Mastering Letters of Recommendation: IMG Guide for Preliminary Surgery Residency

Understanding the Unique LOR Needs of an IMG Applying to Preliminary Surgery

For an international medical graduate (IMG), letters of recommendation (LORs) can make or break a preliminary surgery application. Programs often receive hundreds of applications for a limited number of prelim spots, and many applicants have similar scores and credentials. What often differentiates candidates is how strongly faculty advocate for them in their letters.

This IMG residency guide focuses on preliminary surgery year applications, but most recommendations also apply to categorical surgery and other specialties. The difference is that prelim surgery programs often have very limited time to review files, and they rely heavily on trusted LOR writers to quickly identify candidates who are safe to put in the OR, reliable on call, and pleasant to work with on a busy service.

As an IMG, your letters need to answer three questions for program directors:

1. Clinical readiness: Can this applicant function safely and effectively as a surgical intern on Day 1?
2. Fit for surgery culture: Does this person have work ethic, resilience, and professionalism suitable for surgical training?
3. Comparative strength: Among other students and residents you have worked with, where does this applicant stand?

If your letters do not clearly and strongly address these points, your otherwise solid application may be overlooked—particularly when competing against U.S. graduates for preliminary surgery residency slots.

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What Makes a Strong LOR for Preliminary Surgery (Especially for IMGs)?

Understanding exactly what goes into a strong LOR is the first step in knowing how to get strong LOR that truly support your candidacy.

Core Components of a High-Impact Surgical LOR

Strong residency letters of recommendation for prelim surgery typically include:

• Clear relationship and context

  • How the writer knows you (e.g., 4-week sub-internship, 3-month research rotation, 1-year observer-to-research fellow).
  • Clinical versus research versus academic setting.
  • Whether the writer directly supervised your patient care or observed you in the OR/wards.

• Specific clinical skills relevant to surgery

  • Pre-op assessment and post-op management.
  • Ability to prioritize tasks on busy call nights.
  • Basic procedural skills (suturing, knot tying, line placement, wound care) if applicable.
  • Comfort with common post-op complications (pain management, fevers, fluid and electrolyte issues).

• Performance in the OR and on the wards

  • How you prepare for cases (reading beforehand, knowing the steps).
  • Situational awareness in the OR (sterility, anticipating needs).
  • Communication with scrub nurses, anesthesiologists, and peers.
  • Dependability with notes, orders, and follow-up.

• Professionalism and work ethic

  • Timeliness, reliability, ownership of patients.
  • Response to feedback, ability to improve quickly.
  • Attitude under stress, during long hours, night shifts, and weekends.

• Comparative statements

  • “Among the top X% of students/residents I have worked with.”
  • Comparison to U.S. graduates or prior strong residents if the writer is familiar with both.
  • Clear endorsement for a prelim surgery residency or for entering surgery in general.

• Clear, strong, positive language

  • Avoids vague or lukewarm statements (“good,” “fine,” “pleasant”).
  • Uses decisive wording (“I give my highest recommendation,” “I would be eager to have them as an intern on my team”).

Why Letters Matter Even More for IMGs

As an international medical graduate, you face additional questions from programs:

• Have you successfully adapted to the U.S. clinical environment (if you have U.S. experience)?
• Is your English communication and documentation clear, safe, and efficient?
• Have you demonstrated performance comparable to U.S. graduates in a similar setting?
• Do your writers understand the U.S. residency selection landscape and expectations?

Strong letters from surgeons in U.S. academic centers help answer these questions convincingly. If your letters are vague, non-specific, or written by people unfamiliar with the U.S. system, program directors may hesitate—especially for a high-intensity environment like a prelim surgery residency.

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Who to Ask for Letters as an IMG Interested in Preliminary Surgery

Many IMGs struggle not with how to get strong LOR, but with who to ask for letters that will truly influence program directors. Choosing your recommenders strategically is essential.

Priority 1: U.S. Surgical Faculty Who Supervised You Clinically

For a prelim surgery year, the gold standard letter is:

• From a U.S.-based attending surgeon
• In general surgery or a closely related surgical field (trauma, vascular, colorectal, acute care surgery, SICU)
• Who directly supervised your clinical work (ideally including ward and/or OR performance)

These letters demonstrate:

• That you function safely and professionally in the U.S. system.
• Your ability to handle surgical patients on inpatient services.
• Your readiness for the workflow and pace of a surgical internship.

