IMG Residency Guide: Securing Strong Letters of Recommendation for EM-IM

Understanding the Role of Letters of Recommendation for IMGs in EM-IM

For an international medical graduate (IMG), letters of recommendation (LORs) can be the difference between a cursory glance and serious consideration for an Emergency Medicine–Internal Medicine (EM-IM) combined residency. Programs know that transcripts and test scores don’t tell the whole story—especially when medical education systems vary across countries. Strong, credible residency letters of recommendation help program directors understand who you are as a clinician and teammate in the U.S. training environment.

Because EM-IM combined programs are small, selective, and highly competitive, your LORs carry even more weight. Faculty who write for you are effectively saying: “I would be comfortable working alongside this person in my own department for the next five years.”

This IMG residency guide will walk you through:

• What EM-IM programs look for specifically in letters
• Who to ask for letters and how to get strong LORs
• How many EM vs. IM letters you need
• How to approach U.S. clinical experience (USCE) with LORs in mind
• How to support your letter writers and avoid common pitfalls

Throughout, the emphasis is on the combined emergency medicine internal medicine pathway and the unique challenges faced by international medical graduates.

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What EM‑IM Programs Want to See in Your Letters

Understanding what program directors value is the first step in learning how to get strong LORs. EM-IM directors are reading your letters with a few core questions in mind:

1. Can this applicant function safely and effectively in two demanding environments?

You’re applying to a program that trains you to work in:

• High-acuity, fast-paced emergency departments
• Longitudinal, complexity-heavy inpatient and outpatient internal medicine settings

Letters that stand out show that you:

• Handle high patient volume without sacrificing safety
• Can manage complex medical decision-making at the bedside
• Recognize your limits and ask for help appropriately

Specific examples matter more than adjectives. “She independently saw 8–10 patients per shift in a busy ED and escalated concerns appropriately” is far stronger than “She is very hardworking.”

2. Does this applicant fit the EM-IM “profile”?

EM-IM residents are often described as:

• Curious problem-solvers who enjoy diagnostic complexity
• Comfortable with uncertainty and rapid decision-making
• Able to switch between short-term resuscitation and long-term management thinking
• Collaborative across multiple teams and disciplines

Look for letters that highlight:

• Comfort with both acute and chronic disease management
• Interest in pathophysiology, systems-based practice, or continuity of care
• Ability to communicate clearly with consultants, nurses, and patients under pressure

3. Will this applicant be a reliable, low-drama teammate for 5+ years?

Combined program classes are small; one problematic resident affects the entire group. Programs prioritize:

• Professionalism (on-time, prepared, receptive to feedback)
• Emotional maturity, especially in stressful situations
• Cultural humility and teamwork

For IMGs, this also includes:

• Adaptability to the U.S. healthcare system
• Effective communication in English with patients and staff
• Ability to integrate smoothly into different clinical cultures

Letters that mention these explicitly—especially from U.S.-based attendings or program leadership—carry substantial weight.

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How Many Letters and What Type? EM‑IM Specific Strategy

Requirements vary, but most EM-IM combined programs follow general internal medicine and emergency medicine standards with some nuance.

Typical Expectations

Always verify on ERAS and each program’s website, but broadly:

• Total letters: 3–4 letters of recommendation
• U.S. letters strongly preferred (and often expected) for IMGs
• At least 1 letter from Emergency Medicine
• At least 1 letter from Internal Medicine
• Remaining letters can be from:
  • EM or IM (additional)
  • Another clinical core specialty (e.g., ICU, hospitalist, cardiology)
  • A research mentor (ideally with clinical overlap)

What About Standardized EM “SLOEs”?

Many U.S. applicants to categorical EM programs are expected to submit SLOEs (Standardized Letters of Evaluation). EM-IM programs vary in how strongly they want SLOEs versus traditional narrative letters.

For IMGs:

• If you rotate at a U.S. academic ED that offers a SLOE, prioritize obtaining one; it is often considered more informative and standardized for EM programs.
• If a SLOE is not available, a detailed narrative EM letter from a U.S. attending is still extremely valuable.

IMG-Specific Priorities

For an international medical graduate applying EM-IM, an ideal mix might look like:

1. U.S. Emergency Medicine letter or SLOE (from an academic ED if possible)
2. U.S. Internal Medicine (inpatient) letter
3. Another U.S. EM or IM letter (or a strong ICU/hospitalist letter)
4. Optional: research mentor letter (only if it’s truly strong and aligned with your clinical story; not a filler)

If your home-country letters are exceptionally strong, you may include one—especially for academic or research strength—but prioritize U.S. clinical letters first.

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Who to Ask for Letters (and Who Not To)

Knowing who to ask for letters is just as important as how you perform on rotation. EM-IM programs care more about quality and credibility than titles alone.

