MD AI Trouble - Having difficulty getting LoRs

[mehc012]

TL;DR I've got great grades, good Step, and great feedback, but can't seem to work with an attending consistently enough to get a LoR from an AI.

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[mehc012]

Finally got a meeting with AI director #2 (the one who doesn't know me, but knows the game and often writes letters) tomorrow. Turns out, the first person I emailed just ignored my request for the past week and a half

Should I ask this person for a letter? By their own eval, they don't really know me, but...they're the person who collected all of the feedback for me and deemed fit to give me Honors. I was hoping that the attending I worked with so much on the other service would help; I asked them to speak with this attending and give their feedback for the time they spent with me in the OR, and was hoping to get a LoR based on that feedback, but the eval that attending submitted said very little (even though they know my situation and that they were the only attending who had worked with me consistently at all), so I don't think the information I was hoping would be passed along will be included. I don't want to shoot myself in the foot with a weak letter, but I need something!

 

[nimbus]

Speaking as a letter writer, I wouldn’t pursue a letter from someone who is not enthusiastic about providing you a letter. They probably feel like they cannot provide a strong letter for you.

 

[mehc012]

Speaking as a letter writer, I wouldn’t pursue a letter from someone who is not enthusiastic about providing you a letter. They probably feel like they cannot provide a strong letter for you.

This was my take too. In which case, I honestly don't know what else to do to make people enthusiastic. Beyond working hard, getting good evals, and being sure to spend a fair amount of time with the same attendings...what else is there? I can't do anything about their vacations. I can't do anything about a schedule that puts me on nights for weeks at a time. And I can't apply without letters.

 

[ricksimmonsrafowens]

This is a problem encountered by lots applying to surgery for some reason... You have to be comfortable asking faculty you barely know for letters. They may say no though and you have to find back up letter writers. I matched a surgical sub so I knew my letter writers a little better than some of my gen surg colleagues but not by much (it seems like there's usually less subspecialists working in a group so more chance of working with them on a more consistent basis). However, some of my gen surg colleagues asked for letters only after rounding with a big name trauma surgeon for 2 days max or scrubbing a few cases... and then got great letters because the big name surgeons know that the students need letters for ERAS. Just be ready to make a case for yourself in a meeting.

 

[mehc012]

This is a problem encountered by lots applying to surgery for some reason... You have to be comfortable asking faculty you barely know for letters. They may say no though and you have to find back up letter writers. I matched a surgical sub so I knew my letter writers a little better than some of my gen surg colleagues but not by much (it seems like there's usually less subspecialists working in a group so more chance of working with them on a more consistent basis). However, some of my gen surg colleagues asked for letters only after rounding with a big name trauma surgeon for 2 days max or scrubbing a few cases... and then got great letters because the big name surgeons know that the students need letters for ERAS. Just be ready to make a case for yourself in a meeting.

So...we're all but required to ask for crappy letters, but if we find someone willing to BS for us, victory? This seems like a terrible system. And the ones who have higher standards only screw us over worse. I was turned down by an attending I'd worked with extensively, because they only write for people who have also rounded with them and gone to clinic. I was in their OR a lot, but not officially on their team (because all of my own attendings took multiple weeks off during my AI), so they referred me back to the 'people responsible for me'...who they were aware didn't know me at all.

I'm just very frustrated, and honestly pissed off enough that it's making me not want to apply surgery at this point. My school has a crappy gen surg match history (great for subspecialties, though) and I'm starting to understand why...

 

[Neopolymath]

Every specialty should have SLOEs. That's bull****, OP. You will find a way! Don't be afraid to push hard to make a case for yourself.

 

[mehc012]

Every specialty should have SLOEs. That's bull****, OP. You will find a way! Don't be afraid to push hard to make a case for yourself.

I'm just afraid that this will result in me having poor quality letters from people who don't really want to write them.
I actually got the AI director to agree to write a letter based on resident and other attending feedback during my last meeting. Problem is, I'm very much concerned that it will be a poor quality 'pity' letter, which I really don't want, and feel I shouldn't have to rely on when my evals from these AIs consistently cite me as one of their strongest students. It's just frustrating to finish an AI and walk away with nothing. It's not exactly my fault that the attendings are not very hands-on with their team (or went on vacation, or work at satellite hospitals which don't allow students, or in one case, simply refuses to learn any student names and instead just refers to them by irrelevant nicknames).

I think I can double back to my first AI and get a solid letter out of that one. That director actually compiled feedback into a written eval...and if I can guess which attending supplied the statements in that eval, I should be able to get a gold letter (the eval itself would make a solid LoR if it were slightly longer and had anyone's name attached). Problem is, that was months ago now (didn't ask at the time because I only worked 1wk with that attending, and it was my first week of AIs ever and I then went on 2wks of night shifts and didn't see any attendings regularly. Didn't expect such amazing evals at the end of it all, and those came through well after the actual AI ended).

