Ultimate IMG Residency Guide: Strong Letters of Recommendation for Global Health

Understanding the Role of Letters of Recommendation for IMGs in Global Health

Letters of recommendation (LORs) often decide whether your application gets a serious second look—or an automatic “no.” This is especially true for an international medical graduate (IMG) applying to global health–focused residency programs, where program directors rely heavily on others’ assessments to predict how you’ll function in complex, cross-cultural clinical environments.

For IMGs, LORs are not just a box to check. They are:

• Independent proof of your clinical competence in the U.S. (or equivalent setting)
• Evidence that you can work across cultures and health systems
• Signals of your professionalism, communication, and adaptability
• Context for any gaps, visa issues, or atypical training paths

In global health, programs are specifically watching for:

• Commitment to international medicine and underserved populations
• Ability to work in low-resource settings or with vulnerable groups
• Cultural humility, resilience, and teamwork across disciplines
• Potential to thrive in a global health residency track

This IMG residency guide will walk you through how to get strong LORs—who to ask for letters, when to ask, how to support your writers, and how to use your global health experiences strategically.

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What Global Health Programs Look for in LORs from IMGs

Before planning how to get strong LORs, you need to understand what residency programs are actively looking for when they read them—especially if they are considering an international medical graduate for a global health–oriented position.

1. Evidence of U.S. (or System-Comparable) Clinical Performance

For most U.S. residency programs, particularly in internal medicine, family medicine, pediatrics, EM, and OB/Gyn with a global health residency track, the gold standard is:

• U.S.-based, hands-on clinical experience
• Evaluations written by U.S.-licensed physicians familiar with ACGME training expectations

Strong LORs typically comment on:

• Clinical reasoning and diagnostic skills
• Efficiency, reliability, and follow-through
• Documentation quality and EHR use (if applicable)
• Responsiveness to feedback

If you don’t have much U.S. experience, high-quality letters from comparable systems (Canada, UK, Australia, etc.) plus strong global health field supervisors can still be valuable, but you’ll need at least one or two U.S.-style clinical letters if at all possible.

2. Clear, Concrete Examples of Global Health Potential

For global health residency tracks or programs with strong international medicine components, reviewers love letters that show:

• Work in resource-limited settings (rural clinics, refugee camps, low-income communities)
• Experience navigating language barriers or cultural differences
• Collaboration with NGO teams, community health workers, or public health projects
• Leadership roles in international medicine projects or research

The best letters don’t just say “interested in global health”—they describe specific situations:

“During a mobile clinic in a remote village, Dr. X led the triage process, organized task distribution, and adapted treatment protocols when key medications were unavailable.”

This level of detail reassures programs that you’re not romanticizing global health—you’ve actually done the work and understand its realities.

3. Professionalism and Cultural Humility

For IMGs, programs also read LORs looking for:

• Reliability, punctuality, and respect for systems and hierarchy
• Ability to receive and integrate critical feedback
• Emotional maturity and stress tolerance
• Cultural humility and respect for local norms and team members

A global health LOR that combines clinical skills with examples like:

• Navigating cultural misunderstandings calmly
• Advocating for marginalized patients without being dismissive of local practice
• Learning from community partners rather than “imposing” solutions

will be particularly powerful.

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Who to Ask for Letters: Building a Strategic LOR Portfolio

A common IMG question is who to ask for letters and how to limit the mix between home country, U.S., and global health supervisors. The key is to build a balanced, credible, and global health–aligned set of recommenders.

