The Ultimate IMG Residency Guide: Crafting Strong Letters of Recommendation for Med-Peds

Why Letters of Recommendation Matter So Much for IMGs in Med-Peds

For an international medical graduate, letters of recommendation (LORs) can make or break a Medicine-Pediatrics application. Program directors consistently rank residency letters of recommendation among the top factors in interview and rank list decisions, and this is especially true for IMGs who may be less familiar to U.S. programs.

As an IMG applying to med peds residency, your letters do three essential things:

1. Validate your clinical skills in a U.S. context
   Programs want reassurance that you can safely and efficiently care for both adult and pediatric patients in a U.S. system.

2. Translate your strengths across cultures and systems
   Your CV may show strong achievements, but a trusted U.S. or Canadian physician explaining how you compare to their usual medical students/residents gives committees needed context.

3. Differentiate you from other IMGs
   Many IMG applications can look similar on paper. Strong, specific, comparative LORs help you stand out and show that real clinicians are willing to “vouch” for you.

This IMG residency guide will focus on how to get strong LORs that specifically support your medicine pediatrics match, from who to ask for letters, to timing, to what content matters most for this unique combined specialty.

---

Understanding What Makes a Strong Med-Peds Letter

Before you start asking for letters, you need to understand what programs are actually looking for. A powerful LOR for an international medical graduate in med-peds residency has three main components: the writer, the content, and the credibility.

1. The Writer: Who Matters Most in Med-Peds

Programs care about who is writing as much as what they say. For Med-Peds:

Ideal Letter Writers (Top Tier)
Aim for at least two letters from this group:

• Med-Peds faculty or program leadership

  • Med-Peds program director (PD) or associate PD
  • Med-Peds core faculty who directly supervised you
  • Med-Peds chief residents (occasionally co-signing with faculty)

• U.S. academic internal medicine attendings

  • Especially those involved in residency education (e.g., clerkship directors, site directors, APDs)

• U.S. academic pediatrics attendings

  • Faculty on inpatient wards or continuity clinic, particularly those known to write for residency applicants

These writers are best positioned to comment on your ability to understand and integrate the dual nature of medicine-pediatrics.

Acceptable Additional Writers (Second Tier)

• Hospitalists (adult or pediatric), especially in teaching hospitals
• Subspecialty attendings who supervised you closely (e.g., pediatric cardiology, adult endocrinology)
• Primary care physicians in combined or adjacent settings (family medicine with strong adult/child care experience)

More Limited Value (Use Sparingly)

• Research-only mentors with minimal clinical observation of you
• Non-physician professionals (PhD-only researchers, administrators, etc.)
• Physicians outside of clinical medicine (e.g., purely administrative roles) unless they know you clinically

These letters can be helpful as a fourth letter (for programs that allow it), but they should not replace strong clinical letters from core specialties.

2. The Content: What Programs Want to Read

Regardless of who writes it, a strong LOR for med peds residency should:

• Describe direct clinical observation

  • “I supervised Dr. X for four weeks on the inpatient general pediatrics service, where they managed a census of 8–12 patients daily.”

• Provide specific examples

  • A challenging adult case (e.g., sepsis, CHF exacerbation) and how you managed it
  • A complex pediatric patient (e.g., failure to thrive, asthma exacerbation) and your approach
  • A situation showing your communication skills with families or multidisciplinary teams

• Compare you to a relevant peer group

  • “Among the last 50 medical students and sub-interns I have supervised, Dr. X ranks in the top 10% in clinical reasoning and professionalism.”

• Comment on core competencies, ideally with examples:

  • Medical knowledge and clinical reasoning
  • Patient care and procedural skills
  • Interpersonal and communication skills (with both adults and parents/children)
  • Professionalism (reliability, ethics, humility, resilience)
  • Systems-based practice (resource utilization, follow-up, teamwork)
  • Practice-based learning (how you respond to feedback)

• Address your “IMG transition”
  For an international medical graduate, a strong letter will often comment on:

  • How quickly you adapted to U.S. clinical culture
  • Your English proficiency and clarity of communication
  • How you integrated into interprofessional teams
  • Your ability to navigate EMRs and U.S. hospital systems

3. The Credibility: Why Programs Should Trust the Letter

Credibility comes from:

• Institutional reputation
  A letter from a major academic center or established teaching hospital often carries more weight than one from a non-teaching or unknown clinic.

