Essential Guide to Letters of Recommendation for DO Graduates in Preliminary Medicine

Understanding Letters of Recommendation for a DO Graduate in Preliminary Medicine

For a DO graduate targeting a Preliminary Medicine (Prelim IM) position, letters of recommendation (LORs) can make the difference between landing interviews and being overlooked. This is especially true for DOs navigating the osteopathic residency match and the increasingly competitive unified Match landscape. Strong letters reassure programs that you can function safely and effectively as an intern—often with limited supervision—starting July 1.

This article will walk you through:

• How many and what types of letters you need
• Who to ask for letters (and who not to ask)
• How to get strong LORs on medicine rotations
• Strategy for DO graduates (including those doing or considering a preliminary medicine year)
• Practical timelines, sample email language, and common pitfalls

Throughout, we’ll focus specifically on the needs and realities of a DO graduate applying to a Preliminary Medicine internship—whether as a stand‑alone plan or as a transitional year toward another specialty (e.g., Neurology, Anesthesiology, Radiology).

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1. The Role of Letters of Recommendation in a Preliminary Medicine Application

What programs look for in prelim IM letters

Unlike categorical Internal Medicine, Prelim IM programs know that many applicants are ultimately headed toward another specialty. Still, their priority is the same: can you function as a reliable, safe, and teachable intern on an inpatient medicine service?

Strong letters of recommendation for a DO graduate in preliminary medicine should highlight:

• Clinical competence: history-taking, physical exam, clinical reasoning, and basic management of common inpatient problems.
• Work ethic and reliability: shows up, follows through, responds to pages, and owns their patients.
• Professionalism: respectful communication with nurses, staff, patients, and families; takes feedback well.
• Teamwork: works collaboratively with residents and attendings; not a “lone wolf.”
• Readiness for internship: explicitly stating that the writer would trust you as an intern in their own program.

For a DO graduate, a strong letter also implicitly or explicitly addresses any perceived bias about training background by emphasizing that your performance meets or exceeds the level expected of MD counterparts.

How important are letters compared to other factors?

For a prelim IM application, programs weigh:

• MSPE/Dean’s Letter and transcripts
• USMLE/COMLEX scores (if taken)
• Clinical performance on core and sub-internship rotations
• Personal statement and program fit
• Letters of recommendation

LORs are especially decisive when:

• Your scores are average or borderline.
• You’re switching from another specialty to a prelim year.
• You’re a DO applicant to historically MD-dominant academic programs.

A clear, specific, and enthusiastic letter can mitigate modest test scores or a non-linear path, whereas a generic or lukewarm letter can quietly undermine an otherwise solid application.

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2. How Many Letters, Which Types, and How to Prioritize

How many letters do prelim IM programs want?

Most programs will accept 3–4 letters of recommendation, and ERAS allows up to 4 per program. For a DO graduate applying to a Preliminary Medicine year, a practical breakdown is:

• 2–3 letters from Internal Medicine faculty
• 1 letter from your intended advanced specialty or another strong clinical field

Examples:

• DO applying to Neurology with a prelim IM year:

  • 2 IM letters (preferably inpatient; at least one from a sub‑I or acting internship)
  • 1 Neurology letter
  • Optional 4th letter: IM or another supportive core field

• DO applying to Anesthesiology with a prelim IM year:

  • 2 IM letters
  • 1 Anesthesia letter
  • Optional 4th letter: IM, Surgery, or ICU

Programs understand that prelim applicants may be “dual targeting.” Still, never neglect internal medicine letters; they’re essential to convincing prelim programs you’re serious about medicine training, even if it’s only for one year.

Which rotations should generate letters?

Prioritize:

• Internal Medicine Sub-Internship / Acting Internship (AI)
  • Gold standard. Shows how you perform at near-intern level.
• Inpatient Internal Medicine core rotation
  • Especially at major teaching sites or academic medical centers.
• ICU or CCU rotation (if supervised by IM faculty)
  • Great if you’re pursuing fields like Anesthesia, Neurology, or Radiology, but still useful to prelim IM programs.

