Mastering Letters of Recommendation for Caribbean IMG Residency Success

Understanding the Role of Letters of Recommendation for Caribbean IMGs in Preliminary Medicine

For a Caribbean IMG targeting a Preliminary Medicine spot, letters of recommendation (LORs) can be the difference between landing interviews and being filtered out. Programs know less about your school, may have biases about Caribbean medical school residency applicants, and often rely heavily on strong, trusted voices to validate your clinical skills and professionalism.

For prelim IM positions—especially those connected to competitive advanced specialties (neurology, radiology, anesthesiology, derm, ophtho)—program directors want proof that:

• You can function safely and effectively as an intern on a medicine service
• You are hardworking, reliable, and easy to work with
• You will not be a “problem intern” who needs remediation, micromanagement, or disciplinary attention

Letters of recommendation are one of the only parts of your application where another physician directly vouches for you. For Caribbean IMGs, a thoughtful strategy about who to ask for letters, how to get strong LORs, and how to frame your preliminary medicine interest is crucial.

This guide will walk you through:

• What makes a strong letter for a prelim IM application
• LOR types and which ones matter most for Caribbean IMGs
• How to choose letter writers strategically
• How to ask for and support strong letters
• Timing, logistics, and ERAS details
• Common pitfalls and how to avoid them

Throughout, we’ll focus on the specific realities of SGU residency match and other Caribbean medical school residency pathways, where letters often carry extra weight.

---

What Makes a Strong Letter for a Prelim Medicine Applicant?

Not all “good” letters are strong letters. Residency programs read hundreds, sometimes thousands, each season. A letter that truly helps your application has specific characteristics.

Core Features of a Strong Prelim IM Letter

A strong letter should:

1. Come from the right kind of writer

   • US-based faculty, ideally at an academic or teaching hospital
   • Internal medicine (IM) attendings for prelim medicine specifically
   • Physicians known to be good educators or who have leadership roles (PD, APD, clerkship director, chief, department chair)

2. Contain concrete, comparative comments Programs are looking for more than “Student X was excellent.” They want:

   • Comparisons:
     • “In the top 10% of medical students I have worked with in the past five years”
     • “One of the strongest Caribbean IMG students I’ve supervised”
   • Specific examples of behavior:
     • “Stayed late to call families and clarify discharge plans”
     • “Presented complex cases clearly on rounds and incorporated feedback quickly”

3. Address prelim-relevant skills For a preliminary medicine year (prelim IM), programs want reassurance about:

   • Clinical reasoning and problem solving
   • Reliability, ownership, and follow-through
   • Communication with nursing staff and consultants
   • Ability to handle a heavy workload and cross-cover
   • Response to feedback and teachability
   • Professionalism and teamwork

4. Reassure about IMG/Caribbean training Many faculty know that some PDs are cautious about Caribbean-trained applicants. Strong letters for Caribbean IMGs often explicitly address this:

   • “Although she trained at a Caribbean medical school, her clinical knowledge and performance were on par with, and often exceeded, our US-trained students.”
   • “I have worked with multiple SGU and other Caribbean graduates over the years; this student is among the best of them.”

5. Be clearly enthusiastic, not lukewarm Phrases that signal strength:

   • “I give my highest recommendation”
   • “I would be delighted to have him as an intern on my own team”
   • “I expect her to excel in any preliminary medicine residency”

Weak or vague closings (“I recommend without reservation” with no context, or “I think he will do well”) can be interpreted as neutral.

---

Types of Letters You Need as a Caribbean IMG Applying to Preliminary Medicine

As a Caribbean IMG, you often face an uphill battle: programs may not be familiar with your school, and sometimes have negative stereotypes about Caribbean medical school residency candidates. The right mix of LORs can help counter this.

1. Internal Medicine Clinical Letter (Mandatory)

For a prelim IM application, you should have at least one, ideally two, strong IM letters from:

• Inpatient internal medicine rotations
• Sub-internships / acting internship (AI) in medicine
• Night float or ward-based IM rotations

Best-case scenario:

• 1 letter from a sub-I/acting internship in IM (US-based teaching hospital)
• 1 letter from a ward/hospital IM clerkship or IM elective

These letters show how you behave while doing the exact job you’ll be doing as a prelim intern.

