The Essential Guide to Letters of Recommendation for DO Graduates in EM-IM Residency

Understanding the Unique LOR Needs of a DO Applying to EM-IM

As a DO graduate applying to an Emergency Medicine–Internal Medicine (EM-IM) combined residency, your letters of recommendation (LORs) are one of the most powerful parts of your application. They don’t just confirm that you’re competent; they help programs decide whether you can thrive in a demanding, hybrid specialty that straddles two fast-paced disciplines.

For DO graduates, residency letters of recommendation can also carry additional weight because they:

• Demonstrate how you’ve navigated the transition from osteopathic training into largely ACGME-accredited programs
• Show EM and IM faculty that you are prepared for both specialties
• Provide context if your school offered fewer EM-IM–specific experiences or limited EM rotations

This article will walk you through:

• How many and what type of letters to get for EM-IM
• The ideal mix of EM and IM recommenders for a DO graduate
• How to get strong LOR (step-by-step strategy)
• Who to ask for letters and how to ask effectively
• How to handle red flags, non-traditional paths, and late career decisions
• Practical examples and sample language you can use

Throughout, we’ll focus specifically on the osteopathic residency match environment and the nuances relevant to EM IM combined programs.

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How Many Letters and What Kind Do EM-IM Programs Want?

Typical Requirements for EM-IM Combined Programs

Most EM-IM programs are small, selective, and academically oriented. They usually follow a structure similar to categorical Emergency Medicine or Internal Medicine, but with added expectations.

While exact numbers vary by program, most EM-IM programs will want:

• 3–4 total letters of recommendation
• At least 1 (often 2) letters from Emergency Medicine faculty
• At least 1 letter from Internal Medicine faculty
• Strong preference for standardized EM letters when available (e.g., SLOE—Standardized Letter of Evaluation)

Check every program’s website or ERAS listing. Some may specify:

• “2 SLOEs + 1 IM letter”
• “1 SLOE + 1 IM letter + 1 additional clinical letter”
• Or accept a mix (e.g., 2 EM letters, 1 IM letter, 1 from another specialty)

Because EM-IM spans both fields, your letters should clearly demonstrate:

• You can perform and make decisions in high-acuity, fast-paced ED settings
• You have depth of reasoning, follow-up, and longitudinal care skills essential for Internal Medicine
• You have the work ethic, resilience, and team skills to manage dual training

The Ideal LOR Portfolio for a DO Graduate in EM-IM

For a competitive DO graduate residency application to EM-IM, a typical strong letter portfolio might look like:

1. EM SLOE from a core EM rotation (preferably at an academic site or EM-IM program, if possible)
2. Second EM SLOE or strong narrative EM letter from a different site or sub-internship
3. Internal Medicine letter from an academic IM rotation or sub-internship
4. Optional 4th letter (if programs accept it) from:
   • A subspecialist who saw you handle complex IM/ED patients (e.g., cardiology, ICU)
   • An EM-IM faculty member (ideal)
   • A research mentor in EM or IM who can speak to your work ethic and academic potential

If your school did not offer SLOEs or you trained at a primarily osteopathic facility, you can still build a competitive osteopathic residency match portfolio by:

• Doing away rotations at academic EM sites that offer SLOEs
• Securing strong, detailed narrative letters from EM and IM attendings who worked with you closely
• Making sure your letters emphasize performance relative to other residents/students, even if not formally standardized

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Who to Ask for Letters – And Who Not To

Knowing who to ask for letters is just as important as how many you get. EM-IM programs read thousands of letters every year; they know the difference between a generic “nice student” letter and a powerful, advocacy-driven recommendation.

