Letter of Recommendation: Elective vs. Sub-I?

[DrDude]

Most residencies require something like 3 LORs.

I've heard one letter should be from the core rotation you did during 3rd year in the specialty you're applying to (i.e. if applying for IM residency then get a letter from your IM core rotation, if applying for surgery then get a letter from your surgery core rotation, etc).

My question is about the other 1 or 2 LORs. Specifically, which carries more weight: a LOR from a regular elective or a sub-I? For example if say you're applying for IM, is it better to submit a LOR from an IM subspecialty elective (i.e. Gastro, Nephro, etc) or one from a med sub-I? Assuming both letters are of the same quality.

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[Winged Scapula]

Most residencies require something like 3 LORs.

I've heard one letter should be from the core rotation you did during 3rd year in the specialty you're applying to (i.e. if applying for IM residency then get a letter from your IM core rotation, if applying for surgery then get a letter from your surgery core rotation, etc).

My question is about the other 1 or 2 LORs. Specifically, which carries more weight: a LOR from a regular elective or a sub-I? For example if say you're applying for IM, is it better to submit a LOR from an IM subspecialty elective (i.e. Gastro, Nephro, etc) or one from a med sub-I? Assuming both letters are of the same quality.

Probably neither is > than the other, all things being equal.

If the reputation of the program and the letter writer, is the same I might give slightly more weight to a Sub-I for the following reasons:

1) I presume a Sub-I to be more rigorous with greater expectations, so if you do well, you'll get a good LOR. Of course, we know some sub-Is are not so rogorous, but that is a common assumption that they are harder.

2) I don't particularly like to see subspecialty letters in a resident's file unless it is made clear that there is no specific interest in that field. In the case of IM, I could imagine (and perhaps aPD could weigh in) that I would wonder if you are focusing your interests too early rather than being gung-ho about IM.

Sort of wishy-washy reasons but I don't have any great feeling that there is a significant difference.

 

[NotAProgDirector]

I'd highly favor the Sub-I letter.

The Sub I usually involves a heavier workload, overnight call, etc. It really tests how you will do as a resident.

 

[MSI-Scrub]

2) I don't particularly like to see subspecialty letters in a resident's file unless it is made clear that there is no specific interest in that field. In the case of IM, I could imagine (and perhaps aPD could weigh in) that I would wonder if you are focusing your interests too early rather than being gung-ho about IM.

I kept hearing this prior to applying but now that I have interviewd at a few places, I have realized that the point of applying/interviewing is to find a program that will meet your needs. If you don't discuss your needs, you will not ever truly know. With the timing of fellowship applications, if a program does not support your interest early on, it may not be the program for you.

Where I applied, the majority of people either go on to fellowships or are highly research-oriented. If these are your interests, go to a program that encourages and supports these interests.

I know I want to specialize but that does not mean that I am not interested in obtaining a strong IM base. It also doesn't mean that I"m not open to other subspecialities.

So, in my limited experience, figure out what you want and look for a place that supports what YOU want to do. Also recognize that, along the way, you can't only do what you like ALL the time.

 

[Winged Scapula]

I kept hearing this prior to applying but now that I have interviewd at a few places, I have realized that the point of applying/interviewing is to find a program that will meet your needs. If you don't discuss your needs, you will not ever truly know. With the timing of fellowship applications, if a program does not support your interest early on, it may not be the program for you.

Where I applied, the majority of people either go on to fellowships or are highly research-oriented. If these are your interests, go to a program that encourages and supports these interests.

I know I want to specialize but that does not mean that I am not interested in obtaining a strong IM base. It also doesn't mean that I"m not open to other subspecialities.

So, in my limited experience, figure out what you want and look for a place that supports what YOU want to do. Also recognize that, along the way, you can't only do what you like ALL the time.

And you'll get no argument from me about finding a program that doesn't fit your needs. But the facts are that most programs will adequately prepare you to match into a fellowship because most of the variance will be due to your in-training exam scores and if you have a "special" need (ie, only doing Gastro at at Ivy League fellowship) then presumably you will know in advance, before you apply, which programs have a history of sending residents to those fellowships. There are few places in which the program has so much influence (as opposed to your scores, your letters) over your future that you will fail to match into your desired fellowship - if you don't match, its almost assuredly because of something in your application pertaining to you, not your program. And as I noted above, most applicants don't even bother to apply to residency programs that don't have a good track record of sending people to the fellowship programs they're interested in...once you've arrived for the interview, the horse is already out of the barn because you've signaled your intent of interest.

And I know YOU are interested in obtaining a strong IM base, but I stand by my assertion that to PROGRAMS, it might not look that way.

 

[Blade28]

But the facts are that most programs will adequately prepare you to match into a fellowship because most of the variance will be due to your in-training exam scores and if you have a "special" need (ie, only doing Gastro at at Ivy League fellowship) then presumably you will know in advance, before you apply, which programs have a history of sending residents to those fellowships.

This cannot be overstated.

In any field, most decent residency programs will prepare you adequately. The key is to find a place where you'll fit in - where you get along with the other residents, and where you feel like you have sufficient support from the attendings.

A good piece of advice that I received while on the interview trail was for you to randomly pick out an intern, chief resident and attending that you met at the institution. Can you see yourself as one of them one day? Chances are, you'll start to model your behavior/patterns on your colleagues/role models, and will become that type of physician - so don't go anywhere where you absolutely can't stand the people you work with. The name of the program/institution doesn't matter much when you're absolutely miserable and dreading going to work every day (and while you're there, you're constantly looking at the clock and counting down the minutes until you can leave).

Just my $0.02.