Ideal experiences that produce strong letters:

• Sub-internships / Acting Internships in Surgery
  • 4-week rotations where you function at intern level (with supervision).
  • U.S.-based, especially at academic training programs.
• Audition Rotations or Away Rotations in Surgery
  • Particularly valuable if done at programs where you intend to apply.
• ICU or Trauma Rotations
  • Especially if run by surgical faculty.

Even a single strong letter from a well-known U.S. surgical educator who has worked closely with you can significantly strengthen your prelim surgery application.

Priority 2: U.S. Non-Surgical Faculty with Robust Clinical Supervision

If your U.S. surgical exposure is limited, letters from non-surgical specialties can still help, provided they:

• Are written by U.S. attending physicians.
• Reflect direct, hands-on supervision of your patient care.
• Emphasize:
  • Clinical reasoning
  • Reliability
  • Communication
  • Professionalism
  • Response to feedback

Useful non-surgical letter writers (in order of relevance for surgery):

• Anesthesiology (OR behavior, perioperative care)
• Critical Care / ICU (surgical ICU, medical ICU)
• Emergency Medicine (acute care, procedures)
• Internal Medicine or Family Medicine (general clinical competency, continuity)
• Radiology or Pathology (if they directly supervised your clinical interactions or multidisciplinary work)

These letters should still mention your interest in surgery and highlight traits that suggest you will succeed as a prelim surgery intern.

Priority 3: Research Mentors in Surgery (Especially in the U.S.)

For many IMGs, research is the main pathway into a U.S. academic department. A research-focused attending can be a powerful advocate if:

• You have worked with them for at least 6–12 months.
• You show ownership, reliability, and scientific curiosity.
• They have seen you interact with clinical teams, present at conferences, or collaborate on patient-related projects.

For a research mentor letter to help a prelim surgery application, it should:

• Describe your work ethic, initiative, and perseverance.
• Mention any clinical exposure you obtained through research (e.g., observing cases, helping with prospective trials, presenting at tumor boards).
• Compare you to other research fellows who successfully matched into surgery or prelim residency.

Priority 4: Home-Country Surgical Faculty

Letters from your home country can still be valuable, especially if:

• They are from surgical attendings with whom you had substantial clinical contact.
• They can speak to your:
  • Volume of clinical work
  • Surgical/procedural skills
  • Leadership and teamwork
  • Longitudinal performance over years of medical school or internship

However, program directors tend to give slightly more weight to U.S. letters because they know the clinical context. Therefore, think of home-country letters as supportive but not sufficient alone—they should complement, not replace, U.S.-based LORs when possible.

Who to Avoid Asking (When You Have Alternatives)

Even well-intentioned letters can be harmful if they are weak or not credible. Be cautious about:

• Faculty who barely know you or only met you for a week.
• Non-physician recommenders (unless in addition to physician letters) such as:
  • Nurses
  • Administrative staff
  • Non-physician scientists with no clinical impression of you.
• Faculty who are not comfortable writing in English and might produce a poorly-structured letter.
• Anyone who seems hesitant or gives a lukewarm response when you ask.

A neutral or poorly written letter can be worse than no letter, especially in a crowded prelim surgery applicant pool.

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How to Get Strong LOR: Step-by-Step Strategy for IMGs

Knowing who to ask for letters is only half the battle. The other half is setting yourself up to earn powerful recommendations during your rotations and research.

Step 1: Plan Your Rotations and Experiences Around LOR Potential

For an IMG targeting a preliminary surgery year, design your U.S. experience with letters in mind:

• Aim for at least 2–3 U.S.-based clinical rotations where faculty can evaluate you properly.
• Prioritize:
  • General surgery sub-internship or clerkship.
  • Surgical ICU or trauma surgery.
  • EM or ICU rotations at hospitals with strong surgery departments.
• If possible, secure a longer-term research position (6–12 months) in a surgery department that also allows some observer or clinical exposure.

When evaluating opportunities, ask yourself:
“Will this put me in front of people who can later write strong, detailed residency letters of recommendation?”

Step 2: Perform Like a Future Intern, Not Just a Student

During rotations, faculty are subconsciously asking, “Would I trust this person as my intern?”