Priority #1: EM and IM Clinicians Who Directly Supervised You

Your most valuable letters come from physicians who:

• Directly observed you taking histories, performing exams, formulating differentials, and making decisions
• Watched you manage multiple patients over full shifts or long call days
• Can compare you to other students or interns they’ve taught
• Are faculty or recognized teaching attendings, ideally at ACGME-accredited programs

Examples of strong EM/IM letter writers:

• The EM attending who oversaw your 4-week core or sub-I rotation, especially if they are:
  • Clerkship director
  • Program director or associate PD
  • Faculty known in EM education
• The Internal Medicine attending who worked with you during a ward month or IM sub-I
• An EM-IM combined-trained physician (gold standard if available)

If you’re asking, “who to ask for letters,” start by listing:

• All EM attendings you rotated with, especially those who:
  • Gave you repeat feedback
  • Trusted you with more responsibility over the month
  • Verbally praised your performance
• IM attendings from busy inpatient rotations or team-based settings
• Any EM-IM faculty who saw you in both acute/emergency and longitudinal IM-type settings

Then prioritize those who:

1. Know you best
2. Have observed you over multiple shifts or weeks
3. Are likely to write enthusiastic, detailed letters

Should You Ask Residents, Fellows, or Non-Physicians?

Generally:

• Residents and fellows can be crucial advocates, but they usually cannot write your primary LOR. However:
  • They can give feedback to attendings who are writing your letter
  • Their input (e.g., through an informal mini-evaluation) often shapes what the attending writes
• Non-physician clinicians (PAs, NPs, etc.) should be complementary, not primary. A combined EM-IM program wants to see physician-level evaluation, especially from faculty.

If a resident knows you well, you might say:

“Dr. Smith, you and I worked closely this month. I’m planning to ask Dr. Hernandez for a letter. Would you be comfortable sharing your perspective on my performance with her to help inform the letter?”

Attending Prestige vs. Direct Experience

Programs rarely care about a big name if that person barely knows you. A shorter, detailed letter from a community EM attending who directly supervised your overnight shifts is usually better than a vague letter from a nationally known physician who met you twice.

For DO graduate residency applicants, this is especially important:

• A letter that says “I trust this DO graduate at the level of an intern” with concrete examples often does more for your osteopathic residency match outcome than a generic “fine student” from a department chair.

When deciding who to ask:

• Choose depth of relationship and observation over prestige, unless you’re lucky enough to have both.

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How to Get Strong LORs: Before, During, and After Your Rotations

If you’re wondering how to get strong LOR, think beyond the moment you ask for the letter. The quality of your LOR is set up long before that conversation.

Before the Rotation: Set Yourself Up for Success

1. Clarify your goals early.
   On day 1 (or 2), tell your attending or rotation director:

   “I’m a DO graduate planning to apply to combined Emergency Medicine–Internal Medicine programs. I really want to be pushed and get honest feedback on how I’m doing, especially in resuscitation and complex medical management.”

2. Ask for expectations.

   • How can I function at the level they expect for an EM/IM-bound student?
   • What would make a student stand out in this setting?

3. Signal your interest in letters—without pressuring.
   Near the beginning or mid-rotation, you might add:

   “If things go well and you feel you know my performance, I would be very grateful to be considered for a letter of recommendation for my EM-IM residency applications.”

This plants the seed and lets them pay attention to you as a potential LOR candidate.

During the Rotation: Perform and Get Feedback

To earn a powerful letter for an EM-IM combined application, focus on:

• Ownership of patients:
  Follow each case from triage/admission to handoff or disposition. Present concise, organized plans that show you’re thinking like both an internist and an emergency physician.

• Clinical reasoning:
  Verbalize your differential diagnoses, why you’re choosing certain lab tests or imaging, and how this would play out if the patient were admitted to IM vs. discharged from the ED.

• Work ethic and reliability:
  Arrive early, volunteer for new patients, stay engaged at the end of your shift/call, and help the team. EM-IM means long hours and intense environments; show you can handle that now.

• Team communication:
  Be respectful and efficient with nurses, techs, respiratory therapists, and consultants. EM-IM physicians must coordinate complicated care across settings.

• Teach and learn:
  Read about your patients and briefly share key points. Ask thoughtful, targeted questions.

Ask for mid-rotation feedback such as:

“I’m very interested in EM-IM and I want to be sure I’m performing at the level expected of a strong residency candidate. Could you give me feedback on what I’m doing well and what I should improve over the next two weeks?”

This not only helps you improve, it also signals maturity—and many attendings will later mention this in your letter.

