The Ultimate IMG Residency Guide: Strong Letters of Recommendation for Internal Medicine

Why Letters of Recommendation Matter So Much for IMGs in Internal Medicine

For an international medical graduate, letters of recommendation (LORs) can make or break an internal medicine residency application. Program directors consistently rank residency letters of recommendation among the most important factors for interview offers—often only behind USMLE scores and clinical performance.

For IMGs, strong LORs play an even larger role because they:

• Help programs assess how you perform in a US clinical environment
• Address concerns about differences in training systems and grading
• Provide context for your achievements and professionalism
• Distinguish you from hundreds of other qualified IMGs in the IM match

This IMG residency guide will walk you step-by-step through how to get strong LOR, who to ask for letters, and how to manage the process strategically for internal medicine residency.

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Understanding What Makes a Strong Internal Medicine LOR

Before you start asking for letters, you need to understand what program directors are actually looking for.

Core Qualities of a Strong LOR

A strong internal medicine residency letter of recommendation should be:

1. Specific and detailed
   Generic phrases like “hard-working and pleasant” do not stand out. Strong letters include:

   • Concrete examples of your clinical performance
   • Specific patient cases you managed
   • Clear descriptions of your knowledge, work ethic, and growth

2. Comparative
   Programs want to know how you rank compared to peers:

   • “Top 10% of students I have worked with in the past 5 years”
   • “Among the strongest IMGs I have supervised”
     This type of comparative language is a powerful credibility signal.

3. From credible, relevant authors
   Letters from faculty who regularly work with residents—and especially internal medicine faculty—carry more weight. A beautifully written letter from a non-clinical mentor often carries less impact than a solid letter from an IM attending who knows you well.

4. Aligned with internal medicine values
   Internal medicine programs look for:

   • Clinical reasoning and problem-solving
   • Compassionate patient care
   • Teamwork and communication
   • Reliability, ownership, and follow-through
   • Interest in continuous learning and research (if applicable)

   A strong LOR explicitly addresses these qualities with examples.

5. US-focused for IMGs (ideally)
   While home-country letters can help, most programs strongly prefer at least 2–3 US-based letters for IMGs, especially from internal medicine rotations.

Red Flags and Weak LOR Characteristics

You should aim to avoid letters that:

• Are very short (half a page or less)
• Are generic or template-like
• Focus mostly on personality (“pleasant”, “nice”) without clinical detail
• Contain vague or lukewarm language (“adequate”, “acceptable”, “satisfactory”)
• Hint at professionalism concerns or describe needing “close supervision” without a clear positive trajectory

If a potential writer seems hesitant or says they can only write a “standard” letter, it might be better to politely decline and ask someone else.

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Who to Ask for Letters: Strategy for IMGs in Internal Medicine

One of the most confusing parts for an international medical graduate is deciding who to ask for letters. Internal medicine residency programs typically read dozens of letters every week; knowing what they value helps you prioritize.

Ideal Letter Writers for IMGs Applying to Internal Medicine

For internal medicine, your priority list should look like this:

1. US Internal Medicine Attendings

   • From inpatient ward rotations, ICU, or ambulatory internal medicine
   • Who directly supervised your clinical work
   • Preferably at academic or teaching hospitals

2. US Subspecialty Internal Medicine Attendings

   • Cardiology, GI, nephrology, oncology, pulmonology, etc.
   • Where you had meaningful patient care involvement

3. Program Directors, Clerkship Directors, or Chief Residents (co-signed by attending)

   • Their titles carry additional weight
   • They are familiar with residency expectations

4. Home-country Internal Medicine Faculty

   • Especially department chairs, program directors, or research mentors
   • More useful if you lack enough US clinical experience

5. Research Mentors (Internal Medicine or Related Fields)

   • Particularly valuable if you’re applying to academic or university programs
   • Should emphasize your intellectual curiosity, work ethic, and teamwork

How Many Letters Do You Need?