Target Mix of Letters for an IMG Interested in Global Health

Most programs allow 3–4 letters. A strong combination might be:

1. U.S. Clinical Letter – Internal Medicine/Family Medicine/Core Specialty

   • From a U.S.-licensed attending physician who directly supervised you
   • Ideal: inpatient or outpatient medicine in an academic or teaching hospital
   • Emphasize: clinical reasoning, teamwork, communication, adaptability

2. Second U.S. Clinical Letter or Equivalent

   • Could be another core rotation (e.g., ICU, ED, primary care)
   • Could be from a global health faculty if they saw you in clinical settings
   • Emphasize: growth over time, independence, readiness for intern-level work

3. Global Health Mentor or Field Supervisor Letter

   • From a faculty member or senior clinician overseeing:
     • International elective
     • NGO work or humanitarian mission
     • Long-term community/global health project
   • Emphasize: commitment to international medicine, resilience, cultural competence

4. Home Country or Research Letter (Optional)

   • Only if:
     • The recommender knows you very well
     • Can speak to your clinical excellence or leadership
     • Preferably has global health, academic, or U.S. connections
   • Avoid generic institutional letters signed by a dean who barely knows you

If you can only submit three letters, prioritize:

1. U.S. clinical
2. U.S. clinical or equivalent
3. Global health mentor

Prioritizing Letter Writers: A Decision Framework

Use this sequence when deciding who to ask:

1. Direct U.S. Clinical Supervisors

   • Supervised you for at least 3–4 weeks
   • Saw you with multiple patients, across different shifts
   • Provided formal mid-rotation or end-of-rotation feedback

2. Global Health-Focused Clinicians/Faculty

   • Involved in a global health residency track, international rotations, or global health research
   • Familiar with your work in resource-limited or cross-cultural environments

3. Home Country or International Mentors with Continuing Contact

   • Can provide multi-year perspective
   • Can discuss how you’ve grown, taken on responsibility, and moved into leadership roles

4. Research Supervisors (Preferably Global Health-Related)

   • Especially if:
     • Research is in global health, epidemiology, or health systems
     • They can highlight perseverance, ethics, and communication

Who NOT to Ask (Even if They Have Big Titles)

Avoid relying on:

• Very senior chairs/deans who barely know you personally
• Distant relatives or family friends in medicine
• Non-physician supervisors for purely clinical LORs (they may write a supplementary letter, but these rarely substitute for physician letters)
• Anyone who seems hesitant or lukewarm when you ask

One strong, specific letter from a mid-career attending is more valuable than a vague, effusive paragraph from a famous professor who cannot recall your cases.

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How to Get Strong LORs: Timing, Preparation, and Strategy

Understanding how to get strong LOR letters is as important as choosing who to ask. Here’s a step-by-step process tailored for IMGs aiming at global health–oriented residencies.

1. Plan Early During Your Clinical Experiences

Think about LORs before you start a rotation, not after:

• Introduce yourself to attendings early: share that you’re an IMG preparing for the Match with an interest in global health.
• Ask for mid-rotation feedback and actively incorporate it.
• Request opportunities to:
  • Present on a global health–related topic
  • Help with patient education materials for underserved populations
  • Participate in QI or community outreach projects

This creates a narrative that your letter writer can later describe: a motivated IMG consistently pushing toward international medicine and underserved care.

2. Ask at the Right Time—and Ask Clearly

Aim to ask for the letter:

• Near the end of the rotation or project, while your work is still fresh
• Or soon after completing a major project, research paper, or field placement

When you ask:

1. Request a “strong” letter explicitly
   Example:
   “Dr. Smith, I am applying to internal medicine residency programs with a strong interest in global health. Would you feel comfortable writing a strong letter of recommendation commenting on my clinical performance, work ethic, and suitability for residency in the U.S.?”

2. Give them an easy out

   • “If you feel you cannot provide a strong letter, I completely understand and would still appreciate your feedback about areas I can work on.”

If they hesitate or seem uncertain, thank them and look for another writer. A neutral or lukewarm LOR can hurt you more than it helps.

3. Provide a Focused, Organized “Letter Packet”

After they agree, send a concise, well-structured packet. This is critical for an international medical graduate with complex training history.

