Essential Guide to Letters of Recommendation for Caribbean IMGs

Understanding the Role of Letters of Recommendation for Caribbean IMGs

Letters of Recommendation (LORs) are one of the most powerful parts of your internal medicine residency application—especially as a Caribbean IMG. Programs know that board scores and transcripts don’t tell the whole story. Strong, specific letters can counter bias, validate your clinical skills in the U.S. system, and differentiate you from hundreds of other candidates.

For a Caribbean medical school residency applicant, LORs often answer three key questions for program directors:

1. Can this applicant function safely and effectively in a U.S. hospital?
2. Do trusted U.S. clinicians and educators truly endorse this person?
3. Will this applicant be a collegial, reliable member of our internal medicine residency program?

Because many programs are cautious about Caribbean graduates, letters become even more critical than for US-MDs. A well-strategized set of letters can powerfully support your SGU residency match or match from any other Caribbean school (AUC, Ross, Saba, etc.).

In this guide, we’ll walk through:

• What makes a strong internal medicine LOR
• How many letters you need and the ideal mix
• Who to ask for letters—and who not to ask
• How to get strong LORs as a Caribbean IMG in the U.S. clinical system
• How to manage timing, ERAS uploading, and specialty-specific strategy for the IM match

Throughout, we’ll use examples that apply directly to Caribbean students doing cores or electives in the United States.

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What Makes a Strong Internal Medicine LOR?

Before thinking about who to ask, you need to understand what you’re asking for. A strong letter is not just “positive”; it is specific, comparative, and credible.

Core Elements of a High-Impact IM LOR

A powerful internal medicine residency letter of recommendation typically includes:

1. Clear relationship and context

   • Where and when the writer worked with you (e.g., inpatient internal medicine at a university-affiliated hospital, sub-internship at a community program, SGU-affiliated clinical site).
   • In what role they supervised you (attending physician, subspecialist, clerkship director, program director).

2. Detailed observations of clinical performance

   • History-taking, physical exam skills, diagnostic reasoning, and presentation style.
   • Growth over the rotation (e.g., “By the end of the month, she was pre-rounding independently and presenting succinct, well-organized assessments and plans.”)

3. Direct commentary on ACGME / core competencies

   • Medical knowledge
   • Patient care
   • Interpersonal and communication skills
   • Professionalism and reliability
   • Systems-based practice and teamwork
   • Practice-based learning and improvement

4. Comparative language

   • How you compare to peers:
     • “Top 10% of students I have supervised in the last 5 years.”
     • “Among the strongest Caribbean medical school residency students we have had at our institution.”
   • Program directors pay close attention to these phrases.

5. Evidence of fit for internal medicine

   • Genuine interest in IM, comfort with chronic disease management, follow-up planning.
   • Examples of clinical curiosity, reading, or evidence-based decision-making.
   • Comments on your potential as an internal medicine resident, not just as “a good student.”

6. Strong, unambiguous endorsement

   • Clear closing statements:
     • “I recommend her without reservation.”
     • “He will be an outstanding internal medicine resident.”
     • Avoiding lukewarm phrases like “I expect he will do well” with no clear strength.

Example: Strong vs. Weak LOR Excerpt

Weak:

“John was a pleasure to work with. He was punctual, friendly with patients, and completed all his assigned tasks. I believe he will be a good resident.”

Strong:

“During our four-week inpatient internal medicine rotation, John consistently demonstrated strong clinical reasoning and ownership of patient care. By the end of the rotation, he independently pre-rounded on 6–8 patients, synthesized complex problems into focused daily plans, and communicated clearly during multidisciplinary rounds. Compared to other fourth-year students, including U.S. allopathic and osteopathic students, I would place him in the top 15% for clinical reasoning and professionalism. I recommend him without reservation for an internal medicine residency position.”

The content is similar (he’s good), but the strength of endorsement and specificity are dramatically different.

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How Many Letters You Need and the Ideal Mix for IMGs

Basic Numbers for ERAS and Internal Medicine

• ERAS allows up to 4 letters per program.
• Most internal medicine residency programs expect 3–4 LORs.
• At least 2 letters should be from internal medicine (general or subspecialty).

For a Caribbean IMG applying in internal medicine, the optimal strategy is generally:

• 4 letters total, with:
  • 2–3 strong internal medicine LORs from U.S. clinical experiences
  • 1 letter from another clinical specialty or a research mentor (if strong and relevant)

If you are aiming for a competitive IM match (university programs, large academic centers), emphasize:

• More U.S.-based internal medicine letters
• Preferably at least one inpatient IM letter and one from a sub-internship (sub-I) or acting internship if possible.

How Programs View Different Types of Letters

For a Caribbean IMG, letter source matters a lot. Here is how most program directors implicitly “rank” LORs:

1. Highest impact

   • U.S. internal medicine attendings at a residency training site
   • Internal medicine department chairs, program directors, or clerkship directors
   • Sub-internship supervisors in IM

2. Moderate impact

   • U.S. subspecialty IM attendings (cardiology, GI, heme/onc, etc.)
   • Research mentors in internal medicine with specific clinical observations
   • Non-IM U.S. attendings who worked closely with you on a core rotation (e.g., family medicine, ICU, ED)

3. Lower impact (but still usable)

   • Letter from your Caribbean medical school basic science faculty
   • Non-U.S. clinical attendings (unless applying to programs with strong international ties or you lack alternatives)
   • Generic dean’s letters or character references

Aim for your top 3 letters to be in the first two categories, ideally focused on internal medicine.

