Handling a Negative or Lukewarm LOR as an IMG Applicant

It’s mid-September. You just got a “courtesy copy” of a letter of recommendation from a US attending you were counting on. You open it, expecting praise. Instead you see words like “adequate,” “met expectations,” “willing to learn.” No strong adjectives. No “top 10%.” Maybe a backhanded line about “occasional lapses in confidence.”

Your stomach drops. You’re an IMG. You do not have the luxury of mediocre letters.

This is where you actually are: applications about to go out, limited US clinical experience, and one of your key LORs might be hurting you more than helping. Or you’re already a cycle in, got weak interview numbers, pulled your old letters, and realized one of them was… not good.

Let me walk you through what to do right now—step by step—depending on how bad the situation actually is.

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Step 1: Be Honest About What You’re Dealing With

First, you need to classify the letter. There’s a huge difference between “lukewarm,” “generic,” and “truly negative.” Programs read hundreds of these; I’ve seen all three flavors torpedo otherwise solid apps.

Use this rough scale:

1. Lukewarm but Not Damaging

Phrases like:

• “Performed adequately on the rotation”
• “Met expectations for level of training”
• “Pleasant and cooperative student”
• “Would be a solid addition to a residency program”
• No concrete examples, no ranking language, very short letter

This type does not help you, but usually doesn’t actively sink you. For a US grad, it’s a shoulder shrug. For an IMG, it’s a missed opportunity—because you need your LORs to carry more weight.

2. Generic / Template-ish

Things like:

• Obvious form letter structure with your name dropped in
• “Rotated with us from [date] to [date]” and then a bunch of generic skills any med student could have
• Nothing specific to your patients, your work ethic, or your growth
• Zero ranking language (“one of the best,” “top X%,” “strongly recommend”)

This makes you invisible. For IMGs, invisibility is almost as bad as negativity because programs already have reasons to screen you out.

3. Negative or Damaging

Red flag phrases:

• “At times struggled with…”
• “Improved after initial concerns…”
• “With appropriate supervision, can perform…”
• “I have some reservations about…”
• Any mention of:
  • Unprofessionalism
  • Reliability issues
  • Knowledge gaps that “require close supervision”
  • Concerns about communication with patients or staff

Or the damning faint praise:

• “I can recommend [Name]” with no adverb (no “strongly,” “enthusiastically,” etc.)
• Oddly short letter (2–3 sentences) from someone who spent weeks with you

If you see any version of this, that letter is a liability—especially as an IMG.

Now decide: which bucket are you in? Lukewarm, generic, or damaging. That determines your next move.

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Step 2: Decide If You Should Use It at All

As an IMG, you probably feel you must use every US letter you can get. That mindset is how bad letters quietly ruin applications for years.

Here’s the blunt truth:
A bad or subtly negative letter can hurt you more than having one fewer US letter.

So you need a decision framework. Use this:

Type of Letter	Use It?	Notes
Strong, detailed, specific	Yes	Gold standard; anchor letter
Lukewarm but neutral	Maybe	Only if you have no alternative
Generic template, no specifics	Prefer No	Replace if you can get almost anything else
Short with vague praise	Usually No	Red flag that writer was unwilling to endorse strongly
Any hint of concern/negativity	No	Actively harmful, especially for IMGs

If your letter is:

• Damaging → Do not use it. Period.
• Generic and short → Try very hard to replace it.
• Lukewarm but neutral, somewhat specific → You can use it as a last-resort filler, but only if your other letters are strong.

If the system where you waived your right to see the letter doesn’t let you delete it (e.g., already uploaded to an LoR portal but not yet assigned to programs), assign it to zero programs. ERAS lets you choose which letters go to which programs. Not everything uploaded must be used.

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Step 3: If You Haven’t Asked Yet – How to Prevent This

If you’re early in the process and worried about getting a lukewarm letter, this is the part almost no one tells IMGs clearly:

Never ask, “Can you write me a letter?”
Ask: “Can you write me a strong letter of recommendation for US residency?”

Then shut up and listen.

If they say:

• “Sure, happy to.”
• “Absolutely, you did great on the rotation.”

Good. Proceed.

If they say:

• “I can write you a letter.”
• “Yes, I can write something.”
• “I don’t usually do rankings, but I can describe your performance.”

That’s code for: it will be generic at best. For an IMG, I would either not use that letter or treat it as your backup letter, not a cornerstone.

