Mastering Letters of Recommendation for Caribbean IMGs in Addiction Medicine

Understanding the Power of Letters of Recommendation for Caribbean IMGs

For a Caribbean IMG interested in Addiction Medicine, letters of recommendation (LORs) are one of the most powerful parts of your residency or fellowship application. They can elevate an application from “borderline” to “must interview,” especially when program directors are uncertain how to compare Caribbean medical school applicants to U.S. MD/DO candidates.

Program directors often use LORs to answer questions like:

• Can this applicant function safely and independently in clinical settings?
• Would I trust this person with complex, vulnerable patients—especially those with substance use disorders?
• Are they someone I want on my team at 3 a.m. when a patient is in severe withdrawal or crisis?
• Do they truly understand addiction medicine, or is it just a checkbox on their CV?

As a Caribbean IMG, you may already be aware of stigma or skepticism around “Caribbean medical school residency” applicants. Strategic, targeted, and powerful letters of recommendation can directly address those doubts. Strong LORs can:

• Demonstrate that you are clinically on par with U.S. graduates
• Show that you understand the unique demands of addiction medicine
• Provide concrete evidence of professionalism, empathy, and resilience
• Offset concerns about school name recognition or USMLE performance

This article focuses on how to get strong LOR as a Caribbean IMG applying to:

• Primary residency programs (Internal Medicine, Family Medicine, Psychiatry, etc.) with a strong addiction focus
• Addiction Medicine fellowship (including after residency)
• Programs that emphasize substance abuse training, integrated behavioral health, or dual diagnosis care

Understanding who to ask for letters, when to ask, and what content matters most in addiction medicine will significantly improve your “SGU residency match” or match outcomes from any Caribbean school.

---

What Makes a Strong Letter for Addiction Medicine?

Not all letters carry the same weight. In addiction medicine–related applications, program directors are looking for specific attributes. A strong LOR for this specialty usually has these features:

1. Specificity Over General Praise

Weak LOR example phrases:

• “Hard-working and pleasant”
• “Shows interest in addiction medicine”
• “Did a good job on the rotation”

Strong LOR example phrases:

• “Personally managed 12 patients on our inpatient detox unit, independently formulating withdrawal management plans and presenting succinct, organized assessments.”
• “Demonstrated advanced understanding of opioid use disorder pharmacotherapy, taking initiative to educate patients and families on buprenorphine and naltrexone.”
• “Stayed after hours to participate in group therapy sessions; patients reported feeling heard and respected.”

The more concrete the examples, the more credible the letter.

2. Clear Link to Addiction Medicine or Substance Use Care

For addiction-focused applications, it is powerful if at least one or two letters explicitly reference:

• Experience with substance use disorders (SUDs)
• Detox or withdrawal management (alcohol, benzodiazepines, opioids)
• Co-occurring psychiatric disorders
• Harm reduction, MAT (Medication-Assisted Treatment), or community programs
• Motivational interviewing, trauma-informed care, or stigma reduction

The letter doesn’t have to be from an addiction psychiatrist or addiction medicine specialist (though that’s ideal), but it should show meaningful substance abuse training or exposure.

3. Credibility of the Letter Writer

Program directors weigh:

• Specialty and role: Addiction medicine specialist, psychiatry faculty, internal medicine or family medicine attendings with addiction focus, program director, division chief, or site director.
• Reputation and institution: U.S. teaching hospitals and well-known addiction centers carry particular weight, but strong letters from community-based clinicians with robust addiction practices are also valuable, especially when detailed and personal.
• Depth of relationship: Did the writer supervise you over weeks or months? Can they compare you to other trainees?

A short, generic letter from a famous name is less helpful than a detailed, enthusiastic letter from a mid-level faculty member who truly knows your work.

4. Clear Comparison to Peers

Program directors want to know where you stand. Strong letters may say:

• “Among the top 10% of students I have supervised in the past five years.”
• “Comparable to our U.S. MD students at the same level, and stronger than many in clinical maturity.”
• “Her clinical performance would easily be competitive at any U.S. medical school.”