 

[Select All That Apply]

@mehc012 Out of curiosity, why do you think that your perception of the relationship you have with Attending A or Attending B will have an impact on the LOR that they write for you considering you honored both rotations?

Maybe I'm skeptic, but I feel like what you characterized as being pity letters is pretty much the standard e.g. a template with "insert student name here" and "insert dates here." I also heard from some program directors that the most useful LORs that they have gotten from attendings were when they used two different templates: one for students they actually recommend and another one for students they feel obligated to write about, however if you honored each rotation then I don't see why they wouldn't file you in the former slot rather than the latter. I haven't really heard from any residency programs that a LOR was so meaningful that it made or broke a candidate from getting into a program, more often than not most program directors say that all the writers are the same ****, "So and so would make a fantastic doctor in the field of X!" blah blah blah.

 

[mehc012]

@mehc012 Out of curiosity, why do you think that your perception of the relationship you have with Attending A or Attending B will have an impact on the LOR that they write for you considering you honored both rotations?

Maybe I'm skeptic, but I feel like what you characterized as being pity letters is pretty much the standard e.g. a template with "insert student name here" and "insert dates here." I also heard from some program directors that the most useful LORs that they have gotten from attendings were when they used two different templates: one for students they actually recommend and another one for students they feel obligated to write about, however if you honored each rotation then I don't see why they wouldn't file you in the former slot rather than the latter. I haven't really heard from any residency programs that a LOR was so meaningful that it made or broke a candidate from getting into a program, more often than not most program directors say that all the writers are the same ****, "So and so would make a fantastic doctor in the field of X!" blah blah blah.

Because he initially declined to write me a letter due to not knowing me, even though he was the one who assigned me the Honors grade, because it would be generic. He honestly seemed shocked that I had asked him, even though he was my AI director and had already graded me.
He then asked why I looked so upset and assured me that in 10 years nobody will care whether I go to a good residency. This made me more upset, and I'm embarrassed to admit that I teared up (didn't actively cry, but could not help tears in my eyes).
Then he clearly felt bad/awkward and suddenly agreed, with a lot of qualifiers, that if I could get another attending to give him a paragraph or so about working in the OR with me, he'd try to compile feedback and write a letter for me.


Sooooo...yeah, I'm going to count that as a pity letter. Because he wasn't willing to write anything until I teared up, which is not exactly the impression I want to base my LoRs off of.

 

[Neopolymath]

Because he initially declined to write me a letter due to not knowing me, even though he was the one who assigned me the Honors grade, because it would be generic. He honestly seemed shocked that I had asked him, even though he was my AI director and had already graded me.
He then asked why I looked so upset and assured me that in 10 years nobody will care whether I go to a good residency. This made me more upset, and I'm embarrassed to admit that I teared up (didn't actively cry, but could not help tears in my eyes).
Then he clearly felt bad/awkward and suddenly agreed, with a lot of qualifiers, that if I could get another attending to give him a paragraph or so about working in the OR with me, he'd try to compile feedback and write a letter for me.


Sooooo...yeah, I'm going to count that as a pity letter. Because he wasn't willing to write anything until I teared up, which is not exactly the impression I want to base my LoRs off of.

Ahh things that people who never had any actual competition/boomers say.

 

[Gurby]

Because he initially declined to write me a letter due to not knowing me, even though he was the one who assigned me the Honors grade, because it would be generic. He honestly seemed shocked that I had asked him, even though he was my AI director and had already graded me.
He then asked why I looked so upset and assured me that in 10 years nobody will care whether I go to a good residency. This made me more upset, and I'm embarrassed to admit that I teared up (didn't actively cry, but could not help tears in my eyes).
Then he clearly felt bad/awkward and suddenly agreed, with a lot of qualifiers, that if I could get another attending to give him a paragraph or so about working in the OR with me, he'd try to compile feedback and write a letter for me.


Sooooo...yeah, I'm going to count that as a pity letter. Because he wasn't willing to write anything until I teared up, which is not exactly the impression I want to base my LoRs off of.

This sounds terrible, I'm so sorry you're having to go through all of this. What more are you supposed to do?

 

[mehc012]

Speaking as a letter writer, I wouldn’t pursue a letter from someone who is not enthusiastic about providing you a letter. They probably feel like they cannot provide a strong letter for you.

I agree with this, but I suppose I ought to have phrased my question this way: what can I do to help attendings feel as if they could write a strong letter for me? I have little control over what contexts they know me in, and I have already maximized my performance in the settings where they do see me.

