Ultimate Guide to Letters of Recommendation for IMG in Medicine-Psychiatry

Understanding the Role of Letters of Recommendation for IMGs in Medicine-Psychiatry

Letters of Recommendation (LORs) are one of the most influential parts of your Medicine-Psychiatry residency application—especially as an international medical graduate (IMG). For combined medicine psychiatry programs, LORs help program directors answer three core questions:

1. Can you function as a strong, reliable internal medicine resident?
2. Can you function as a strong, insightful psychiatry resident?
3. Are you a good fit for the integrated, biopsychosocial mindset that medicine-psychiatry combined training requires?

As an IMG, your LORs are often scrutinized even more carefully because:

• Program directors may not know your medical school or home country systems.
• They rely on LORs to gauge your clinical readiness, professionalism, and adaptability to the U.S. training environment.
• Strong letters can offset perceived weaknesses (older graduation date, exam failures, limited U.S. experience).

This IMG residency guide focuses specifically on how to get strong LORs for medicine psychiatry combined programs, including who to ask for letters, what content should be emphasized, and how to plan your experiences to generate excellent recommendations.

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What Makes a Strong Letter of Recommendation for Medicine-Psychiatry?

A strong LOR for Medicine-Psychiatry is not just “positive.” It is specific, comparative, and contextualized for combined training. When thinking about how to get strong LOR letters, focus on three dimensions:

1. Content: What Program Directors Want to See

Strong residency letters of recommendation for Med-Psych should address:

Clinical competence in internal medicine

• Accuracy and completeness of history and physical exams
• Clinical reasoning and differential diagnosis skills
• Ability to manage complex medical patients, especially those with co-morbid psychiatric conditions (e.g., heart failure + depression, diabetes + substance use disorder)
• Reliability in following up labs, imaging, and care plans

Clinical competence in psychiatry

• Skill in interviewing patients with psychiatric illness
• Comfort discussing sensitive topics (suicidality, trauma, addiction)
• Understanding of psychopharmacology basics
• Awareness of risk assessment and safety evaluation

Integrated thinking (core of medicine psychiatry combined training)

• Ability to connect physical and mental health in every patient
• Recognition of how psychiatric illness affects medical outcomes (and vice versa)
• Examples of biopsychosocial formulations or integrated treatment plans
• Interest in working with complex, multi-morbid, high-needs populations

Professional attributes

• Work ethic, reliability, and ownership of patient care
• Ability to work in a multidisciplinary team (social work, nursing, case management)
• Cultural humility and sensitivity (especially vital for IMGs)
• Communication skills with patients and colleagues, including in challenging situations

Fit for Medicine-Psychiatry specifically

• Explicit mention that the writer understands you are applying to medicine-psychiatry combined programs
• Commentary about your suitability for a dual-identity role (internist and psychiatrist)
• Evidence of resilience and adaptability—Med-Psych is demanding and intensive

2. Strength: How Strong Letters Are Recognized

Program directors recognize a powerful LOR by certain features:

• Concrete examples: “She stayed late three evenings in a row to stabilize a suicidal patient with complex medical needs” is far more powerful than “She is very dedicated.”
• Comparative language: “Among the top 5% of students I have supervised in the last 10 years” or “One of the strongest IMG trainees I have ever worked with.”
• Clear endorsement: A direct, unambiguous recommendation such as “I give her my highest recommendation for a position in Medicine-Psychiatry residency.”
• Personalized: Specific details of your cases, projects, or unique strengths, not generic cut-and-paste paragraphs.

3. Credibility: Who Writes the Letter and From What Setting

For an IMG applying to Med-Psych, the source of the LOR heavily influences how it is received:

• U.S.-based clinical supervisors (especially those familiar with residency expectations) carry significant weight.
• Faculty in academic teaching hospitals are highly valued.
• Faculty in internal medicine, psychiatry, or those already involved in medicine psychiatry combined or integrated care work are ideal.

A shorter, detailed, U.S.-based letter from a faculty member who worked closely with you is usually more valuable than a very long, generic letter from a distant supervisor abroad.

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Who to Ask for Letters (and How Many of Each Type You Need)

One of the most common IMG questions is who to ask for letters for a combined medicine psychiatry application and how to balance medicine vs. psychiatry letters.

