Letters of Recommendation

General Letter Requirements

Your letters of recommendation can serve as important distinguishing elements of your application that highlight both academic accomplishments and personal qualities. The Electronic Residency Application Service (ERAS) requires at least 3 letters of recommendation to be considered complete but allows no more than 4 letters, depending on program-specific requirements. Specific requirements should be reviewed on each program’s website before beginning the application cycle to ensure that all requests for letters are made in a timely fashion. 

For more information, please also see the Letter of Recommendation Chapter in this Atlas. 

Of the 4 letters, at least 1 recommendation should be written by the neurosurgery department chairman from your home institution and/or the institution for which you performed an away rotation. The other letters are typically written by academic neurosurgeon mentors who can thoroughly attest to your personal and professional qualities.

The Medical Student Performance Evaluation (MSPE), or dean’s letter, which summarizes your academic performance, is required but is not included in the 4-letter limit. The MSPE/dean’s letter is uploaded separately by your medical school and might not even be mentioned unless it highlights unprofessional or poor academic performance.


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Importance of Recommendation Letters

According to results of the 2018 National Resident Matching Program (NRMP) Program Director Survey for Neurological Surgery, after the United States Medical Licensing Examination (USMLE) Step 1/COMLEX-USA Level 1 score, the most cited factor (100%) with the highest mean importance rating (on a scale from 1 to 5) in selecting applicants for interview was the quality of the letters of recommendation.

Visa status was also cited as a factor for selecting interviewees by 52% of the programs, with a mean importance rating of 3.7 of 5 for international medical graduate (IMG) applicants. Other important factors included interactions with faculty during the interview and visit (cited by 96% of programs; mean importance value, 4.9 of 5). 

Overall, these data highlight the importance of letters of recommendation in selecting interviewees. For IMG applicants, visa status is considered again after the interview, but USMLE Step 1 scores, letters written on the applicant’s behalf, and interpersonal skills shown during the interview/visit remain the most important factors for all applicants.


It is essential for applicants to follow the strict deadlines set. The sooner your application is submitted, the sooner you will receive interview invitations.

On June 25, the Educational Commission for Foreign Medical Graduates (ECFMG) begins distributing ERAS tokens to IMG applicants so they can start working on their application. After this date, applicants can begin generating letter-request forms for each author of their letters through the letter-of-recommendation portal. Letters of recommendation should be uploaded to the ERAS before the application is unlocked for submission and certification on September 5.

Accreditation Council on Graduate Medical Education (ACGME)-accredited programs can begin viewing submitted applications on September 15. In contrast, MSPE letters are not released to residency programs until October 1. Lastly, according to the 2018 NRMP Program Director Survey, 67% of interview invitations are sent before November. This is an important consideration, because most programs send interview invitations in October, which means that most applications are considered well before then. It is crucial, therefore, that applicants look to the September 15 release date as more of a deadline, especially for competitive programs such as neurosurgery residency.

Always remember to be respectful of each letter author’s time, and ask them well in advance of these deadlines. It is good practice to give each letter writer at least 1 month’s notice, and always ask for the letter to be uploaded well before September 15. It would be beneficial to ask each one to submit their letter by August 15. This buffer time will allow for peace of mind when unanticipated circumstances prevent a letter writer from meeting your exact deadline.

When requesting letters of recommendation, especially from those who might not know you well, such as the chairs from your away rotations, it is always a good idea to briefly remind the writer of your noteworthy accomplishments. Sending your CV along with your request can go a long way. Also, sending a courteous reminder to the writer’s administrative assistant regarding the deadline might be a good idea if the due date you provided passes without a reply or as September 5 approaches.

Whom Do I Ask and How?

The letter written by the chair of your home institution’s neurosurgery department (or where you have spent time as a US research fellow) might be the most important letter of all. It is a good idea to have built a relationship with your chair before asking for the letter of recommendation. Plan on requesting this letter early so that he or she is aware of your strong interest and commitment to neurosurgery.

The majority of neurosurgery applicants from US institutions complete 1 to 3 additional subinternships. For IMG applicants, the number of away subinternships is likely to be less, but these away rotations are still highly encouraged.

Letters reflecting your performance at subinternships, although not mandatory, are considered carefully, because it is an evaluation of your performance working within a neurosurgical department. Such letters also provide an objective view of how you work with neurosurgical residents, faculty, and staff. Interview committees can look to these letters for an unbiased opinion of your aptitude for neurosurgery. In addition, not having a letter from a subinternship could be considered unusual, so be sure that you will be able to explain why you chose to send the letters you did if asked.

Making an active effort from the beginning to get more than an impersonal paragraph from the chair at your subinternship can help you later. Before starting an away rotation, it is recommended that you contact the chair’s administrative assistant to find out if the chair has time to meet with you during your time there. If he or she is able, a meeting provides another opportunity for the chair to get to know you and write a more personal letter.

Remember to treat this meeting as seriously as you would an interview, be prepared to answer questions, and dress appropriately. The chairs at some of the most popular neurosurgical subinternships can be known for writing generic, impersonal letters. However, such letters should still be included in your application, but compensate for them with letters from others who know you well.

Last, connections to institutions to which you are applying are an important consideration. The ERAS has no limit on the number of letters that can be submitted in total, but only 4 can be designated to each residency program. This arrangement allows you to send different letters to different institutions.

Although it is not recommended that you send an entirely different set of letters to different programs, if a faculty member who knows you well has a connection to a particular program, it might serve you well to include a letter from this person instead of another in your regular line-up of recommendation writers. Remember that a generic letter from the most well-known faculty member will not add value to your application. As always, use your best judgment, and do not sacrifice the quality of a letter for connection to a program.

Letter Content

Overall, the letter content can range from a more distant, short summary written by the chair at an away rotation to a long, detailed narrative describing many of your accomplishments and personal attributes. Perhaps the most important part of this process is selecting letter writers who believe in your aptitude for neurosurgery and want to see you succeed. If there is doubt in your mind about the positivity of a letter, it is best not to ask that person for a recommendation.

Also, be prepared to explain why you selected the letters that you did at interviews. Prepare yourself to answer questions based on the narratives that your letter writers might have chosen to provide. In other words, be able to anticipate the experiences your letter writers might have included so that you are not surprised by interview questions related to them.

Last Remarks to Remember

Although some programs allow you to send more than 4 letters, it is not necessary to send that many, and you should usually avoid doing so. Programs are different, so some might invite more letters, while others would frown or entirely ignore an extra letter. Use your best judgment, and consult a trusted mentor if there is some aspect of your application for which you are uncertain.

Also, whether you are an IMG or a US medical student, for the ERAS, everyone is expected to waive their right to view each letter of recommendation requested. If any individual you ask to write a letter of recommendation for you chooses to show you their letter, then that is their own choice, but it is not something you should request or expect.

Individual programs decide on consideration of IMGs and which visas will be supported. For subinternships, it is important to explore these opportunities early in your medical education. As previously mentioned, letters from neurosurgery subinternships are considered carefully as objective evaluations of your aptitude for neurosurgery. Letters of recommendation that result from these away rotations might be what sets you apart from other IMG applicants.


Victoria E. Sanchez, BS

DOI: https://doi.org/10.18791/nsatlas.v13.7

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