For a Caribbean medical school residency applicant, this kind of comparative language can be extremely powerful in addressing bias.

---

Who to Ask for Letters (and How Many You Need)

Standard Numbers and Types of Letters

Most residency and fellowship programs ask for 3 letters of recommendation, sometimes plus the MSPE/Dean’s Letter and/or chair’s letter (for residency). Check each program’s specific requirements, but this is a common pattern:

• Residency (Internal Medicine, Family Medicine, Psychiatry, etc.)

  • 2–3 clinical letters from attendings who directly supervised you
  • 1 may be from a department chair or program director (especially for IM/FM)
  • At least 1 letter demonstrating strong interest in addiction medicine (if available)

• Addiction Medicine Fellowship (post-residency)

  • 2 letters from core residency faculty (program director, associate PD, or frequent supervisor)
  • 1 letter specifically from an addiction medicine/psychiatry mentor or someone who can speak in detail about your work with SUD patients

Prioritizing Letter Writers as a Caribbean IMG

When deciding who to ask for letters, rank potential writers based on:

1. How well they know you clinically
   • Long rotations (4+ weeks), multiple rotations with the same attending, or longitudinal clinic experience is ideal.
2. Their connection to addiction medicine
   • Addiction specialist, psychiatrist, IM/FM with an addiction consult role, or attendings from detox/rehab/recovery programs.
3. Their reputation and role
   • Program directors, clerkship directors, site directors, and faculty heavily involved in education are especially influential.
4. Location of training
   • Letters from U.S.-based clinical rotations (e.g., SGU residency match partner hospitals, U.S. teaching sites associated with Caribbean schools) are often more impactful for U.S. programs than letters solely from the Caribbean campus, unless the author is particularly well known.

Ideal Letter Mix for a Caribbean IMG Targeting Addiction Medicine

For a typical Caribbean IMG applying into, say, Internal Medicine or Psychiatry with the goal of Addiction Medicine fellowship, an optimal mix might be:

• Letter 1 (Core Specialty): Internal Medicine or Psychiatry attending from a U.S. academic teaching hospital who supervised you on inpatient service.
• Letter 2 (Addiction-Focused): Addiction medicine or psychiatry attending from a detox unit, SUD clinic, methadone/buprenorphine clinic, or integrated behavioral health setting who can attest to your work with substance use patients.
• Letter 3 (Supportive Educator/Leader): Program director, clerkship director, or site director who can vouch for your professionalism, communication, and consistent performance across settings.

If you attended St. George’s University or another major Caribbean school with a strong “SGU residency match” infrastructure, leverage those relationships:

• Ask rotation coordinators which attendings are known to write strong, detailed letters.
• Identify addiction-related elective sites used frequently by SGU or similar schools; attendings there may be very familiar with writing effective letters for Caribbean IMGs.

---

How to Get Strong LOR: Strategy, Timing, and Execution

Knowing who to ask is just the start. The real question is how to get strong LOR—letters that stand out and substantively support your candidacy.

1. Start Planning Early

For residency applications (ERAS):

• 6–12 months before application season:

  • Identify addiction-related rotations or electives you can schedule (detox units, VA substance use clinics, psychiatry consult services, etc.).
  • Let coordinators know you are particularly interested in addiction medicine and are hoping to obtain a strong letter.

• During rotations:

  • Show consistent interest in SUD patients: volunteer to take them on your team, read on your own, ask thoughtful questions.
  • Attend extra patient groups or educational sessions relevant to addiction. Document your involvement so you can remind your letter writer later.

2. Signal Your Interest Clearly

Attendings are often more generous with letters when they know:

• You are serious about the field
• You are a Caribbean IMG who needs strong proof of clinical ability
• Their letter could be pivotal in your career

Early in the rotation, say something like:

“Dr. Lee, I’m a Caribbean IMG very interested in Internal Medicine with a strong focus on addiction medicine. I know letters of recommendation are extremely important for my residency application. I’d really appreciate any feedback during the rotation on what I can do to reach the level where you’d feel comfortable writing a strong letter for me.”