Include:

• Updated CV (highlight global health and international medicine activities)
• Personal statement draft, tailored to global health or underserved care
• ERAS/Program list and deadlines
• Brief summary of rotation/project with them:
  • Dates, setting, your role
  • Specific patients or cases (de-identified) that illustrate your strengths
• Bullet points of accomplishments they may want to mention:
  • “Led patient education session on TB adherence for refugee patients”
  • “Initiated QI mini-project on improving vaccination counseling in low-literacy populations”
• Key global health themes you hope they can address, e.g.:
  • Cultural humility
  • Resilience in low-resource settings
  • Leadership in multidisciplinary teams
  • Long-term commitment to underserved populations

You are not writing the letter for them—you’re making it much easier for them to remember what you did and frame it in a way that supports your global health narrative.

4. Coach Your Writers (Subtly) on Global Health-Relevant Content

Many attendings will ask, implicitly or explicitly, “What should I emphasize?” You can suggest:

• “It would be especially helpful if you could comment on my potential in a global health residency track, including any examples where I worked effectively with diverse or resource-limited populations.”
• “Programs also value specific examples of clinical reasoning, teamwork, and professionalism, especially for IMGs.”

By framing your request this way, you increase the chance that your letters:

• Contain detailed examples
• Align with what program directors are looking for
• Go beyond generic praise

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Crafting a Cohesive Story: Aligning Your LORs With Your Global Health Narrative

Your letters don’t exist in isolation—they interact with your personal statement, experiences, and CV. Thoughtful coordination can make your application feel coherent and compelling, especially as an international medical graduate targeting international medicine–oriented programs.

1. Match Each Letter to a Piece of Your Story

Think of your application narrative as three pillars:

1. Clinical Readiness in the U.S. System
2. Longstanding Commitment to Global Health/Underserved Care
3. Professionalism, Resilience, and Adaptability as an IMG

Assign each recommender a “focus area”:

• U.S. inpatient attending:

  • Primary focus: Clinical readiness, efficiency, teamwork, communication
  • Secondary: Adaptability and willingness to learn U.S. system

• Global health mentor:

  • Primary focus: Commitment to international medicine, fieldwork, cultural humility
  • Secondary: Leadership and long-term career trajectory in global health

• Research or home-country mentor:

  • Primary focus: Work ethic, persistence, academic curiosity
  • Secondary: Long-term professional growth and reliability

You don’t have to script their letters, but when you send your bullet points and reminders, gently emphasize these angles.

2. Make Sure LORs Address Common IMG Concerns

Many program directors look to LORs to help them answer unspoken questions about IMGs, such as:

• Can this applicant function safely and efficiently under U.S. supervision?
• Will language or communication barriers be a problem with patients or teams?
• Are there any concerns about professionalism, reliability, or adaptability?
• Does this applicant truly understand what U.S. residency involves?

You can ask your U.S. supervisors explicitly:

“It would be really helpful if you could comment on my ability to function at the level of a U.S. intern and any observations about my communication with patients and the team, since I’m an IMG and program directors may be wondering about that.”

When your letters answer these questions proactively, it builds trust.

3. Highlight Global Health Without Neglecting Core Residency Goals

Some IMGs unintentionally make global health sound like their only interest, leading programs to worry:

• “Will this applicant leave after training for international work only?”
• “Are they more interested in travel than in core residency responsibilities?”

Your letters should demonstrate that you:

• Are committed to excellent core clinical training
• See global health as integrated with high-quality primary or specialty care
• Understand that a strong foundation in internal medicine/family medicine/pediatrics/etc. is essential for meaningful global practice

Ask your global health mentor to help by emphasizing:

• Your respect for evidence-based medicine
• Your desire to be clinically strong enough to contribute meaningfully to international health systems
• Your understanding that global health includes local underserved populations in the U.S.