Ideal Letter Writers for EM‑IM IMGs

Prioritize writers who:

1. Directly supervised your clinical work in the U.S.

   • EM attendings, IM attendings, ICU/hospitalist attendings
   • Subspecialty attendings (e.g., cardiology, pulmonary/critical care) who saw you care for multiple patients over time

2. Can compare you to U.S. trainees

   • Attendings who regularly teach U.S. medical students and residents
   • Program directors, clerkship directors, or site directors

3. Understood your EM-IM interest

   • Mentors who know why you chose the combined path
   • Faculty who can speak to your strength in both acute and longitudinal care
   • Someone who can credibly say, “This applicant is an excellent fit for emergency medicine internal medicine training.”

4. Have experience writing U.S.-style residency letters

   • Faculty who have written successful residency letters of recommendation before
   • Those who understand what program directors want to read

Examples of Strong Letter Writers

• EM attending at a U.S. academic medical center where you did an audition rotation
• IM ward attending who supervised you over a full month of inpatient service
• Associate program director in EM or IM who interacted with you closely
• ICU attending who observed you manage high-acuity patients and communicate with families

Less Ideal (But Sometimes Necessary) Writers

If you lack extensive U.S. clinical experience:

• Senior home-country attendings who supervised your work over months or years
• Department chairs who truly know your work (not just your name)
• Research mentors who also supervised clinical aspects or can detail your work ethic and reliability

If you must include non-U.S. letters, make sure they are:

• Detailed, with clear descriptions of your clinical role
• Explicit about the level of your responsibility
• Free from overly generic or exaggerated praise

Who You Should Avoid Asking

• Faculty who barely know you (“You were quiet but did nothing wrong”)
• Non-physician supervisors (unless explicitly allowed and uniquely relevant)
• Family members or close friends, regardless of their titles
• Faculty who supervised only one or two shifts and have no specific examples
• Anyone who hesitates when you ask—they may not be able to write you a strong letter

When program directors ask themselves, “Who wrote this?” you want the answer to be: “Someone who clearly worked with this IMG closely, in a U.S. setting, and understands what residency training requires.”

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How to Get Strong LORs: Strategy During Rotations and Observerships

The foundation of a strong letter is not the request email; it’s how you perform clinically. For IMGs, U.S. rotations (especially in EM and IM) are the main window programs have into your readiness.

1. Choose Rotations Strategically for EM‑IM

For an EM-IM combined application, try to structure your U.S. clinical experience (USCE) to include:

• 1–2 months of Emergency Medicine (ideally at a teaching hospital with an EM residency program)
• 1–2 months of Internal Medicine (inpatient)
• Optional: ICU or a high-acuity IM sub-specialty (especially if it interfaces with emergencies, like cardiology or pulmonary/critical care)

Explain to your attendings that you’re targeting the combined EM-IM pathway so they can observe you through that lens.

2. Behaviors That Lead to Strong Letters

During EM and IM rotations, consistently demonstrate:

• Ownership of patient care

  • Know your patients in detail—labs, imaging, active issues
  • Anticipate next steps and follow through

• Clinical reasoning and synthesis

  • Don’t just list data; create an assessment and clear plan
  • In EM: present a prioritized differential and immediate actions
  • In IM: demonstrate longitudinal, systems-based thinking

• Communication and teamwork

  • Give concise, organized presentations
  • Be respectful and collaborative with nurses, techs, pharmacists
  • For IMGs, actively work on accent clarity, pacing, and avoiding jargon when speaking with patients

• Adaptability and teachability

  • Receive feedback without defensiveness
  • Show improvement quickly when corrected
  • Ask thoughtful questions that show you’re integrating new knowledge

• Professional reliability

  • Arrive early, stay engaged, help close patient loops
  • Avoid last-minute schedule changes unless absolutely necessary

Letter writers typically comment on these domains; give them real examples to draw from.

3. Turning an Observership Into a Useful LOR

Observerships can be challenging for IMGs because of limited hands-on participation. To maximize them:

• Clarify what you’re allowed to do (documentation, presentations, shadowing only, etc.)
• Even if you’re only observing, be active:
  • Formulate assessments and plans, then discuss them with your attending
  • Offer to present patients on rounds
  • Ask if you can help with literature searches or guideline reviews for interesting cases

Your goal is to show that—even with constraints—you think and behave like a resident.

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The Mechanics: Asking for Letters and Supporting Your Writers

Even the best clinical performance can lead to an average letter if you don’t ask thoughtfully or provide context. Handling the logistics well is a major part of this IMG residency guide.

When to Ask for a Letter

• Ideal time: Final week of the rotation (or earlier if it’s a short rotation and you’ve already worked closely with the attending)
• Ask in person if possible, then follow up by email
• If you are applying in a later cycle, you can still ask now and have them save a draft or upload later when ERAS opens

How to Ask: Exact Phrasing

Your key question is not “Can you write me a letter?” but:

“Would you feel comfortable writing me a strong letter of recommendation for combined Emergency Medicine–Internal Medicine residency?”

This wording:

• Gives them an easy way to decline if they can’t be enthusiastic
• Signals that you care about quality, not just completion

If they hesitate or say something like “I don’t know you that well,” thank them and consider asking someone else.

