Will You Do Me the Honor?

“We need this physician,” said Reginald Washington, MD, the chief medical officer of the Rocky Mountain Hospital for Children at Presbyterian/St. Luke’s Medical Center in Denver. “This is the kind of physician I want to launch this service.” Washington had just read the reference letters on Mindy Banks, MD, an internal medicine/pediatric nephrology fellow nearing completion of her training at Northwestern University in Chicago. Banks had done very well in her first on-site interview and things were moving steadily, if slowly, toward an offer for a hospital-employed position.

There were timing issues and additional logistical challenges, such as parallel adult and ped call schedules, which could easily have derailed her candidacy. Banks’ reference letters changed the game—turning up the burner several notches. Not only did the Northwestern faculty members endorse her professional competency and intelligence, but the letters were highly personalized and offered anecdotes about her style with patients and co-workers.

They were clearly written by references that knew her and cared about her future. They lauded her common sense, her ability to bond with patients and parents, and her innate understanding of teamwork dynamics. Not only did the letters depict a physician any administration would welcome to its medical staff, they also described a person who would fit perfectly with the team Washington was assembling to lead Denver’s newest children’s hospital. “Make it happen,” said Washington, “I won’t lose this recruit.” And he didn’t.

Before your job search begins

Banks says one of the reasons her references went out of their way for her is, “they never once heard the phrases ‘not my patient’ or ‘I’m off shift now.’ I didn’t view residency or fellowship as shift work, and neither do the faculty members and attendings in most programs.” Banks advises physicians in training to remember most of their prospective references trained before the advent of the 90-hour workweek. When asked about a patient, they remember being expected to either know the answer or find it quickly.

“The culture is changing today,” Banks says. “It may not be possible for someone in a large program to know every patient, but it’s certainly advisable to understand that perfectly accurate responses like, ‘she’s not my patient’ or ‘Dr. Smith is on shift now,’ are going to push buttons in a very negative way. If you’re willing to discuss any patient regardless of what time it is, and it’s obvious that you have taken the time to get to know patients, they see in you the traits they would like to have in a colleague. The genuine respect and regard generated by that bond is the difference between a good reference and a superlative one,” she says.

Brian Dwinnell, MD, an internist and an associate professor of medicine at the University of Colorado in Denver reminds residents, “the best speakers tell the audience what they are going to teach, teach it, then recap what they taught.” Use this technique when you know you’re going to be working with a faculty member whose style and interests are aligned with yours. Dwinnell suggests saying, “I’m looking forward to this rotation because I’m especially interested in _____. I’m hoping to do really excellent work for you here so that I merit a strong letter of reference.” Then you must give a 110 percent performance. If you emphasize how important the rotation is to you, excellent performance will stand out and be more memorable. However, if your performance is mediocre, your prospective reference will be wondering just how awful your weakest rotation was, since this was supposedly your best work.

William Flynn, MD, a psychiatrist on faculty at Georgetown University of Medicine for more than 30 years, agrees that the best references he gave were enhanced by the “halo effect” following a superb presentation or outstanding performance in a rotation. Once the letter is drafted and on file with the faculty member’s administrative assistant, it may be updated and addressed as needed for future use.

Identifying your physician job references

Most employers are looking for three to five references. Some will ask you to have three letters sent and they will follow up with phone calls to the references only if the letters are ambiguous or not congruent. Others eschew letters entirely and only want contact information so they may call or e-mail their own reference-checking questions. Ideally, a candidate should have four to five reference contacts ready so one physician’s vacation or administrative delay does not hold up any prospective employer’s decision process. The general rule is not to include references with the initial CV, but if discussions progress to that point, ask the administrator which they prefer—letters or a list of contacts.

Jessica Freedman, MD, is an emergency medicine physician and the president and founder of MedEdits, LLC (www.mededits.com), a medical admissions consulting and editing firm. Freedman speaks and writes on the topic of references, based on her experiences as a former emergency medicine associate residency program director and member of the admissions committee for New York City’s Mt. Sinai School of Medicine. She suggests finding out which faculty members and attending physicians wrote good letters for the class ahead of you. “Not everyone can write,” she says. “Writing a really good reference letter is an art.”