For osteopathic students and DO graduates, you may have rotations at:

• Former AOA programs
• Community osteopathic hospitals
• MD-allopathic academic centers

All can produce strong letters if the attending knows you well and works in a setting recognized by programs you’re targeting.

Which letters matter most for a DO prelim applicant?

Order of importance (for most programs):

1. Medicine sub‑I/AI attending letter – most critical
2. Another strong inpatient IM attending letter
3. Letter from the advanced specialty you’re targeting (if applicable)
4. Additional medicine or ICU attending letter

Letters from non-clinical faculty (e.g., research-only mentors, basic science professors) are usually less impactful unless you are seriously research-focused or applying to very academic programs that specifically value this.

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3. Who to Ask for Letters—and Who Not To

Who to ask for letters

When deciding who to ask for letters, prioritize:

1. Faculty who directly supervised you clinically

   • They should have observed your work over at least 2–4 weeks.
   • Ideal writers: attending physicians on your team, not just residents or fellows.

2. Internal Medicine attendings from inpatient rotations

   • Especially on teams structured like an intern/resident team—exactly what prelim programs care about.

3. Faculty who know you as a person

   • Attending who saw your growth, resilience, and professionalism.
   • Someone who can comment on how you respond to feedback and handle stress.

4. Faculty in your intended advanced specialty

   • If you’re pairing prelim IM with a specialty like Neurology, Radiology, or Anesthesiology, at least one letter should echo your commitment and suitability for that field.

For a DO graduate, it can be helpful—but not mandatory—to have at least one letter from a faculty member familiar with both DO and MD trainees, especially if you’re targeting competitive ACGME programs with mostly MD residents. Such faculty can directly state that your performance is on par with excellent interns they’ve worked with.

Who not to ask (or when to think twice)

Avoid or be cautious with:

• Faculty who barely know you

  • A famous name with a vague letter is far less valuable than a lesser-known attending who can write in detail.

• Short-rotation faculty (≤1 week)

  • Unless they explicitly state they were “very impressed” and agree they know you well enough, the letter will usually be thin.

• Non-clinical faculty who never saw you take care of patients

  • Acceptable as a 4th letter if they supervised significant research or leadership, but not as a primary letter in prelim IM.

• Anyone who seems lukewarm or hesitant

  • If you ask, “Do you feel you could write a strong letter for my prelim medicine application?” and they hesitate, listen to that hesitation.

• Relatives or family friends who are physicians

  • These are not considered objective and can reflect poorly on professionalism and judgment.

DO-specific considerations: osteopathic vs allopathic letters

For a DO graduate, an ideal mix might include:

• 1–2 letters from osteopathic IM attendings who know your DO background and can speak to your development from early clerkships through graduation.
• 1–2 letters from allopathic (MD) IM attendings at ACGME-accredited centers, which some programs still perceive as more directly comparable to their own training environment.

If you trained at a primarily osteopathic institution, having at least one letter from an MD faculty member (when possible) can help some programs calibrate expectations—but it is not mandatory for every program.

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4. How to Get Strong LORs: From Rotation to Request

Step 1: Perform like an intern on your medicine rotations

Before thinking about how to get strong LOR, you must first give someone a strong performance to write about. On your medicine sub‑I or inpatient IM rotation, focus on:

• Owning your patients

  • Know every lab, imaging result, and key part of the plan.
  • Anticipate overnight issues, follow up on consults, and update the team.

• Being reliable and present

  • Show up early, stay as long as the team reasonably needs you.
  • Volunteer for new admissions and “scut” that helps the team run smoothly.

• Communicating professionally

  • Clear handoffs, structured presentations, timely updates to residents and attendings.

• Asking for feedback early

  • Around week 1–2, ask: “What can I improve in my presentations and clinical reasoning?” Then actively show you’re working on it.

Attending physicians often base their LOR content on how you performed in the last week or two. Finishing strong is crucial.

Step 2: Signal your interest in a letter during the rotation

If you’ve identified an attending as a potential letter writer:

• Let them know before the last day that you’re interested in a career involving a preliminary medicine year, and you value their evaluation.

Example script at mid-rotation:

“Dr. Smith, I’m a DO graduate applying to a preliminary medicine year before Neurology. I’ve really appreciated your teaching and feedback. If my performance continues to meet your expectations, would you consider writing a strong letter of recommendation for my prelim IM applications?”