 

[mrbreakfast]

Sooooo...yeah, I'm going to count that as a pity letter

This is definitely a pity letter, and I would be apprehensive about using a letter that you only got after you essentially cried in front of the attending. The statement about "no one will care what residency you go to" is disconcerting. This is not the philosophy you want from someone writing a letter for your future.

Having said that, I definitely feel for you. I haven't followed this thread too closely, but it's clear you're in a tough spot not of your own doing. Going on a tangent, I've seen my own friends going into surgery have these same issues, and it's really unfortunate that some surgery attendings seem to have little interest in working with students on rounds/clinics. On my clerkship I had some who cared and went through care plans with us, but also had one attending who told students they wanted to know if the patient peed enough, pooped, or had a fever, and absolutely nothing else.

what can I do to help attendings feel as if they could write a strong letter for me?

I had a surgeon offer to write me an unrequested letter (despite my OR skills overall being very average) due to my outpatient clinic performance. I know clinic is supposedly anathema to you surgery types, but it allows you to demonstrate critical thinking, diagnostic skills, and compassion for care in a way you could never accomplish in the OR (where, in contrast, you demonstrate your arm strength and camera steadiness, and little else). I got to ask questions directly to the attending and review images with him, etc, stuff I could never do during speed-rounds.

OP: can you find the time to spend some clinic days with some attendings? Forget rounding, just shadow. You can also go to the OR to pick up cases with them when you're free. I know this can be hard to do with your time commitments, but think of it as building letters. I personally know an ortho resident with sub-par scores who matched because he spent his free time in the OR/clinic and earned extremely strong letters for it.

 

[mehc012]

This is definitely a pity letter, and I would be apprehensive about using a letter that you only got after you essentially cried in front of the attending. The statement about "no one will care what residency you go to" is disconcerting. This is not the philosophy you want from someone writing a letter for your future.

EXACTLY. I don't plan on using the letter, even if I have to go through the work of collecting it to save face with the guy who is offering to do me this 'favor'. I'm not sure why he has this attitude, considering my evals, which he consolidated, were good and he gave me the Honors mark.

But yeah, I fully recognize this as a pity letter, I just didn't give all the details up front because, well...it's embarrassing. I had more detail initially, but it was honestly an intimidating wall of text and the rant served my own need to vent more than anything else.

Having said that, I definitely feel for you. I haven't followed this thread too closely, but it's clear you're in a tough spot not of your own doing. Going on a tangent, I've seen my own friends going into surgery have these same issues, and it's really unfortunate that some surgery attendings seem to have little interest in working with students on rounds/clinics. On my clerkship I had some who cared and went through care plans with us, but also had one attending who told students they wanted to know if the patient peed enough, pooped, or had a fever, and absolutely nothing else.

On the service I'm discussing, the attendings don't come to rounds, full stop. Ever. So OR is your only chance. And then they were on vacation for weeks.

I had a surgeon offer to write me an unrequested letter (despite my OR skills overall being very average) due to my outpatient clinic performance. I know clinic is supposedly anathema to you surgery types, but it allows you to demonstrate critical thinking, diagnostic skills, and compassion for care in a way you could never accomplish in the OR (where, in contrast, you demonstrate your arm strength and camera steadiness, and little else). I got to ask questions directly to the attending and review images with him, etc, stuff I could never do during speed-rounds.


OP: can you find the time to spend some clinic days with some attendings? Forget rounding, just shadow. You can also go to the OR to pick up cases with them when you're free. I know this can be hard to do with your time commitments, but think of it as building letters. I personally know an ortho resident with sub-par scores who matched because he spent his free time in the OR/clinic and earned extremely strong letters for it.

We had no way of knowing when our attendings' clinics were held, nor did they round with us. The attending who wanted those was on a different service and had his own students during those slots (I asked).

I did go to the OR on my own time to pick up cases. The attending I spent so much time with in the OR was very one-on-one about teaching, and I sought out at least 7 full OR days with him when my team gave me downtime. When I joined him, we discussed case management, reviewed imaging, he quizzed me on that patient's specific workup and what we might be doing differently if X had happened instead of Y, what we would do if we didn't find what we were expecting, what criteria we would use to determine success, workup of similar diseases, pathophysiology, heck even cancer genetics and zebras that I never learned for Step. He quizzed me on anatomy during the operations, including "what do you see in the field?" questions with no clues and having me point out what I did notice (for example, a normal parathyroid, which if you can recognize it without hints or prompting is actually pretty good). I did reasonably well on these, even earning a few fistbumps. I fully expected a solid letter from this guy, and the intern who worked with us basically told me I'd be silly not to ask. I've never spoken so much with an attending, even ones I've shadowed (I have been a huge proponent of shadowing since day 1 in med school). He didn't seem to think poorly of me, as he offered to contact other attendings at other hospitals to speak well of me and encourage them to work with me so they could write me letters. It was all very confusing.

