Today I got an email from a reader asking me for some advice on which referees he should ask to write his three letters for medical school admissions. If you haven’t read my first article on reference letters, I urge you to do so before reading this one. If you’re too lazy, the cliff notes of that article are that you should pick referees who know you very well and who you know genuinely want to support you in your quest to become a doctor. Simply put, unless your referee has known you for a long time, he will have nothing of substance to say about you. And unless your referee really wants you to become a doctor, then he has no reason to producing something with substance.

Of course, the question that remains is: “but what if my three strongest references are too similar”?

Why Diversity is Good

We have established that the strength of the letter is more important than who wrote it. It’s easy to see that what is written is significantly more important than who it is written by. For example, a one page letter written by your research supervisor is probably going to be better than one paragraph written by the dean of your faculty. However, one clear exception would be if your strongest possible letters would end up being too similar in content.

Reference letters can become redundant if they are focused on the same thing, and worse, they can leave out important information. For instance, if your three referees were all professors / researchers you worked with, chances are a lot of the same traits will be mentioned (e.g. intelligence, work ethic, problem solving, etc.). While these are most definitely traits necessary for a good physician and traits you want highlighted by your referees, you want to ensure that your reference letters hit on as many relevant traits as possible. You also want one or more of your referees to evaluate your abilities in compassion, empathy, etc. – traits less likely to be seen in a research environment, but commonly utilized in various community/volunteer experiences (which many of you are bound to have).

One quick way to think about this (at least for Ontario medical school applicants) is to check the OMSAS reference form and see what traits the referee is supposed to rate you on: intellectual capacity, initiative, leadership capabilities, maturity, cooperation, integrity, problem solving, fluency in spoken/written English, ability to communicate, ability to relate to others, ability for self-directed learning, and critical thinking ability.

Knowing that you are being rated on these qualities, you want to select referees whose relationship/experience with you is diverse enough to achieve high ratings across all of these traits, even if those high ratings don’t necessarily come from the same referee. The point is to prove you are strong in all of these categories in some way or another, and it may be hard to do that if all of your referees are commenting on the same few traits. Two referees saying you are smart and one saying you are compassionate is way better than three referees saying you are just smart (That being said, it would be even better if all three said you were both smart and compassionate, so let’s aim for that when picking our referees!).

Long story short, physicians are multi-dimensional and therefore, you want your reference letters to reflect the same about you. It can be hard to do this unless your referees themselves come from diverse backgrounds and have different experiences with you.

So how should we go about obtaining diversity? The 2+1 Rule

To make it easier, let’s start by simply dividing up all possible referees into two groups: academic vs. non-academic. Academics would be individuals like course professors, research supervisors, etc – basically anyone who has seen you in an academic setting and can comment on you as a scholar and student. Non-academics would be individuals like volunteer supervisors, club facilitators, team coaches, etc. – anyone who has seen you in a non-academic, and more extra-curricular capacity.

We’ve established that if possible, we don’t want all three referees as academics, and nor do we want all three as non-academics. In that case, the only satisfactory solution is what I will now name as the 2+1 Rule of reference letters: you should aim for at least one academic and one non-academic reference letter, with the third letter being anything that you want (leading to 2 academic/1 non-academic or 2 non-academic/1 academic, and hence, the 2+1 Rule).

Personally, I had one academic (research supervisor) and two non-academic (two volunteer/community experience supervisors). While my research supervisor could most definitely account for my intellectual capacity, problem solving and critical thinking ability, there’s no way he would have been able to comment on my cooperation and ability to relate to others to the extent that my choir director was able to, and vice versa. But taken together, all three reference letters were able to create a complete picture of me, as a candidate with all of the traits sought for.

In the story I referenced at the beginning of the article, the student who emailed me listed all of his potential referees, and it was clear that he felt his strongest three letters would come from three academics. But once I saw that he had a volunteer supervisor who he had worked a fair bit of time with and whose strength of letter he predicted would be almost as good as the other three, in my mind, it was an easy decision to pick the two best academic letters and include the volunteer supervisor as the third, even though the three academic letters would each have been better in a vacuum. The key point here was deciding on which three letters work together best in combination, and that is best achieved using the 2+1 Rule as a foundation.

What if I can only find 3 strong references of the same type?