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Who to Ask for Letters—and Who Not To

Many Caribbean students ask, “Who to ask for letters?” and “How to get strong LOR from my rotations?” The key is choosing writers who know you well enough to make your performance feel real and memorable.

Ideal Letter Writers for a Caribbean IMG in IM

1. Internal Medicine Attendings at U.S. Teaching Hospitals

   • Inpatient ward attendings where you saw a reasonable patient volume.
   • Supervisors from an IM sub-internship or acting internship.
   • Those who directly observed you taking histories, presenting, and creating plans.

2. Internal Medicine Subspecialty Attendings

   • Cardiology, pulmonary/critical care, GI, nephrology, etc.
   • Particularly helpful if you had substantial patient responsibility and were integrated into the team.

3. Clerkship Directors or Site Directors

   • If they directly evaluated you or reviewed detailed feedback from multiple attendings.
   • Often have strong credibility with program directors.

4. Program Director or Associate Program Director (if they supervised you clinically)

   • Very high-impact if they are writing based on actual clinical experience, not just hearsay.

5. Research Mentors in Internal Medicine

   • Best when:
     • You worked closely with them over months, and
     • They can speak to your work ethic, reliability, communication, and academic curiosity.
   • Especially useful if your research was clinical or quality-improvement oriented.

Who NOT to Prioritize (or Use Only If Necessary)

• Residents or fellows alone

  • They can give input, but the actual letter should be from an attending. Some programs explicitly disregard resident-written letters.

• Basic science faculty from your Caribbean medical school

  • Helpful only as a supplemental letter if you are missing enough U.S. clinical letters.

• Family friends, non-clinical employers, or community leaders

  • Unless directly relevant (for example, a long-term job where they can speak to important professional qualities), these are viewed as weak and often ignored.

• Anyone who seems lukewarm about you

  • If someone hesitates or is noncommittal when you ask, that’s a red flag.

How to Gauge Whether Someone Will Write a Strong Letter

When you ask, be explicit. Instead of:

“Can you write me a letter of recommendation?”

Say:

“Based on my performance on this rotation, would you feel comfortable writing me a strong letter of recommendation for internal medicine residency?”

This gives them an “out” if they can’t genuinely advocate for you. As a Caribbean IMG, this is crucial—you can’t afford lukewarm letters.

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How to Get Strong LORs: Step-by-Step Strategy for Caribbean IMGs

Understanding how to get strong LOR begins long before you ask for it. You start building your letters the moment your rotation begins.

1. Set Intentions Before the Rotation

Before your internal medicine or subspecialty rotation starts:

• Research the setting: Is it a teaching hospital? Community site? Academic center?
• Know your evaluation structure: Who fills out evaluations? Who has final say in grades?
• Decide your “LOR rotations”: Choose 2–3 rotations where you will consciously aim for letters (IM core, IM sub-I, IM subspecialty).

If you’re from SGU or another Caribbean school, also find out which sites historically led to strong SGU residency match outcomes—these sites are often used to letters being important for IMGs.

2. Perform at a “Resident-Ready” Level

Internal medicine attendings are more likely to write excellent letters when you look like a future colleague. Focus on:

• Ownership of patients

  • Know every detail about your patients (labs, meds, overnight events).
  • Anticipate next steps—don’t just wait for orders.

• Clear, concise presentations

  • Practice SOAP format, be problem-focused.
  • After rounds, ask: “How could I improve my presentations?”

• Work ethic and reliability

  • Arrive early, stay until the team’s work is done.
  • Follow up on questions you couldn’t answer on rounds, and circle back.

• Professionalism

  • Respect nurses, staff, and patients.
  • Show humility—admit when you don’t know something and be eager to learn.

3. Communicate Your Goals Early

Within the first week of a key rotation, schedule a brief check-in or speak informally with your attending:

“I’m a Caribbean IMG from [School Name], and I’m very interested in internal medicine. I hope to apply to internal medicine residency this upcoming cycle, and this is an important rotation for me. I’d really appreciate feedback on how I can perform at the level expected for residents.”

This does two things:

• Signals your seriousness about IM.
• Gets the attending to observe you more closely, which leads to richer letters.

4. Ask for Mid-Rotation Feedback

At the halfway mark:

“Could I get your feedback on how I’m doing so far, especially in clinical reasoning and presentations? I want to make sure I’m on track for residency-level expectations.”

Use the feedback immediately. Attendings are more likely to strongly endorse someone who demonstrates visible improvement.

5. When and How to Ask for the Letter

Timing:

• Ideal: Last week of the rotation.
• If you need to wait (e.g., you’re applying next year), still ask at the end and then follow up the year you apply.

Approach:
Ask in person if possible, then follow up by email.

