A lot goes into the emergency medicine structured reference letter. These letters are not as straightforward as a , but require specific structures and comments. CaRMS’ reference letters follow a specific format, which is why reviewing a will be helpful.
Because this process can be difficult for both the referee and the student, we are going to give a comprehensive look at the structured reference letter in this article. We will cover everything, from how to approach your referee and who they should be, all the way through how to write the letter with expertly-written examples.
One of the most important steps in this process will be ideal selection of your referees. There are several necessary qualities you need to look for.
An Emergency Medicine Specialist
If you’re looking for somebody to recommend you for emergency medicine, this person needs to be in the field. This support will mean more than support from any other specialty or area of your past medical or academic career. This might be a teacher who specializes in emergency medicine or an EMT you’ve worked with, but your referee should be from the emergency medicine world.
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Each recommendation letter you get needs to come from somebody who knows you on a personal level. This doesn’t mean that the referee is somebody who knows you in your personal life, but rather, that they should be somebody with whom you have a good relationship, who knows you very well.
For example, if you took a class with a highly-respected professor and this person graded a few of your , that’s not enough of a connection for you to ask for a reference letter. This should be somebody who you have worked with, closely, who knows you by name, and who is familiar with you as a person, not just a few quiz results.
Someone Who Fully Supports You
Knowing you personally is good, but your referee really needs to value you highly. Make sure that the people you ask will give you the best letter possible. Don’t ask for reference letters from anybody else. ’How to Ask a Referee for a Letter
Asking for a reference letter is a big deal. This is a lot of work for the referee to take on, so you cannot just ask this person in a completely casual manner. You cannot casually slip it into any old conversation. Your ask for a letter of recommendation needs to be professional, undemanding, and clear.
How to Approach Your Referee
Whether you send an email, a written letter, or ask in person, you should start this conversation early. At least three months before you need the letter is the right time to have these conversations. When you ask your potential referee for help, always remember to be courteous, police, and unassuming. Clearly state what you need from them and let them know when you would need the letter; that way, they will know concretely what they have to do, which will let them gauge whether or not they can devote their attention to the letter.
Give the referee every piece of information they could want. It’s better to be over-informed than lack knowledge, so when you send information to your referee, send everything. The most important items to send them are:
- Example of the
- Submission information – how to actually submit the form
- Any links and emails they will need
- Your personal information – like your full name, , , and so forth.
- A timeline
- A list of experiences you have had with the referee
On a purely practical level, your referee needs to know when to send in their letter. Deadlines change depending on which match you are in, as well as from year to year. We have included a rough guide for each match’s referee submission deadline as a reference point:
FM/ES is Family Medicine/Enhanced skills, which covers Emergency Medicine, and so this is the pertinent deadline specific to the Emergency Medicine structured reference letter. In the recent year, your Emergency Medicine structured reference letter would need to be in by mid-September.
Also practical, your referee must be made aware of how to submit their CaRMS emergency medicine structured reference letter.
For yourself, you will log into CaRMS online and select “reference requests” from the drop-down menu. Click on the + icon, fill out the required fields, and click “save.” After this, review the information and click “finalize.” Click on the “send to referee” button, at which point your referee will be notified.
At this point, the referee needs to create a CaRMS account to fill out their structured reference letter and submit it.
Your referee needs to click on the Actions column and then on “Create online,” which will let them fill in the structured reference letter. They can then click on “view letter,” to review what they have written and “submit,” to finalize and send the letter.
Referees cannot upload structured reference letters.
Links and Emails
Make sure your referee has the necessary links and emails to send in their submissions. The pertinent email address is , and the most important link is the link to create a referee account in CaRMS online, which is right .
Make sure your referee has your information, like your full name. While your referee knows you very well – they should, anyway – that doesn’t mean they might not remember how to spell your name or the year you first met or anything. People don’t have perfect memories – most of them – so just assume that your referee doesn’t have a lot of your information and send over anything they will need to talk about you.
Personal information might also include your resume and transcript.
Send along a reminder timeline so that your referee doesn’t have to look up the dates for anything you might have done together. This timeline could include any work, research, or clinical experiences you have had with your referee. This will prevent your referee from needing to look up any dates or any other detail that might not be immediately available to them.
Mention your role and tasks, but be brief and stick to facts. Avoid trying to tell the referee which experiences to include or what to write in any way.
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Referees should make sure to cover the following areas:
- Cognitive skills and knowledge
- Problem solving and patient management
- Behaviour and attitudinal skills
- Communication skills and working relationships
- Ability to work in a team
- Motivation and punctuality
- Sense of responsibility
- Procedural skills specific to the discipline
Those characteristics are highlighted by CaRMS as essential. When describing a candidate and their experiences, emphasize those qualities for great results.