 

[ScubaV]

It may not have anything to do with you and everything to do with him. He may be unfamiliar or uncomfortable writing LoRs (which are unfortunately necessary but useless for evaluating candidates 90% of the time). I don't work in an academic setting, but if I did I would dread having to write a letter for someone. When applying for fellowships I had an attending basically say "write your own letter and I'll sign it". I hated it.

Unfortunately I don't have any practical advice other than to find someone else. Just don't let yourself fall into that trap of neurotic self-analysis that a lot of medical students do.

 

[mehc012]

Sure, I'll just find someone else...and my AI director's advice was "well, just do another AI". Because throwing away a month of my M4 on a rotation that gained me nothing is totally nbd, and I can absolutely just fit another AI (of course they won't be full) in before applications on top of what I already have scheduled!

It shouldn't be this gorram hard, is all. I've literally never bought into the whole 'surgeons are jerks' stereotype at ALL, but now I'm seeing my fellow classmates going to workshops with attendings in their future specialties where they help them plan apps, give advice on AIs and letters, their AI directors volunteer to write them letters because it's the expected thing, etc. And here I am with no LoRs after 2 AIs, having to resort to subterfuge to get an attending to learn my name after working with them for 2wks, because "oh, they never use names for students." It's just frustrating. And where's the guarantee that the next AI will get me anything better? Isn't insanity doing the same thing and expecting different results?

 

[Dr. Retractor]

Have you talked to your surgery chairperson and/or PD at your home program, or a research mentor?

 

[mehc012]

Have you talked to your surgery chairperson and/or PD at your home program, or a research mentor?

This would be them. Well, they're not the chair, but the surgery chair at this hospital doesn't really write letters cuz he's not general surgery.
Research mentor is the only letter I'm banking on right now. Unfortunately, that overlaps with my first AI so it doesn't help numbers wise.

 

[PTPuser]

I am so sorry you're going through this. I would tear up too and start cussing. I can only empathize how ridiculous and exhausting this must be. I wish you the best.

 

[enalli]

A good letter of recommendation could imply that you have decent interpersonal skills, which is antithetical to the practice of surgery. It could sink your application. These attendings are actually looking out for you.

Sorry you're going through this. From what I've heard from some of my general surgery peers, stats are everything. So even if you can't get the letter you want, things may work out in the end.

 

[mehc012]

On the (selfishly) plus side, today I found out that the PD who turned me down was impersonal with the other students, too, and actually gave another AI (who I typically consider to outperform me) an actual lowered clerkship grade without being able to explain why, even though he then offered to write a letter.
Multiple other students chimed in that the other surgeon I worked with in the OR gives great teaching and in-person feedback, but always refuses to give written feedback, even sometimes stating "I don't remember them" about people he still greets by name in the hallways. So. I feel better that it's a tough environment and not just me doing terribly. I think that the fact that I got a few generic sentences out of him is honestly better than average, which doesn't help my application but does lessen the sting.

I'm starting to think there's a reason our school matches crappy in Gen Surg, and it's not that we have crap students. I have classmates who have switched specialty after dealing with this BS; for those on the fence it's a final push in one direction or the other.

 

[ricksimmonsrafowens]

I feel like this situation is very common in general surgery. You still have an AI left and it will yield letters - ask upfront (at beginning of rotation) and state that you're passionate about gen surg and need letters. Don't wait until end of rotation.

 

[Hyahh15]

I matched a surgical subspecialty this year, and this was somewhat of a problem for a few in my cohort - they reached out to the faculty member advising us on the application process on who they should ask for letters from. If you have an AI director who put together evals for you from what other attendings have written/reported, you could ask him/her if they have suggestions on who you could ask for letters. Typically, attendings in the same program talk about who they like and who they don't, so this person should be able to suggest who could write you a strong letter.

 

[mehc012]

I matched a surgical subspecialty this year, and this was somewhat of a problem for a few in my cohort - they reached out to the faculty member advising us on the application process on who they should ask for letters from. If you have an AI director who put together evals for you from what other attendings have written/reported, you could ask him/her if they have suggestions on who you could ask for letters. Typically, attendings in the same program talk about who they like and who they don't, so this person should be able to suggest who could write you a strong letter.

I talked to our school and it sounds like this is an ongoing problem with this hospital's surgical culture. Attendings just dodge writing evals and whatnot. The fact that he didn't even write an eval for my AI grade is not allowed by our school to begin with.