Everyone in healthcare has had an opportunity to require or to write a letter of recommendation. They are a mandatory part of the application for most new positions, almost regardless of the entry level. They are also a major element of the decision-making process for awards and grants.
I do not know how many letters of recommendation I have written. I am confident that the number is somewhere in the hundreds.
There is a common wisdom that letters of recommendation have an "internal code." Lukewarm letters use the words "good" or "very good." Those that are positive but not exceptionally enthusiastic use the words "excellent." Those that are strongly supportive use the words "outstanding" or "superior."
For many people, writing a letter of recommendation is formulaic. Its first paragraph describes the purpose, and the last paragraph describes the writer's true feelings. There are many paragraphs in the middle. But in most letters, the main text simply describes the person's training and accomplishments in a way that is not all that different than the information available on the curriculum vitae.
Often, the middle paragraphs are so mundane and uninformative that the person who needs the recommendation is actually asked to write this part of the letter themselves. The person signing the letter only needs to work on the wording of the first and last paragraphs.
Some people are responsible for writing hundreds of letters of recommendation each year. As you might imagine, they have staff that actually do the work. But when the number of letters is small, the responsibility of writing them can be viewed as burdensome. Typically, when asked for a letter, the response is "Of course!" But this is generally accompanied by the unspoken hope that the day to write the letter will never come.
Everyone has a personal philosophy about how to write a letter of reference. Since this is my blog, I have an opportunity to describe my own way of thinking about it. My approach is simple: When someone requests a letter of recommendation, I ask myself three questions.
First, is it a good idea to write the letter of recommendation at all?
All too often, I am asked to write a letter of reference for someone I hardly know. They mistakenly believe that a letter from me carries weight, even if it is impersonal. Alternatively, I may be asked to write a letter of recommendation for someone who I really do not think highly of. My interactions with them have been disappointing, and that negative sentiment will be so apparent in the letter that its existence will serve them no good whatsoever.
Some of my colleagues will write these letters, but use the adjectives "good" or "very good" to describe their mixed feelings. They will emphasize the person's "potential" to achieve, rather than actual achievements. These letters are generally a death sentence for the applicant's chances.
I do not write such letters, because I know the negative impact that they have. So my response is: "I am not in a position to write an effective letter of recommendation for you. The demands on my time just will not allow me to do it. You really should ask someone else."
Second, am I writing the letter because I want to or because I need to?
Usually I have had highly relevant interactions with the person who has requested the letter, and the application process requires a letter of support from me. Typically, my experiences with them have been uniformly positive. I truly want to support their advancement, but I may not think that they are unique. They need my support, and they deserve it.
In these circumstances, my letter for them will be wonderful. It will use the descriptors "excellent" or "outstanding." It may even say that I recommend the person "in the highest possible terms." But the letter's framework is still formulaic. My positive expressions reside primarily in the first and last paragraphs. Typically, these letters take about 30 minutes to write.
Most people who read such letters think that they are the strongest possible letters that I can write. But they are not.
Third, do I really want the person to get the position or the award?
Sometimes, I am asked to write a letter of support for someone who I think is amazing beyond words and should unequivocably be granted the position or award. The person is so qualified that I cannot think of anyone who is more qualified. If the letter achieves its goal, I will celebrate, perhaps as much as they will. My feelings on hearing the news of their success would be akin to my enthusiasm for a local sports team that wins the world championship -- especially if it is the underdog.
In this situation, it is my responsibility to write a letter of support that truly makes a difference. The letter represents my opportunity to sway the process. I can choose to write a letter than accomplishes its goal or falls short.
The primary purpose of such a letter is not to provide my support. Instead, the letter is intended to ensure that the candidate succeeds. It is not written to be helpful. It is written to persuade.
It is really challenging to write such a letter. For me, such a letter does not follow any formula. It does not rely on the words "outstanding" or "exceptional." It does not recollect the person's achievements or my personal interactions with her or him. In general, these will already be common knowledge.
And certainly, it does not go on for pages and pages. If you want a letter to be effective, length is a distraction.
Instead, my letter is a concise and compelling presentation of the reasons the person should get the position or award. In a nutshell, I say "here is what the position or award requires, and this is the person you are looking for." If you choose this person, it is not she or he who benefits. It is the position or award that now looks good because the process has selected the right individual.
When I write such a letter, I imagine that I am sitting in front of the committee who will make the decision, and I have five minutes to persuade them.
Just five minutes. So every word counts.
How long is such a letter? Typically, it is not very long. It is certainly no longer than one of my "very strong, but ordinary" letters. How long does it take me to write such a letter?
It takes hours and hours.
An exceptionally great letter of support requires a great deal of thought, and to make it work, you really need to mean it. Your unqualified support must show through in every sentence.
To write such a letter, you must discard every previous letter of recommendation that you have ever written. You cannot borrow from anything that has worked in the past. The messaging must be highly individualized, focused, and directed to be incredibly effective.
Such a letter goes through many drafts. It is not possible to get it right the first time. You need to think whether you have chosen the right words and whether you have made your arguments in a compelling manner.
Your letter is your one chance to influence the process. You can waste the opportunity or you can make it work.
The goal is simple. Imagine yourself at the meeting at the time that your letter of support is presented. You want everyone in the room to say: "Wow! Now that is an incredible letter!" The intent is to blow people away.
Mark Twain has been credited with the saying: "If I had more time, I would have written a shorter letter." But credit for the aphorism really goes to the French mathematician and philosopher Blaise Pascal, who (in 1657) wrote:
"I have made this longer than usual because I have not had time to make it shorter."
But I would frame the whole idea about writing such a letter a bit differently.
If you want to write a letter of recommendation that succeeds, you have two choices. You can spend 30 minutes to write a letter that is likely to be ignored, and thus, you will have wasted 30 minutes.
Or you can dedicate hours to write a letter that makes a difference. And you will have made every minute worthwhile.
Disclosures
Packer recently consulted for Actavis, Akcea, Amgen, AstraZeneca, Boehringer Ingelheim, Cardiorentis, Daiichi Sankyo, Gilead, J&J, Novo Nordisk, Pfizer, Sanofi, Synthetic Biologics, and Takeda. He chairs the EMPEROR Executive Committee for trials of empagliflozin for the treatment of heart failure. He was previously the co-PI of the PARADIGM-HF trial and serves on the Steering Committee of the PARAGON-HF trial, but has no financial relationship with Novartis.