One caveat to the 2+1 rule is if you feel you lack a strong reference in either the academic or non-academic field – if this is you, it might be important to ask to what degree you are exploring both your academic and non-academic aspects of your life, and if there is something you should explore further. However, sometimes you may simply have to go with three academic or three non-academic referees – and that’s fine. There are most definitely medical students who had three academic or three non-academic referees.

That being said, I would ask your referees to comment on as many traits as possible, beyond what they normally would (e.g. if you have three academic references, ask them to comment on more than the usual academic-related traits). Bring up specific experiences of yours that you think they should keep in mind. For example, if you have three academic references, ask them if they know of your experiences beyond the academic setting. Have any of them see you do things in the academic setting that would demonstrate compassion or empathy, for instance?

Who writes your letter isn’t as important as the letters presenting you as well-rounded, complete candidate. As long as they can do that, I think it’s fine if your referees are all academic (or all non-academic).

To sum up, you want to pick referees who have known you the longest, who genuinely want to help you get into medical school, and who as a group, can positively comment on all of your different qualities.

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If you applied to medical school this past year, you probably know where you’ll be this fall by now. Some of you may have been accepted into medical school and are excited for the journey that lies ahead. If so, congratulations, and best of luck as you start a brand new chapter in your life! Getting into medical school is an amazing accomplishment, but a lot of hard work and challenges still lie ahead. I’d suggest enjoying your summer as much as you can before the work really piles on =).

Others, however, may have fallen a bit short in the process and are now wondering what your next steps should be. If that’s you, then this article is for you. Before we go any further, you need to do something first.

Give Yourself a Pat on the Back

I know giving yourself a pat on the back won’t change the results of this past year, but fact is, you deserve it. Applying to medical school is hard, especially when you consider that you’ve really been “applying” since day one and not just when you started writing your application last fall. I’ll say it again: applying to medical school is hard. And tiring.

From filling out applications, to getting references letters, to doing interviews (not to mention staying on track of your school work, extra-curricular involvements, and your personal life) – the whole process is draining. And don’t delude yourself into thinking the process ends once you get into medical school. It keeps going because, well, you will have to compete for residency spots as well. Of course that is ways into the future, but it’s important to keep in mind that you’re still going to have to compete in the years that follow entering medical school. It is what it is.

So congratulate yourself for getting through this year. Even though you didn’t get in this year, going through the application process can only make you a better applicant for next year’s cycle. You will learn from your mistakes. Not only that, but you can build on last year’s application – a lot of the basic grunt work (for example, figuring out who your references will be, creating a list of all your achievements/experiences, etc.) is now done, and what happens now is more about improving than starting from scratch. That makes a huge difference.

Still, we can’t start analyzing what you should do in preparation for applying again. There’s still one more important question to ask at this point.

Should I even apply to medical school again?

Just because you have applied once or twenty times already, doesn’t mean you have to apply again this year, or ever again. Before you consider how to improve your chances, you need to decide whether this is something you want to try for again.

Perhaps you have realized there is something else you want to pursue instead of medicine. Maybe your responsibilities in life are increasing and taking a chance on medical school is no longer an option (e.g. you have a growing family, and you need to start your career now). Maybe you think you’ve done all that you can and you won’t be able to do this again.

Whatever the case, take the time to think about whether you really want to apply again. As we have established, the application process is time consuming, draining, and hard.

If your answer is still yes, you want to apply, then keep reading.

GPA / MCAT

As I have written many times before, if you are applying to medical school, you should care about your GPA and MCAT scores the most. Your academics are what get your foot in the door. It doesn’t matter how good the rest of your application is – if your academics aren’t good enough, you have no shot.

You need to ask yourself if your GPA is preventing you from being eligible or competitive for certain medical schools. If not, can you do well enough with another year of undergraduate courses to give yourself a better chance at more schools? For instance, if you had a <3.70 GPA for your first three years of undergrad, but a >3.70 GPA for your last year, it may be worth doing a fifth year of undergraduate studies and hopefully be eligible for Western and Queen’s medical schools, which require two years with a GPA >3.70.