You’re allowed to say: “Thank you so much. I actually need a really strong letter as an IMG to be competitive. If you don’t feel you can write that, I completely understand and I’ll ask someone else.”

That one sentence saves people from exactly the situation you’re in now.

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Step 4: If It’s Lukewarm and You Already Have It

Let’s say it’s not actively negative. Just… meh. You’ve already seen it or heard about it from a trusted coordinator.

Here’s how to salvage things this cycle.

4A. Rebalance Your LOR Portfolio

For IMGs, I want your LOR set to look like this whenever possible:

• 2 letters: Strong, detailed, specific US clinical letters
• 1 letter: Strong letter from home institution (especially if continuity with your dean/department)
• 1 optional: Research letter, if it’s truly strong and from someone who knows you well

Your lukewarm US letter should never be the best letter in your file. If it is, your first priority is not “fix this letter,” it’s “get at least one stellar one to drown this out.”

That means:

• Extending or repeating an observership/externship where you did well, and explicitly asking for a letter at the end
• Asking a preceptor who gave you strong verbal feedback to write you a letter now
• Reaching back to an older supervisor who loved you and updating them on your journey, then requesting a fresh letter

You want the admissions committee to see a consistent, positive pattern that contradicts any mediocrity.

4B. Manage How Programs See It

If you have 4 letters, you don’t have to send all 4 to every program.

Strategy:

• For programs where you think you’re borderline (competitive city programs, community programs with lots of USMDs): send only your top 3 strongest letters.
• For programs more open to IMGs where you don’t have as much competition: you can include the lukewarm letter as a “bonus,” as long as it’s not negative.

Remember: you’re not being dishonest by excluding a letter. You’re curating your application.

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Step 5: If You Suspect a Truly Negative Letter Was Sent

Worst-case scenario: You waived your right, never saw the letter, and your cycle results were terrible compared to your stats and other feedback. A coordinator quietly hints, “One of your letters might not have been very strong.”

I’ve seen this happen. Especially to IMGs who relied heavily on one “big-name” attending who barely knew them.

You cannot see the letter. But you can act as if one letter is contaminated.

Here’s the recovery plan:

1. Do not reuse that letter next cycle.
   Ask for new letters from different people. Not upgraded versions of the old one.

2. Build one rotation where you absolutely crush it.
   Preferably:

   • In the US
   • In the specialty you’re applying to
   • With ongoing, face-to-face interaction with the attending (not just rounding once a week)

3. Ask very directly this time:
   “Based on how I’ve worked with you, do you feel you can write me a very strong letter for residency?”

4. Ask 1–2 trusted mentors to review your whole application (minus the letters) and give an honest opinion:
   “If you saw this app with neutral letters, would you expect more interviews?”
   If their answer is yes, a bad letter was likely dragging you down.

You can’t scrub the old letter from old cycles, but you can absolutely keep it from hurting you again.

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Step 6: How to Talk to the Letter Writer (If You Need To)

This part is tricky and people handle it badly when they’re panicking.

You don’t email:
“I saw your letter and it was weak. Can you change it?”

That almost never goes well.

Instead, depending on the relationship, you do one of these:

Option 1: You Haven’t Sent It Anywhere Yet

You:
“Dr. Smith, thank you again for agreeing to write on my behalf. As an IMG, I’ve been advised that my letters need to be very strong to be competitive. Would you feel comfortable making this a strong endorsement, emphasizing specific examples from our work together? If that’s not possible, I completely understand and I can use another letter instead.”

This gives them an out. If they hesitate or say anything vague, quietly stop using that letter.

Option 2: You’ve Already Sent It, and You Know It’s Lukewarm but Not Negative

You don’t usually ask for changes. They’ve already told programs what they think. Pushing them often just irritates them.

Instead, you focus on overriding that letter with other strong letters and your performance. You can also:

• Ask them for feedback on how you can improve:
  “As I prepare for another application cycle, I’d really value your honest feedback about areas I should work on clinically or professionally.”

If they bring up specific issues, fix them and then get fresh letters from other people who see the improved version of you.

Option 3: You Strongly Suspect it’s Negative and Already Sent

You do not ask them to rewrite. If they were willing to undercut you once, I don’t trust them to help you now.

You:

• Stop using that letter for any future cycles.
• Overcompensate with 3 new, strong letters from other people.

You might still ask for feedback to understand what happened, but treat it like a post-mortem, not a rescue mission.