• Writer’s role in education
  Letters from program directors, clerkship directors, core faculty, or hospitalists heavily involved in teaching are particularly influential.

• Concrete, honest language
  Directors can recognize generic, overly positive, or “template” letters. Authentic, balanced praise plus mild, constructive critique feels more real and trustworthy.

---

How Many Letters You Need and How to Balance Med vs Peds

Understanding how many residency letters of recommendation to submit—and from which specialties—is essential as you plan your medicine pediatrics match strategy.

Standard Requirements

Most Med-Peds programs follow ERAS/NRMP norms:

• 3 letters minimum
• 4 letters maximum (ERAS limit), though many programs truly “read deeply” the first 3

Always check each program’s website, but this breakdown works for most IMGs applying to med-peds residency.

Ideal Letter Mix for a Med-Peds IMG

For an international medical graduate targeting Med-Peds specifically, a strong configuration is:

• Letter 1: Med-Peds Program Director or Med-Peds Faculty

  • From a U.S. Med-Peds residency where you did an observership, sub-internship, or acting internship (if possible)
  • This is the most powerful letter because it demonstrates direct endorsement from someone who understands the specialty deeply

• Letter 2: Internal Medicine Attending (U.S.)

  • Preferably inpatient, academic, and actively involved in training residents/medical students
  • Should emphasize your adult medicine clinical reasoning, efficiency, and professionalism

• Letter 3: Pediatrics Attending (U.S.)

  • From inpatient wards, NICU, PICU, or a strong outpatient continuity clinic
  • Should speak to your rapport with children and families, developmental understanding, and team communication

• Optional Letter 4: Supplemental Letter

  • Could be:
    • Another Med-Peds or internal medicine or pediatrics attending
    • A research mentor who can highlight longitudinal qualities (work ethic, leadership, initiative)
    • A strong letter from your home country only if it’s highly specific and from a respected clinical educator

If You Can’t Get a Med-Peds Letter

Some international medical graduates have limited access to Med-Peds programs. In that case:

• Aim for two strong internal medicine and one strong pediatrics letter
• Ask internal medicine or pediatrics attendings to comment explicitly on your interest in and suitability for a combined med-peds career:
  • Example: “Although our institution does not have a Med-Peds program, Dr. X consistently expressed interest in combined adult and pediatric primary care and actively sought both populations during their rotation.”

Programs understand that not all IMGs can rotate at Med-Peds sites; what matters is that your letters show clear competence in both domains and alignment with Med-Peds values.

---

Who to Ask for Letters and When to Ask

A critical part of this IMG residency guide is helping you decide who to ask for letters and how to approach them strategically.

Priority Order: Who to Ask for Letters

Use this hierarchy as you plan:

1. Attendings who directly supervised you in U.S. clinical rotations, particularly:

   • Med-Peds
   • Internal Medicine
   • Pediatrics

2. Attendings who saw you manage both complex and routine cases

   • Including adults with comorbidities (e.g., diabetes, heart failure, COPD)
   • And pediatric patients across age ranges (infants, toddlers, adolescents)

3. Faculty who are known “educators”

   • Clerkship directors
   • Site directors
   • Education chiefs
   • Faculty who regularly write for U.S. graduating students

4. Mentors who’ve seen your long-term growth

   • Research or quality improvement mentors who also know your clinical mindset
   • Longitudinal preceptors

Red Flags: Who Not to Ask If You Can Avoid It

• Attendings who barely know you or only worked with you 1–2 days
• Physicians who expressed concerns about your performance
• Letter writers from non-clinical settings who cannot comment on your bedside skills
• People who hesitate or seem unsure when you ask them directly

If you must ask someone after a short experience, be direct and give them extra information (CV, personal statement, case logs) to help them write something specific.

When to Ask for Letters

Timing matters, especially for IMGs who may have limited time in U.S. rotations:

• Ask near the end of a rotation when your performance is freshest:

  • Near the final week or last few days of your rotation
  • After you’ve had a chance to demonstrate growth and reliability

• For late-season rotations (July–September):

  • Tell the attending your ERAS timeline
  • Ask if they can submit within 2–3 weeks
  • You may submit ERAS with some letters pending, but try to have at least two uploaded by the time applications open

• For early rotations (January–June):

  • Ask for the letter at rotation end, even if applications are months away
  • Politely remind your letter writers closer to ERAS opening if they choose to delay submission

---

How to Get Strong LORs as an IMG: Strategy, Communication, and Materials

Understanding how to get strong LOR is just as important as knowing who to ask. For an international medical graduate, clear communication and professional organization can significantly improve letter quality.

