Essential Guide for Caribbean IMGs: Securing Strong Neurology Residency LORs

Letters of recommendation (LORs) can make or break your neurology residency application—especially as a Caribbean IMG. Program directors consistently rank LORs among the most important factors in interview and rank list decisions. For Caribbean medical school residency applicants, strong letters help counter bias, contextualize your training, and highlight the specific strengths you bring to neurology.

This guide focuses on exactly what you need as a Caribbean IMG targeting neurology residency in the US: how to get strong LORs, who to ask for letters, how to plan during your Caribbean medical school years, and how to present your letters strategically in ERAS.

---

Understanding the Role of Letters of Recommendation in Neurology

Letters of recommendation serve three main purposes in a neurology residency application:

1. Validate your clinical ability
   They tell programs you can function safely and effectively as an intern: take call, manage patients, communicate, and work on a team.

2. Signal specialty fit
   Neurology is a cognitively demanding, communication-heavy specialty. Strong neurology-focused letters demonstrate that you:

   • Think logically through complex cases
   • Can handle diagnostic uncertainty
   • Connect well with patients with chronic neurologic disease

3. Contextualize your background as a Caribbean IMG
   For Caribbean medical school residency applicants, LORs often address:

   • The rigor of your rotations in the US clinical setting
   • How you compare to US MD/DO students
   • Your growth, professionalism, and resilience

Why letters matter even more for Caribbean IMGs

As a Caribbean IMG, programs may have:

• Limited familiarity with your school’s grading system
• Concerns about variability in clinical training quality
• Questions about your ability to adapt to US hospital culture

Strong, detailed LORs—especially from US-based academic neurology faculty—directly counter these concerns. They help bridge any skepticism about:

• Caribbean medical school residency training environments
• Step scores that might be average
• Limited home-institution neurology exposure

Neurology-specific expectations

Neurology residency program directors often look for:

• Evidence of clinical reasoning: How you approached undifferentiated neurologic complaints
• Examination skills: Quality and completeness of your neurologic exam
• Communication: With patients (often frightened or confused) and with the team
• Teachability and curiosity: Interest in reading, asking good questions, seeking feedback

An effective neuro match strategy includes LORs that explicitly speak to these qualities.

---

Planning Your LOR Strategy as a Caribbean IMG

You shouldn’t start thinking about letters right before ERAS opens. If you’re at SGU or another Caribbean school with a large IMG pipeline, your best SGU residency match advisors will tell you: plan early and intentionally.

Step 1: Know how many letters you actually need

For most neurology programs:

• ERAS allows up to 4 letters per program
• Many programs require 3–4 letters, often specifying:
  • At least 1–2 letters from neurologists
  • Sometimes 1 letter from internal medicine or another core specialty
  • US clinical experience letters strongly preferred

Ideal mix for a neurology-bound Caribbean IMG:

• 2 LORs from US neurologists who supervised you directly
• 1 LOR from internal medicine (inpatient or subspecialty, preferably in a setting with lots of neurology overlap—stroke units, ICU, etc.)
• 1 additional letter (neurology, research, or another clinical core) you can use selectively

Step 2: Map your rotations to LOR opportunities

As a Caribbean IMG, you may rotate at multiple affiliate hospitals in the US. Before clinicals start, map out:

• Core neurology rotation

  • Priority #1 for neurology residency LORs
  • Try to do this earlier in your core/clerkship sequence if possible, so you have letters ready in time

• Sub-internships or electives in neurology

  • Inpatient neurology (stroke, general neuro)
  • Neuro ICU
  • Epilepsy or EMU
  • Outpatient general neurology or subspecialties (MS, movement disorders, neuromuscular)
  • These are excellent for a strong, neurology-focused LOR

• Internal medicine / ICU / emergency medicine

  • Good backup or complementary sources of letters
  • Especially helpful if they can describe your ability to manage acutely ill patients

Build a timeline like:

• Year 3 (early): Internal medicine core → build relationships with residents/attendings
• Year 3 (mid): Neurology core → primary LOR source
• Year 3 (late) / Year 4 (early): Neurology sub-I/elective at an academic center or at your dream neuro match institution → “capstone” LOR

Step 3: Prioritize US-based academic settings

For a Caribbean medical school residency application, US clinical letters carry more weight than non-US or purely community site letters. Ideal LOR writers:

• Are US-based faculty at teaching hospitals
• Have academic titles (Assistant/Associate/Full Professor)
• Work directly with residents and US MD/DO students, so they can compare you fairly
• Are known within neurology or internal medicine circles

If you can, target neurology electives at:

• University-affiliated hospitals
• Institutions with established neurology residencies
  This makes your LORs even more credible.