Flynn says the most relevant letters are written by individuals aligned with the environment in which you aspire to practice. “An academic physician with a research focus is going to be better at talking about your suitability to meet the challenges of an academic environment. That recommendation is going to carry more weight with academic physicians,” he says. Similarly, there is always one attending to avoid asking, according to Lynden Kidd, JD, an attorney and human resources consultant. She is also the president and managing partner of Next Iterations, a healthcare human capital services firm. “There is always one attending who is a really nice guy but who also has a habit of blurting things out without thinking.” If the recruiter for your dream job tells you they typically telephone references or follow up on letters by phone, you may want to leave the less-than-articulate attending off your list. “References who are too glib on the phone inadvertently plant seeds of doubt with employers,” says Kidd.

According to Freedman, there is a steep learning curve to reference-letter writing. If a resident chooses references who are all relatively new in their roles as attendings, he may end up with conservatively written letters that send the wrong message. As a new assistant residency director at Mt. Sinai, Freedman wrote her first letter for a resident she held in high regard. She wrote in a formal style and used all of the terms she thought were appropriate. She thought it was a great letter until she got a call from the chair of the institution to which her resident was applying, asking her to explain her reservations about the candidate. The department chair explained that the letter seemed “very lukewarm” and he was calling to find out if she had any concerns before tabling the candidate. She corrected the mistaken impression and the resident got the job, but Freedman was shaken by the experience.

Remember to include your residency program director or associate director in your references. Excluding them is a major red flag to prospective employers and potentially an insult to the faculty members. If you don’t feel you have a relationship with your program director or associate director now, make an appointment to sit down and talk about your performance to date and your intended career path. Take your CV and evaluations with you. “If it’s a really large program and you have little or no interaction, take the personal statement you prepared for residency applications with you, too” says Freedman. The director may have no idea that you speak fluent Spanish or have excellent presentation skills from your previous career. Details buried on the bottom of the CV get overlooked if you don’t work to make sure your program directors get to know you.

Freedman says, “This meeting lays the groundwork for references, both current and future.” Have a frank discussion about your strengths and weaknesses and talk about which environments might be the best fit for you. You may find that a director who thinks you’re an average resident becomes more enthusiastic when enlisted for career planning to identify an environment where your strengths synch well with the job criteria.

Washington of Rocky Mountain Hospital for Children echoes the importance of making sure your references are speaking about you from personal experience. As a former member of the University of Colorado School of Medicine admissions committee, Washington could tell immediately if the letter writer knew the candidate.

“Grades and scores told me the person could do the work,” he says. “To select the best candidates, I needed input from a physician who observed what kind of person this candidate is.” Flynn agrees that the most important information gleaned from references relates to the candidate’s temperament and personality. “We [employers] want to know if this person will mesh with and enhance our organization.”

Resist the urge to include friends, family, or business contacts among your references. “Non-physicians don’t belong on your reference list,” says Freedman. “Let your physician references comment on how well you work with staff and colleagues.” Many employers would suspect the addition of peer or administration references to be filler—a possible clue the candidate is trying to hide a mediocre or poor reputation with faculty.

Requesting the reference

Request reference letters no later than four to six weeks before you anticipate needing them and sign any release, consent or waiver your program and the prospective employer may provide. Ask your references for their preferred method of contact. You need their e-mail address, department phone and cell phone or pager number.

The University of  Colorado’s Dwinnell says the best reference request he ever received was from internal medicine resident Jake Gray, MD. “Jake handed me a packet with his CV, all of his evaluations, a personal bio, the job description, and stamped, addressed envelopes.  Style makes an impression. The request reminded me of just how considerate and organized this resident was,” Dwinnel says.

As a psychiatrist who has provided many references to residents at Georgetown University, Flynn recommends young physicians recognize the request for a reference is a personal, as well as professional, interaction and asks them to put themselves in the attendings’ shoes. “If someone is asking for your help, what consideration would you expect and appreciate?” Flynn asks.

Give your reference:

• Advance notice to schedule the task without disrupting other work
• Acknowledgment of the time and effort that the task takes, on top of the physician’s job duties
• Facilitation by lining up the resources and contact information
• Appreciation of the reference
• Report of the outcome

When you ask for a reference, thank the attending for what you have learned and explain why you have selected him or her to be your reference. A sincere compliment is not out of line. Dwinnell remembers a resident who told him, “You have been a real role model for me, and I really hope to be able to take what I have learned from you about the importance of humanism and put it into practice.”