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Step 7: Use the Rest of Your Application to Counter the Damage

Even if one letter is weak, the rest of your application can send a different message. You’re not powerless.

Focus hard on these:

Personal Statement: Direct but Not Defensive

If you know your performance was weaker earlier (say, your first US rotation), and you’ve improved, you can subtly tell that story without referencing the LOR.

For example:

• “Early in my US clinical experience, I realized my communication style, which was effective in my home country, sometimes left patients here confused. I made a point to ask for direct feedback from nurses and residents and began adjusting my explanations…”

Then later:

• “By my second and third US rotations, I was consistently trusted to pre-round independently, present concise plans, and help teach newer rotators.”

You’re drawing a line: early you vs. improved you. Committees notice.

Experiences Section: Specific, Concrete Impact

Don’t write fluff. Use specific actions and outcomes that show you’re reliable, teachable, and effective.

Instead of:

• “I learned to work well with the team.”

Write:

• “I actively asked for mid-rotation feedback from my senior resident and, after being told my presentations were too long, I worked to present in under 3 minutes while still including all critical information. By the end of the rotation, I was often asked to present first because my structure was clear and efficient.”

That level of detail helps override vague or generic letters.

Interviews: Control the Narrative

If you get interviews, be ready for subtle questions like:

• “Tell me about a time you received constructive criticism.”
• “Tell me about a rotation that challenged you.”

This is where you gently acknowledge growth without outing the bad letter.

Example: “There was an early US rotation where I realized I needed to adjust quickly. I received feedback that I was too quiet on rounds and not speaking up with my plans. I made a deliberate effort to pre-read charts, come in with clear assessments, and speak confidently. On subsequent rotations, my attendings highlighted my concise presentations and initiative in their evaluations.”

You’re telling them: yes, once I was average. Then I fixed it.

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Step 8: Long-Term Fix if You’re Reapplying as an IMG

If this is not your first cycle and you know or strongly suspect a letter hurt you, you need a bigger reset.

IMG LOR Recovery Plan

Step	Description
Step 1	Identify weak/negative LOR
Step 2	Stop using that LOR
Step 3	Secure new US clinical experience
Step 4	Ask clearly for strong LORs
Step 5	Update PS and experiences to show growth
Step 6	Apply with new LOR set

The serious version of that:

1. Stop relying on the same small pool of letter writers.
   Especially the one you’re suspicious of.

2. Invest in one high-yield, high-contact US experience.
   Not 10 scattered observerships where nobody remembers you. One 4–8 week block where:

   • You show up early.
   • You volunteer for the unglamorous work.
   • You ask explicitly for feedback in week 1 and week 3.
   • You tell the attending your goal: a strong letter.

3. Ask the attending how they’d describe you in a letter—before they write it.
   Something like:
   “If you were to write a letter about me, what would you say are my biggest strengths and areas for improvement?”

   If they lead with strengths that sound generic, push for more specifics in your behavior so they see and remember them.

4. Burn the old letter set for future cycles.
   Don’t reuse outdated, lukewarm letters just because “they’re US letters.” A fresh, strong letter from this year beats a mediocre letter from three years ago.

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Step 9: Reality Check – How Much Damage Does One Letter Actually Do?

You’re an IMG. Programs are already screening you based on:

• School
• Year of graduation
• Step scores
• US experience
• Visa status

A terrible letter can absolutely be a hard stop. But a simply lukewarm letter, buried among strong ones, isn’t the end of the world.

What matters:

• Pattern. Do 3 people say you’re fantastic, and 1 person is vague? Most PDs will trust the pattern.
• Consistency. Do your transcript, MSPE (if you have one), and experiences section match the “strong performer” story?
• Time. Are your best letters the most recent ones? That’s what people care about.

So: one mediocre letter is not fatal. One negative letter can be. Treat them differently.

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Step 10: What You Should Do Today

Do this now, not “later when I have time”:

1. Write down the names of every current or potential letter writer.
2. Next to each, label them: Strong / Unsure / Weak / Suspect Negative.
3. Circle your top 3 Strong or “very likely Strong” writers.
4. Open an email draft to one of your “Unsure” writers and type this line:

“Because I am an international medical graduate, I’ve been advised that my letters need to be very strong to support my application. Do you feel you can write me a strong, detailed letter of recommendation for US residency?”

Leave it open. Do not close the tab.

Now send that email to at least one person today. That single clarification can prevent you from walking into another cycle with a letter that quietly works against you.