For the internal medicine residency ERAS application:

• You can assign up to 4 LORs per program
• Most internal medicine programs expect 3–4 letters
• For IMGs, a strong target mix is:
  • 2–3 US Internal Medicine clinical letters
  • 1 additional letter (could be from research, subspecialty IM, or home-country IM faculty)

If you’re unsure, prioritize quality and relevance over quantity. Three excellent IM-focused letters are better than four average ones.

Who NOT to Ask (Except in Special Situations)

In general, avoid letters from:

• Non-physicians (nurses, administrators, social workers)
• Physicians from unrelated specialties (surgery, psychiatry, etc.), unless they supervised substantial internal-medicine-type clinical work
• Family friends or relatives who are doctors
• Someone who barely worked with you (“I met the applicant on a single occasion…”)

These letters can weaken your application by taking space that could have gone to a more relevant writer.

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How to Earn Strong Letters During Your Rotations

The best time to think about residency letters of recommendation is before you start your US clinical experiences. As an IMG, you often have limited opportunities to impress attendings, so you must be intentional.

Before the Rotation: Set Yourself Up for Success

1. Clarify your goals
   Before starting, ask yourself:

   • Do I want a letter from this rotation?
   • What specific skills do I want to demonstrate?

2. Briefly introduce your background and goals to your attending
   On day 1 or 2, say something like:

   “I’m an international medical graduate from [country] interested in internal medicine residency in the US. I’m hoping to learn as much as possible about inpatient IM and, if possible, earn a letter of recommendation based on my performance.”

   This signals you are serious and allows the attending to observe you more intentionally.

3. Know expectations for your level
   Understand what’s expected of a medical student vs. observer vs. extern, especially as an IMG. Read about:

   • How to write SOAP notes
   • Presenting patients concisely
   • Basic US hospital culture and etiquette

During the Rotation: Behaviors That Generate Strong LOR Content

Attendings write better letters when they see specific, memorable behaviors. Focus on:

1. Professionalism and Reliability

   • Arrive early; never be late for rounds
   • Follow through on every task
   • Dress professionally; be respectful and calm

2. Clinical Initiative (Within Your Role)

   • Volunteer to present patients
   • Read about your patients’ conditions and propose plans
   • Look up guidelines and share summaries with the team
   • Offer to help with discharge summaries or patient education

3. Communication and Teamwork

   • Be kind and respectful to nurses, residents, and other staff
   • Listen actively during teaching; ask thoughtful, concise questions
   • Show maturity when receiving feedback—and then apply it

4. Patient-Centered Care

   • Spend time talking with patients and families
   • Demonstrate empathy, especially across language or cultural barriers
   • Help clarify plans to patients in understandable language

5. Teachability and Growth

   • When you make a mistake (everyone does), own it and correct it
   • Show improvement day by day: better presentations, better notes, more independent reasoning

All of these actions give your attending concrete material to write about—leading to the type of detailed, compelling residency letters of recommendation that stand out in the IM match.

Example: What Attendings Remember When Writing LORs

Imagine two IMGs, both smart and hard-working:

• Candidate A: Always on time, did tasks when asked, quiet, rarely volunteered opinions.
• Candidate B: Also reliable, but:
  • Asked to follow two complex patients more closely
  • Came the next day with relevant guideline summaries
  • Helped prepare discharge instructions for a complex diabetic patient
  • Improved presentations noticeably after mid-rotation feedback

When it’s time to write letters, the attending will remember specific patient encounters and growth for Candidate B. That’s the candidate who gets phrases like “outstanding,” “top 10%,” and detailed clinical descriptions that catch program directors’ attention.

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Asking for Letters: Timing, Process, and How to Make It Easy

Even outstanding performance won’t automatically translate into a strong letter unless you ask strategically and professionally.

When to Ask for a Letter

For clinical rotations, the best times are:

• End of the rotation (last week): When your performance is freshest in the attending’s mind
• Immediately after a major positive interaction: For example, after you managed a difficult patient particularly well and received praise

If you’re reading this after your rotation has ended, it’s still possible. Reach out by email as soon as you can, even if months have passed, but provide extra context and reminders (more on this below).