After the Rotation: How to Ask for a Strong Letter

Once you’ve completed most or all of the rotation (or at least 2–3 weeks), schedule a brief conversation or catch your attending at a good time.

The key phrase is:

“Would you feel comfortable writing a strong letter of recommendation for my EM-IM residency applications?”

This wording matters:

• It gives them an “out” if they can’t be enthusiastic.
• If they hesitate, you can redirect your efforts to someone else.

If they say yes, be prepared with:

• Your CV
• A draft personal statement (even if not final), especially tailored to EM-IM
• A short summary of cases or contributions you’re proud of
• A list of programs you’re targeting and why EM-IM specifically

You can say:

“I’m so grateful. I’ll send you my CV and a one-page summary of what I learned on this rotation and the types of EM-IM programs I’m applying to. I’m especially excited about combined training because of [brief reason]. If there’s anything else you’d find helpful, please let me know.”

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Tailoring LOR Strategy to EM-IM and the Osteopathic Applicant

Highlighting the EM-IM Fit in Your Letters

Even though you don’t write your own letters, you can influence how your EM and IM attendings frame your readiness for a combined program.

When you send them your materials, include a brief LOR info sheet with:

• Why EM-IM as a specialty fits you
• Specific strengths you hope they might address (if they agree), such as:
  • Comfort with acute resuscitation and procedural skills
  • Strong longitudinal follow-up mindset (thinking about admission, chronic disease management, and outpatient implications)
  • Ability to balance high-acuity ED cases with complex, multi-morbid IM patients
  • Interest in leadership, education, or research in both domains

Example email excerpt:

“Because I’m applying specifically to combined Emergency Medicine–Internal Medicine programs, letters that can speak to both my acute care abilities and my internal medicine–style reasoning and follow-up would be especially helpful. For example, if you feel it’s accurate, comments about how I managed complex patients, worked within the team, and handled uncertainty would be very valuable to programs.”

This doesn’t tell them what to write, but it gives context that helps them frame your performance through an EM-IM lens.

DO Graduate Considerations and Osteopathic Residency Match Nuances

As a DO graduate, programs may have questions about:

• The structure and rigor of your core rotations
• Your exposure to high-acuity EM and IM patients
• Your performance relative to MD peers

Strong letters can directly address these.

You can even gently note to letter writers:

“As a DO graduate, many of the programs I’m applying to are ACGME EM-IM programs that may be less familiar with my school’s grading or rotation structure. If you feel comfortable, commenting on how my performance compares to previous MD and DO students you have worked with would be extremely helpful.”

This invites them to:

• Place you in a national comparison, not just your class
• Highlight that you’re ready to compete in a fully integrated environment

What If You Don’t Have Access to SLOEs?

Not every DO student has easy access to standardized letters of evaluation, especially in EM.

If you cannot obtain formal SLOEs:

1. Maximize narrative EM letters.
   Explain to your letter writer that some programs expect SLOEs and ask if they can:

   • Address performance compared to other students
   • Comment on your anticipated performance as a resident
   • Be explicit about any concerns (or lack thereof)

2. Use away rotations strategically.
   Try to secure at least one EM rotation at an academic site that commonly writes letters for EM-bound students. Even if they don’t use formal SLOE formats, their letters carry weight.

3. Be transparent in your application materials.
   In your personal statement or an interview, you may briefly note if your school/region had limited SLOE access—then pivot to how your narrative letters still reflect high performance.

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Managing Red Flags, Non-Traditional Paths, and Gaps

Not every application is perfectly linear. For many DO graduates, the path to EM-IM may include:

• A late switch from another specialty
• A leave of absence or academic delay
• Lower early board scores or failed attempts
• Significant non-clinical work between graduation and application

Using Letters to Contextualize Challenges

If you have any potential red flags, your letters can:

• Provide reassurance that you’re safe, reliable, and growing
• Show that recent performance is strong and consistent
• Offer context, not excuses, for prior issues

For example, if you struggled early in medical school but excelled on your EM/IM rotations, a letter might say:

“While [Name]’s early academic record shows some initial difficulty, their performance during this rotation was among the top third of students I’ve worked with in the past five years. They consistently demonstrated reliable clinical reasoning, ownership of patients, and emotional resilience during high-acuity shifts.”