This approach:

• Shows respect and self-awareness.
• Gives them room to decline if they don’t feel they can write a strong letter.
• Reminds them of your path (DO + Prelim + Advanced Specialty).

Step 3: Ask clearly, specifically, and early

When asking for the actual letter, be explicit:

• Mention that you’re seeking a strong letter.
• Clarify that it’s for Preliminary Internal Medicine (not categorical IM unless you’re also applying there).
• Provide a concise summary of your goals and context as a DO graduate.

Sample email (after the rotation):

Subject: Request for Strong Letter of Recommendation – Preliminary Medicine (ERAS)

Dear Dr. Smith,

Thank you again for the opportunity to work with you on the inpatient medicine service this August. I learned a great deal from your teaching on clinical reasoning and patient communication.

I am a DO graduate applying to a Preliminary Internal Medicine year in conjunction with a Neurology residency. I greatly value your perspective on my clinical performance and professionalism. If you feel you can do so, I would be honored to have a strong letter of recommendation from you for my ERAS applications.

I have attached my CV, personal statement draft, and a short summary of the patients I cared for and the feedback I received on your service. ERAS will send you a formal request link shortly if you agree.

Thank you for considering this, and for all of your teaching and support.

Sincerely,
[Your Name], DO

Step 4: Make it easy to write a detailed letter

Help your letter writer recall your work and tailor the letter by sending:

• Updated CV
• Personal statement draft (tailored to prelim IM + your advanced specialty)
• Short bullet list of:
  • Patients or cases you managed
  • Specific feedback they gave you
  • Any tangible achievements (e.g., wrote a discharge summary that became a teaching example)

Example 1-page “letter writer packet”:

• Paragraph: Remind them of when and where you worked together.
• Bullet points: 4–6 key strengths you hope they highlight (e.g., reliability, team communication, clinical reasoning).
• Note: That you are a DO graduate and briefly explain your career path (e.g., “I plan to complete a preliminary medicine year and then Neurology, ultimately focusing on stroke care.”)

This is not “writing your own letter”; it is providing context. A professional letter writer will use or ignore these suggestions as appropriate while writing an honest assessment.

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5. Timing, Logistics, and Strategy for DO Graduates

When should you ask for letters?

Ideal timing:

• End of the rotation or within 2–4 weeks after while your performance is fresh in their mind.
• For July–September 4th-year rotations: ask before ERAS opens and send reminders well before programs start reviewing applications.

If you’re already a DO graduate taking a gap year or working in another role:

• Ask as soon as you decide on the preliminary medicine year route.
• Reach out to recent attendings (from final year of school or early postgraduate experiences) who still remember you.

ERAS logistics: assigning letters for prelim vs advanced programs

In ERAS, you can assign different combinations of letters to each program:

• For Prelim Internal Medicine programs:

  • Primary letters: Internal Medicine faculty
  • Optional: one letter from your advanced specialty

• For your advanced specialty programs:

  • Primary letters: faculty from that specialty
  • Supplement: best IM letters (especially from sub‑I)

This flexibility allows you to tailor how you present yourself:

• To IM programs: “I can be an excellent intern on your inpatient service.”
• To advanced specialty programs: “I have the foundation and specific interest to excel in your field.”

Addressing DO-specific concerns in letters

If you sense that some programs may undervalue DO training or COMLEX scores:

• Ask at least one letter writer to explicitly address how your performance compares to MD students or interns they have worked with. Example:

  • “In my experience supervising both MD and DO students, [Name] performed at the level of a strong intern.”

• If you took USMLE as well as COMLEX, let your writers know, but they usually don’t need to quote your scores—your performance on the wards is more important for LOR content.

If you already completed a preliminary medicine year or another PGY‑1

Some DO graduates re-apply after a prior year of training (either in a different specialty or non-categorical year). In that scenario:

• Secure at least one letter from a program director or core faculty from your prior training year.
• Ask them to comment on:
  • Your progression
  • Responsibility level
  • Fit for a medicine-heavy workflow

Programs highly value evidence that you’ve functioned successfully as a PGY‑1.

