Mastering Letters of Recommendation for Caribbean IMG Transitional Year

Understanding Letters of Recommendation for Caribbean IMGs Applying to Transitional Year

Letters of recommendation (LORs) are one of the strongest tools you have as a Caribbean IMG when applying to a transitional year residency (TY program). Program directors rely heavily on LORs to answer questions they can’t get from numbers alone:

• Can you function safely and independently in a U.S. hospital?
• Do you communicate effectively with patients and teams?
• How do you handle pressure, feedback, and responsibility?
• Will you “fit” with their residency culture?

For a Caribbean medical school residency applicant—especially from schools like SGU, Ross, or AUC—strong letters help counteract common biases about international training and reassure programs that you are residency-ready.

This article will walk you through exactly how to get strong LORs, who to ask for letters, how to manage timing and ERAS logistics, and what’s unique about LOR strategy when applying to transitional year programs.

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How Many LORs You Need and Which Types Matter Most

Basic Numbers and Requirements

Most transitional year residency programs require:

• 3 letters of recommendation
• Some will accept 4 and ERAS allows you to assign up to 4 per program

A solid structure for a TY application:

• 3–4 total letters, ideally:
  • 2 clinical letters from core rotations (Internal Medicine, Surgery, Family Medicine, Pediatrics, etc.)
  • 1–2 letters from sub-internships, electives, or specialty areas related to your long-term plan (e.g., Radiology, Anesthesiology, Dermatology) if you know your ultimate specialty

As a Caribbean IMG, aim for 4 strong letters total, then select the best 3–4 strategically for each program.

What Transitional Year Program Directors Look For

A TY program prepares interns for a broad range of specialties. LORs should emphasize:

• Clinical competence in general medicine
• Work ethic and reliability
• Teamwork and communication
• Adaptability across different services
• Professionalism and maturity
• Ability to handle cross-cover and acute issues

Letters from U.S. clinical experiences are disproportionately valuable for Caribbean IMGs because they:

• Demonstrate that you can function in the U.S. healthcare system
• Reduce uncertainty about training quality
• Help residency committees compare you more directly to U.S. graduates

If you are at a major Caribbean school (e.g., SGU), you may have access to large affiliated U.S. teaching hospitals. SGU residency match data consistently show that applicants with strong U.S. LORs from those sites match at higher rates than those without them.

Priority hierarchy for TY LORs (from strongest to weaker):

1. U.S.-based core inpatient clerkship letters (IM, Surgery, FM)
2. U.S. sub-internship or acting-internship letters
3. U.S. outpatient core rotation letters
4. U.S. elective rotation letters
5. Non-U.S. letters (home country or Caribbean campus)
6. Research letters (good as a supplement but not as your main clinical LORs)

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Who to Ask for Letters (and Who to Avoid)

Knowing who to ask for letters is just as important as how you perform.

Ideal Letter Writers for a TY Program

You want letter writers who can speak to your hands-on clinical performance and professionalism. For a Caribbean IMG targeting transitional year programs, consider:

1. U.S. Internal Medicine Attendings

   • Especially those on inpatient wards
   • Can comment on:
     • Patient load management
     • Note-writing and sign-out skills
     • Cross-cover and acute issue handling
   • Highly valued for almost all transitional year programs

2. U.S. Surgery or Surgical Subspecialty Attendings

   • Show that you:
     • Function safely in an OR and perioperative setting
     • Follow through on tasks
     • Work well under pressure
   • Particularly helpful if your future specialty is procedural (e.g., Anesthesiology, Radiology, PM&R with procedural components)

3. Family Medicine or Internal Medicine Outpatient Attendings

   • Demonstrate continuity of care, preventive care skills, and communication style
   • Useful for programs with strong ambulatory components

4. Sub-Internship / Acting-Internship Supervisors

   • Gold-standard letters when they comment you functioned at “intern level”
   • Specifically relevant for transitional year programs (which want to know what kind of intern you’ll be)

5. Program Directors, Clerkship Directors, or Site Directors

   • Strong institutional weight
   • Can compare you with a larger pool of students
   • Very credible for Caribbean medical school residency candidates, especially from SGU or similar institutions

When to Use a Specialty Letter

If you know your target advanced specialty (e.g., Radiology, Anesthesiology, Neurology), a letter from that field can be very helpful, especially if you are applying to categorical + advanced or pairing TY with an advanced specialty application.

A specialty letter is best used as:

• Your third or fourth letter, in addition to strong general clinical letters
• Evidence of:
  • Fit for that specialty
  • Work ethic and curiosity within that field
  • Long-term career goals

Who NOT to Ask (Or Use with Caution)

Avoid or be careful with:

• Residents alone as letter writers

  • Residents can give great feedback but typically should not be the primary signee
  • However, they can draft input or co-sign through the attending

• Non-clinical basic science faculty

  • Acceptable only if:
    • You have no alternative clinical letters (e.g., early in training)
    • They know you extremely well academically
  • Less impactful for a residency application focused on clinical readiness

• Family friends or physicians who never supervised you clinically

  • These are often viewed as “character references,” not true LORs
  • Can hurt your credibility if they overpraise without clinical evidence

• Very short-term observers (“shadowing only”)

  • Pure observerships without hands-on responsibilities lead to weak, generic letters
  • If you must use one, ensure you had a defined role (case presentations, notes, or clear participation)

Rule of thumb: If the writer cannot honestly answer, “Would I be comfortable working alongside this person as a co-resident at 3 a.m.?” their letter is usually not ideal.

