Essential Guide to Residency Letters of Recommendation for Caribbean IMGs

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

For a Caribbean medical school residency applicant, letters of recommendation (LORs) can make the difference between a courtesy review and a serious interview invitation—especially in a niche field like Medicine-Psychiatry. Program directors know less about your school than they do about large U.S. institutions, so they lean heavily on what trusted U.S. faculty say about you.

For a combined medicine psychiatry residency (often called Med Psych residency), LORs serve three major functions:

1. Validate your clinical abilities in both internal medicine and psychiatry.
2. Bridge any perceived gaps or bias related to being a Caribbean IMG.
3. Signal your specific commitment to Medicine-Psychiatry rather than just applying “wherever you can match.”

If you are coming from St. George’s University or a similar institution, your SGU residency match (or other Caribbean medical school residency match) prospects will depend heavily on:

• The quality and specificity of your letters, not just the number.
• Strategic selection of writers who can speak to your readiness for a dual-training environment.
• Clear communication with your letter writers about your goals and story.

This guide will walk you through how to get strong LORs, who to ask for letters, and how to tailor your strategy for Medicine-Psychiatry as a Caribbean IMG.

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How Many Letters You Need—and What Kind

Most Med Psych programs follow general internal medicine/psychiatry guidance on letters of recommendation for residency, but always verify on ERAS and program websites.

Typical requirements:

• 3 letters of recommendation (some will accept 4)
• 1 Department Chair (or designee) letter in Internal Medicine (often required)
• 1 Department Chair (or designee) letter in Psychiatry (often required or strongly recommended)
• At least 1 clinical letter from a supervising attending who worked with you directly
• All letters submitted via ERAS, usually by early to mid-September

Because you are a Caribbean IMG, it is wise to aim for:

• 4 total letters, then choose the best 3–4 per program
• At least 2 from U.S.-based clinical experiences
• At least 1 clearly strong letter in each core field (Medicine and Psychiatry)

Strategic mix for Medicine-Psychiatry:

• 1 × Internal Medicine Chair (or designee) letter
• 1 × Psychiatry Chair (or designee) letter
• 1 × Clinical Medicine attending (preferably inpatient, ward or ICU, who knows you well)
• 1 × Clinical Psychiatry attending (preferably from a core or strong elective)

You can then customize which letters to assign:

• Pure Internal Medicine programs → 2–3 medicine-heavy letters + psychiatry letter as a “bonus”
• Pure Psychiatry programs → 2–3 psych-heavy letters + medicine letter as a sign of broad competence
• Medicine-Psychiatry combined programs → balanced mix of medicine + psychiatry letters

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Who to Ask for Letters—and Who Not To

Knowing who to ask for letters is as important as how many you get. Medicine-Psychiatry programs look for writers who can speak to your performance in complex, team-based, dual-discipline environments.

Best letter writers for a Medicine-Psychiatry applicant

1. U.S.-based Internal Medicine Attendings

   • Preferably from:
     • Inpatient wards
     • ICU/CCU
     • Night float
   • Why: They can speak to:
     • Clinical reasoning
     • Ownership of patients
     • Reliability and work ethic
   • Ideal if they have:
     • Academic titles (e.g., Program Director, Clerkship Director, Associate Professor)
     • Known affiliation with residency training

2. U.S.-based Psychiatry Attendings

   • Preferably from:
     • Inpatient psychiatry
     • C/L (consult-liaison) psychiatry
     • Emergency psychiatry
   • Why: They can highlight:
     • Communication skills
     • Empathy and professionalism
     • Comfort with complex psychiatric presentations

3. Department Chairs or Clerkship Directors

   • Internal Medicine Chair / Psychiatry Chair (or designees) letters carry weight.
   • These often summarize:
     • Class rank or relative standing
     • Shelf/subject exam performance
     • Professionalism issues (or the lack thereof)
   • Even if they don’t know you personally, their formal endorsement is important.

