Your Ultimate Guide to Letters of Recommendation for DO Graduates in IM

Understanding Letters of Recommendation for DO Graduates in Internal Medicine

Letters of recommendation (LORs) are one of the most influential parts of your Internal Medicine residency application—especially as a DO graduate. In a crowded osteopathic residency match and increasingly competitive IM match, your letters often serve as the “voice in the room” when you’re not there to advocate for yourself.

For Internal Medicine specifically, programs want letters that clearly demonstrate:

• Clinical competence and reliability on the wards
• Ability to care for complex adult patients
• Ownership of patient care and follow-through
• Professionalism, teamwork, and communication skills
• Capacity to grow into an excellent internal medicine resident

As a DO graduate, strong, well-chosen LORs can:

• Mitigate concerns about COMLEX vs. USMLE or perceived differences between DO and MD training
• Highlight your strengths in holistic, patient-centered care
• Show that you’ve succeeded in both osteopathic and, if applicable, allopathic environments
• Signal that Internal Medicine is a deliberate, mature career choice

This article walks you through how to get strong LORs for Internal Medicine, who to ask for letters, how many you need, what they should say, and specific strategies tailored to a DO graduate residency applicant.

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How Many Letters You Need (and What Type)

Internal Medicine programs typically require:

• 3–4 total letters of recommendation, including:
  • 1 Department Chair or Program Director letter (often required or strongly preferred)
  • 2–3 clinical letters from IM faculty (ideally inpatient rotations)
  • Optional: 1 additional letter (research, subspecialty, or subspecialty IM)

ERAS Logistics for IM Applicants

• ERAS allows you to assign up to 4 LORs per program.
• Most categorical Internal Medicine programs expect at least 2 letters from Internal Medicine physicians.
• Some community or DO-friendly programs may be flexible, but aiming for 3 IM letters provides a competitive advantage.

Ideal LOR Mix for a DO Graduate in Internal Medicine

For a DO graduate applying to Internal Medicine:

1. Internal Medicine Chair / PD Letter
   • From your home institution’s IM department (DO or MD)
   • Sometimes a “summary” letter that includes input from multiple faculty
2. Inpatient IM Attending Letter #1
   • From a core IM or sub-internship rotation
3. Inpatient IM Attending Letter #2
   • From a different IM service or hospital site (e.g., academic vs. community)
4. Optional Fourth Letter
   • Subspecialty IM (cardiology, GI, pulm/critical care)
   • Research mentor in an IM-related project
   • Strong outpatient IM or continuity clinic letter, especially if well-known faculty

If you are a DO graduate targeting highly competitive academic IM programs, having at least two letters from MD faculty (ideally at ACGME programs) can be especially helpful. For more community-based or osteopathic-oriented programs, strong DO faculty letters are equally valuable.

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Who to Ask for Letters (and Who Not To)

Understanding who to ask for letters is crucial. The question of who to ask for letters is often more important than how many you ultimately submit.

Priority #1: Inpatient Internal Medicine Attending Physicians

The strongest letters for your Internal Medicine residency application almost always come from:

• Attendings who directly supervised you on:
  • Core Internal Medicine inpatient rotations
  • Sub-internships or acting internships (AI/Sub-I)
  • Night float or ICU rotations (when clearly IM-run)

Ideal characteristics:

• They observed you closely for at least 2–4 weeks
• They can comment in detail on your:
  • Clinical reasoning and assessment/plan formulation
  • Work ethic and reliability
  • Communication with patients and the team
  • Growth over the rotation
• They are enthusiastic about your performance (not just “adequate”)

Priority #2: Internal Medicine Subspecialty Attendings

Subspecialty IM attendings (cardiology, gastroenterology, nephrology, hematology/oncology, etc.) can write excellent letters if:

• They supervised you on a consult or inpatient service
• They saw you manage complex patients or perform detailed assessments
• You are considering that subspecialty in the future, or did research in that field

These letters are particularly helpful if they still emphasize:

• Broad internal medicine skills
• Ability to handle general IM residency training
• Your potential as a well-rounded resident, not just future subspecialist

Priority #3: Department Chair / Program Director Letters

Some IM programs explicitly ask for a Chair’s letter or a Program Director letter from your home institution.

• Often based on:
  • Direct observation (if they worked with you clinically)
  • Collated feedback from multiple faculty
  • Your exam scores, professionalism record, and class rank (if applicable)

For DO graduates, this letter can:

• Provide important context for your osteopathic curriculum
• Explain rotation structure, grading, and COMLEX/USMLE performance
• Reassure programs about your professionalism and reliability

Priority #4: Research Mentors (Preferably IM-Related)

A research letter can strengthen your application if:

• The mentor supervised you closely on a long-term project
• You are applying to academic IM or research-focused tracks
• They can speak to:
  • Critical thinking and analytical skills
  • Perseverance and intellectual curiosity
  • Ability to work in a team and handle feedback

However, a research letter should not replace strong clinical IM letters. It should be supplemental, unless the mentor also worked with you clinically.