You should also highlight the mission statement of whichever program you are applying to. As an example, here are the program objectives fromMcMaster University’s emergency medicine residency program:
“Our program objectives include:
- Improving patient care through excellence in EM education and research
- Building and strengthening a unified McMaster EM presence at local, national, and international levels
- Engaging in meaningful EM research and innovation
- Training and fostering EM leaders in clinical, educational, and research oriented areas."
In these objectives, as with any program objectives, vision statements, or mission statements, notice key terms that will make the candidate appear more valuable to the program. In this case, we can see “patient care,” "research,” “innovation,” and “unified,”" which says that emphasizing a candidate’s eagerness to learn and research, scientific background, teamwork (unified), and personal values – which will build a stronger McMaster EM presence, will be best. There are several areas on the structured reference letter that just require a box to be ticked off, but there are also areas for narrative answers and comments.
Narrative answers should follow the rule of show-don't-tell, and should demonstrate with specific incidents why a candidate would be perfect for emergency medicine – or should be avoided, if it comes to that. Any narrative answer is looking for an actual story about the candidate, an opportunity to showcase their abilities. Think about the mission statement for the program: which stories emphasize what the program is looking for?
The experiences and qualities you’re looking to highlight are anything that makes the candidate seem extra-ordinary compared to his or her peers.
Comments can be more direct and should clarify other answers. For example, if a question asked the referee to rate the candidate on a scale of 1-10, the comments might clarify that answer. For example:
I gave Pat a 9 out of 10 because I have seen that they have mastered most of the clinical skills necessary for this field. Pat would certainly have received a 10/10 with only a few more days in clinical rotation; they grew in skill and ability exponentially over even the short time they spent as part of our team.
Above all else, your writer should know have direct experience with you from an emergency medicine setting. Your referee knowing you from the specific program emphasis – emergency medicine – will give you the best support and increase your chances of admission.
Below is a guide to the CaRMS emergency medicine structured reference letter. We cover each section and what you need to know about it. Some sections are quick and straightforward, others are more subjective and complicated.
Applicant and Referee Information
The first part of the reference letter is just pure information – the names of candidate and the referee as well as the referee’s contact information.
Confidentiality of Content
This is a yes or no, with no elaboration, and asks if the candidate has viewed the reference letter or influenced its content. While honesty is requisite, ideally this should be a “no.” If you are a candidate, you should not influence the writing of the referee in any way. Trust that they have your best interests at heart and so you will not need to see the letter of reference.
The two sub-sections here ask how well the referee knows the candidate, and in what capacity; and a frame of reference for the first box.
In box number one, you will fill out how you know the candidate and for how long. So, you might say:
I have known Lisa for three years, during which time she was a student of mine and a research assistant. In addition to class time and projects assigned, I also got to know Lisa working with me between 10 and 15 hours per week for approximately eight or nine months out of the year.
Notice the detail – specifying how many hours per week and the duration of the research assistant position – that gives any readers clear knowledge of the relationship between the referee and the candidate.
In box number two, you would provide context for the information in the first box.
Typically, I have between 2 and 3 research assistants working with me out of the student body. Class sizes are usually between 25 and 50 students.
This lets the reader see that this referee has a lot of working experience with Lisa and definitely knows her well.
How Would You Rate the Candidate in the Following Areas:
This section has five sub-headings, and referees are asked to provide “narrative comments,” and specific examples. This is where rules of “show, don’t tell” come into play.
Commitment to specialist emergency medicine. Have they thoughtfully considered their career choices?
Right from the start of Andrew’s clinical rotation, he came in with a powerful energy and a great attitude. There was something special about his enthusiasm that made him a wonderful student to work with. However, it was his last night in the ER rotation that made him really stand out.
We had a gunshot victim come in who needed immediate assistance, and Andrew stayed calm throughout the procedure. The victim was in and out of consciousness, but charged up with adrenaline, and struck Andrew in the face, lashing out in his disorientation. Andrew never missed a beat. He helped get the patient under control and restrained, but with all the gentility of a person without a welt forming on his cheek.
At the end of that night, I was helping Andrew ice his face and write up a report, and I got a chance to talk with him about the big question: “?” and Andrew told me that he wanted to help and to heal where he’s needed the most, and that, after several clinical rotations, he knew that place was the ER. After his performance throughout his rotation, I agree.
The first thing Jane asked me was how my night was going, and I laughed because Jane had only been home for an hour after her last shift in her rotation had ended before we called her and asked if she could come back in. We were working short, and I really needed the help. She said yes, with no hesitation, and delayed only long enough to feed her cat and change clothes.
Regardless of the situation, Jane steps up. She studies on her breaks, she’s always ready to help out, and she looks for anywhere she can be of service. I know the school she attends is not one of the , and it’s easy to see why Jane made it through.
I must admit, when she first showed up in my class, Theresa seemed like she would not make it. For the first week she seemed disoriented. I quickly learned how wrong my first impression was as I witnessed Theresa’s growth.
