Does a Letter of Intent Change Your Rank List?
Does a residency letter of intent change a program's rank list? What NRMP and specialty surveys actually show, and what they can't tell you.
Does a Letter of Intent Change Your Rank List?
Short answer: nobody can tell you that it will, and nobody can honestly tell you that it won't. In NRMP's latest survey to publish this factor, about one program director in five said post-interview contact entered ranking decisions. Most program directors in specialty surveys say applicant declarations don't change their lists. A letter is at most one small input, and after certain dates it can't be one at all.
What NRMP's program director survey shows
In NRMP's 2021 Program Director Survey, 20.7% of program directors across specialties cited "Other post-interview contact" as a factor in deciding whom to rank. By comparison, 64.7% cited "Perceived interest in program" and 87.1% cited "Interpersonal skills" (checked 2026-09-28). It is the latest edition with a static per-factor table; 2026 factor figures are only in NRMP's interactive report, so we don't quote one.
Caveats:
- It doesn't isolate letters of intent, and it measures whether the factor was considered, not whether anyone moved.
- Specialties vary widely. In the same report, the figure was 5.6% in orthopaedic surgery (n = 36) and 3.6% in otolaryngology (n = 28), but 31.0% in anesthesiology (n = 42) and 35.3% in diagnostic radiology (n = 34).
- Sample limits: a 23.3% response rate (n = 1,033), in a virtual-interview year.
"Perceived interest in program" was cited three times as often, and the survey doesn't say how programs form that perception.
What specialty surveys show
| Population | Finding | Source |
|---|---|---|
| Orthopaedic surgery program directors (n = 29) | 93.1% said a letter of intent "did not affect ranking"; 6.9% said it affected ranking positively | JAAOS Global Research & Reviews, 2021 |
| Otolaryngology program directors | "No PD agreed that declarations of intent from applicants have an impact on their rank lists" | Solis et al., 2020 |
| Urology program directors | "Most program directors (81.7%) responded that promises by applicants did not influence their rank list" | Farber et al., 2019 |
| EM program directors, on thank-you messages | "22.6% reported that an applicant could be moved up their program's rank list and 10.8% reported that an applicant could move down" | Jewell et al., 2019 |
These are small single-specialty surveys from different years. The pattern: most program directors say declarations don't change their lists, and a minority say applicant communication can, in either direction.
Do "love letters" to residency programs work?
"Love letter" is the applicants' name for a letter of intent: a note telling one program it is your first choice, or telling several programs you will rank them highly. The 2026–27 specialty guidance answers the question more directly than any survey, and in several specialties the answer is that the letter is not used. All quotes below were checked 2026-11-07.
| Specialty | What the 2026–27 guidance says | Source |
|---|---|---|
| Dermatology | Letters of intent and thank-you letters "are typically not used by residency programs in decision-making and lead to downstream pressures on applicants" | APD statement, May 1, 2026 |
| Anesthesiology | A thank-you note or letter of interest is welcome, but the program director "may not respond, and this correspondence will not be utilized to influence interview/rank list outcomes" | OPDA anesthesiology |
| Pediatrics | "Letters of intent are not expected and, if sent, should only be sent to one program. Programs are not expected to reply to such communications." | APPD, June 2026 |
| Neurology | "Applicants are not expected to engage in post-interview communication but may contact programs with specific questions." | AAN recruitment statement |
| Integrated plastic surgery | Post-interview communication is "against the policy set forth by ACEPS and should not be done" | OPDA plastic surgery |
Read together with the surveys, the evidence points one way: in dermatology and anesthesiology the program directors say in writing that the letter does not feed the rank decision, and in pediatrics and neurology nobody expects one. Where a specialty is silent, the survey numbers above are the best guide, and they show a minority of programs that weigh applicant contact at all. The full specialty table, including the specialties that welcome a letter, is in the residency letter of intent guide.
Pediatrics adds the rule that applies everywhere: one letter of intent, to one program. Telling two programs each is your first choice is the version of the love letter that does real damage: the claim can't be true twice.
Applicants send them anyway
In a 2024 survey of neurosurgery applicants, "Sixty-four (84.2%) respondents reported submitting a letter of intent (LOI) to their number 1 ranked program. Sixty-one (82%) felt pressured to send a LOI" (Laskay et al., World Neurosurgery). They felt pressured "to improve their rank status, fearing that it may harm them if they did not."
When a letter can't help, or shouldn't be sent
- After a program locks its list. Internal medicine, pediatrics and vascular surgery programs in NRMP's voluntary lock pilot are expected to lock by 11:59 p.m. EST on February 8, 2027, or at least 24 hours before their first in-person post-interview visit, whichever comes first. NRMP's pilot FAQ is plain: "A certified and locked ROL cannot be changed." Its process timeline adds that programs "cannot uncertify and edit their ROL under any circumstance." You can see which programs opted in through NRMP's R3 system or on the program's website.
- After the Rank Order List Certification Deadline, March 3, 2027, 9 p.m. ET.
- When your specialty or program asks you not to. Dermatology and plastic surgery do.
What you actually control
You can't control whether a letter moves a list; you control whether it is accurate and specific. NRMP lets you "voluntarily communicate" interest and forbids asking for a ranking commitment. State your real interest once, give a reason only this program could prompt, and ask for nothing: that is a letter you can stand behind. See three annotated residency letter of intent examples.
If you changed your mind, or a program says "ranked to match"
A letter of intent binds no one, including you. If you told a program it was your first choice and your ranking has since changed, rank your true first choice first; the guide to changing your mind after a residency letter of intent covers the two-line correction. The same rule runs the other way: NRMP lets a program "voluntarily communicate to an applicant that they are viewed favorably and will be ranked by the program," and that statement doesn't commit the program either. Read what a "ranked to match" email means before you move a program up your list because of one.
For IMGs
The same specialty rules apply to international medical graduates. What can matter is new information a program needs to rank you: ECFMG certification, a passed Step 3, or a change in visa status. Pediatrics lists "Updates to provide to an application" among the post-interview messages it allows. Send that news as an update, using the templates in the IMG update email guide, and if you also send a letter of intent to one program, the annotated IMG letter of intent example shows how to state visa and ECFMG status inside it.
If you decide to send one, you can check your draft against the residency letter of intent rubric. The feedback is qualitative: specificity, clarity, and anything that reads as asking about ranking.
Before you submit, compare the draft with the public Residency — Post-Interview Letter of Intent or Interest rubric, which lists each review area and the check a program director applies.
Does your letter say why this program, clearly and honestly?
Get feedback on your program-specific reasons, how you state your interest, and any update. Paste your specialty's or program's communication instructions above your draft.