Essential Letters of Recommendation Guide for Caribbean IMG Residents

Understanding the Role of Letters of Recommendation for Caribbean IMGs in Pediatrics-Psychiatry

For a Caribbean IMG applying to a combined Pediatrics-Psychiatry (often called “peds psych”) or Triple Board program, letters of recommendation (LORs) can make or break your application. Your USMLE scores and clinical grades get you past initial filters—but your letters help programs decide if you are the kind of colleague, trainee, and physician they want for the next 3–5 years.

As a Caribbean medical school graduate, you may feel extra pressure to “prove” yourself—especially if you’re aiming for a competitive combined specialty or Triple Board position. Strong, strategically chosen residency letters of recommendation can help bridge doubts about school name, step timing, or gaps, and emphasize what truly matters: your clinical performance, professionalism, and potential.

This guide is tailored specifically for Caribbean IMGs interested in:

• Combined Pediatrics-Psychiatry programs
• Triple Board (Pediatrics–Psychiatry–Child and Adolescent Psychiatry)
• Pediatrics or Psychiatry categorical programs with an eye toward child mental health

It focuses on how to get strong LORs, who to ask for letters, how many you need, and how to leverage your background—including SGU residency match or other Caribbean medical school residency outcomes—to your advantage.

---

What Programs Look For in Letters of Recommendation

Before you think about who to ask for letters, you need to understand what residency programs are actually looking for in those letters.

1. Clinical Competence in Both Pediatrics and Psychiatry

For peds psych or Triple Board programs, your letters should collectively show:

• Solid pediatric clinical skills: history taking with families, physical exams on children of various ages, growth and development knowledge, clinical reasoning, and comfort in busy inpatient or outpatient pediatric settings.
• Genuine psychiatric interest and ability: rapport with patients and families, empathic communication, thoughtful diagnostic formulation, and evidence-based treatment planning.

Programs know that not every applicant will have extensive experience in both fields, but your letters should clearly support at least:

• Strength in one field (peds or psych) and
• Real potential and interest in the other.

2. Professionalism and Reliability

As a Caribbean IMG, program directors are especially sensitive to:

• Reliability: shows up on time, completes notes and tasks, responds to pages
• Teamwork: works well with nurses, residents, attendings, and other staff
• Resilience: handles stress, feedback, and long hours professionally
• Cultural competence: works respectfully with diverse families and staff

Letters that include explicit, concrete examples of these qualities are more powerful than generic praise.

3. Fit for Pediatrics-Psychiatry or Triple Board

Programs want to see you are not just “shopping around” but genuinely drawn to the interplay of child health and mental health. Letters can support this by highlighting:

• Your interest in developmental, behavioral, or psychosocial aspects of illness
• Your engagement with families around emotional and behavioral concerns
• Your ability to integrate medical and psychosocial formulations

A letter that says, “This student is one of the few I’ve seen who naturally thinks about both physical and emotional health in every patient encounter” directly signals peds psych readiness.

4. Strength of Endorsement and Specificity

The most impactful letters:

• Use strong language: “top 5% of students I’ve worked with,” “I will be disappointed if I can’t recruit this candidate,” “outstanding” rather than “adequate” or “good.”
• Describe specific cases, behaviors, and improvements
• Compare you to peers: “among the best IMGs we have trained,” “compares favorably with our US senior medical students”

For a Caribbean medical school residency applicant, these comparative statements help counter vague bias against offshore schools.

---

How Many Letters You Need and the Ideal Mix for Peds-Psych and Triple Board

Basic Numbers for ERAS

Most residency programs require:

• 3 letters of recommendation (not including the MSPE/Dean’s letter)
• Some allow up to 4 letters to be uploaded in ERAS per program

Always:

• Check each program’s website for specific LOR requirements
• Respect any specialty-specific guidelines (e.g., at least 2 letters from core specialty faculty)

For Pediatrics-Psychiatry or Triple Board Applicants

For a combined or Triple Board applicant, aim for a balanced and strategic mix:

Core target mix (3–4 letters):

1. Pediatrics letter from a US-based attending (ideally in an ACGME-accredited hospital)
2. Psychiatry letter from a US-based attending (adult or child psychiatry; child psych is ideal)
3. Third letter from either pediatrics or psychiatry (whichever is strongest)
4. (Optional) Fourth letter: A strong “character plus clinical” letter (e.g., sub-internship director, research mentor in child mental health, or medical director at a community clinic)

For Triple Board specifically, most programs like to see:

• At least one pediatrics letter
• At least one psychiatry letter
• Ideally, at least one that explicitly comments on your potential for multidisciplinary or longitudinal training (following children/families over time, thinking biopsychosocially, etc.)