You do not control their wording, but you can:

• Choose letter writers who know your full story
• Explain the context to them briefly when you ask for the letter
• Ask if they feel they can address your current readiness to train in EM-IM

If You Are Already a DO Graduate, Not an MS4

If you’ve already graduated and are applying after some time:

• Get fresh clinical letters as close to your application date as possible
  • Consider a supervised clinical experience, transitional internship, or locum-style supervised work
• Ask letter writers to specifically address:
  • How your skills have matured since graduation
  • Your readiness to re-enter or enter formal residency training
  • Your ability to handle EM-IM’s dual demands

A strong recent letter can counterbalance older evaluations and show that you’re match-ready now.

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Practical Tips and Common Pitfalls to Avoid

Timing Your LOR Requests

• Aim to request letters near the end of each rotation when your performance is fresh.

• Follow up 1–2 months before ERAS submission if letters are still pending.

• Use gentle reminders:

  “I hope you’re doing well. I’m finalizing my ERAS application for EM-IM programs this month. I wanted to kindly check whether you anticipate being able to submit the letter of recommendation we discussed. I’m very grateful for your support.”

Avoid These Common Mistakes

• Waiting too long to ask for letters, making it difficult for attendings to remember details.
• Asking someone who barely worked with you or only saw you on a few shifts.
• Not clarifying that you’re applying specifically to EM-IM combined programs.
• Failing to provide your CV and personal statement, leaving your writer without context.
• Collecting only one specialty’s perspective (all EM or all IM) for a combined specialty.

Keep Track of Your Letters

Use a simple spreadsheet to monitor:

• Who you asked
• Date requested
• Whether they agreed
• ERAS status (requested / uploaded)
• Specialty focus of each letter

Aim for a balanced, clearly intentional LOR set that tells a coherent story of a DO graduate who is ready and excited for the dual world of Emergency Medicine-Internal Medicine.

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FAQs: Letters of Recommendation for DO Graduates Applying to EM-IM

1. How many EM vs. IM letters should I have for EM-IM?

Most EM-IM applicants do well with:

• 2 letters from EM (preferably at least 1 SLOE or EM-standard letter)
• 1 letter from Internal Medicine
• Optional 4th letter from another relevant physician or EM-IM faculty

Always check each program’s specific requirements, but a 2 EM + 1 IM structure is a good starting target.

2. As a DO graduate, do I need MD letter writers, or are DO attendings acceptable?

DO attendings are absolutely acceptable, especially if they:

• Worked closely with you
• Are faculty at ACGME-accredited training programs
• Can clearly compare you to both DO and MD students/residents

A mix of DO and MD faculty is ideal, but strength and specificity of the letter matter far more than the initials after your writer’s name.

3. What if my EM rotation didn’t offer SLOEs? Will that hurt my osteopathic residency match chances in EM-IM?

Not necessarily, especially if:

• You have strong narrative EM letters from attendings who know you well
• Those letters include comparative assessment (top third of students, ready for intern-level responsibility, etc.)
• Your overall application shows robust clinical performance and clear EM-IM interest

If you can arrange at least one EM rotation at a site familiar with EM-bound students, that’s ideal—but lack of a formal SLOE can be mitigated with well-chosen narrative letters.

4. Is it okay to ask to see my residency letters of recommendation?

Most residency letters in the US system are waived by the applicant (you don’t have the right to view them through ERAS). Waiving your right to see them is generally expected and can make letters appear more credible. For that reason, it’s better to:

• Ask, “Would you feel comfortable writing a strong letter?”
• Choose writers you trust
• Provide them with the context and materials they need

Some schools allow internal composite letters or feedback summaries, but standard ERAS LORs are typically confidential.

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By planning ahead, choosing your letter writers strategically, and approaching the process with professionalism and clarity, you can build a set of letters that strongly supports your goal: matching as a DO graduate into a demanding and rewarding Emergency Medicine–Internal Medicine combined residency.