4. Program Directors from Transitional Year or Preliminary Medicine Internships
   (If you complete a prelim year before matching combined)

   • They can describe:
     • Performance at intern level
     • Readiness for more advanced responsibility
     • Team leadership potential

Who NOT to rely on as primary writers

You can have one such letter as an “extra,” but avoid using them as core LORs:

• Non-clinical research mentors only (unless they also supervised your clinical work)
• Family friends or community physicians abroad with no U.S. clinical contact
• Non-physicians (psychologists, social workers, nurse practitioners), unless they are a small supplemental letter on top of your required physician LORs
• Letters older than 2–3 years (outdated and may reflect a different version of you)
• Letters from basic science professors in the Caribbean (rarely helpful unless you truly have no U.S. clinical options—and even then, not ideal for Med Psych)

For a Caribbean medical school residency application, U.S.-based clinical letters almost always carry more diagnostic value for program directors.

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How to Get Strong LORs as a Caribbean IMG in Med-Psych

When thinking about how to get strong LOR, focus on building the letter from the first day you meet your attending—not just asking for one at the end.

Step 1: Perform like an intern during clinical rotations

Medicine-Psychiatry programs care deeply about day-to-day behavior. Strong letters often use phrases that indicate “intern-level” reliability. On both medicine and psychiatry rotations:

On Internal Medicine:

• Pre-round reliably and know your patients’ details better than anyone else.
• Volunteer for procedures (paracentesis, thoracentesis, line assist if allowed).
• Present clearly and concisely; practice problem-based presentations.
• Be the student who identifies subtle but important issues (QTc prolongation, drug interactions, capacity questions).

On Psychiatry:

• Take thorough psychiatric histories with strong attention to trauma, substance use, and risk.
• Show curiosity about both medical and psychiatric comorbidities.
• Offer to write notes, call family, and coordinate collateral information.
• Demonstrate comfort with difficult patients while maintaining boundaries and safety.

Letter writers notice patterns:

• Showing up early every day
• Following up on tasks
• Asking thoughtful, clinically relevant questions
  All of these convert into phrases like, “functions at the level of an intern,” which Caribbean IMGs particularly need to have in their letters.

Step 2: Signal your interest in Medicine-Psychiatry early

Faculty are more likely to write detailed, tailored letters if they understand your specific career trajectory:

• Early in the rotation, say something like:
  “I’m particularly interested in a Medicine-Psychiatry combined residency, because I want to treat complex patients who move between medical and psychiatric units. I’d really like feedback on how I can grow towards that.”

• Ask Med-Psych–oriented questions:

  • On medicine: “How do you manage this patient’s depression while he’s in heart failure?”
  • On psychiatry: “What lab work-up should we prioritize given her medical comorbidities?”

This signals that:

1. You know Med Psych exists.
2. You’ve thought about why it’s the right path.
3. You understand the interface of medicine and psychiatry—critical for this field.

If your school has Med Psych faculty (SGU and some other Caribbean schools are affiliated with U.S. programs that do), try to shadow or meet them. Even if they don’t write your letter, they can advise you on letter strategy for Medicine-Psychiatry combined programs.

Step 3: Identify which attendings likely give strong letters

By the last week of your rotation, you should have a sense of:

• Who saw your work up close.
• Who gave you helpful feedback.
• Who seemed to trust you with more responsibilities.

Signs an attending might write a strong letter:

• They let you manage more complex patients over time.
• They explicitly praise your work in front of others.
• They ask your opinion during rounds, not just for facts.
• They mention, “I’d be happy to help with your residency application” or “Let me know if you need anything.”

If you’re unsure, use a polite test question:

“Dr. X, I’ve really appreciated working with you. I’m applying to Medicine-Psychiatry combined programs and internal medicine. Do you feel you know my work well enough to write me a strong letter of recommendation?”

This wording (“strong” letter) gives them permission to decline if they can’t be enthusiastic. A lukewarm letter can hurt a Caribbean IMG more than no letter at all.

Step 4: Ask at the right time and in the right way

Timing:

• Ask near the end of the rotation, while your performance is fresh.
• For core rotations, this is often during the final week.
• For early rotations (e.g., MS3), you can still use the letter for the next cycle if you plan ahead.