Tailoring Letters by Program Type

You can strategically choose which letters to assign to which type of program in ERAS:

• For Pediatrics categorical programs: Emphasize pediatrics letters; include one psych letter if it’s very strong and highlights child-related mental health.
• For Psychiatry categorical programs: Emphasize psychiatry letters; include one peds letter if it shows strengths in working with children and families.
• For combined Peds-Psych or Triple Board: Use your very best letters from both specialties and any that highlight integration of medical and psychiatric care in kids.

---

Who to Ask for Letters (and How to Get Strong LORs as a Caribbean IMG)

Many IMGs struggle most with this question: who to ask for letters and how to get strong LORs instead of lukewarm, generic ones.

Prioritizing US-Based Clinical Supervisors

For a Caribbean medical school residency applicant, US clinical experience—and especially US letters—is critically important. Your priority list should be:

1. US-based attendings who directly supervised you in pediatrics or psychiatry
2. US-based sub-internship/acting-internship directors (peds, psych, or both)
3. Program directors, clerkship directors, or site directors who know your work well
4. Research mentors in pediatrics, psychiatry, or child mental health who have seen your clinical or academic performance up close, especially if US-based
5. Home-institution letters (Caribbean school attendings) as supplemental, not primary, letters—unless they know you extremely well and can offer unusually detailed advocacy

Ideal Letter Writers for Peds-Psych and Triple Board

Try to secure letters from:

• A pediatrician who can say:

  • You are strong clinically with children
  • You interact well with families
  • You are reliable on the team
  • You show interest in developmental and psychosocial issues

• A psychiatrist (adult or child) who can say:

  • You formulate cases biopsychosocially
  • You are thoughtful, empathic, and psychologically minded
  • You communicate clearly about sensitive topics

• Someone who sees your integrative potential, such as:

  • An attending on a pediatric consult-liaison psychiatry service
  • A physician in developmental-behavioral pediatrics
  • A child and adolescent psychiatrist in a pediatric hospital setting

These integrative settings are ideal for Triple Board applicants, and their letters can be especially persuasive.

How to Ask for a Strong Letter (Not Just Any Letter)

When you approach a potential letter writer, don’t just ask, “Can you write me a letter?” Instead, explicitly ask:

“Would you feel comfortable writing me a strong letter of recommendation for pediatrics-psychiatry and Triple Board programs?”

This wording gives them a polite way to decline if they cannot fully support you. A lukewarm letter (“hard worker,” “nice,” “adequate”) can seriously hurt your application.

To help them say “yes,” you should:

• Ask early—ideally at the end of a rotation when your performance is fresh in their mind.
• Remind them of specific things you did (presentations, challenging patients, leadership).
• Share your CV, personal statement draft, and a short paragraph summarizing:
  • Why you’re interested in peds psych / Triple Board
  • Traits you hope they can highlight (e.g., empathy, reliability, integrative thinking)

This isn’t “writing your own letter”—it’s providing context so they can tailor their letter to your goals.

---

Timing, Strategy, and Logistics: Making Your Letters Work for You

When to Request Letters

For most applicants entering the match cycle:

• End of 3rd year / early 4th year (or equivalent): Start identifying strong potential letter writers during key rotations.
• Immediately after strong US rotations: Ask at the end of the block while the attending remembers you well.
• At least 4–6 weeks before ERAS submission: Give writers enough time to craft a thoughtful letter.

As a Caribbean IMG, rotations and exam timelines might be non-traditional. Map backward from ERAS submission (usually in September):

• Identify when your final pediatrics and psychiatry rotations will be
• Ensure at least one strong peds and one strong psych letter will be ready by that time
• If you’re leveraging an SGU residency match track or similar, ask academic advisors about specific departmental expectations for letters

How Many Letters to Actually Collect

Even if you can only upload 3–4 letters, it’s wise to collect 4–5 total so you can choose the strongest:

• 2–3 pediatrics-related letters (including one clearly your best)
• 2 psychiatry-related letters
• Possibly 1 research or longitudinal mentor letter (if very strong and relevant)

Then assign letters strategically within ERAS:

• Strongest 3–4 letters to each program, tailored by specialty
• Avoid loading a program with 3 letters from the same short rotation; variety shows consistency across settings

ERAS Waiver: Always Waive Your Right to See Letters

Residency programs expect letters to be confidential. On ERAS, you’ll be asked if you want to:

• Waive your right to view the letter, or
• Not waive your right

You should always waive your right. Non-waived letters are seen as less candid and therefore less reliable.

What if You Don’t Have Enough US Letters?