Demonstrate that the answer is “yes” by:

• Arriving early, leaving late as appropriate for the team.
• Knowing your patients in depth:
  • Labs, vitals trends, imaging, medications.
  • Overnight events and current problems.
• Reading before and after cases
  • Anatomy, steps of the operation, common complications.
• Owning tasks:
  • Volunteer to call consults (under supervision), follow up on imaging, or update families.
  • Deliver on what you say you will do.

Faculty need to see your trajectory (improvement across the rotation) and your consistency (reliable performance over time) to feel confident endorsing you for a prelim surgery residency.

Step 3: Signal Your Interest in Surgery Early

Don’t wait until the end of a rotation to tell people you’re applying to surgery. Early in the rotation:

• Let your residents and attendings know:
  • You are an IMG.
  • You are applying for a preliminary surgery year (or categorical if applicable).
• Ask for feedback:
  • “What can I work on to be competitive for a surgery prelim position?”
  • “Is there anything I should focus on improving over the next few weeks?”

This serves two purposes:

1. They will watch you more closely, giving them material for a detailed LOR.
2. You show maturity and self-awareness, which are valued by program leadership.

Step 4: Build Relationships with Potential Letter Writers

Strong LOR writers are usually people who:

• Have interacted with you multiple times in different settings (rounds, OR, conferences).
• Have seen you handle stress, feedback, and responsibility.
• Have had direct supervision of your work.

To deepen these relationships:

• Ask if you can present a mini-journal club or a brief topic review during the rotation.
• Volunteer to help with a case report, QI project, or small research task.
• Schedule brief follow-up conversations where you:
  • Seek career advice.
  • Update them on your plans and next steps.

These small actions help your potential letter writers remember you as more than “one of many visiting students.”

Step 5: Ask Clearly, Early, and Professionally

Time matters. Faculty are busy, and prelim surgery application season is intense.

When to Ask

• For clinical rotations: In the final week (or earlier if you have a strong relationship).
• For research mentors: A few months before ERAS opens, or as soon as you decide on your application timeline.

How to Ask

You can ask in person first, followed by a professional email. Example in-person question:

“Dr. Smith, I have really valued working with you on this rotation. I’m applying for a preliminary surgery residency as an international medical graduate. Do you feel you know my work well enough to write a strong, supportive letter of recommendation for my application?”

The word strong is important—it gives them an opportunity to decline if they cannot enthusiastically support you.

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Optimizing the Content and Logistics of Your LORs

Once a faculty member agrees to write, your job is to make it as easy as possible for them to craft a strong, specific letter.

What to Provide to Your Letter Writer

Send a concise, organized email with:

• Your updated CV
• A brief personal statement or summary paragraph (especially your interest in preliminary surgery)
• USMLE/COMLEX scores (if you’re comfortable sharing)
• A photo (so they remember who you are)
• A summary of your work with them:
  • Dates of rotation or research.
  • Key projects, cases, or presentations.
  • Any specific patient encounters they might recall.
• A list of programs or type of programs you’re targeting (e.g., university-based prelim surgery programs, community programs with strong operative exposure).

You can also politely share anything specific you hope they can highlight, for example:

• “If appropriate, I would greatly appreciate if you could comment on my performance compared to other students or interns you have worked with, and my readiness for a surgical prelim year.”

This is not “writing your own letter”; it is giving your writer specific prompts so they can be more detailed and supportive.

ERAS Logistics and Timing for IMGs

For the residency match and applications process:

• ERAS typically opens for applicants in early summer.
• Programs begin downloading applications in September.
• Aim to have all LORs uploaded before programs download applications, or as close as possible.

Key logistics:

• ERAS allows you to assign specific letters to specific programs.
  For prelim surgery:
  • Prioritize surgery-related letters for all surgical programs.
  • If you have more letters than slots, choose the combination that best highlights your clinical readiness for surgery.
• You can waive or not waive your right to see the letters.
  • Most program directors feel it is more credible if you waive your right, indicating the writer could be fully candid.

For IMGs, delayed letters can be especially harmful because your application may already face extra scrutiny. Follow up politely:

• About 2–3 weeks after you send materials, if the letter is not yet uploaded.
• Again one month later if still pending.