Similarly, is it worth re-taking your MCAT? If you know you’re capable of doing better, and it could open up doors to more schools, then maybe it’s worth retaking. For example, you have a 40M on your MCAT, and have not gotten into the few medical schools you’ve applied to the past few years. It might be worth taking the MCAT again to give yourself a shot at Western/Queen’s (which require a higher WS score), especially since having scored 40, it’s likely you will do more than well enough on the non-WS sections. On the other hand, if you struggled to get a 30P, then it might not be worth taking the risk of writing the MCAT again unless those schools you will apply to again only look at your best score, and not your most recent.

Volunteering, Extra-Curriculars, etc.

Do you have medically/health care related experiences? Do you have leadership experience? Do you have teamwork experience? If your answer is no to any of these, then I’d suggest starting to do something in those areas.

Medically/health care related experience like shadowing physicians, volunteering in a hospital, attending a conference for students interested in medicine, etc. demonstrate a real interest in medicine and show that you have some basic understanding. It shows you are at least somewhat serious about a career in medicine – that you’ve really though about it and taken the time to explore medicine.

Physicians often need to take on leadership roles, such as in a health care team. You want to have some sort of leadership experience, such as running a school club.

Of course, physicians aren’t always in charge, and are very often team players. If you haven’t yet, get involved in something where you have to work with others, such as a team sport, musical band, school club, etc.

If you want to be really safe, read the CanMEDS roles, and see if you have some sort of experience that demonstrates those qualities.

Reference Letters

It would also be a good idea to think about whether you got the best reference letters possible the last time around. Is there someone who would write you a stronger letter? Could you benefit from a bit more diversity (e.g. are all your referees academics? Are they all non academics? etc.)?

Remember, most importantly, you want a referee who wants you to get into medical school. If you don’t think they support you that much, I would suggest looking for an alternative referee if you can.

Essays

If your essay(s) were good enough to get an interview, then it is probably not worth changing completely.

But if you didn’t garner an interview, it is probably worth starting completely from scratch and coming up with new and improved angles to answer the question.

And don’t think it’s too early to start thinking about something as challenging as revising, or perhaps, re-writing your essay. A friend of mine asked me for advice on an essay that wasn’t successful in this past year’s cycle, just a few months ago. I am confident his hard work will pay off in the upcoming application cycle.

Have a Contingency Plan

I have to conclude by saying that no matter what, you need to be planning long term. Although you don’t have to stick to this plan, it’s good to think about your alternatives. If I don’t get in the next time, is that it for me? Should I apply again? Should I take a year off first?

These are all important questions you want to have at least some vague answer to so that you can form an outline for not just the coming year, but for the next few years to come.

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Every medical school has a different philosophy when it comes to evaluating applicants. Some schools, like Queen’s and Western, look at your GPA and MCAT scores first, and pretty much guarantee you an interview if you meet certain cutoffs. Some schools, like the University of Toronto, look at your entire application package first before granting an interview: GPA, MCAT, personal essay, biographical sketch, and reference letters.

As with any medical school, you will get complaints about the process. Personally, I think it’s great that the medical schools have such different philosophies on admissions, so that many great candidates with different backgrounds are likely to get in somewhere. But when it gets more personal, and your application package isn’t as competitive at a certain school, it’s understandable for people to be a bit frustrated.

As an example, some applicants have voiced frustration with the fact that UofT’s medical school admissions places a greater weight on reference letters than some other schools. The most common argument is that there is a lot of variance involved with reference letters since it is out of the applicant’s control, in terms of how well the referees are able to write. So it is very possible that an applicant is fantastic, but his or her referee just lacks the skills, experience, and knowledge to put those ideas well onto paper.

In this article I want to analyze this common frustration, and then give my argument for why I think a medical school (or scholarship organization, summer program, etc.) might value reference letters.

Variance Exists Everywhere – Deal with It

I’m not going to deny that there is variance when it comes to reference letters. Considering the letters are supposed to be confidential, it’s quite possible that no matter how hard your referee tries, he/she could end up writing a letter that is relatively poor compared to the average, simply because he/she isn’t used to writing stuff like this. For sure, there is some skill involved in writing a strong reference letter, and it takes experience and knowledge to do that.

The problem with this complaint is that it’s essentially founded on the ideas of variance, chance, and luck. If you’re going to be upset with variance, then logically, you should be upset with the entire medical school application process.

For instance, it’s true that some applicants are naturally better writers than others. Should we throw out the personal essay too? Or, let’s analyze that fact that most applicants don’t get the same interviewers, which also leads to a lot of variance (as I’ve written extensively on before). Should we scrap the interview process too?