As a Caribbean medical school residency candidate, sometimes you don’t get the US rotations you hoped for. In that case:

1. Prioritize any US-based peds or psych rotation you can get, even late in your timeline.
2. Consider short electives or observerships where you can demonstrate work ethic and clinical thinking.
3. Use strong home institution letters as back-up but clearly emphasize US experiences in your personal statement and interviews.
4. In your application and interviews, address the challenge honestly and highlight how you maximized every available opportunity.

---

Content of a Strong Letter: What Makes You Stand Out as a Caribbean IMG in Peds-Psych

While you can’t (and shouldn’t) write your own letters, you can influence what’s highlighted by how you present yourself and by what you discuss with letter writers.

Key Themes for Peds-Psych / Triple Board Letters

Encourage letters that touch on:

• Biopsychosocial thinking: You consider medical, psychological, social, cultural, and developmental factors.
• Family-centered care: You communicate effectively with both child and caregiver.
• Adaptability and maturity: Especially important for a Caribbean IMG who often has navigated complex paths, visas, and multiple healthcare systems.
• Cultural humility and competence: Your background can be a strength in working with diverse families and communities.

Examples of Strong Content in a Letter

Below are the types of details that residency directors love to see:

• “On our inpatient pediatric service, the student independently followed 8–10 patients, consistently delivered concise, organized presentations, and integrated psychosocial factors into daily care plans.”
• “While evaluating an adolescent with somatic complaints, the student thoughtfully explored mood, school stressors, and family dynamics, and suggested a referral that led to early identification of depression.”
• “Despite being an IMG from a Caribbean medical school, this student performed at or above the level of our US senior students. Their clinical reasoning, professionalism, and work ethic place them in the top 10% of trainees I have supervised.”
• “The student’s interest in Triple Board training is evident in the way they see children and families holistically. They are precisely the kind of trainee who will thrive in a combined program.”

Embracing Your Caribbean Background as a Strength

Program directors understand that Caribbean medical school residency applicants bring:

• Experience learning in resource-variable settings
• Flexibility and adaptation to new systems and cultures
• High motivation and persistence

Letters should highlight how your background has:

• Strengthened your resilience and empathy
• Prepared you to work with underserved, immigrant, or multicultural communities
• Given you a unique perspective on child mental health and pediatric care

If your school has a strong reputation (e.g., SGU residency match outcomes), a letter that references how you compare favorably to typical graduates can help contextualize your training.

---

FAQs: Letters of Recommendation for Caribbean IMG in Pediatrics-Psychiatry

1. How many pediatrics vs psychiatry letters should I have for peds psych or Triple Board?

Aim for at least:

• One strong pediatrics letter and
• One strong psychiatry letter

Your third (and optional fourth) letter can be from either field, depending on where you have your strongest advocacy. For Triple Board, having both specialties represented is especially important, and an integrative letter (e.g., from consult-liaison or developmental-behavioral pediatrics) is a major plus.

2. Do programs care if my letters are from Caribbean vs US attendings?

US-based letters generally carry more weight because they:

• Reflect performance in the system where you’ll train
• Are written by attendings familiar with US residency expectations

However, a very strong, detailed Caribbean attending letter is better than a vague US letter. Ideally, have at least 2 letters from US-based supervisors and 1 from your Caribbean institution (if they know you well). For Caribbean medical school residency applicants, that US component is especially important.

3. What if my peds or psych rotation was short—can I still ask for a letter?

Yes, but be strategic:

• Ask attendings who worked closely with you, even if for a short time.
• Provide them with your CV, personal statement, and a reminder of specific patients or projects.
• Say something like, “I know we worked together for only four weeks, but this was a pivotal rotation for me, and I really valued your feedback on my growth.”

If they hesitate, it might be better to ask someone who had more exposure to your work.

4. How can I improve my chances of getting strong LORs during my rotations?

During each pediatrics and psychiatry rotation:

• Show up early, be prepared, and volunteer for tasks.
• Ask for feedback halfway through the rotation and act on it.
• Show clear interest in integrated care—ask questions that connect physical and mental health.
• Give a short, well-prepared talk or presentation if possible.
• At the end, if feedback has been positive, say:

  “I’m planning to apply to pediatrics-psychiatry / Triple Board programs. Would you feel comfortable writing me a strong letter of recommendation?”

Being proactive, engaged, and teachable throughout the rotation is the single most powerful way to ensure that when you ask for a letter, the answer is an enthusiastic “yes.”

---

By understanding what programs want, choosing your letter writers wisely, and intentionally cultivating strong relationships during your rotations, you can build a set of letters of recommendation that powerfully support your path from Caribbean IMG to pediatrics-psychiatry or Triple Board resident.