Step 1: Perform Intentionally During Rotations

Your future letters start on Day 1 of your rotation. Focus on:

• Reliability

  • Arrive early, stay appropriately late, complete notes on time
  • Follow up on labs, imaging, and patient updates

• Active learning

  • Read about your patients each night
  • Prepare brief literature summaries for interesting cases
  • Ask focused, thoughtful questions

• Communication

  • Practice concise, structured presentations
  • Speak clearly with patients and families, checking for understanding
  • Be especially sensitive with parents of pediatric patients

• Professionalism

  • Be humble, accept feedback, and show improvement
  • Respect nurses, ancillary staff, and co-learners
  • Avoid complaining or comparing systems negatively

Attendings are much more willing to write strong LORs for learners who consistently demonstrate these behaviors.

Step 2: Ask the Right Question: “Can You Write a Strong Letter?”

When the time comes:

1. Request a meeting (in person or via video) near the end of your rotation.
2. Ask specifically:
   • “I am applying for Medicine-Pediatrics residency as an international medical graduate. Based on our work together, do you feel you could write a strong letter of recommendation on my behalf?”

If they hesitate, seem uncertain, or use vague language (“I can write you a letter…” but not “strong”), consider asking someone else. A lukewarm letter can hurt more than help.

Step 3: Provide a Helpful Letter Packet

Make it easy for your writer to personalize the letter. Offer:

• An updated CV

• Your personal statement (draft is okay)

  • Especially useful if it clearly explains your interest in med-peds

• A 1-page “LOR support document” that includes:

  • ERAS ID, full name, email, and deadlines
  • List of rotations you did with them (dates, sites, inpatient/outpatient)
  • 2–3 patients or cases you managed that they might recall (de-identified)
  • Your key strengths you hope they can highlight:
    • Example: “Adaptability as an IMG,” “Working with both adult and pediatric populations,” “Communication with families,” “Interest in chronic disease management from childhood into adulthood”
  • Your specific target: Medicine-Pediatrics residency

• Instructions for ERAS upload

  • Briefly explain that ERAS will send them an email link
  • Confirm whether the letter should be addressed generally (e.g., “Dear Program Director”) or specifically to Med-Peds (usually “Dear Internal Medicine-Pediatrics Residency Program Director” is appropriate)

This kind of packet is particularly helpful in the IMG residency guide context: many attendings may not know your full background or how to frame your experience as an international medical graduate.

Step 4: Gently Remind and Follow Up

Physicians are busy. Professional follow-up is both acceptable and often necessary.

• 1–2 weeks after your request:
  Send a polite email:

  • Thanking them again
  • Asking if they need any additional information
  • Mentioning your target submission date

• 2–4 weeks before ERAS submission:
  If the letter still isn’t uploaded, send a brief, respectful reminder.

• After submission:
  Send a final thank-you email. Later, update them on your interview offers and match result. These relationships may help you again (fellowship, jobs, or future reference letters).

---

Special Considerations for IMGs: Home Country Letters, Gaps, and Red Flags

International medical graduates face some unique questions when collecting residency letters of recommendation. Here’s how to handle common challenges.

Should You Use Letters From Your Home Country?

Home-country letters can be useful, but they rarely carry the same weight as U.S. or Canadian letters. General guidance:

• Use at most 1 home-country clinical letter, and only if:

  • The writer supervised you extensively (e.g., internship attending, department head)
  • The letter is specific, detailed, and comparative
  • The physician is recognized in their field or runs a major academic department

• Avoid relying entirely on non-U.S. letters if you want a strong medicine pediatrics match outcome. Most programs prefer at least 2–3 U.S. clinical letters to demonstrate your readiness for their environment.

What If You Have Gaps in Clinical Experience?