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How to Get Strong LORs: Performance, Relationships, and Timing

Knowing how to get strong LORs is just as critical as knowing who to ask. As a Caribbean IMG, you are often under closer scrutiny; well-crafted letters can tip a borderline application into an interview invite.

Step 1: Plan Your LOR Strategy Early

By the start of your core U.S. clinical rotations, you should already be thinking:

• Which rotations are best for LORs?
• Which attendings are known to be strong teachers or mentors?
• Where do I have the most time to build a relationship?

A sample LOR timeline for a Caribbean IMG:

• Third year / Core rotations:
  • Identify 2–3 potential letter writers in IM, Surgery, FM, or Peds
  • Request at least 2 letters during this year
• Fourth year / Sub-internships & electives:
  • Do at least one sub-internship in Internal Medicine or Family Medicine if possible
  • Request at least 1 letter from a sub-I or advanced elective
• Before ERAS submission (September):
  • Aim to have all 4 letters uploaded by early to mid-September

If you’re from a large Caribbean medical school such as SGU, check your school’s match advising office. Many SGU residency match advisors can help you map which affiliated hospitals and rotations are particularly strong for LORs.

Step 2: Perform Like an Intern, Not a Student

To earn a powerful letter, you must stand out clinically. Transitional year letters are especially convincing when they describe intern-level readiness.

Focus on:

• Ownership of patients
  • Know your patients’ vitals, labs, meds, and hospital course better than anyone
  • Anticipate next steps on rounds
• Efficient, high-quality notes and presentations
  • Clear, concise SOAP notes
  • Focused, organized oral presentations
• Reliability
  • Show up early, stay until work is done
  • Volunteer for tasks, follow through
• Professional behavior
  • Respectful communication with nurses and staff
  • No complaining about hours or scut work
• Eager learning
  • Ask focused questions: “Can I read about this tonight and present a brief summary tomorrow?”
  • Offer to look up guideline-based management for specific patients

Concrete behaviors that often get mentioned in LORs:

• “Always present before sign-out, prepared and organized”
• “Never needed to be reminded to complete tasks”
• “Acted at the level of a sub-intern or early intern”
• “Frequently went above and beyond for patient care”

Step 3: Signal Your Interest Early

If you think an attending might be a good letter writer:

• Ask for ongoing feedback:
  • “Is there anything I could be doing better to function more like an intern?”
• Mention your goals (e.g., “I’m planning to apply to transitional year and then radiology”)
• Express that you value their mentorship:
  • This frames your eventual LOR request as natural, not out of nowhere

Step 4: Ask for a “Strong” Letter—Directly and Professionally

When you’re ready to ask, it’s essential to phrase it in a way that avoids weak or lukewarm letters.

How to ask (in person or over email):

“Dr. Smith, I’ve really appreciated working with you this month and learning from your team. I’m applying for a transitional year residency and I’m hoping to secure strong letters of recommendation from attendings who have seen my clinical work closely.
Would you feel comfortable writing a strong letter of recommendation in support of my application?”

This phrasing:

• Gives them an “out” if they can’t write a strong letter
• Protects you from weak letters that might harm your chances
• Signals that you understand the importance of honest evaluations

If they hesitate or seem unsure, thank them and ask someone else. A mediocre letter can be worse than no letter.

Step 5: Provide Supporting Materials

To help your writer produce a detailed letter:

Send or hand them:

• Your updated CV
• A personal statement draft (especially if you know your final specialty)
• A short “brag sheet” including:
  • 3–5 specific patients or situations where you made an impact
  • Any honors, leadership, or research relevant to your goals
  • Why you’re applying to a transitional year program
• ERAS Letter Request Form and instructions
• Deadline (make it earlier than the real deadline)

This is a core part of “how to get strong LOR” letters—you’re giving writers raw material and context rather than hoping they remember everything about you.

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ERAS, Logistics, and Customizing LORs for Transitional Year Programs

Understanding the technical side of LORs in ERAS is crucial so you don’t lose time or opportunities.

