7 tips on letters of intent for residency applications

After residency interviews and before the Match can become an interesting time for fourth-year medical students. This small window is much like an eye of the storm, filled predominantly with anxiety while waiting it out. Of course, the ranking must occur—with applicants ranking programs and programs ranking applicants—but apart from that, this time is often filled with sitting on hands or nervously biting nails, making it an ideal time for applicants to decide if they want to send letters of intent.

This letter is an email sent by the applicant to a program they intend to rank highly. There are many opinions circulating throughout the residency application sphere regarding letters of intent, including what they should and should not contain, or if they should be sent at all.

In this column, I hope to cut through the noise and provide some guidelines and important information about letters of intent. I scavenged this valuable information from successful applicants and my current program director.

In May 2022, I wrote an article for The DO that provided information from 38 interviews I had with those who successfully matched into their #1 residency program choice. During these interviews, I asked the now-residents if they sent a letter of intent and what their thoughts were regarding them. This column dives deeper into that information.

Thoughts from successful applicants

When asked about letters of intent, the 38 interviewees who matched in their #1 residency program indicated the following:

The vast majority of these successful former applicants sent letters of intent. The advice they had on the matter is insightful and can help guide fourth-year students as they weigh whether to send a letter of intent.

Be brief

Many of the interviewees mentioned they intentionally kept their letter of intent short. Many said it was no longer than two or three paragraphs. This is because residency leadership is busy and therefore brevity is appreciated. 

Write to your #1 program only—and be clear that they are your #1

Of the 28 interviewees who sent letters, almost all of them indicated they only sent one letter of intent and that this single outreach was to their #1 program. In the email, the interviewees explicitly stated that the program was their first choice. Be clear!

Many of the interviewees decided not to write to their second- and third-choice programs because they could not honestly say it was their #1 choice. This potential ambiguity could be interpreted incorrectly by the program director and have the potential to negatively impact their ranking.

Express interest

Virtually all of the interviewees who sent letters of intent stated that most of the letter expressed interest in the program. Applicants should share what they liked about the program and why they wanted to attend residency there. Be specific. If there are geographical reasons, family ties, or other similar reasons for having interest, do not hesitate to share these reasons as well. Expressing interest is an important part of the letter of intent.

Explain goodness of fit

Another common thing contained in a letter of intent is why an applicant feels they are a good fit for the program. “Goodness of fit” can be expressed by mentioning relationships with current residents and faculty, connection with the patient population, or other similar thoughts and feelings. This is one of the main things program directors are looking for in applicants and sharing goodness of fit is crucial in a letter of intent.

Explain a weakness in the application

A few interviewees mentioned they again explained a weakness in their application. The weakness was addressed in their interview, and they used the letter of intent as an opportunity to re-address the issue. Applicants may choose to do this in a letter of intent if they feel it is appropriate to do so.

Follow program director instructions

If a program director explicitly states they do not want letters of intent, do not send one. Several interviewees mentioned this was the reason they did not send a letter of intent to their #1 program.

Be honest

My current program director, Daniel Sklansky, MD, program director of the University of Wisconsin-Madison pediatrics residency program, said nothing is more valuable to a physician than their integrity.

Applicants may be tempted to tell more than one program that they are their #1 choice in hopes of increasing their chances of matching. Note that many program directors keep letters of intent (Dr. Sklansky does).

Also keep in mind that many things follow residency, including jobs and/or fellowship. This will require endorsement from program leadership and if dishonesty is discovered, the consequences could be severe.

Thoughts from a program director

In addition to the thoughts of the former successful applicants who matched in their first-choice residency, I wanted to share some pertinent information from my program director, Dr. Sklansky, on the subject of letters of intent.

First and foremost, Dr. Sklansky says that he follows the NRMP guidelines for ranking applicants, which is explicitly to “… rank applicants in the order of [the residency program’s] true preference, not how you think applicants will rank your program.” (More complete background information on the intricacies of The Match algorithm can be found in an article I wrote earlier this year.) With this in mind, a letter of intent would not alter Dr. Sklansky’s approach to ranking the vast majority of applicants.

However, Dr. Sklansky mentioned that letters of intent could alter his approach in two special cases. First,if an applicant is ranked further down the program’s rank order list, near where the perceived “cut-off” might be and he receives a letter of intent, he will review their application materials again to do a “deeper-dive” on the applicant. This may positively or negatively impact the applicant’s position on the rank order list depending on what information is found. It may also change nothing.

Second, if an applicant has a minor weakness, issue or problem on their application, Dr. Sklansky calls this a “yellow flag.” This yellow flag may also have resulted in the applicant being ranked near the cut-off point. However, if Dr. Sklansky receives a letter of intent from an applicant with a yellow flag, he will similarly initiate a deeper dive into the applicant’s application.

It is worthy to note that programs operate differently. But what can be learned from Dr. Sklansky’s insight is that sending a letter of intent may result in more scrutiny of an applicant’s background. The result may be positive, negative or negligible.

Letters of intent are tricky. The information provided by Dr. Sklansky and the data from the 38 interviewees who matched in their first-choice program may seem conflicting in some ways. Choosing to send a letter of intent should be a personal choice made with the help of trusted mentors and advisors.

Related reading:

Applying to residency: Tips for personal statements and letters of recommendation

Residency interviews: Successful residents share their 9 top tips