Love Letters

Will a letter of intent change your residency rank order?

Most applicants change their residency rank order lists after receiving one.


After conquering interview day, creating the perfect rank order list becomes the next priority for fourth years in the residency application process. Some students and residency programs will write letters indicating a strong intent to rank each other highly.

NRMP Match policies allow program directors and students to express interest in each other. Non-binding statements such as, “We plan on ranking you highly,” or “We hope to work with you next year,” are sometimes misinterpreted by students, who then think they have a guaranteed match.

“The Match is a hard time. Students want to match and program directors want to have all their spots filled with their top applicants,” John Ashurst, DO, emergency medicine program director of Kingman Regional Medical Center in Kingman, Arizona, says. “Take everything with a grain of salt.”

Here’s a breakdown of letters program directors and students will send each other:

The thank you note

For Dr. Ashurst, thank you notes serve as a nice gesture, but some of his colleagues look favorably on receiving a handwritten note.

“I don’t expect to receive them, and I don’t think it’d really give you an edge,” Dr. Ashurst says.

If a student sends Dr. Ashurst a thank you note, he’ll usually acknowledge he received it. He chooses to limit post interview communication to not lead students on and influence their rank order list.

While a thank you note or email is considered common courtesy, Peter Schnatz, DO, associate chairman and residency program director of ob-gyn at The Reading Hospital in West Reading, Pennsylvania, says he’s never heard of a program lowering someone’s rank for not receiving one.

Writing the love letter/letter of intent

In order to express a strong interest in a program, some students will write love letters or letters of intent. Many students indicate their plans on ranking a program highly.

Because of the competitiveness of the Match, some students may feel like they have to do something extra to show they are committed to a program, Dr. Ashurst says.

While applicants feel they need to contact programs to improve their ranking, one study showed only 5% of program directors said they would move applicants up on their rank order list.

“Almost every applicant says they are, ‘interested’, ‘highly interested,” or ‘at the top of your list,’ so comments like that are not likely to be influential,” Dr. Schnatz says.

Dr. Schnatz advises his student mentees to tell their top choice they plan on ranking the program No. 1. In his research, 29% of program directors said they would consider ranking an applicant more favorably if the applicant expressed interest beyond a thank-you note.

He also suggests letting programs know about significant new achievements such as publications or COMLEX scores. Students who didn’t communicate with programs were at a disadvantage compared with students who did, according to research published in the American Journal of Obstetrics & Gynecology.

Receiving the love letter/letter of intent

Receiving a favorable letter after interview day doesn’t imply commitment, but it often does influence a student’s rank order.

It’s common for students to receive letters from programs expressing interest. In one study, about 90% of emergency medicine applicants were contacted before rank lists were due by a residency program after interviewing.

The majority of those contacted described feeling “happy” or “excited” to hear from programs. After the interaction, over half of applicants changed their rank order list.

Dr. Ashurst prefers not to send letters. On the interview trail he says he has seen numerous students receive letters from programs expressing they would rank them highly. Students would then only rank a few institutions that sent them letters and end up not matching.

“It’s something good to receive, but I wouldn’t take it as the final word,” Dr. Ashurst says.

He says students shouldn’t feel obligated to respond in the same way or write a similar letter back to the program.

“If the program is really that interested, a response to that letter wouldn’t make a difference,” Dr. Ashurst says.

More reading

Tips for prepping your Match rank order list

The most important part of your emergency medicine residency application

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