How to Ask: In Person

If possible, ask in person first:

“Dr. Smith, I’ve really appreciated working with you this month and I’m very interested in applying for internal medicine residency. Would you feel comfortable writing me a strong letter of recommendation for my application?”

Using the word “strong” is intentional. It gives them a graceful way to say no if they can’t write you a positive letter. If they hesitate or say something like “I can write a standard letter,” consider it a warning sign.

If they agree in person, follow up with a thank-you email and the documents they need.

How to Ask: By Email (Sample Template)

If in-person is not possible, send a concise, professional email:

Subject: Request for Letter of Recommendation – [Your Name], Internal Medicine Residency

Dear Dr. [Last Name],

I hope you are well. I had the privilege of working with you on the [Inpatient/Outpatient/Internal Medicine] service at [Hospital Name] from [dates]. I greatly appreciated your teaching and the opportunity to learn from your approach to patient care.

I am an international medical graduate from [Medical School, Country] and I am applying to internal medicine residency in the upcoming ERAS cycle. I am writing to ask if you would feel comfortable writing a strong letter of recommendation on my behalf based on my performance during our rotation.

To make things easier, I would be happy to provide my CV, personal statement draft, ERAS ID, and a summary of the patients and projects I worked on with you.

Thank you very much for considering my request and for the guidance you provided during my rotation.

Sincerely,
[Full Name]
[Degree]
[Contact Information]

If they do not respond within 7–10 days, you may send a polite follow-up.

What to Provide Your Letter Writers

To help them write the best possible letter, send:

• Updated CV
• Personal statement draft (even if not final)
• ERAS ID and AAMC instructions for uploading letters
• Your specific goals (e.g., “I am focusing on categorical internal medicine at academic programs.”)
• Bullet points of your work together, including:
  • Specific patients you followed
  • Any presentations you gave (case or topic)
  • Any feedback they gave you that you acted on

You are not writing the letter for them; you’re jogging their memory and giving them material to work with.

Waiving Your Right to See the Letter

ERAS allows you to choose whether to waive your right to see each letter. Program directors strongly prefer that applicants waive this right, because:

• It suggests the letter is more likely to be honest and unbiased
• It’s the expectation in US academic culture

Unless you have a very specific reason not to, you should waive your right to see residency letters of recommendation.

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Managing Multiple Letters and Tailoring for the IM Match

Once you have several letters underway, you need a system to stay organized and to align them with your IM match strategy.

How Many Total Letters Should You Collect?

It’s common (and wise) to collect more letters than you will actually use. For an IMG applying internal medicine, consider aiming for:

• 4–6 total letters collected
• Then pick the best 3–4 to assign per program

For example:

• IM inpatient attending (US)
• IM subspecialty attending (US)
• IM research mentor (US or home country)
• IM department chair (home country)
• Possibly an additional US IM outpatient attending

You can customize which letters go to which programs.

Assigning Letters Strategically in ERAS

Because you can only assign up to 4 letters per program, think about:

• All programs:
  • At least 2 strong US IM clinical letters
• Academic or university programs:
  • Include 1 research-oriented letter, especially if you have publications or scholarly work
• Community hospitals:
  • Highlight strong clinical performance and work ethic with clinical letters

If you know a letter is only average—short, generic, or not IM-focused—do not assign it to competitive programs.

Following Up and Gentle Reminders

Faculty are busy. Many genuinely intend to write your letter but may forget. It is your responsibility to manage this politely and professionally.

Timeline for reminders:

• 1–2 weeks before their stated deadline:
  • Send a brief reminder email with appreciation
• 1 week after expected completion date (if still not uploaded):
  • One more very polite reminder

Example:

Dear Dr. [Last Name],
I hope you are well. I wanted to gently follow up regarding the letter of recommendation for my internal medicine residency application. ERAS recommends having letters uploaded by [date], and I just wanted to check whether you might be able to submit it by then.

