Letters from mentors and other neurosurgeons are a critical element of every application. Over the past several years, the SNS has been working with program directors and other stakeholders to significantly improve and standardize the written evaluations provided on behalf of resident applicants. In light of the transition to a pass/fail format for the USMLE Step 1 examination and many medical school transcripts, letters of recommendation have taken on an even more prominent role during the application process, and it is critical to identify multiple reliable letter writers who are both well positioned to advocate for you as an applicant, and who know you well enough to speak about your achievements and character traits with authority. In addition to conventional letters, the SNS now advocates for writers to utilize a Standardized Letter of Evaluation (LOE) to more quantitatively and objectively assess student applicants which are intended to represent feedback from the program at large including residents and other faculty. Although use the standardized LOE is voluntary, most programs participate at present, and as of the 2023-2024 season, a conventional application will typically feature 3 SNS LOEs, one from the home program and each of two away rotations, as well as a fourth free-form letter from another home program mentor.
Formal SNS guidelines recommend that standardized LOEs be completed by an evaluation committee within each department, in order to maintain continuity between students and years — for most institutions, this will include the department chair, PD, and any other core faculty on the education team. Conventional letters potentially accompanying the standardized LOEs may be written by individual authors or teams, at the discretion of each institution; for example, many departments have adopted a policy where the chair and PD will jointly write a letter on behalf of each visiting student. With regard to the fourth letter, students are advised to seek out an individual with whom they have worked closely over several years, as such an author will be most likely to both know them well and to be their strong advocate. Absent atypical circumstances such as an MD-PhD applicant whose thesis advisor was not a neurosurgeon, or a re-applicant who has a PD from their prelim program, most students should seek letters exclusively from neurosurgeon writers, as these will be valued much more highly by program faculty at outside institutions.