The fact is that most things in life, whether medical school related or not, consist of some things out of our control. Sometimes you just need to be lucky.

That being said, one question we can ask is whether a component of the admissions process has an unacceptably high amount of variance. While we can’t eliminate variance or chance, we should always try to reduce it whenever possible. And this is a question that needs to be asked for every component of the process.

Unfortunately, I don’t have the knowledge or experience to say whether there is too much variance in the use of reference letters. I would like to think that the admissions committees have seen enough reference letters over the years to recognize the type of variance involved, and adjust their selection process accordingly (and likewise with other aspects of their admissions process).

The Second Factor: How Strongly a Potential Referee is Likely to Support You

I’d imagine that most applicants have only been on one side of the reference letter process – that is, have had reference letters written for them but have never been in a position to write reference letters for others. As the founder of SMARTS, I have had to write my fair share of reference letters for some of our student volunteers over the past few years. By now having been on both sides of the fence, I’ve come to understand an extremely important concept that I don’t think many applicants realize about reference letters.

There are essentially two factors that affect the strength of your reference letter. The first factor is something we already know, and that is somewhat uncontrollable: the skills of the referee in writing a good reference letter. However, there is a second factor that most applicants don’t really realize, and I don’t think put enough thought into when choosing potential referees.

You see, many applicants just assume that anyone they could reasonably ask is going to write them the most fantastic reference letter. They assume that just because they asked for a fantastic letter, they are going to get one. The reality is that this is simply not the case. How good of a reference letter you can get also comes down to how strongly your referee feels about supporting you.

For example, when I’m asked to write reference letters for SMARTS student volunteers, I can honestly say that not all students get the same quality of letter from me. If you’re a student who I don’t work with on a personal basis, not only is it hard for me to fill up a letter with content and impossible for me to comment on your personal qualities, but I don’t have a strong enough personal connection with you to feel the urge to write you the best letter possible. The result is a letter that is much more formal and sparser in detail – I’d be lying if I wrote otherwise. In such a case, it would have made much more sense to ask a teacher or other supervisor who has seen your work in action, and can comment on personal qualities in a detailed fashion.

On the other hand, if you are a SMARTS student volunteer who I know personally and have seen in action on a regular basis, not only can I write much more detailed about you, but I end up writing a ridiculously fantastic letter. Why? Because of the personal connection we have developed, I personally want you to succeed and want to do anything possible to help.

So What Do Reference Letters tell Medical School Committees (or other judging committees)?

The importance of the reference letters is that they tell medical schools about how other people think about you, and how good of a physician they think you’d make. It’s easy for you to write a personal essay claiming to be a fantastic person – but of course they expect you to do that. And of course your opinion of yourself is going to be positively biased. You might say that you are a fantastic leader, communicator, and team player – but where is the proof? The closest thing to objective proof that the judges have are your referees.

Extremely strong reference letters show medical schools that there are actually people, other than yourself/your family, who genuinely believe you would make a great physician. If someone else can write a letter advocating for you so strongly, logic says there must be something really good about you. And unless they lack a ton of integrity (and are just making stuff up), referees are generally not going to write you absolutely fantastic letters unless they really believe you deserve one – I mean, do you really think that first year biology professor who only knows you from class really cares to write you an outstanding letter? I mean, why would he care whether you get into medical school or not? Why would he waste his time getting the letter “just right”? Furthermore, strong letters show that you can form meaningful personal relationships with other individuals.

I’d imagine that any referee would approach the letter writing process like I do. If they know you well, are impressed by you, and honestly desire to support you to the best of their ability, they will spend their time writing the best letter possible. But if they barely know you or aren’t particularly impressed by you, it’s a bit naive to expect a really strong letter.

So What Does this Mean for Picking My Referees?

In short, this means that you should pick referees who know you very well and who you know want to support you.

Don’t just pick someone because they have a really prestigious title. The person’s title makes up a few words, but what he/she writes makes up the entire page – which part do you think the judge is going to focus on and remember?

I know when I picked my medical school referees this year I followed those two exact criteria. I picked people who I knew for at least a few years, who I felt were impressed by me, and who I knew genuinely wanted to support me in my endeavours.

If you do that as well, I think you will be getting your best reference letters possible.

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