ERAS Mechanics for LORs

• Each letter is uploaded once to ERAS by the writer or their designee
• You can assign different combinations of letters to each program
• You cannot see the content of the letters if you waive your right (you should almost always waive your right; non-waived letters are more suspicious)

Make sure you:

1. Generate Letter ID in MyERAS for each letter
2. Send the ERAS Letter Request Form to each writer
3. Politely follow up 2–3 weeks before your intended submission date

How to Assign Letters to Transitional Year vs. Advanced Programs

If you are applying to:

• Transitional year + advanced specialty (e.g., Radiology, Anesthesia, Derm):

  • For transitional year programs, prioritize:
    • General IM, FM, or Surgery letters that emphasize intern readiness
  • For advanced specialty programs, include:
    • At least one specialty letter (e.g., Radiology attending, Anesthesia attending)
  • Some letters can be used for both, especially strong IM or FM letters praising your intern-level performance

• Transitional year only (undecided future specialty):

  • Focus on:
    • 2–3 strong IM/FM/Surgery clinical letters
    • Optional additional letter from research or leadership if truly strong and personal

Program-Specific Considerations

Some transitional year programs (especially those associated with competitive specialties) may:

• Value letters from academic institutions more highly
• Favor letters from U.S.-based university hospitals over small community settings
• Read your LORs for signs of:
  • How you handle complex, high-acuity cases
  • How you work in multidisciplinary teams

If you trained at a large Caribbean school (like SGU), programs may already recognize the affiliated sites listed on your CV. A strong SGU residency match track record from your site, plus enthusiastic LORs, can offset concerns about being an IMG.

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Red Flags, Common Pitfalls, and How to Avoid Them

Even excellent Caribbean IMGs can damage their applications with preventable LOR mistakes.

Common LOR Pitfalls

1. Generic or Template Letters

   • Signs:
     • Vague language
     • No specific patient examples
     • Looks identical to letters written for others
   • Prevention:
     • Choose writers who know you well
     • Provide specific talking points and experiences

2. Late or Missing Letters

   • Programs may not review incomplete files
   • Prevention:
     • Ask early (at least 4–8 weeks before you need them)
     • Send polite reminders
     • Keep a backup writer in mind

3. Too Many Non-U.S. or Non-Clinical Letters

   • Especially risky for Caribbean IMGs
   • Prevention:
     • Prioritize U.S. clinical letters whenever possible
     • Limit research/basic science letters unless highly relevant and personal

4. Over-reliance on Big Titles with Little Contact

   • A department chair who barely knows you is often less helpful than a core attending who worked closely with you for 4 weeks
   • Prevention:
     • Choose writers based on depth of relationship, not just title

5. Red-Flag Language in Letters

   • Words like “average,” “adequate,” or “acceptable” can be damaging
   • You cannot see the letter, but:
     • Asking for a “strong” letter helps
     • Selecting attendings who are enthusiastic about your work reduces risk

What If You Don’t Have Enough Strong Clinical LORs?

If you lack strong U.S. clinical letters:

• Consider arranging:
  • Additional U.S. electives or sub-internships
  • Observerships with structured roles where attendings can genuinely assess your skills
• Engage actively:
  • Present cases, research questions, or mini-talks
  • Ask for feedback explicitly

Remember: Programs will often weigh a recent, enthusiastic U.S.-based LOR more heavily than older or foreign letters.

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FAQs: Letters of Recommendation for Caribbean IMG in Transitional Year

1. How many LORs should I have for a transitional year residency application?

Aim for 4 total letters:

• Use 3–4 letters per program (depending on their maximum allowed)
• At least 2 letters from U.S. core clinical rotations (IM, FM, or Surgery)
• Additional letters from:
  • Sub-internships
  • Electives or your intended specialty

This gives you flexibility to tailor letter combinations for different programs.

2. As a Caribbean IMG, are letters from my home country acceptable?

They are acceptable but less impactful than U.S. letters. If possible, prioritize:

• U.S. inpatient IM or FM rotations
• U.S. sub-internships

If a home-country attending knows you extremely well and supervised you extensively, that letter can still be valuable—but it should supplement, not replace, your U.S. clinical LORs.

3. Who should I ask for letters if I’m unsure about my ultimate specialty?

Focus on attendings who can speak to how you’ll function as an intern, regardless of specialty:

• Internal Medicine
• Family Medicine
• General Surgery

Tell them you’re applying to transitional year programs and emphasize your interest in broad clinical training. You can later supplement with specialty-specific letters if you decide on a particular field.

4. What’s the best way to follow up if my letter writer is delayed?

Use a professional, appreciative tone:

“Dear Dr. Smith,
I hope you’re doing well. I wanted to kindly follow up regarding the letter of recommendation for my transitional year residency application. ERAS suggests having letters uploaded by [date], so I wanted to check if there’s any additional information I can provide or anything I can do to help with the process. I’m very grateful for your support.
Best regards,
[Your Name]”

Send this 1–2 weeks before your internal deadline. If there’s no response after another week, consider a brief, polite reminder or secure a backup writer.

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Letters of recommendation are one of the few parts of your application where someone else can credibly say, “I have seen this Caribbean IMG perform in a U.S. hospital, and they are ready to be an intern.” If you are thoughtful about who you ask for letters, how you earn their trust and enthusiasm, and how you manage the logistics, your LORs can transform your transitional year application from average to competitive—even in the face of the added scrutiny Caribbean medical school residency applicants often face.