What's a bigger red flag: lukewarm LOR or no letter from one of my sub-Is?

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ChordaEpiphany

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I have what should be some incredibly strong LORs from top names in the field (gen surg). Overall I have 5 letters: Chair letter, research letter (from a surgeon), M3 letter (clinical, surgeon), sub-I letter (clinical/research, surgeon), and another sub-I letter (clinical, surgeon).

However, one of the sub-I letters is a bit tainted. One of the PAs on service just decided they hated me. I don't know why. I've never had any other experience like this. I get along with just about everyone. We never had any specific clashes, but around 3 weeks in he took me aside to tell me I was incredibly rude and sometimes interrupted him while he was teaching the 3rd years (I spoke with all M3s after hearing this and all told me this was an insane take and that I was completely socially appropriate). This PA has a history of clashing with interns, but the attendings don't know about this. Anyway, he decided to elevate it to the attending after I had already asked for a letter. My final evaluation from this attending was good (Honors, good comments), but ultimately was a little bland, and in the comments just to me I was warned to be "careful how you come off to support staff. It can be easy to cross the line between confidence and arrogance." My final Dean's letter comments were bland.

I don't think this surgeon would write a bad LOR, but they may write a lukewarm one. I could submit a chair letter, research letter, M3 letter, and sub-I letter, but that's only 2 clinical letters, and a sub-I is not represented.

Is it more of a red flag to have a missing sub-I LOR or a lukewarm LOR?

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A lukewarm letter is a red flag. People are able to choose who writes their letters. If they can't find 3-4 people willing to go to bat for them, it is a red flag.

Better to not have it if the rest of your app is good.
 
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Don’t include it just due to the risk but surgery PAs are legit the worst. They think they’re surgeons lmao. On my rotation, we had a PA who would always question radiologist reads. So in 2 years, he became not only a SICU expert but also a radiologist.

To answer your question, you’ll be fine and match a top program regardless of whether you decide to have a lukewarm letter or a missing subi letter. clearly you go to a top school and that’s the only thing that matters.
 
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Don’t include it just due to the risk but surgery PAs are legit the worst. They think they’re surgeons lmao. On my rotation, we had a PA who would always question radiologist reads. So in 2 years, he became not only a SICU expert but also a radiologist.

To answer your question, you’ll be fine and match a top program regardless of whether you decide to have a lukewarm letter or a missing subi letter. clearly you go to a top school and that’s the only thing that matters.
Off topic, and you probably know this, but a radiologist’s read frequently lacks clinical context and without an appropriate question, even a novice reader would spot things that weren’t commented on. I don’t know what the PA was disputing in this case, just wanted to point that out for those perusing.
 
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I have what should be some incredibly strong LORs from top names in the field (gen surg). Overall I have 5 letters: Chair letter, research letter (from a surgeon), M3 letter (clinical, surgeon), sub-I letter (clinical/research, surgeon), and another sub-I letter (clinical, surgeon).

However, one of the sub-I letters is a bit tainted. One of the PAs on service just decided they hated me. I don't know why. I've never had any other experience like this. I get along with just about everyone. We never had any specific clashes, but around 3 weeks in he took me aside to tell me I was incredibly rude and sometimes interrupted him while he was teaching the 3rd years (I spoke with all M3s after hearing this and all told me this was an insane take and that I was completely socially appropriate). This PA has a history of clashing with interns, but the attendings don't know about this. Anyway, he decided to elevate it to the attending after I had already asked for a letter. My final evaluation from this attending was good (Honors, good comments), but ultimately was a little bland, and in the comments just to me I was warned to be "careful how you come off to support staff. It can be easy to cross the line between confidence and arrogance." My final Dean's letter comments were bland.

I don't think this surgeon would write a bad LOR, but they may write a lukewarm one. I could submit a chair letter, research letter, M3 letter, and sub-I letter, but that's only 2 clinical letters, and a sub-I is not represented.

Is it more of a red flag to have a missing sub-I LOR or a lukewarm LOR?

If all your other letters are otherwise stellar, no one’s going to notice (or care) that you’re missing a sub I letter.

A mediocre letter will DEFINITELY stand out.
 
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Mediocre letters do standout but sometimes I wish they didn’t. Many interviewees who ended up being great candidates had pretty lukewarm letters and I actually told a few of them that and advised them to ask for stronger letters for fellowship. I think some accountability should fall on the attendings who should realize this is going to affect an individual’s future.
 
Had applicants last year that would have been invited to interview if it wasn't for their letters. The thing about less-than-amazing letters is that they stand out like a sore thumb among the piles of flowery endorsements that are boilerplate for most applicants.
 
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Had applicants last year that would have been invited to interview if it wasn't for their letters. The thing about less-than-amazing letters is that they stand out like a sore thumb among the piles of flowery endorsements that are boilerplate for most applicants.
The first part is highly dependent on field/program. The bolded is universal. Reading some of these letters, you'd be surprised how unseriously some take this role and how it can hurt an application. To put it in perspective, we literally deduct points for such letters that can negate a 10 pt. difference in Step 2 CK M3s spend the entire year studying for... I am not sure if it's due to lack of effort, time, unwillingness to help, or if some of the LOR writers writing bad LORs think they are doing a good job.

Letters feel like a crapshoot because unlike grades/scores/research, this doesn't seem like it requires deliberate effort. Many leave it to chance feeling their hard work should speak for itself. Try not to do that. You do have some control over the situation and just like grades/scores/research, it takes some forethought/planning.

1.) Identify the correct faculty: They don't have to be the department chair or PD. Having some leadership would be better than none though because after the first part of the LOR, they describe their experience. After that, figure out how supportive they are. Do they like interacting with students/residents. Any rumors on if they write good LORs? This part's critical because if you pick the wrong person, any further persistence is meaningless.

2.) Longitudinal relationship: Make an effort every few months to ask them about research or something. It takes persistence and it should also be genuine interest. I personally didn't do this as much because I thought it would be perceived as annoying and figured I'd be better off to keep my head down. Truth is there are ways to develop longitudinal relationships without being annoying. Find that balance. This will truly make your LOR stand out because the mentor will be able to write specifically how they worked with you and give specific examples of why you'd make a good resident.

Achieve these two things and your 250 Step 2 CK converts to a 260 Step 2 CK.
 
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DO NOT submit a lukewarm letter. I am a retired physician, 1977 MD, who was a hiring partner at one of the country’s largest single specialty practices in my field.
 
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