How to ask (in person or by email):

In person example:

“Dr. Smith, I’ve really valued this rotation and your teaching. I’m applying for Medicine-Psychiatry and Internal Medicine residencies next year. Would you feel comfortable writing me a strong letter of recommendation commenting on my clinical performance and my suitability for a combined Med-Psych career?”

Follow up with an email including:

• Your CV
• Your personal statement draft (even if rough)
• A short “brag sheet” or bullet list (see below)
• Any important deadlines

Step 5: Provide a helpful “brag sheet”

Most attendings appreciate a one-page summary to make letter-writing easier and more specific. Include:

• Your name, school, anticipated graduation year
• Specialty focus: Medicine-Psychiatry combined (and Internal Medicine/Psychiatry if dual applying)
• 3–5 bullet points of things you did on their service:
  • “Led discussion on capacity evaluation in medically complex patient with delirium.”
  • “Identified serotonin syndrome in a patient admitted for presumed sepsis.”
  • “Worked with social work and nursing to de-escalate a suicidal patient in ED.”
• Any Med-Psych relevant experiences:
  • C/L psych, addiction work, medical-psych interface cases
• Board scores (if strong and you are comfortable sharing)
• SGU residency match / Caribbean medical school residency outcomes you’re aiming for (academic vs community, geography)

This helps ensure the letter includes Med-Psych–specific content rather than generic praise.

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Making Your Letters Work for Medicine-Psychiatry

Once letters are requested, your job isn’t done. You need to manage and align them with your Med Psych narrative.

Emphasize the medicine–psychiatry interface

When sharing your personal statement and CV with letter writers, gently highlight:

• Cases where you had to manage both medical and psychiatric complexity.
• Your comfort working across inpatient, ED, and consult settings.
• Any interest in:
  • C/L psychiatry
  • Primary care for individuals with serious mental illness
  • Addiction medicine
  • Psychosomatic medicine

You can add a short note like:

“Because I’m applying primarily to Medicine-Psychiatry combined programs, it would be especially helpful if you could comment on how I integrate medical and psychiatric thinking in patient care, or my comfort handling medically-ill psychiatric patients.”

This doesn’t script their letter; it just directs attention to the qualities that Med-Psych programs prioritize.

Customizing LOR assignments on ERAS

Within ERAS, you can choose which letters go to which programs. For a Caribbean IMG applying broadly (Med Psych + categorical IM + Psychiatry), consider:

• Med Psych programs:

  • 1 Internal Medicine Chair letter
  • 1 Psychiatry Chair letter
  • 1 strong clinical IM or Psych attending who saw you handle interface cases
  • Optional 4th: whichever is more detailed/strong between additional IM or Psych letters

• Categorical Internal Medicine programs:

  • Internal Medicine Chair letter
  • 1–2 strong IM attendings
  • Optional Psychiatry letter as evidence of communication skills & interest in comorbidities

• Categorical Psychiatry programs:

  • Psychiatry Chair letter
  • 1–2 strong Psych attendings
  • Optional Internal Medicine letter to show comfort with complex medical patients

Aligning letters with each program type subtly answers:
“Is this applicant genuinely interested in what we offer, or just applying everywhere?”

Monitoring and following up (without being annoying)

• Track letter status in ERAS (Requested / Uploaded).
• If a letter is still missing 3–4 weeks after your request:
  • Send a brief, polite reminder:

    “Dear Dr. X, I hope you’re doing well. I’m writing to kindly check in regarding the letter of recommendation you agreed to submit for my Medicine-Psychiatry and Internal Medicine residency applications. ERAS is now open for uploads, and programs will begin reviewing applications soon. Please let me know if there’s any additional information I can provide. Thank you again for your support.”

• If they remain unresponsive and you’re close to deadlines, activate backup writers.

For Caribbean IMGs, timeliness also matters. Late letters can delay your complete application, which can hurt your competitiveness.

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Common Pitfalls Caribbean IMGs Should Avoid

1. Relying mostly on Caribbean-based or non-U.S. letters

Program directors often have limited context for Caribbean schools. While they respect your training, they gain more confidence from U.S. clinicians who know local standards and expectations.