Ideal Mix of Letters for Medicine-Psychiatry

Most Med-Psych programs accept 3–4 letters. A strong, commonly recommended combination for an international medical graduate is:

• 2 letters from Internal Medicine (at least 1 U.S.-based, if possible)
• 1–2 letters from Psychiatry (at least 1 U.S.-based, if possible)
• Optional: 1 additional letter from a related field (e.g., primary care, neurology, addiction medicine, emergency medicine) if it clearly supports your fit for Med-Psych

If you can only get three total:

• 1 strong U.S. Internal Medicine letter
• 1 strong U.S. Psychiatry letter
• 1 additional strong letter (either IM or psych; prioritize whichever is stronger and more detailed)

Prioritizing U.S. Clinical Experience (USCE) Letters

For IMGs, U.S.-based experiences are crucial. Program directors often look for at least 1–2 letters from U.S. supervisors who:

• Observed you directly with patients (not just research or observerships with no patient interaction)
• Can comment on your clinical reasoning, communication, and professionalism
• Understand U.S. residency expectations

If your experience was an observership/externship where you had limited authority, the letter can still be strong if:

• The writer clearly describes what you were allowed to do (e.g., present cases, write notes, discuss management plans, attend rounds).
• They highlight your growth, curiosity, and integration into the team even within those limitations.

Who to Ask for Letters: Practical Priorities

Here is a prioritized framework for who to ask for letters in an IMG residency guide context:

1. U.S. Internal Medicine faculty

   • Attending physicians who supervised you on wards, clinics, or sub-internships
   • Preferably at academic or teaching hospitals
   • Choose those who saw you repeatedly over days to weeks

2. U.S. Psychiatry faculty

   • Supervisors on inpatient psychiatry, consult-liaison psychiatry, or outpatient psychiatric clinics
   • Psychiatrists working in integrated care, collaborative care, or hospital medicine-psychiatry services are especially valuable

3. Home-country faculty (if U.S. letters are limited)

   • Department heads or senior faculty in medicine or psychiatry
   • Faculty who know you well and can speak in detail about your performance over time
   • Supervisors from internships or post-graduate training with clear clinical responsibilities

4. Research mentors (only when strongly relevant)

   • Particularly if your research is in areas like integrated care, psychosomatic medicine, behavioral health in primary care, or chronic disease + mental health
   • They should still comment on professional attributes beyond research skills (leadership, teamwork, communication)

When deciding who to ask, choose faculty who know you best, not just the most famous names. A well-known name with a generic letter is weaker than a lesser-known faculty member with a detailed, enthusiastic endorsement.

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When and How to Ask: Step-by-Step Strategy for IMGs

Knowing who to ask for letters is only half of the challenge; how you approach them and what you provide can strongly influence the final quality.

Step 1: Time Your Request Strategically

• Ask near the end of your rotation, when your performance is still fresh in the evaluator’s mind, or within 2–4 weeks afterward.
• If you completed a rotation months ago, it is still acceptable to ask—just provide a detailed reminder of your activities and contributions.
• For the ERAS cycle, aim to secure commitments from letter writers by May–June before September applications, especially if they are very busy academic physicians.

Step 2: Ask for a “Strong” Letter Specifically

When you request a letter, explicitly ask if they can write you a “strong supportive letter of recommendation for Medicine-Psychiatry residency.” This phrasing gives them permission to decline if they aren’t comfortable fully endorsing you.

Sample email wording:

Dear Dr. [Name],

I greatly appreciated the opportunity to work with you on the [service/rotation] from [dates]. I learned a tremendous amount from your teaching, especially about [specific point].

I am applying to Medicine-Psychiatry combined residency programs this application season. Given your direct supervision of my clinical work, I was wondering if you would feel comfortable writing a strong letter of recommendation on my behalf.

I would be happy to provide my CV, personal statement draft, and a summary of the patients and projects we worked on together. I understand you have many commitments; please feel free to let me know if you do not feel you can provide a strong endorsement.

Thank you again for your time and for considering my request.

Sincerely,
[Your Name, Credentials]

This approach is respectful and allows weaker supporters to opt out, which helps protect you from mediocre or neutral letters.