Lower Priority (Use Only If Necessary)

These letters are usually less impactful for Internal Medicine residency:

• Non-IM clinical letters (e.g., surgery, OB/GYN, psychiatry) – unless exceptionally strong
• Letters from non-physicians (e.g., PhD only, unless heavily research-focused programs)
• Letters from family friends, primary care doctors who never supervised you clinically, or former employers outside medicine

If you have a phenomenal letter from another specialty, consider using it as a fourth letter for selected programs, but not as a primary IM letter.

Special Considerations for DO Graduates

As a DO graduate, consider:

• Mix of DO and MD letter writers
  • DO attendings highlight your osteopathic training and holistic approach
  • MD attendings can help demonstrate that you perform equally well in ACGME environments
• If you took both COMLEX and USMLE, a PD or Chair can help contextualize performance
• Rotations at MD-heavy or university-affiliated IM programs can provide “bridge” letters that reassure PDs about your readiness for any IM setting

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How to Get Strong LORs: Step-by-Step Strategy

Knowing how to get strong LORs is different from simply asking for them. You need a deliberate plan.

Step 1: Plan Early (Before Your Clinical Year)

During your third year (or earlier), map out:

• Which rotations are most likely to yield excellent IM letters
• Where your strongest clinical mentors work (home institution vs. away rotations)
• Timelines:
  • When you’ll be on IM or Sub-I rotations
  • When ERAS opens and LORs are due (typically by late September)

Aim to have at least two key IM rotations (core IM + Sub-I) completed before July–August of your application year so there is time to request and upload letters.

Step 2: Be Intentional on Rotations

To set yourself up for strong letters:

• Introduce yourself early
  • “I’m planning to apply in Internal Medicine and would really appreciate any feedback on how I can grow into a strong IM residency applicant.”
• Ask for mid-rotation feedback
  • “I’d love to check in on how I’m doing and what I can do to improve my performance on the team.”
• Demonstrate consistent strengths:
  • Show up prepared with patient updates and literature review
  • Own your patients (know every lab, imaging, overnight event)
  • Communicate clearly with nursing, consultants, and families
  • Be proactive but not overbearing; anticipate needs

Faculty are much more likely to write a detailed, personal letter if they:

• Know you’re interested in IM
• See you actively acting like a budding internist
• Observe you responding to feedback and growing

Step 3: Choose Your Letter Writers Strategically

When deciding who to ask, prioritize:

1. Enthusiastic supporters
   • Attendings who have complimented your work directly
   • Faculty who said they would be “happy to support your application”
2. Depth over fame
   • A detailed letter from a mid-level faculty who knows you well is better than a generic letter from a nationally known chair who barely remembers you
3. Balance of settings and credentials
   • One academic IM attending
   • One community or DO-focused IM attending (great for osteopathic residency match and DO-friendly programs)
   • One PD/Chair if required

Step 4: Ask the Right Way (and Ask for a “Strong” Letter)

How you ask matters. Ideally:

• Ask in person, near the end of the rotation (or set up a video call if needed)
• Script you can adapt:

“Dr. Smith, I’ve really enjoyed working with you these past weeks and I’m planning to apply to Internal Medicine residency. I was wondering if you would feel comfortable writing a strong letter of recommendation in support of my application.”

The key phrase “strong letter of recommendation” gives them an easy way to say no if they have reservations. If they hesitate or suggest someone else, take that seriously and thank them—then ask a different attending.

Follow up with:

• Clarifying deadlines (“Letters are ideally in by early September.”)
• Confirming upload method (ERAS letter portal, sometimes school office)

Step 5: Provide a Helpful Letter Packet

To make it easier for your letter writer (and get a better letter), send a concise, organized packet:

• Updated CV
• Personal statement draft (especially if focused on Internal Medicine)
• Photo (optional but helpful for recall)
• Brief “brag sheet” or highlights:
  • 4–6 bullet points with:
    • Projects or cases you worked on with them
    • Specific patient care examples that showcase your strengths
    • Any particular feedback they gave that you incorporated
  • Your intended specialty (Internal Medicine) and types of programs targeted

This isn’t to script their letter, but to jog their memory and give them stories to write about.

Step 6: Track and Follow Up Professionally

Use a simple spreadsheet to monitor:

• Who you asked
• Date you asked
• Deadlines
• Whether the letter has been uploaded

If the letter is not submitted 2–3 weeks before your target deadline, politely follow up:

• Short, respectful email:
  • “I hope all is well. I’m writing to follow up on the letter of recommendation you kindly agreed to write for my Internal Medicine residency applications. ERAS recommends letters be uploaded by [date]. Please let me know if you need any additional information from me.”

Never send repeated, urgent-sounding emails; one or two reminders is usually enough.

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What Makes a Strong Internal Medicine LOR (and What Programs Look For)

Understanding what program directors value helps you choose the right letter writers and guide what they emphasize.