This does three things:

1. Puts your interest on their radar
2. Signals maturity and coachability
3. Gives them permission to be honest with you about your performance

3. Earn the Letter Through Performance

Actions that typically lead to strong letters in addiction-related settings:

• Take ownership:

  • Be the primary student/resident on patients with substance use disorders.
  • Follow up labs, call consults, coordinate discharges, and know your patients’ stories deeply.

• Demonstrate comfort and respect in addiction care:

  • Use non-stigmatizing language.
  • Practice motivational interviewing and active listening.
  • Show patience and empathy with relapses and complex psychosocial situations.

• Read and apply knowledge:

  • Understand protocols for alcohol withdrawal (CIWA), opioid withdrawal, benzodiazepine tapering.
  • Learn about MAT options and be able to discuss them with patients and staff.

• Be reliable and professional:

  • Arrive early, be prepared, and respond positively to feedback.
  • Maintain meticulous documentation and follow-through.

4. Ask the Right Way—and Ask for a Strong Letter

When the rotation is going well (often in the last week), ask directly and professionally:

“Dr. Smith, I’ve really appreciated working with you on the addiction consult service. I’m applying for Internal Medicine residency with a plan to pursue an addiction medicine fellowship. Would you feel comfortable writing a strong letter of recommendation for me?”

Asking for a “strong” letter is important. If the attending hesitates or suggests someone else, that’s often a sign they might write a lukewarm letter. It is better to avoid weak letters altogether.

If they agree, follow up with:

• A current CV
• Your personal statement (or a short paragraph about your interest in addiction medicine if the personal statement is not ready yet)
• A bullet-point list of cases, projects, or interactions you had with them (to jog their memory)
• Any program-specific requirements for the letter (e.g., needs to be submitted via ERAS or a specific portal)

---

Content That Matters: What Your Letters Should Highlight

You cannot write your own LOR, but you can guide your writer by what you provide in your CV, email, and conversations. For addiction medicine–oriented applications, encourage content in these areas.

1. Clinical Competence and Safety

Program directors want assurance that you are:

• Safe with prescribing (especially controlled substances)
• Thoughtful about monitoring for withdrawal, overdose risk, and medical complications
• Able to manage complex, co-morbid patients (e.g., cirrhosis, psychiatric illness, homelessness)

Examples you can remind your letter writer of:

• Cases where you noticed early signs of withdrawal or overdose risk
• Times you escalated care appropriately or advocated for a higher level of care
• Contributions to complex medication management plans

2. Communication and Empathy With SUD Patients

Addiction medicine is built on trust and therapeutic alliance. Letters should, ideally, show:

• Your non-judgmental attitude towards patients with substance use disorders
• Skill in building rapport and motivating behavior change
• Cultural sensitivity and respect for diverse backgrounds (particularly relevant for Caribbean IMGs)

You might remind your writer of specific encounters such as:

• Difficult conversations you navigated around relapse, overdose, or leaving AMA
• Group therapy sessions you helped facilitate or attended
• Positive feedback patients gave about your care

3. Commitment to Addiction Medicine and Substance Abuse Training

Even if your immediate goal is a primary residency (e.g., IM/FM/Psych), it is valuable for letters to signal your long-term plan for an addiction medicine fellowship. Program directors appreciate applicants with clear direction.

Your LORs can mention:

• Electives or research related to substance use or dual diagnosis
• Quality improvement (QI) projects in detox, MAT clinics, ED screening, etc.
• Participation in AA/NA meetings (as an observer), harm reduction initiatives, or community outreach
• Formal substance abuse training (courses, workshops, CME, or certificates)

4. Resilience and Professional Growth as a Caribbean IMG

Without dwelling on stigma, a thoughtful letter can subtly address:

• How you adapted to a new healthcare system (U.S., Canada, or UK)
• Your perseverance and maturity as a Caribbean IMG navigating clinical environments with high expectations
• Your ability to integrate into diverse teams and maintain professionalism under stress

For Caribbean medical school residency applicants, this kind of narrative reassures programs that you are:

• Well-acculturated to U.S. clinical practice
• Resilient and resourceful
• Likely to thrive in rigorous, high-volume training environments

---

Practical Tips, Common Pitfalls, and FAQs

Common Mistakes Caribbean IMGs Make With LORs

1. Waiting too long to ask

   • If you ask months later, attendings may not remember you clearly, leading to vague letters.