---

Who to Ask for Letters (and Who Not To)

The question of who to ask for letters is central to how to get strong LOR as a Caribbean IMG. The title and prestige of the writer matters, but not as much as their ability to describe you in detail.

Ideal LOR authors for neurology-bound Caribbean IMGs

1. Neurology attendings who supervised you closely

   • In inpatient neurology, stroke, or neuro ICU
   • In a busy outpatient neurology clinic with complex cases
   • On a sub-internship or acting-internship where your responsibilities were high

   Why they’re valuable:

   • They can comment directly on your neurologic exam skills
   • They see your neurologic reasoning daily
   • Their letters are clearly specialty-specific, which is vital for neurology residency

2. Neurology clerkship director or elective director

   • Especially if they observed you personally or reviewed your performance frequently
   • Their letter carries the institutional context:
     • “Top 10% of all students I’ve supervised”
     • “Performed at the level of a strong US MD student”

3. Internal medicine or ICU attendings

   • Preferably in settings with:
     • Stroke patients
     • Neurologic consultations
   • They can speak to:
     • Your general clinical competence
     • Your ability to manage acutely ill adults
     • Work ethic, communication, reliability

4. Research mentors in neurology or neuroscience

   • Particularly if:
     • You had a significant role (data collection, analysis, writing)
     • You worked with them over months to years
   • These letters complement, but should not replace, strong clinical LORs

Suboptimal or weak LOR sources

Avoid relying on:

• Letters from very short rotations (1–2 weeks)
  The writer likely cannot comment in depth.

• Non-US letters (unless truly exceptional)
  In general, US-based neurology residency programs give more weight to US clinical experiences. A non-US letter might be a 4th “bonus” letter, but not one of your primary three.

• Letters from non-clinical preclinical faculty
  These rarely matter much by the time you’re applying to residency, especially in neurology.

• Letters from family friends or alumni who didn’t supervise you clinically
  These are often recognized as courtesy letters and carry minimal weight.

• Generic department chair letters with no personal knowledge of your work
  Unless the chair has directly supervised you, this type of letter can feel formulaic. It may be useful only if it explicitly consolidates strong feedback from faculty who did know you.

Academic reputation vs. content: which matters more?

A common fear: “Should I get a letter from the famous department chair who barely knows me, or the associate professor who worked with me every day?”

For neurology residency and neuro match decisions, content wins:

• A detailed, enthusiastic letter from a mid-level academic neurologist who truly knows your work

  Stronger than

• A generic “good student” letter from a famous name with little personal experience with you

As a Caribbean IMG, you particularly need letters that:

• Describe your day-to-day performance
• Compare you favorably to US students
• Highlight growth and resilience

---

How to Get Strong LORs: Before, During, and After Your Rotations

Knowing who to ask is only the first step. The more important question is how to get strong LOR letters that are specific, enthusiastic, and tailored for neurology.

Before the rotation: set yourself up for success

1. Clarify your goals

   • Decide: “This neurology rotation is one of my primary LOR targets.”
   • Tell yourself: “Everything I do here is part of my neurology residency application story.”

2. Introduce your interest early On day 1 or 2:

   • Tell your attending:
     “I’m a Caribbean IMG planning to apply to neurology residency. I’m really hoping to learn as much as possible and, if I perform well, eventually ask you for a letter.”

   This:

   • Signals your seriousness
   • Encourages them to pay closer attention to your performance

3. Prepare foundational knowledge Before the rotation, review:

   • Basic neurologic exam
   • Common neurological conditions:
     • Ischemic and hemorrhagic stroke
     • Seizures and status epilepticus
     • Delirium vs dementia
     • Headache types
     • Neuromuscular emergencies (GBS, myasthenic crisis) Coming in prepared shows commitment and gives faculty more to comment on.