Example script:

“Dr. Smith, I’ve really valued working with you on this internal medicine rotation. I’m planning to apply for internal medicine residency, and I was wondering if you’d feel comfortable writing me a strong letter of recommendation based on my performance here.”

If they say yes:

• Thank them sincerely.
• Immediately follow up with a polite, organized email including:
  • Your CV and personal statement draft
  • ERAS Letter Request Form (with their email and AAMC ID if known)
  • A brief reminder of specific patients or cases you worked on together
  • Your target specialty and any specific strengths you hope they can highlight (e.g., “clinical reasoning,” “work ethic,” “teamwork”).

6. Support the Letter Writer (Without Ghostwriting)

Some Caribbean schools or sites push students to “draft” their own letters. This is risky and often obvious to PDs, especially if written in a different voice from the rest of your application. Instead of ghostwriting:

• Provide a bullet list of:
  • Memorable patient encounters
  • Examples of initiative (e.g., QI project, educational presentations)
  • Any awards or honors you received

This helps the writer recall key details and leads to a richer, authentic letter.

7. Handling Delays and Reminders

Attendings are busy; some will forget. You can send a polite reminder:

“Dear Dr. Smith,
I hope you’re doing well. I wanted to follow up on the letter of recommendation for my internal medicine residency application that we discussed. ERAS deadlines are approaching, and I would be very grateful if the letter could be uploaded by [date]. Please let me know if there’s any further information I can provide.
Thank you again for supporting my application,
[Your Name]”

Plan for buffer time—start requesting letters at least 4–6 weeks before you need them uploaded.

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Special Considerations for Caribbean IMGs and the IM Match

Overcoming Bias with Strong LORs

Program directors may have concerns about:

• The variability of Caribbean medical school residency training environments
• Lower average USMLE scores among Caribbean graduates
• Less robust preclinical academic structure

Letters that explicitly compare you favorably to U.S. students and residents can counter these assumptions. Example language to hope for (and gently encourage):

• “She performed at the level of our top U.S. MD students.”
• “I would rank him among the strongest applicants we see, regardless of medical school origin.”
• “I would be happy to have her as a resident in our own program.”

Balancing Home-School Letters vs. U.S. Letters

For Caribbean IMGs:

• Prioritize U.S. clinical letters, especially from internal medicine.
• School-based or dean’s letters are often required but carry less weight individually.
• If you must include a basic science or home-school letter:
  • Choose someone who knew you over time and can describe your work ethic, resilience, and improvement.

Using Letters Strategically in ERAS

You can assign different combinations of letters to different programs (up to 4 each). For most internal medicine programs, a strong combination for a Caribbean IMG would be:

• LOR #1: U.S. inpatient IM attending (core rotation or sub-I)
• LOR #2: U.S. IM subspecialty attending (e.g., cardiology)
• LOR #3: Clerkship director or site director in IM
• LOR #4: Research mentor in IM or another strong clinical letter (e.g., ICU, ED)

If you are dual-applying (e.g., IM and family medicine or preliminary medicine positions), you can:

• Use your IM-oriented letters for IM programs.
• Swap in a broader or FM letter for those programs if appropriate.

Red Flags to Avoid in LORs

Program directors are alert to:

• Vague, generic letters with no details.
• Letters that faintly praise but don’t strongly endorse (e.g., “competent,” “completed tasks adequately”).
• Inconsistencies with your personal statement or CV.
• Typos suggesting the writer didn’t care enough to proofread.

If you sense a letter might be weak or generic, better to not use it and rely on stronger ones.

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Frequently Asked Questions (FAQ)

1. How many letters of recommendation do I really need for internal medicine residency?

Most internal medicine programs are comfortable with 3 letters, but as a Caribbean IMG, you should aim for 4 strong letters if possible. At least 2 should be from U.S. internal medicine attendings. Sub-I or acting internship letters are particularly valuable.

2. Are letters from my Caribbean medical school worth including?

They can be, but they’re generally less impactful than U.S. clinical letters. If you have 3 strong U.S. IM letters, a school-based letter is fine as a 4th or as a dean’s letter (MSPE). If you lack enough U.S. letters, a detailed and specific letter from a basic science or early clinical faculty member is better than a missing letter—but not a substitute for strong U.S. clinical LORs.

3. Should I waive my right to see my letters?

Yes. Program directors expect that applicants waive the right to view letters, and non-waived letters may be seen as less candid. Waiving your rights signals that you trust your writers and that they wrote honestly.

4. What if my attending offers to give me a “template” or asks me to draft my own letter?

Avoid fully writing your own letter. Instead, offer to provide:

• Your CV and personal statement
• A bullet list of specific cases and strengths
• A short summary of the qualities you hope they might address (e.g., clinical reasoning, professionalism)

Encourage them to put this into their own words. Program directors can often tell when a student has written their own letter; authentic attending-written letters are more credible and effective.

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Powerful, well-chosen letters of recommendation can transform your internal medicine application as a Caribbean IMG. If you are thoughtful about who you ask, intentional in how you perform on rotations, and strategic in how you support your writers, your LORs can strongly support your IM match—regardless of where your MD degree was earned.