If you performed any projects or presentations, the preceptor can speak to that, as projects are a cornerstone of residencies.

4. Other Preceptors

Don’t limit your definition of “preceptor” to just those whom you had on rotation. Was there a pharmacist you spent time with working on a project, research, or publication? (Those are all buzzwords among residencies.)

Performing research while you’re still in pharmacy school is not commonplace, as it is usually not part of the curriculum, so that already shows you have drive. Depending on what your work entailed, you may have already gained some skills or certification necessary for residency, so that pharmacist can highlight those achievements.

5. Non-Pharmacy Recommendations

Some of you may have had a non-pharmacy-related job or volunteer position for a long time and feel that the person in charge is qualified to speak to your leadership or time management skills. If that person is well versed in the structure of a postgraduate training program, then it may be a good idea to ask him or her for a recommendation.

Remember: coming from a traditional hospital-based residency program, I am looking more for clinical proficiency, research skills, and teaching opportunities. So, if your non-pharmacy recommendation cannot speak to these areas, then you may have just wasted one-third of your recommendations.

6. Peers

Generally speaking, you don’t want to have your peers or classmates write letters of recommendations for you. Most likely, they will not know what programs are looking for in regards to letters, and they will not be able to speak to those areas.

Receiving a letter from a peer may also raise red flags for the program (eg, did you not have adequate learning opportunities or impress enough preceptors who you could ask for a recommendation?)

A Note to Local Applicants

If you are applying to programs in the geographic area where you went to school and completed rotations, chances are the programs know a good amount of the faculty and preceptors. Programs can read between the lines and decipher what the letter writer truly is saying. They can also compare your recommendation to other candidates who the writer is vouching for and place the appropriate amount of weight on the letter. This can either help or hinder you.

The PhORCAS Form

Since moving over to a fully electronic system, the way in which letters of recommendation are submitted has changed.

There is a standard form that limits the amount of characters that writers have to describe the candidate. In addition, writers must rank candidates as “exceeds,” “appropriate,” “fails to meet,” or “none-applicable” on the following characteristics:

• Writing skills (clinical, email, and assigned writings)
• Oral communication skills
• Leadership/mentoring skills
• Assertiveness
• Ability to organize and manage time
• Ability to work with peers and communicate effectively
• Clinical problem solving skills
• Effective patient interactions
• Dependability
• Independence and resourcefulness
• Willingness to accept constructive criticism
• Emotional stability and maturity
• Professionalism (professional attire and professional demeanor)

Writers must indicate strengths and weaknesses in at least 3 of these characteristics, though some programs may request more.

At the very end, the writer recommends the candidate as one of the following:

• Highly recommend this candidate
• Recommend this candidate
• Recommend this candidate, but with some reservation(s)
• Do not recommend this candidate

These are all very important things to keep in mind when requesting letters of recommendations. Good luck to all candidates!