Step 3: Provide a Helpful “Letter Packet”

To help your writer build a strong, specific letter, provide:

• Updated CV
• Personal statement draft, especially if already focused on medicine psychiatry combined training
• USMLE/COMLEX scores (if you are comfortable sharing)
• List or brief bullet summary of:
  • Rotations completed with them (dates and settings)
  • Specific patients or cases you discussed or managed together
  • Any presentations, QI projects, or research you did under their supervision
  • Key strengths you hope they might highlight (e.g., integrated thinking, team leadership, cross-cultural communication)

You are not telling them what to write; you are giving them raw material so they can write a richer, more detailed LOR.

Step 4: Clarify That You’re Applying to Medicine-Psychiatry

Many letter writers are more familiar with categorical internal medicine or psychiatry than with combined programs. Briefly explain:

• What medicine psychiatry combined training is
• Why you are drawn to it (complex patients, overlaps between physical and mental health, integrated care models)
• How their rotation shaped or reinforced this interest

You can include a short paragraph in your email or a one-page summary attached to your materials.

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Crafting Experiences That Generate Excellent LORs

Strong letters don’t begin when you ask for them—they begin when you start the rotation. As an IMG, you must be deliberate in how you perform and how you connect with faculty.

During Internal Medicine Rotations

To support your Med-Psych application, emphasize:

• Ownership of patients: Know your patients’ stories, labs, imaging, and plans inside out. Be the person the team turns to when they have questions.
• Attention to psychiatric comorbidities: Proactively screen for mood symptoms, anxiety, substance use, cognitive changes, or suicidality in your medical patients, and bring these concerns to your attending.
• Communication with psychiatry and other services: If psychiatry is consulted, be active in those discussions and show your interest in integrating their recommendations.
• Complex case examples: Seek opportunities to follow patients with both significant medical and psychiatric illness (e.g., COPD and panic disorder, cirrhosis and alcohol use disorder, diabetic foot ulcer and depression).

Tell your supervisor about your interest in Medicine-Psychiatry early in the rotation. This nudges them to view your performance through that lens and mention it in the letter.

During Psychiatry Rotations

To strengthen your Med-Psych profile, focus on:

• Thorough medical assessment: Don’t ignore physical health. On psychiatry rotations, show that you systematically consider medical contributors to psychiatric symptoms (e.g., thyroid disease, infections, medication side effects).
• Consult-liaison psychiatry exposure: If possible, rotate on or at least shadow CL psychiatry, where psychiatric care is provided in medical settings. This directly aligns with medicine psychiatry combined training.
• Integrated formulations: Practice writing or orally delivering biopsychosocial formulations that tie together medical, psychiatric, social, and cultural factors.
• Interest in complex systems of care: Ask about community resources, transitions of care, and how to coordinate with primary care and medical subspecialties.

Again, explicitly share your Med-Psych interests with supervising psychiatrists. Ask them for feedback on how you’re progressing toward being a physician who can operate competently in both domains.

Non-U.S. and Non-Core Rotations

If your primary clinical training is outside the U.S., you can still generate valuable letters:

• Make sure the writer clearly explains:
  • Your level of responsibility (Were you like a U.S. intern? A sub-intern? A junior resident?)
  • The type of health system and patient population
• Ask them to focus on observable behaviors and outcomes: Did you lead rounds, manage admissions, teach juniors, or run clinics?

From other specialties (e.g., neurology, family medicine, emergency medicine), ask them to highlight your ability to:

• Manage medically and psychiatrically complex patients
• Communicate clearly under pressure
• Demonstrate empathy and professionalism with challenging patients

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Technical Considerations: Uploading, Waiving, and Customizing LORs

Strong content is critical, but you also need to handle the logistics correctly in ERAS.

Waiving Your Right to View Letters

You will be asked whether to waive your right to see each letter. Almost all residency advisors recommend:

• Yes – waive your right
  • This signals to programs that the letter is more likely to be honest and unbiased.
  • Non-waived letters may raise concern that the writer felt pressured.

Discuss with your writer if you feel uncertain, but in most IMG residency guide recommendations, waiving is strongly encouraged.