Keep reminders respectful and brief, showing gratitude for their time.

Balancing Number and Types of Letters

ERAS usually lets you assign up to four letters per program. Ideal combinations for a preliminary surgery application as an IMG might be:

Scenario A: Strong U.S. Surgical Exposure

• Letter 1: U.S. General Surgery Attending (sub-I/acting intern rotation)
• Letter 2: U.S. Surgical Subspecialty or Trauma Surgeon
• Letter 3: U.S. ICU or Anesthesiology Attending (clinical performance)
• Letter 4: U.S. or Home-country Surgical Research Mentor or senior surgery faculty

Scenario B: Limited U.S. Surgery, But Good U.S. Clinical Exposure

• Letter 1: U.S. Internal Medicine or Hospitalist Attending (strong clinical work)
• Letter 2: U.S. Emergency Medicine or ICU Attending
• Letter 3: U.S. Research Mentor in a Surgical Department
• Letter 4: Home-country Surgery Department Chair or Senior Attending

In all scenarios, at least one letter should explicitly mention that you are prepared for the demands of a prelim surgery residency and would be trusted as an intern.

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Common Mistakes IMGs Make With LORs—and How to Avoid Them

Even strong applicants can undermine their prelim surgery applications through preventable LOR mistakes. Be aware of:

1. Overemphasizing Prestige Over Content

A brief, generic letter from a “famous” surgeon who barely knows you is less helpful than a richly detailed letter from a less well-known attending who supervised you closely.

Focus on depth of relationship, not only department reputation.

2. Collecting Only Non-U.S. Letters

If you submit only home-country or non-U.S. letters, programs have little evidence of your ability to function within the U.S. healthcare system. Whenever possible, secure at least one to two U.S.-based letters, even if from non-surgical specialties.

3. Asking Too Late

If you wait until months after a rotation to ask, the attending may:

• Struggle to remember specific details.
• Write a generic or superficial letter.

Ask near the rotation’s end and then follow up with the ERAS link when the application season begins.

4. Not Coordinating LOR Types With Your Overall Application Story

Your letters should tell the same story as your personal statement and CV:

• Interest in surgery.
• Readiness for prelim workflow.
• Long-term goals (e.g., categorical surgery, surgical subspecialty, or transitional plan).

If your letters don’t mention surgery at all, programs may doubt your commitment to the field.

5. Ignoring Red Flags or Weak Writers

If a faculty member seems hesitant or says, “I can write you a letter,” without saying “strong” or “enthusiastic,” you may be better served asking someone else. A neutral letter reads as “not recommended” in a competitive prelim surgery pool.

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FAQs: Letters of Recommendation for IMGs in Preliminary Surgery

1. How many letters of recommendation do I need for a prelim surgery residency as an IMG?
Most programs accept up to four letters. Aim for three to four strong letters, with at least two from physicians who directly supervised your clinical work, ideally including one surgeon or surgery-adjacent faculty (trauma, SICU, anesthesiology) if possible.

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2. Is it better to have a U.S. non-surgical letter or a surgical letter from my home country?
Ideally, have both. But if you must choose:

• A U.S. non-surgical letter that describes your clinical performance in detail often carries more weight for assessing U.S. system readiness.
• A home-country surgical letter is still valuable to demonstrate long-term surgical interest and skills.
  If possible, submit both types among your allotted letters.

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3. Can a research-only letter help my preliminary surgery application?
Yes, especially if:

• It is from a surgical research mentor in the U.S.
• The letter describes your work ethic, initiative, problem-solving, and any interaction with clinical teams. However, research letters should supplement, not replace, clinical letters that show how you perform with patients, teams, and real-time responsibilities.

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4. Should my letters explicitly mention “preliminary surgery” or just “surgery”?
Whenever possible, ask your letter writers to reference your plan to pursue a preliminary surgery year and your interest in a long-term surgical career (if true). Explicit mention of “preliminary surgery residency” helps program directors understand that your writers know your path and still fully endorse you for that demanding role.

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By thinking strategically about who to ask for letters, how to earn strong endorsements, and how to manage the logistics, you substantially improve your chances of standing out as an IMG in the competitive preliminary surgery residency landscape. Your letters can be the bridge between “qualified on paper” and “trusted as a future surgical intern.”