2. Choosing title over substance

   • A generic letter from a famous name is weaker than a specific, enthusiastic one from someone who knows you well.

3. Not confirming that the letter was submitted

   • Use ERAS or other portals to track receipt. If a deadline is nearing, send a polite reminder email.

4. Using only Caribbean-based letters when U.S. clinical letters are available

   • U.S. clinical evaluations often carry more weight with U.S. residency programs. Use your strongest ones.

5. Ignoring the addiction medicine angle

   • If you know you want addiction medicine, build at least one or two letters that explicitly reflect SUD experience and interest.

How to Organize and Track Your Letters

Create a simple spreadsheet with:

• Letter writer’s name, specialty, and institution
• Type of rotation and dates
• Date you requested the letter
• Date you sent CV/personal statement
• Deadline for applications
• Date the letter was confirmed as received

Send thank-you emails after the letter is submitted, and consider updating your letter writers after interview season or Match Day; they often appreciate hearing how things turned out.

---

FAQ: Letters of Recommendation for Caribbean IMG in Addiction Medicine

1. How many addiction-specific letters do I actually need?

For core residency (IM/FM/Psych), at least one strong addiction-focused letter is ideal, especially if you are clearly signaling future interest in addiction medicine. If you have two such letters (e.g., one from an addiction medicine attending and one from a psychiatry or behavioral health rotation), that’s even stronger. You still need at least one letter from the specialty you’re applying into (e.g., IM for an IM application).

For an addiction medicine fellowship, you should have one letter specifically from an addiction specialist plus 1–2 letters from residency leadership or core faculty who can attest to your overall clinical performance and professionalism.

2. Are letters from Caribbean faculty helpful, or should I only use U.S. letters?

Well-written letters from Caribbean faculty who know you well can be useful, especially for highlighting your academic performance and long-term growth. However, for U.S. residency programs, letters from U.S.-based clinical rotations usually carry more weight, because they directly show your performance in the clinical environment where you’ll train.

A balanced approach for a Caribbean medical school residency application:

• 2–3 letters from U.S. clinical attendings (at least one addiction-related if possible)
• Optional: 1 institutional letter from your Caribbean school (Dean’s letter/MSPE, or a faculty member who has known you over years)

3. If I rotated at multiple addiction-related sites, who should I prioritize for letters?

Prioritize:

1. Attendings who directly supervised you for the longest duration (4+ weeks)
2. Those who saw you manage a range of SUD cases independently
3. Those who gave you positive feedback about your performance or explicitly offered to support your career
4. Faculty with educational or leadership roles (e.g., addiction rotation director, residency faculty liaison for SUD care)

If you’re unsure, you can ask a faculty member:

“Based on how we worked together, do you think you could write a detailed, strong letter supporting my application to residency with a focus on addiction medicine?”

Their response will often clarify whom you should prioritize.

4. Can I reuse my residency letters when applying for addiction medicine fellowship later?

Sometimes, yes—but with caution. Addiction medicine fellowships typically expect fresh letters reflecting your performance as a resident. A letter from medical school is usually too outdated by the time you apply for fellowship.

However, you can:

• Ask an old letter writer from a powerful addiction rotation (e.g., from your SGU residency match clinical years) to update or rewrite a letter based on your newer achievements.
• Provide them with your residency CV and list of addiction-related activities to help them craft a current, robust fellowship letter.

---

Strong letters of recommendation are one of the most effective ways for a Caribbean IMG to stand out—especially in a field like addiction medicine, where character, empathy, and clinical maturity matter as much as test scores. By choosing the right letter writers, building deliberate addiction-related experiences, and asking thoughtfully and early, you can create a powerful, coherent narrative that makes residency and, later, addiction medicine fellowship programs confident in choosing you.