2. Specialty Letter from Your Intended Advanced Field (Optional but Helpful)

If you’re applying to prelim medicine plus an advanced specialty (e.g., neurology, radiology, anesthesiology, PM&R), having 1 letter from that specialty can:

• Show commitment to your long-term career path
• Help your advanced programs feel confident about you

For example:

• Applying advanced neurology + prelim IM:
  • 1–2 IM letters
  • 1 neurology letter

But for most preliminary medicine programs, IM letters remain the priority.

3. Department Leadership Letter (Nice to Have)

For Caribbean IMGs, a letter from someone in leadership can help:

• Program Director (PD) or Associate PD of IM
• Clerkship director for Internal Medicine
• Chair or vice chair of medicine

These letters are especially powerful if:

• The writer has directly supervised you
• Or has reviewed multiple evaluations from your supervisors and can synthesize them

If you’re at SGU or another Caribbean school and rotate at a hospital with many Caribbean students, PDs at that site may have a track record of successful SGU residency match outcomes—their letters carry credibility.

4. Non-IM Letters (Use Sparingly)

Surgery, OB/GYN, pediatrics, or research letters can still be helpful in certain situations:

• When they highlight work ethic, professionalism, and teamwork
• When you had extended, close contact with the writer (e.g., research spanning many months)

However, for a prelim IM application, no more than one letter should be non-IM, and only if the content is truly outstanding.

---

Who to Ask for Letters: Strategy for Caribbean IMGs

Choosing who to ask for letters is one of the highest-impact decisions you’ll make. A famous name is not automatically better than someone who knows you well.

Priority 1: Attendings Who Know You Well and Supervised You Closely

The best letters usually come from:

• Inpatient IM attendings who saw you day after day on wards
• Sub-I attendings who observed you performing intern-level tasks
• Faculty who watched you handle cross-cover, on-call, or complex patients

Ask yourself:

• Did this attending see me:
  • Present cases multiple times?
  • Write notes and develop assessments and plans?
  • Interact with nurses, families, and consultants?
  • Respond to feedback or handle a difficult situation?

If yes, they’re a strong candidate to write a high-impact LOR.

Priority 2: Faculty with Recognized Roles or Titles

If you can get both depth of knowledge (they know you well) and institutional weight (they have a title), that’s ideal:

• Clerkship director of IM
• Site director for student rotations
• Program Director or APD in IM
• Chief resident (co-signed by an attending or PD)

A PD letter stating, “I would gladly take this student into our own program” is very persuasive, especially when programs are uncertain about Caribbean graduates.

Priority 3: US-Based Clinical Supervisors

For Caribbean IMGs, US-based letters are typically stronger than:

• Letters solely from Caribbean faculty who haven’t worked in US training programs
• Letters from non-clinical basic science professors

Programs want to know: Can this person function in a US hospital environment? US-based attendings are best positioned to answer that.

Think Beyond “Famous Name”

It’s tempting to chase a letter from a “big name” (e.g., a department chair you barely met). This can backfire if the letter is generic. A lesser-known attending who clearly knows your work is usually more valuable than a famous name writing a vague, two-paragraph note.

---

How to Get Strong LORs: From Clinical Rotations to the Ask

You can influence letter quality long before you actually request it. Think about how to get strong LOR as a process starting on day one of a rotation.

During the Rotation: Build the Foundation

1. Show up as the future intern you want them to describe

   • Be on time (or early) every day
   • Read about your patients nightly
   • Anticipate next steps and follow up on to-do items
   • Communicate clearly with nurses and families

2. Let them know your goals early

   • On day 1–2, during a quiet moment:
     • “Dr. Smith, I’m a Caribbean IMG from [school], aiming for a preliminary medicine residency in the US. I’m hoping to use this rotation to grow as much as I can clinically. I’d be very grateful for any feedback.”