If you’ve been away from consistent clinical work:

• Try to obtain recent U.S. clinical experience (observerships, externships, sub-internships) and prioritize letters from those rotations.
• Ask your letter writers to:
  • Highlight your rapid return to clinical competence
  • Emphasize how you maintained knowledge (courses, reading, research) during gaps
  • Comment on your adaptability and commitment

Gaps are less concerning when letter writers clearly state that you are now performing at or above the expected level of your peers.

How to Handle a Mediocre Evaluation

If you had a challenging rotation:

• Reflect honestly: was it a poor fit, personal stressor, or communication issue?
• Choose letter writers from rotations where:
  • You improved consistently
  • You had better rapport with attendings
  • Your evaluations were strong

If a potential writer gave you negative or average feedback, do not feel obligated to ask them for a letter, unless your options are severely limited. Even then, it’s better to seek writers who can at least speak to your growth.

Confidential vs. Non-Confidential Letters

Most U.S. programs expect confidential letters (you waive your right to view them in ERAS).

• Waiving your right increases letter credibility.
• If you refuse to waive this right, some program directors may worry that the letter is less candid.

As a general rule: waive your right to see the letters in ERAS unless your advisor gives a specific reason not to.

---

Putting It All Together: A Sample Med-Peds LOR Strategy for an IMG

Imagine you are an IMG who completed:

• 1 month Inpatient Internal Medicine at a U.S. academic center
• 1 month General Pediatrics wards at a community teaching hospital
• 1 month Ambulatory Pediatrics plus some adolescent medicine
• 2-month Med-Peds observership at a Med-Peds residency site

A strong LOR plan might be:

1. Letter 1 (Med-Peds PD or faculty at the Med-Peds site)

   • Emphasizes your interest in dual care, ability to integrate adult and pediatric perspectives, and your overall fit for med-peds.

2. Letter 2 (Internal Medicine attending from inpatient rotation)

   • Focuses on your adult inpatient skills: differential diagnosis, complex care, multidisciplinary rounds, handling cross-coverage.

3. Letter 3 (Pediatrics inpatient attending)

   • Highlights your interaction with parents, developmental understanding, child-friendly communication, safe discharge planning.

4. Optional Letter 4 (Ambulatory pediatrics or research mentor)

   • Demonstrates continuity care understanding, chronic disease management, or long-term mentorship and professionalism.

This combination shows programs:

• You can practice safely in both medicine and pediatrics
• You understand the philosophy and structure of med-peds
• Multiple clinicians in different settings support your candidacy

---

FAQs About Letters of Recommendation for IMGs in Medicine-Pediatrics

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

Aim for at least three U.S. clinical letters if possible, ideally from internal medicine, pediatrics, and med-peds. If you cannot obtain three U.S. letters, try for at least two strong U.S. clinical letters and use a detailed home-country clinical letter as your third. Programs know that access varies for international medical graduates, but recent U.S. experience is extremely helpful.

2. Is it better to have a famous professor or someone who knows me well?

For a medicine pediatrics match, a specific, detailed letter from someone who knows you well is almost always better than a short, generic note from a famous but distant professor. The ideal is a well-known clinician-educator who has worked closely with you; if you must choose, prioritize depth of knowledge about your work, not just the writer’s title.

3. Can I reuse the same letters for internal medicine and med-peds applications?

Yes, but with care. Many IMGs apply to both internal medicine and med-peds. Most general internal medicine letters will still work for med-peds, especially if they describe your interest in adults with chronic disease. However, for explicitly med-peds–focused letters, ask the writer to address them to “Internal Medicine-Pediatrics Residency Program Director.” If you plan to apply to both, you can ask letter writers to keep the salutation slightly more general (e.g., “Dear Program Director”) and emphasize your strengths in adults while mentioning your comfort with pediatric patients when relevant.

4. What if my English isn’t perfect—will that hurt my letters?

Programs understand that for an international medical graduate, English is often a second language. Minor accent or language issues are not a problem if you can communicate clearly and safely. In fact, strong letters often explicitly reassure programs: “While English is not Dr. X’s first language, I have never had concerns about their communication with patients or staff.” Focus on improving clarity, practicing presentations, and asking your letter writers (if appropriate) to mention how well you communicate in a clinical setting.

---

By approaching your letters of recommendation with the same strategy and professionalism that you bring to patient care, you can significantly strengthen your med peds residency application. As an IMG, your letters are your voice in a crowded field—make sure they tell a clear, compelling story of who you are and why you belong in Medicine-Pediatrics.