During the rotation: perform like a future neurology resident

To earn a strong neurology residency LOR, demonstrate:

1. Excellence in the neurologic exam

   • Always perform a thorough, structured exam
   • Present your findings clearly and concisely
   • Ask for feedback: “Could you watch my exam and let me know how I can improve?”

2. Clear, logical presentations

   • Present neurologic H&Ps organized by:
     • Localization
     • Differential
     • Most likely diagnosis
     • Plan
   • For example:

     “This patient has acute onset right hemiparesis and aphasia, localizing to the left MCA territory…”

3. Curiosity and initiative

   • Read about your patients’ conditions daily
   • Volunteer to follow up on imaging, labs, or consult notes
   • Offer to present short teaching topics (5 minutes on optic neuritis, for example)

4. Professionalism and reliability

   • Arrive early, stay appropriately late
   • Help with discharge summaries, follow-up calls, or patient education when appropriate
   • Show empathy with patients facing chronic, debilitating neurological disease

5. Teamwork and communication

   • Be respectful to nursing, PT/OT, and other services
   • Communicate clearly with residents and respond promptly
   • As a Caribbean IMG, showing you integrate smoothly into US teams is crucial

When and how to ask for the letter

Aim to ask for each LOR in the last week of the rotation, when your performance is fresh.

The most important question to ask is:

“Would you feel comfortable writing me a strong letter of recommendation for neurology residency?”

Adding the word “strong” gives the attending an option to decline if they can’t be enthusiastic.

If they hesitate, consider:

• Asking a different attending
• Using this letter only as a backup

If they say yes:

• Thank them sincerely
• Confirm how they prefer to receive your materials (CV, personal statement, ERAS info)

What to provide to your letter writers

Make it easy for them to write a detailed, neurology-focused letter. Send:

1. Updated CV

   • Highlight neurology experiences, research, leadership

2. Personal statement draft (even if not final)

   • So they understand your narrative and goals

3. ERAS letter request form / AAMC token

   • With clear instructions and deadlines

4. A brief “LOR support document” (1–2 pages) Include:

   • Your neurology career goals (e.g., general neuro vs academic vs neurocritical care interest)
   • Why you’re applying as a Caribbean IMG and what you want them to highlight
   • Specific cases or projects you worked on with them (to jog their memory)
   • A gentle reminder of any standout feedback they gave you:
     • “You told me I presented at the level of an intern on our stroke service.”

This is not “writing your own letter” (which is unethical); it’s giving your writer relevant context.

---

Presenting and Using Your Letters Strategically in ERAS

Once you’ve secured your letters, you still need to use them wisely for neurology residency applications.

How many neurology vs non-neurology letters?

For a strong neuro match profile as a Caribbean IMG, aim for:

• 2 neurology LORs (US-based, clinical, detailed)
• 1 internal medicine (or ICU/ED) letter
• 1 additional LOR (neurology or research) as optional

If you have more than 4 letters, you can assign different combinations to different program types:

• Academic programs with research focus → include your neurology research mentor letter
• Community programs with diverse patient care → include strong IM or ICU letters emphasizing your clinical efficiency and work ethic

US vs non-US letters

For US neurology residency programs:

• Prioritize US clinical letters whenever possible
• If you have a stellar non-US neurology letter (e.g., from a renowned neurologist who supervised you long-term), use it as:
  • A 4th letter
  • A supplement to, not a replacement for, US-based letters

What programs read between the lines

Program directors look for clues in LORs that matter particularly for Caribbean medical school residency applicants:

1. Comparative statements

   • “Among the top 10% of students I have supervised”
   • “Performed better than most US MD students on this rotation”

2. Concrete examples

   • Specific case presentations you handled
   • Examples of diagnostic reasoning or patient communication

3. Consistency across letters

   • Do multiple writers highlight your curiosity and work ethic?
   • Are there any red flags (e.g., faint praise, very generic language)?