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6. Common Pitfalls and How to Avoid Them

Pitfall 1: Waiting too long to ask

Delaying until just before ERAS submission has two costs:

• Faculty may have already forgotten specific details about you.
• Letters may be rushed or even submitted after programs start reviewing applications.

Plan backward from typical timelines:

• Aim to have all letters uploaded at least 1–2 weeks before you intend to certify and submit your ERAS application.

Pitfall 2: Weak or generic letters

Warning signs of a weak LOR:

• Uses vague phrases (“good student,” “pleasant to work with”)
• Little to no detail about patient care, teamwork, or specific strengths
• No comparative language (e.g., “top 10% of students I’ve worked with”)

You can’t control exactly what someone writes, but you can reduce the risk by:

• Asking only those who express enthusiasm about your performance.
• Using the phrase “strong letter of recommendation” in your request.
• Providing a concise summary of your accomplishments and strengths.

Pitfall 3: Misalignment between your story and your letters

Programs look for coherence:

• Your personal statement says you are deeply committed to Neurology, but you have no Neuro letter and all letters are generic IM? Red flag.
• You say you want a preliminary medicine year to build generalist skills, yet your IM letter mentions you disliked inpatient work? Another red flag.

Align your letters with your narrative:

• IM letters should emphasize your capability and readiness for a busy medicine internship.
• Specialty letters should highlight your motivation and potential in your long-term field.

Pitfall 4: Ignoring the DO-to-MD cultural differences

As a DO graduate, you may have:

• Rotated at smaller osteopathic hospitals where faculty are not as accustomed to writing ERAS-style letters.
• Faculty who are generous in person but vague in written evaluations.

Mitigation strategies:

• Offer your writers example LOR templates from your school or GME office.
• Explain that programs value specific examples, comparative statements, and explicit endorsement (e.g., “I give [Name] my highest recommendation.”)
• If possible, pair an osteopathic letter with one from an allopathic academic setting to cover both perspectives.

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FAQ: Letters of Recommendation for DO Graduates in Preliminary Medicine

1. How many letters of recommendation do I really need for a prelim IM application?

Most Preliminary Medicine programs expect three letters, and many allow a fourth. A typical strong setup for a DO graduate is:

• 2–3 Internal Medicine letters (ideally including a sub‑I/AI)
• 1 letter from your future specialty (if you are pairing prelim IM with an advanced position)

You can assign different combinations in ERAS so that prelim programs see mostly IM-focused letters, while advanced specialty programs see more specialty-focused letters.

2. As a DO graduate, is it a problem if all my letters are from osteopathic hospitals?

Not inherently. Many programs value osteopathic training highly, especially those with a history in the osteopathic residency match or those now fully integrated in the single accreditation system. However, if you’re aiming at competitive university-based ACGME programs, having at least one letter from a faculty member at a larger academic center can add helpful context to your file. What matters most is not DO vs MD, but whether the letters are detailed, specific, and enthusiastic.

3. Who should I prioritize if I have more than four potential letter writers?

Use this order:

1. Medicine sub‑I/AI attending
2. Another strong inpatient IM attending
3. Specialty-specific attending (e.g., Neurology, Anesthesia)
4. ICU/CCU or third IM attending who knows you well

If you need to choose between a “big name” attending who barely knows you and a mid-level faculty member who worked with you daily and was very impressed, always choose the latter.

4. What if one of my attendings offers to share their letter with me—should I read it?

In the US residency system, letters are typically expected to be confidential. Many programs and deans recommend that applicants waive their right to see LORs because selection committees view confidential letters as more credible. If an attending insists on sharing their draft with you, you should follow your school’s or advisor’s guidance—but in most cases, it’s better to maintain the standard of confidentiality and ensure the letter is uploaded directly to ERAS by the writer or your medical school.

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Key takeaway for DO graduates pursuing a Preliminary Medicine year: prioritize high-quality medicine rotations, build strong relationships with attendings, ask clearly for strong, specific letters, and present a coherent narrative that aligns your DO training, your prelim IM year, and your ultimate specialty goals. Thoughtful, well-chosen LORs can substantially elevate your application and reassure programs that you will be a dependable and capable intern from day one.