If you must use a Caribbean faculty letter:

• Pair it with multiple strong U.S. clinical letters.
• Ensure the Caribbean letter is truly stellar and describes your relative standing.

2. Generic, template-style letters

Weak letters often use:

• Vague language (“hardworking,” “nice,” “pleasant”)
• No concrete examples
• No comparison to peers

To reduce risk:

• Choose writers who have seen you perform repeatedly and know you by name.
• Provide your brag sheet and Med-Psych focus.
• Avoid asking for letters from attendings who barely worked with you.

3. Over-emphasizing research while under-emphasizing clinical ability

Research is a bonus; clinical performance is core. For Medicine-Psychiatry:

• One research-focused letter is okay only if:
  • The writer is a physician
  • They also know your clinical skills, or
  • They are very well-known in the field and can speak to your potential as a clinician-investigator

Otherwise, prioritize letters that highlight you as a reliable, thoughtful, patient-centered clinician.

4. Letters that ignore or minimize your IMG status

Your letters don’t need to explain why you chose a Caribbean school, but they should:

• Emphasize that you perform at or above the level of U.S. students or interns.
• Highlight adaptability, resilience, and strong work ethic.
• Specifically comment on how well you integrated into U.S. clinical teams.

Phrases like “performs at the level of our U.S. medical students,” “indistinguishable from our home students,” or “already functioning like a PGY-1” are extremely reassuring to program directors reviewing Caribbean IMG applications.

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Final Thoughts: Using LORs to Tell a Coherent Med-Psych Story

For a Caribbean IMG targeting a Medicine-Psychiatry combined residency, letters of recommendation are not just boxes to check; they are co-signatures on your story:

• You’re clinically strong in both medicine and psychiatry.
• You understand and enjoy the interface between body and mind.
• You can handle complex, high-acuity, medically and psychiatrically complicated patients.
• You perform at or above the level expected of incoming interns in the U.S.

If you:

• Choose the right writers,
• Communicate clearly about your goals,
• Back it up with strong clinical performance, and
• Align letters with each program type,

you significantly improve your chances of a successful match—whether that’s a Medicine-Psychiatry combined program, a strong categorical Internal Medicine spot, or a psychiatry residency that values your dual-interest background.

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FAQ: Letters of Recommendation for Caribbean IMGs in Medicine-Psychiatry

1. How many Med vs Psych letters should I have for Medicine-Psychiatry?

Aim for at least one strong letter in each field:

• 1 Internal Medicine Chair (or designee)
• 1 Psychiatry Chair (or designee)
• 1–2 additional clinical letters (IM or Psych), choosing the strongest overall

For most Med Psych programs, a balanced mix (e.g., 2 medicine-focused and 2 psychiatry-focused) works well. Then assign 3–4 per program based on their stated preferences.

2. I’m an SGU student (or other Caribbean IMG) with mostly non-U.S. rotations. What can I do?

Try to:

• Obtain at least two U.S. clinical letters, even from short electives or sub-internships.
• Prioritize rotations at hospitals with active residency programs.
• If you truly cannot obtain enough U.S. letters, ensure your Caribbean-based letters:
  • Clearly state how you compare to U.S. students they’ve taught.
  • Include strong, specific examples of your clinical abilities.

Your SGU residency match prospects improve when at least some U.S.-based attendings can vouch for you.

3. Can a non-physician (psychologist, social worker) write a letter for Med-Psych?

They can write supplemental letters, but they should not replace the core 3–4 physician letters required by most programs. If a psychologist or social worker knows your work extremely well:

• Use their letter as an additional perspective.
• Still prioritize 3–4 strong letters from physicians (MD/DO) in medicine and psychiatry.

4. Should I waive my right to see my letters of recommendation?

Yes. For residency letters of recommendation, it is strongly recommended that you waive your right to view the letter (FERPA waiver) in ERAS. Program directors place more trust in letters that are confidential because they assume writers can be fully honest. If you’re worried, that may be a sign you should choose a different letter writer.

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By being intentional about who you ask, how you ask, and how you prepare your writers, you can turn your letters of recommendation into one of the strongest elements of your Medicine-Psychiatry application—even as a Caribbean IMG.