Core Elements of a Strong IM Letter

A competitive Internal Medicine LOR typically includes:

1. Clear relationship and context

   • How long and in what setting the writer worked with you
   • Type of rotation (ward, ICU, subspecialty, Sub-I) and patient population

2. Evidence of clinical reasoning

   • Your ability to synthesize data into coherent assessments
   • Quality of your differential diagnoses
   • Ownership of management plans

3. Work ethic and reliability

   • Timeliness, follow-through on tasks, willingness to help the team
   • Handling of cross-cover or night responsibilities if applicable

4. Communication and professionalism

   • Interaction with patients and families, especially during difficult conversations
   • Collaboration with residents, nurses, and consultants
   • Response to feedback and professionalism under pressure

5. Comparative comments

   • “Among the top 10% of students I’ve worked with in the past 5 years.”
   • “Comparable to our best incoming interns.”

6. Specific, memorable anecdotes

   • Detailed examples carry more weight than generic praise

7. Clear endorsement

   • “I give my highest recommendation for [Applicant] for an Internal Medicine residency position.”

DO-Specific Strengths That Can Shine in LORs

As a DO graduate, your letters can powerfully highlight:

• Skill in holistic, patient-centered care
• Strong bedside manner and rapport-building
• Comfort with chronic disease management and preventative care
• Exposure to both osteopathic and allopathic environments (if applicable)

Your letter writers might mention:

• How your osteopathic training informs your patient interactions
• Adaptability across varied clinical sites—community, academic, VA, etc.
• Commitment to underserved or primary care populations (if relevant)

Red Flags or Weak Letters to Avoid

Watch out for signals that a letter might not be strong:

• Vague phrases: “did fine,” “met expectations,” “pleasant to work with”
• Very short letters (half a page or less) with little detail
• No mention of comparative performance or clinical ability
• Focus only on personality, not clinical performance

If you suspect a letter may be lukewarm, it is better not to use it. This is another reason why asking for a “strong” letter is so important.

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Applying Strategically to the IM Match as a DO Graduate

Your letters of recommendation are part of a larger application strategy for the Internal Medicine residency and IM match. For DO graduates, alignment between letters, personal statement, and program list is essential.

Tailoring Letters to Program Types

You can assign different combinations of letters to different programs in ERAS:

• Academic university programs
  • Use:
    • Chair/PD letter
    • IM inpatient attending from academic site (MD if possible)
    • IM subspecialty or research mentor letter
    • Another strong IM attending
• Community and DO-friendly programs
  • Use:
    • Strong DO IM attending letter
    • Home institution IM faculty letter
    • Chair/PD letter
    • Optional: outpatient IM or community hospital attending letter

This flexibility allows you to highlight your strengths for each program category.

Timing Considerations for the Osteopathic Residency Match and ACGME IM Match

• Start collecting letters by late spring / early summer of the application year.
• Aim to have all core IM letters uploaded by early September when programs begin reviewing applications.
• If you complete a late Sub-I (August/September) with a phenomenal experience, ask if the attending can write a late-add letter—it can still help for later interview offers or in rank list decisions.

Coordinating With COMLEX and USMLE Scores

If there are concerns in your academic record (e.g., COMLEX failure, late USMLE, lower scores), a well-chosen letter can:

• Provide mitigating context (illness, family issues, late testing)
• Emphasize your clinical strength and growth beyond test scores
• Reassure programs about your performance once in the clinical setting

In this context, a detailed, supportive Chair or PD letter can be particularly valuable.

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Frequently Asked Questions (FAQ)

1. How many Internal Medicine letters do I really need as a DO graduate?

Most Internal Medicine programs want at least two IM letters, and many applicants submit three strong IM letters plus one additional letter (Chair, subspecialty, or research). As a DO graduate, aim for at least three clinical IM letters if possible, including one from a Chair or PD if your school recommends it.

2. Is it okay if some of my letters are from DO physicians and some from MDs?

Yes. A mix of DO and MD letter writers is often ideal for a DO graduate residency applicant. What matters most is that the letters are strong, specific, and come from attendings who know you well. DO letters can emphasize your osteopathic background and holistic care, while MD letters—especially from ACGME-affiliated institutions—can reassure programs that you perform well in any environment.

3. What if I didn’t get along well with my Internal Medicine clerkship director?

You do not need a letter from every leader in the department. Prioritize attendings who:

• Supervised you directly
• Gave positive feedback
• Seemed enthusiastic about your performance

If your clerkship director didn’t know you well, it’s often better to choose another attending. If your school requires a standardized Chair or PD letter, it will usually be based on a compilation of evaluations, not your personal relationship alone.

4. Can I use a strong letter from another specialty for Internal Medicine applications?

Yes—but selectively. A single very strong letter from another specialty (e.g., ICU run by anesthesiology, emergency medicine, or surgery) can be used as a fourth letter at some programs, especially if it strongly highlights your general internal medicine skills, teamwork, and clinical reasoning. However, it should not replace your core Internal Medicine LORs, which remain the foundation of a competitive IM match application.

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Thoughtful, well-chosen letters of recommendation can significantly strengthen your Internal Medicine application as a DO graduate. By selecting the right writers, asking the right way, and helping them highlight your best qualities, you give programs compelling evidence that you’re ready to thrive in residency.