3. Ask for feedback mid-rotation This signals maturity and gives you time to improve before final evaluations:

   • “Could you share one or two things I can improve before the end of the rotation? I want to be at intern level as much as possible.”

4. Behave like an intern, not a passive student

   • Take ownership of patient data, labs, imaging, and consults
   • Volunteer to call families, write drafts of discharge summaries, organize sign-outs
   • Demonstrate that you can be trusted with responsibility

5. Be explicit about your interest in prelim IM when appropriate

   • “I’m planning to apply to preliminary medicine positions and then [advanced specialty]. I want to be well-prepared to handle a busy medicine service.”

When an attending sees you consistently functioning at a near-intern level, they are more likely to write the kind of strong, specific letter you need.

When and How to Ask for Letters

Ideally, ask for letters near the end of the rotation while your performance is fresh.

How to Phrase the Request

Aim for something like:

“Dr. Smith, I’ve really appreciated working with you this month and the feedback you’ve given me. I’m applying for a preliminary medicine residency position this cycle. Based on your experience working with me, would you feel comfortable writing a strong letter of recommendation for my prelim IM applications?”

Key element: Using the word “strong” gives them a graceful way to say no if they cannot write a supportive letter.

If they hesitate, say:

• “I understand completely, and I appreciate your honesty.”
  Then ask another attending.

Prepare a LOR Packet

Make it easy for them to write something detailed. Include:

• Updated CV
• USMLE/COMLEX score report (if appropriate)
• Personal statement draft (even rough is fine)
• A one-page “brag sheet” or bullet list:
  • Your career goals (prelim IM + advanced specialty if applicable)
  • Key cases you managed or presented on their service
  • Specific feedback they gave you that you worked on
  • Any research, leadership, or teaching experiences

You can also gently suggest themes:

• “If appropriate, I’d be grateful if you could comment on my clinical reasoning, reliability, and readiness to function at the level of an intern, particularly since I’m applying as a Caribbean IMG.”

ERAS Logistics for Letters

Most prelim medicine programs will accept 3–4 letters. A common, strong setup for a Caribbean IMG:

• Letter 1 – Inpatient IM attending (sub-I/acting internship, US hospital)
• Letter 2 – Another IM attending (ward rotation, US hospital)
• Letter 3 – PD/APD/clerkship director in IM (or specialty letter for advanced field)

Key ERAS points:

• Waive your right to see the letter. Program directors prefer confidential letters.
• Assign letters carefully:
  • You can tailor which letters go to prelim medicine programs vs advanced specialty programs.
• Keep track of who has submitted:
  • Follow up politely about 3–4 weeks before your application submission date if needed.

---

Common Pitfalls Caribbean IMGs Face with LORs—and How to Avoid Them

Pitfall 1: All Letters from Non-US Settings

If all your letters are from Caribbean attendings or non-US clinics, US PDs may still wonder if you can thrive in a US system. Try hard to secure at least two US-based IM letters.

Pitfall 2: Generic Letters from Big Names

A two-paragraph letter from a department chair who barely knows you is usually weaker than a detailed three-page letter from a ward attending who supervised you daily. Depth beats prestige.

Pitfall 3: Vague Content and No Benchmarks

Letters that say:

• “She was always pleasant.”
• “He completed all tasks as assigned.”

…without concrete examples or comparisons are usually interpreted as lukewarm. You can’t directly control the content, but you can:

• Choose attendings who have seen your work in depth
• Provide them with specific cases and examples in your brag sheet
• Remind them (gently) that programs appreciate comparative language

Pitfall 4: Mismatch Between Letter and Application Story

If your personal statement emphasizes a strong desire to pursue, say, radiology after a preliminary medicine year, and your IM letter writer says you appear unsure or unfocused, this inconsistency can hurt you.