Vetting your reference

Find out what a prospective reference would say about you. How to do this? It’s scary but simple: Just ask. Bottom line—you need to find out two things: 1) Is this a faculty or attending you want to include as one of your references? and, 2) What are they going to say if pressed for weaknesses or shortcomings? Kidd offers this sample script:

“Dr. ____, you and I have worked together on several rotations over the past three years and I’ve learned a lot from you. I feel we worked well as a team. Would you be comfortable writing a supportive reference letter?” Most residents  fail to ask the key question, “If there are any shortcomings or areas for concern you would discuss, if asked, would you share those with me now so I might be prepared to respond to follow up questions from prospective employers?”

If the physician identifies a valid weakness that is likely to pop up with other references, this is your opportunity to help frame your response. If a prospective reference unloads several concerns or even one devastating shortcoming, this may be your signal that this person should be omitted from your references. In that case, an appropriate response might be something like, “It sounds like you’re not comfortable being a reference for me for this position. Would you suggest someone who might have another perspective or is there a different environment you think might be a better fit for me?”

Telling your references about the job helps them target their comments to the particular set of skills most needed in that environment. “I told my references about the job after my first interview,” says Mindy Banks, MD, whose reference letters helped her clinch a job in Denver. They knew that it was a new service line for a new hospital, and they responded by emphasizing the personality traits that were most relevant to the ambiguities and political realities of a start-up environment.

“It really does help if I know the role and environment the resident is seeking,” says Dwinnell. The challenges for a physician joining a single-specialty private practice are quite different from those required for a managed care multi-specialty clinic, he says. “Knowing the practice—or at least a little about the job scope—helps me speak directly to this candidate’s fit with the environment.”

Tell your references if you know that a particular factor is going to weigh heavily in the selection process. “I remember one resident who learned in his interview he would be working with a diverse, multi-cultural patient base if he got the job,” says Flynn. “He knew they wanted confirmation of his ability to forge the therapeutic relationship with minorities. Once he shared that with me, I was able to make sure his skill set in this area was addressed with appropriate emphasis.”

Problem references and backdoor checks

Many physicians mistakenly assume they are protected by their employer’s or hospital system’s HR policies or that fear of legal action will deter backdoor reference checks. Not so in healthcare where it’s accepted that in the interest of public safety, absent of any malicious intent, references are given a little more latitude in speaking freely about a candidate’s qualifications. Attorney Kidd has developed an axiom about the job search process, “There are no secrets,” she says.

“If there is negative information out there, it will almost certainly surface and cause more damage when it comes as a surprise.” Kidd is referring primarily to unofficial contacts known as “backdoor references.” Physicians and administrators will pick up the phone or dash off an e-mail if they know someone where you trained. If there is dirt, it will be delivered in the unsanitized and sometimes sensationalized manner that anonymity fosters. As long as there is no malicious intent—no intentional misrepresentation of facts—there are usually no repercussions to backdoor reference checking.

One resident in a major southeastern university program decided to remain silent about a potential problem because she thought she had squelched the story. She presented three good letters to her first-choice group—the largest single-specialty practice in the state where several alumni from her training program were partners. When asked in the  interview about her areas of weakness, she gave the boring and benign standby response, “I sometimes push myself too hard.” Everything was looking good for her to get an offer letter the next week until the backdoor reference checks began. They were explosive. “Insufferably rude to nurses,” “banned from a popular surgeon’s ORs,” and “kicked out by her own roommate,” were some of the comments that came back as partners in the medical group called old buddies who had joined the university practice. The recruiting committee dropped her cold and she never got a second chance to address the allegations.

Of course, there was another side to the story. This resident looked like Grace Kelly and had a reserved, cool demeanor that female peers read as cold, staff read as condescending and would-be suitors interpreted as playing hard to get. The conflict with females was real, but she had good letters because the program directors had investigated and decided she made real progress toward amending the interpersonal conflicts in an untenable situation.

A culture that condoned fraternization and backbiting hatched a perfect storm in the surgical suites. Morale was terrible and everybody suffered. The resident disclosed the problem to the next employer and gave faculty members free reign to talk about the issues and what she had tried to do to resolve them. She had an offer and signed a contract within weeks.

Close the loop

Be sure to confirm with the recruiter that your references have been received. Documents may arrive in strange formats and fax machines still mangle and crease letters. Your references put in time and effort to help you get a job. Return the favor by taking the time to thank them and let them know how the process is going.

Closing the loop is common courtesy and maintains a bridge you may need to cross again. Sharing your excitement and enthusiasm as you start your career is one of the best ways to say “thank you” to teachers, mentors and references.