What to Provide to Your Letter Writer

Make it easy for them to write a detailed, program-relevant letter. Send:

• Updated CV
• Draft of your personal statement (especially if already EM-IM focused)
• ERAS ID and instructions on how to upload (when available)
• A short summary of your work with them, for example:
  • Dates of rotation
  • Typical number and type of patients you saw
  • Specific cases you discussed together that highlight your EM-IM qualities

You can also include a 1–2 paragraph note:

• Why you’re specifically interested in emergency medicine internal medicine
• Key strengths you hope the letter might touch on (e.g., “comfort with high-acuity patients,” “interest in complex chronic disease in the ED setting”)

This is not about scripting their letter; it’s about giving them material and context.

ERAS and Waiving Your Right to View Letters

On ERAS, you will be asked whether you waive your right to view the letter under the Family Educational Rights and Privacy Act (FERPA).

For residency applications:

• You should almost always waive your right
• Programs interpret waived letters as more candid and trustworthy
• Non-waived letters may raise concern that writers softened criticism knowing you could read it

For an international medical graduate, waiving your right also signals that you understand and follow U.S. professional norms.

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Tailoring Letters for EM-IM and Avoiding Common IMG Pitfalls

Even though you don’t write the letter, you can strongly influence its content by clarifying your goals and reducing misunderstandings.

1. Make Your EM‑IM Interest Explicit

Many faculty are more familiar with categorical EM or IM. When you ask for the letter:

• Explain briefly what an EM-IM combined program is
• Share why it fits your skills and career goals
• Ask if they can comment on your strengths that are relevant to both acute and longitudinal care

This helps them write a letter that doesn’t accidentally describe you as “only EM” or “only IM.”

2. Addressing IMG-Specific Concerns Proactively

Program directors sometimes worry about IMGs in three areas:

1. Communication and cultural adaptation
2. Systems knowledge and documentation
3. Visa and long-term commitment

You can’t completely script your letters, but you can encourage writers to address:

• Your progress with patient communication and teamwork
• Your ability to use the electronic health record (if applicable)
• Your reliability and long-term interest in U.S. training and practice

If a letter explicitly states, “Despite initial challenges related to new healthcare systems, she quickly adapted and now functions at or above the level of our U.S. students,” this can substantially reassure programs.

3. Avoiding Generic or Overly Flowery Letters

Some home-country letters suffer from:

• Over-the-top praise without examples
• Vague statements like “one of the best students I have ever had” without specifying over how many years
• Lack of details about your actual clinical responsibilities

If you sense that a potential writer might produce a generic or excessively formal letter, consider:

• Providing them with a structured outline of what U.S. programs expect
• Gently emphasizing the need for concrete examples
• Or choosing a different writer who understands U.S.-style LORs better

4. Red Flags and How to Prevent Them

Program directors look out for subtle warning signs, such as:

• Faint praise: “He completed all tasks assigned to him”
• Lack of enthusiasm: “I have no reservations in recommending…” (without stronger positive statements)
• Short, two-paragraph letters with little content

Don’t be afraid to ask writers directly:

“Do you feel you know me well enough to write a detailed and strongly supportive letter for EM-IM?”

This helps filter out well-meaning but unhelpful letters before they’re written.

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Frequently Asked Questions (FAQ)

1. As an IMG, do I absolutely need U.S. letters of recommendation for EM‑IM?

For most EM-IM programs, yes, U.S. letters are strongly preferred and often expected, especially for clinical competence. You can include one strong home-country letter, but try to have at least two letters from U.S.-based attendings who directly supervised you in EM, IM, or ICU-type settings. Without U.S. letters, programs may struggle to compare you to their usual applicant pool.

2. Can I use the same letters for both categorical EM/IM and EM‑IM combined programs?

Yes. A strong EM letter and a strong IM letter are relevant across categorical and combined applications. However, it helps if at least one letter explicitly acknowledges your interest in emergency medicine internal medicine and comments on your fit for combined training. When you ask for a letter, tell your writers you are applying to both categorical and EM-IM programs so they can phrase their recommendations broadly.

3. Is a research mentor letter useful for EM‑IM as an IMG?

A research letter can be valuable only if:

• The mentor knows you well
• The letter highlights your clinical reasoning, professionalism, and reliability
• The research is clinically or systems relevant (e.g., sepsis care, ED flow, chronic disease management)

Do not use a research letter just to fill space. Clinical letters—especially from EM and IM attendings—will almost always carry more weight than a generic research endorsement.

4. How many letters should I send to each EM‑IM program?

Most programs will read up to 3–4 letters. More is not better if the additional letters are weaker or repetitive. A strong strategy for an international medical graduate targeting EM-IM is:

• 1 U.S. EM letter or SLOE
• 1 U.S. IM inpatient letter
• 1 additional U.S. EM/IM/ICU letter
• Optional 4th letter (strong research or home-country letter) if it adds genuinely new information

Focus on quality, relevance, and credibility, not just quantity.

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By seeking the right clinical experiences, choosing your writers strategically, and supporting them with clear information about your EM-IM goals, you can transform your residency letters of recommendation from a formality into a powerful advocate for your application. For an IMG competing in a small, specialized field like emergency medicine internal medicine, that difference can be decisive.