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Practical Tips, Timelines, and Common Pitfalls for IMGs

Ideal Timeline for LORs as an IMG

For a typical application cycle (ERAS opens in June, programs start reviewing in September):

• January–April (before application year)

  • Secure U.S. clinical rotations or observerships with potential for LORs
  • Begin or continue global health projects you can sustain

• March–July

  • Ask for letters at the end of rotations
  • Provide writers 4–6 weeks to complete the letter
  • Enter them into ERAS as letter writers early

• August–September

  • Confirm letters have been uploaded
  • Follow up respectfully if needed (e.g., “My ERAS deadline is approaching, just checking in…”)

Common Mistakes IMGs Make with Residency Letters of Recommendation

1. Relying entirely on home-country letters

   • U.S. programs strongly prefer at least 2 letters from the U.S. or comparable systems

2. Choosing prestige over familiarity

   • A lesser-known attending who can write three detailed pages is better than a famous professor who remembers only your name

3. Late or rushed requests

   • Last-minute letters are more likely to be generic or delayed, which can hurt your application

4. Not aligning LOR content with global health goals

   • Missing the opportunity for your global health mentor to discuss your specific international medicine experiences and potential

5. Not verifying ERAS upload status

   • Every cycle, applicants miss interviews because a key LOR was never uploaded

Sample Email Template to Request a Letter (Adapted for Global Health IMGs)

Subject: Request for Strong Letter of Recommendation for Internal Medicine Residency

Dear Dr. [Name],

I hope you are well. I am preparing my application for internal medicine residency programs with a strong interest in global health and caring for underserved populations. I greatly valued the opportunity to work with you on [rotation/project] from [dates], particularly our work with [brief global/underserved detail if applicable].

I am writing to ask if you would feel comfortable writing a strong letter of recommendation on my behalf, commenting on my clinical performance, work ethic, and suitability for U.S. residency training as an international medical graduate.

I would be happy to provide my CV, personal statement draft, a summary of our work together, and any additional information that would be helpful. ERAS allows letters to be uploaded directly, and my application deadline is [date], so a letter by [earlier date] would be ideal if possible.

I completely understand if your schedule does not allow for this or if you do not feel you can provide a strong letter, and I am very grateful for your teaching and mentorship regardless.

Thank you again for your time and consideration.

Sincerely,
[Your Name], MD (IMG)

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FAQs: Letters of Recommendation for IMGs in Global Health

1. How many global health–specific letters should I have?

For most applicants, one strong global health–focused letter is ideal, in addition to 2–3 core clinical letters. That single letter should clearly demonstrate your commitment to international medicine, your performance in low-resource or cross-cultural settings, and your potential for a global health residency track. More than one is fine if all are strong, but never sacrifice solid clinical letters just to increase the number of global health letters.

2. Can a non-physician (e.g., public health professional or NGO director) write a letter for my residency application?

They can write a supplementary letter, but it usually cannot replace a core clinical letter from a physician. If you worked closely with a non-physician global health leader who knows your work deeply, consider asking them for an additional letter (if the program allows more than 3) or asking them to share comments with a physician co-supervisor who can incorporate that perspective into a physician-signed letter.

3. Are home-country letters still useful for an IMG?

Yes—if they are detailed, specific, and written by someone who knows you extremely well. A strong home-country LOR can:

• Provide long-term perspective on your growth and professionalism
• Highlight your early commitment to underserved or international health
• Validate your clinical excellence in your original system

However, it should complement, not replace, U.S. (or U.S.-equivalent) clinical letters. If you must choose, prioritize recent U.S. clinical LORs.

4. What if my global health experience was mostly research and not clinical?

A research-focused global health letter can still be valuable, especially if:

• It highlights your perseverance, ethical conduct, and teamwork
• It shows your understanding of health systems and international medicine
• It ties your research to real-world impact in underserved or global contexts

If possible, supplement it with at least one letter from someone who has seen you in direct patient care, even if that care occurred in a traditional hospital rather than a global health field site.

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Well-planned, strategically chosen, and carefully supported letters of recommendation can transform your application from “generic IMG” into a compelling future global health physician. Start early, choose wisely who to ask for letters, help your recommenders highlight your strengths, and ensure that your LORs reinforce the story you want program directors to see: a clinically strong, culturally humble, globally minded physician ready to thrive in residency.