I am very grateful for your support and for taking the time to help me with this process.

Sincerely,
[Your Name]

If they remain unresponsive after multiple reminders, you may need to seek an additional writer.

Thanking Your Letter Writers

Always:

• Send a thank-you email after they agree
• Send another thank-you once the letter is uploaded (if you can see the status in ERAS)
• After Match Day, send a brief update:
  • Share where you matched
  • Express gratitude for their role in your journey

These relationships can remain valuable through residency and beyond, especially if you’re interested in fellowship later.

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Maximizing Impact: Putting It All Together for IMG Success in Internal Medicine

As an international medical graduate, you often must work harder to prove that you’re ready for US internal medicine residency. Residency letters of recommendation are your chance to let trusted US physicians speak on your behalf.

To summarize a high-yield strategy for IMGs:

1. Focus on US Internal Medicine Experience

   • Aim for at least two strong inpatient or outpatient IM rotations in the US
   • Be explicit about your interest in internal medicine from day one

2. Identify Strong Potential Letter Writers Early

   • Seek attendings who see you frequently and supervise your work directly
   • Let them know you’re hoping to earn a letter based on performance

3. Perform Intentionally

   • Show reliability, curiosity, teamwork, and growth
   • Ask for midpoint feedback and actively improve

4. Ask Clearly and Professionally

   • Request a “strong letter of recommendation”
   • Provide your CV, personal statement, and a short summary of your work

5. Collect and Curate Letters Strategically

   • Gather 4–6 letters; assign the best 3–4 to each program
   • Prioritize US internal medicine clinical letters
   • Use research/home-country IM letters to round out your application

6. Stay Organized Throughout the IM Match Cycle

   • Track who has agreed, who has uploaded, and deadlines
   • Send polite reminders and sincere thank-you messages

Done well, your letters can transform your application from “another IMG” to a trusted future colleague in the eyes of internal medicine program directors. For many successful IMGs, strong LORs are the difference-maker that turns solid scores and experience into a residency position.

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FAQ: Letters of Recommendation for IMGs in Internal Medicine

1. How many US letters of recommendation do I really need as an IMG?

For an internal medicine residency, most program directors prefer at least 2 US-based internal medicine letters for IMGs, and 3 is ideal if you can obtain them. If you only have 1 US IM letter, you can still apply, but your application may be less competitive at many programs. In that case, maximize the strength and detail of your non-US IM letters and highlight any US clinical experience you do have.

2. Are home-country letters of recommendation still useful?

Yes, especially if they are from internal medicine faculty, such as a department chair, long-term mentor, or program director who knows you well. While US letters carry more weight for the IM match, a strong home-country IM letter can highlight your overall clinical maturity, leadership, and long-term performance. Use them to complement, not replace, US IM letters whenever possible.

3. Is it okay if my letters are not all from internal medicine?

Ideally, the majority (if not all) of your letters for internal medicine residency should be IM-focused. However, 1 of your 3–4 letters can come from a related specialty or research mentor, especially if:

• They supervised you closely
• They can speak in depth about your clinical reasoning, professionalism, or scholarly work

If that mentor is not in internal medicine, make sure your other letters are clearly internal medicine–oriented.

4. What if my attending asks me to write a draft of my own letter?

This is common in some countries and occasionally happens in the US. You should:

• Politely agree to provide a detailed summary of your clinical work, achievements, and key cases rather than writing a full letter verbatim, if possible
• Emphasize internal medicine competencies: clinical reasoning, patient care, teamwork, professionalism
• If they insist on a draft, write honestly but not excessively flattering; focus on specific behaviors and examples, and allow them to edit freely

Remember: the final responsibility and signature must be the attending’s. Your role is to provide accurate information and context, not to exaggerate.

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By approaching residency letters of recommendation with the same seriousness and planning as your exams and personal statement, you greatly improve your chances in the internal medicine IM match as an international medical graduate.