4. Clear endorsement

   • “I give my highest recommendation for neurology residency”
   • “I would be thrilled to have them as a resident in our program”

Special notes for SGU and other large Caribbean schools

If you’re from SGU or a similar Caribbean medical school with a substantial US match track record:

• Leverage sites that have a known SGU residency match history in neurology or internal medicine
• Attending physicians at these sites may:
  • Already have experience with prior successful SGU residency match candidates
  • Be comfortable comparing you to previous strong graduates
• A letter that says:
  • “Comparable to our previous SGU students who matched into neurology at X program” can be quietly powerful.

---

Common Pitfalls and How to Avoid Them

Pitfall 1: Waiting too long to ask

If you wait months after the rotation:

• The attending may not remember details
• The letter becomes more generic

Solution: Ask near the end of the rotation, and politely remind them 4–6 weeks later if needed.

Pitfall 2: Asking someone who barely knows you

This leads to vague statements:

• “Hardworking and punctual”
• “Pleasure to work with”
• But no specific examples or comparative strength

Solution: Prioritize attendings who:

• Worked with you daily
• Gave you feedback
• Saw you handle multiple complex patients

Pitfall 3: Overloading on research letters

For neurology, research is a plus, but:

• Clinical performance still matters more for most programs
• A research-only letter (no clinical supervision) is often seen as secondary

Solution: Use research letters as supplemental, not primary, unless the mentor also supervised you clinically.

Pitfall 4: Weak or lukewarm letters

Sometimes the words look fine, but the tone is flat. This can subtly hurt your neuro match chances.

Solution:

• Use the phrase “strong letter” when you ask
• If someone seems hesitant, thank them and consider asking someone more enthusiastic

Pitfall 5: Not tailoring your application

Sending the exact same letter mix to every program can be suboptimal.

Solution:
Use ERAS flexibility:

• Academic, research-heavy neurology programs:
  • 2 neurology clinical + 1 neurology research + 1 IM
• Community neurology programs:
  • 2 neurology clinical + 1 IM + 1 ICU/ED or strong generalist letter

---

FAQs: Letters of Recommendation for Caribbean IMG in Neurology

1. How many neurology-specific letters do I need for neurology residency?

Most neurology programs prefer at least two neurology-specific clinical LORs.
As a Caribbean IMG, having 2 neurology letters + 1 internal medicine letter (plus an optional 4th letter) is ideal. If you only have one neurology letter, your application may still be considered, but having two clearly strengthens your neuro match profile.

2. Does it matter if my letter writer is from a community hospital vs a university?

Both can write excellent letters. For Caribbean medical school residency applicants:

• University-affiliated attendings may be able to:
  • Compare you directly to US MD/DO students
  • Provide more perceived “academic credibility”
• Community attendings can:
  • Describe your hands-on skills and work ethic in busy, real-world settings

If possible, aim for at least one letter from a university or academic neurology department, but a strong, detailed community letter is far better than a vague academic one.

3. Should I waive my right to see my letters in ERAS?

Yes. For neurology residency and most US specialties:

• Waiving your right (FERPA) signals that:
  • The letter is candid
  • Programs can trust that the writer felt free to be honest
• Some program directors may be wary of non-waived letters

You can still get a sense of your letter quality indirectly (e.g., through the writer’s enthusiasm and what they say to you), but you typically should waive access.

4. I’m a Caribbean IMG with mostly non-neurology rotations. Can I still get a strong neurology residency application together?

Yes, but you need to be strategic:

• Prioritize at least one strong neurology core or elective in a US setting, ideally before ERAS submission
• Get one or two neurology LORs from that time
• Use strong internal medicine or ICU letters to:
  • Demonstrate overall clinical competence
  • Show comfort with complex, acutely ill adults

If timing forces you to complete neurology electives later in the year, let programs know in your personal statement or interviews that you are booked for those rotations—this can still help during rank list formation.

---

Letters of recommendation are one of the most powerful tools you have as a Caribbean IMG applying to neurology residency. With early planning, thoughtful selection of letter writers, and intentional performance during your neurology and internal medicine rotations, you can build an LOR portfolio that not only counters bias but actively convinces program directors that you will thrive in their training environment.

Use your time in clinicals not just to learn neurology, but to show future letter writers—and future programs—the kind of neurologist you’re becoming.