During her first lab work, she made an error with the order of the steps I had laid out. She asked me questions about the order of the steps, why they were one way and not the other. This was the first time I saw Theresa’s greatest strengths in action: her curiosity and her willingness to learn quickly from mistakes.
As I got to know Theresa, I came to understand that she never gave up and never made the same mistake twice. She told me about her struggles. She considered , but instead took summer courses to boost her GPA, and meet even the most vigorous .
Theresa is a consummate student: always learning, always eager to learn, and always growing.
Clinical knowledge base (differential diagnosis generation, ability to formulate a management plan etc.)
“It might be a tumor, too,” said Kate, always last to speak, and always with an insightful answer. Kate was on her clinical rotation in my ER, and she had just helped me with a patient who was in an automobile accident. This patient was exhibiting signs of manic behavior – including driving recklessly – but Kate had brought in some knowledge from her psychiatry rotation: any mental health disorder might be a tumor.
I asked her what she would do with the patient, and she said that, now that the patient was in a stable condition, she would want to continue to treat the physical problems, but she would get a detailed history and mental health screening. If the mental health screening was inconclusive, that’s when she’d look for a tumor.
As you can see, Kate’s ability to search for differentials, leave no stone unturned, and her ability generate a good plan for treatment are both top-grade.
Ability to work as part of a team/communication skills
For two years, I have worked with Jed. Jed has been invaluable as part of my research team. He volunteered to take notes and write up our findings, and his detailed, accurate, and well-organized documentation has kept us on-track. Jed went above and beyond with his notes, coordinating research documentation through an online app which allows the team to organize ourselves better and review our findings in clear, concise ways.
I was impressed by Jed’s willingness to take on this extra work – often viewed as mundane or dull by other team members – as well as his efficiency in doing so. He is a credit to our team, and the only thing I could say negative about him is that he’s heading off to residency and he’ll be hard to replace.
Global assessment – How does this trainee compare to ALL medical students you have worked with?
This section starts with a ranking, asking the referee to put you in the top 1%, 5%, 10%, 25%, 50%, or bottom 50% of all medical schools they have worked with. This might seem harsh, since a relative ranking of all students might put you in a lower category without reflecting on your actual skills or quality level as a physician. You should pick a referee who will put you in the top 1%, 5%, or at very least 10%. There is also a comments section here for clarification. Unlike the narrative sections, these comments can be more direct and do not need to tell a specific story since they are to be used for clarifying the referee’s answer.
These comments might look like this:
Gary excels in his clinical skills and medical knowledge, but what really sets him apart is his ability to empathize with patients and create a fast connection. Particularly useful in emergency settings, Gary’s empathy allows him to calm patients down and help them through very traumatic experiences.
Would you be comfortable with a friend or family member being cared for by this candidate?
This question has yes/no boxes to check as well as a comments section. Again, this might be used for clarification in the negative, although it is more likely that the comments will support the yes/no.
Please enter any other comments that you have might have about the candidate here.
The final field to fill in on the CaRMS emergency medicine structured reference letter has a section for general comments. This is a perfect place to indicate additional skills, talents, attributes, clinical ability, potential, or other qualities. This also might be used to spell out any misgivings or drawbacks with a candidate.
Hopefully, you have made a choice of referee where that won’t be a problem and you’ll get nothing but the best.
As with previous fields, narrative comments are better, and specific examples of experiences your referee has shared with you will be the optimum assistance you can receive in the recommendation letter.
Given that the can be very tight, we trust that this article will have streamlined and smoothed out your process. We know that, with this advice in your corner, you will have no problem securing the perfect letter of recommendation. Keep going! There’s a lot to do still, like your , but if you keep seeking assistance as you have been, you’ll have the best chance you can get.
1. How many references do I need?
Most programs are looking for 3 letters of reference, so you will need to approach at least three referees for your letters.
2. What is CaRMS?
The Canadian Resident Matching services is used by Canada’s medical system to match medical school grads to residencies.
3. Does my referee need to have seen me in an emergency medicine setting?
Ideally, yes. At least one of your 3 references must be an emergency medicine specialist.
4. What do I do if my top choice referee says no?
Have a list of others you can approach so that the loss of one or two isn’t the end of the world.
5. Should I thank my referees?
Absolutely, you should. Send them a letter or email thanking them for the work they put in, saying you appreciate it.
6. How many residencies should I apply to?
Each application adds more to your plate and could split your focus. We recommend you apply to between 15 and 35 residencies.
7. Can my referee change the letter after writing it?
Yes, the referee can edit the letter of recommendation by re-completing the form and re-submitting, as long as it is before the deadline.
8. Can I suggest what my referee should write about?
No. Do not attempt to exercise control over the letter itself or what your referee writes. You can send necessary information – like timelines and resumes – but nothing else. Trust that you have made a good choice in referees and be confident in knowing that they will give you an excellent recommendation.