Letter Formatting Essentials

• Letters should be:
  • On institutional letterhead
  • Dated and signed (electronic or handwritten)
  • Addressed generally (e.g., “Dear Program Director”)
• Ask your letter writers to mention:
  • How long and in what capacity they knew you
  • Specific examples of your performance
  • That you are applying to Medicine-Psychiatry combined (not just “medicine” or “psychiatry”)

Customizing LOR Assignments per Program

You don’t need a completely different set of letters for every program, but you can assign specific letters to specific programs in ERAS. For example:

• For Med-Psych programs:
  • 2 Internal Medicine letters
  • 1 Psychiatry letter
  • 1 optional additional letter (e.g., integrated care, CL psychiatry, or strong general IM/psych letter)

If you are also applying to categorical internal medicine or psychiatry as a backup, you can adjust the mix:

• For Internal Medicine categorical:

  • 2–3 IM letters
  • 1 Psychiatry or related medicine-psychiatry/integrated care letter

• For Psychiatry categorical:

  • 2–3 Psychiatry letters
  • 1 IM or integrated care letter

Use the same core letters, but assign them strategically based on the program type.

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Common Pitfalls IMGs Should Avoid with LORs

To maximize your chances as an international medical graduate targeting medicine psychiatry combined programs, try to avoid these frequent issues:

1. All letters from home country with no U.S. clinical exposure

   • Whenever possible, obtain at least one U.S.-based letter, ideally more.

2. Generic or overly brief letters

   • These can hurt more than help. A neutral letter with minimal detail may signal that you were average or that the writer did not know you well.

3. Letters from non-physicians as primary clinical references

   • Letters from PhD researchers, social workers, or psychologists can supplement your application, but the primary LORs for residency must be from physicians who supervised your clinical work.

4. Not aligning letters with your stated interests

   • If your personal statement focuses heavily on integrated medicine psychiatry combined care, but all your LORs only discuss general internal medicine, the application feels less cohesive.

5. Last-minute or rushed requests

   • Busy attendings may write weaker letters if given insufficient time. Aim for at least 4 weeks’ notice whenever possible.

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Frequently Asked Questions (FAQ)

1. How many letters of recommendation do I really need as an IMG applying to Medicine-Psychiatry?

Most programs accept 3–4 letters. A common and effective approach is:

• 2 Internal Medicine letters (at least 1 from the U.S.)
• 1 Psychiatry letter (ideally U.S.-based)
• Optional: 1 additional letter (from psychiatry, internal medicine, or integrated care)

You can reuse the same letters across multiple programs but assign them strategically in ERAS depending on whether a program is Med-Psych combined, categorical medicine, or categorical psychiatry.

2. What if I can’t get a U.S. Psychiatry letter before applications open?

You can still apply:

• Use U.S. Internal Medicine letters and strong home-country psychiatry letters.
• Explain your interest in med psych residency clearly in your personal statement and in any interviews.
• If you later complete a U.S. Psychiatry rotation, add that new letter to ERAS and notify programs (some will review updated documents even mid-season).

Programs understand that IMGs sometimes have limited access to U.S. psychiatry rotations, but any effort you can make to secure at least one psych-oriented letter is helpful.

3. Does it matter if my letter writers are not familiar with Medicine-Psychiatry combined programs?

They do not need to be experts in med psych residency, but they do need to:

• Understand that you’re applying for training that covers both medicine and psychiatry.
• Comment on qualities that align with this dual focus: ability to integrate mind and body, work with complex patients, collaborate across disciplines.

You can help by sending them a short explanation of medicine psychiatry combined training and your career goals. A brief paragraph in the letter explicitly supporting your fit for Med-Psych is very beneficial.

4. Is a shorter, detailed letter better than a long but generic one?

Yes. Content and specificity matter far more than length. Programs prefer:

• Clear, concrete examples of your performance
• Comparative statements about your standing among peers
• Honest, enthusiastic endorsement

A concise, focused, highly personalized letter from someone who supervised you closely is more powerful than a long, vague letter full of general praise.

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Strong residency letters of recommendation are one of the most powerful tools you have as an international medical graduate applying to Medicine-Psychiatry. By choosing the right letter writers, performing intentionally on your rotations, and guiding your recommenders with thoughtful information, you can present a compelling, integrated narrative that truly reflects your readiness for med psych residency and for a career bridging medicine and psychiatry.