Coordinate your narrative:

• Let letter writers know your intended advanced specialty
• Make sure your personal statement, CV, and letters tell a consistent story about:
  • Why prelim IM
  • Why your chosen advanced field
  • How your strengths fit both

Pitfall 5: Poor Timing

Waiting until August/September to request letters often leads to:

• Rushed letters
• Letters arriving after you submit ERAS
• Less detailed commentary

Instead:

• Start planning your LOR strategy 6–9 months before application season.
• Aim to secure at least two letters by July–August of your application year.

---

Actionable Timeline and Checklist for Caribbean IMGs Targeting Prelim Medicine

9–12 Months Before Applying

• Identify key IM rotations (ward months, sub-I/AIs) that will be your main LOR sources.
• Research which attendings frequently write strong letters for SGU residency match or similar Caribbean IMGs.

6–9 Months Before Applying

• On rotations, actively perform at intern level:
  • Show initiative, ask for feedback, and clarify that you’re aiming for prelim IM.
• Start drafting your personal statement and CV.

3–6 Months Before ERAS Opens

• Request letters near the end of each crucial rotation.
• Provide each attending with a LOR packet (CV, PS draft, brag sheet).
• Register for ERAS and generate Letter Request Forms.

1–3 Months Before Application Submission

• Confirm with letter writers that they have submitted or will submit before your target date.
• Assign letters appropriately:
  • Emphasize IM letters for prelim medicine programs
  • Include specialty letters for your advanced field programs

Final Pre-Submission Check

• You have 3–4 strong letters, including:
  • 2+ US-based IM clinical letters
  • 1 leadership or specialty letter (if available)
• Letters are uploaded, you’ve waived your right to view them, and assignments in ERAS are correct.

---

FAQs: Letters of Recommendation for Caribbean IMGs in Preliminary Medicine

1. How many letters of recommendation do I need for preliminary medicine programs?

Most prelim IM programs accept up to four letters. A solid strategy as a Caribbean IMG is:

• Minimum: 3 letters
• Ideal combination:
  • 2 internal medicine clinical letters (US-based, inpatient if possible)
  • 1 letter from a PD/APD/clerkship director or from your advanced specialty (if applying to an advanced program as well)
  • Optional 4th letter if it is truly strong (e.g., long-term research mentor who can speak to work ethic and professionalism)

Quality matters more than quantity. Three detailed, enthusiastic letters beat four generic ones.

2. Should I prioritize letters from my Caribbean medical school or from US rotations?

For Caribbean medical school residency applicants, US rotation letters typically carry more weight, especially from internal medicine attendings in teaching hospitals. If you have a truly exceptional relationship with a Caribbean faculty member who has trained or practiced in the US and knows your work well, that can be a good supplementary letter, but it should not replace strong US-based IM letters for a prelim medicine application.

3. Does it matter if my letter writers know I’m applying only for a preliminary medicine year?

Yes, and it can help you. Tell them clearly:

• That you’re applying for preliminary medicine year (prelim IM)
• Whether you’re also applying for an advanced specialty (and which one)

Ask them to comment specifically on your readiness to function as an intern on a busy medicine service, since that’s exactly what prelim IM programs are trying to assess. This alignment makes their letter more targeted and useful for PDs.

4. What if I think one of my letters is weak but I’ve already assigned it in ERAS?

If you suspect a letter may be weak before it’s submitted, consider:

• Politely asking another attending for an additional letter and using that instead.

If the letter is already uploaded and assigned, ERAS does not allow you to view or delete it from your profile, but you can:

• Choose not to assign that letter to additional programs going forward.
• Ask a stronger writer for another letter and prioritize that new one for any remaining or new applications.

Because you cannot see the exact content, the best strategy is to prevent weak letters from the start by explicitly asking, “Would you feel comfortable writing a strong letter of recommendation?” when you make the request.

---

By approaching letters of recommendation as a deliberate, long-term strategy—rather than a last-minute checkbox—you significantly increase your competitiveness as a Caribbean IMG seeking a preliminary medicine position. Thoughtful selection of writers, strong clinical performance, and clear communication about your goals can help your LORs transform from generic endorsements into powerful advocacy for your success in the match.