Mastering Letters of Recommendation for EM/IM Residency Success

Understanding the Role of Letters of Recommendation in EM–IM

For an MD graduate targeting an Emergency Medicine–Internal Medicine (EM IM combined) residency, letters of recommendation (LORs) are one of the most powerful components of your allopathic medical school match application. When programs have hundreds—or thousands—of applicants with similar scores and grades, residency letters of recommendation often become a major deciding factor.

In the combined emergency medicine internal medicine world, LORs do more than simply “confirm” your competence. They:

• Demonstrate that you can thrive in two distinct but overlapping cultures: high-acuity, fast-paced EM and detail-oriented, longitudinal IM.
• Provide evidence of clinical readiness to care for complex, undifferentiated patients.
• Offer insight into your work ethic, professionalism, and team dynamics in busy environments.
• Help programs assess whether you “fit” the unique demands of a dual residency.

If you’re an MD graduate—especially if you’ve taken research time, a transitional year, or a preliminary year— your letters can also clarify your current clinical level, explain any gaps, and show that you’re ready to step into residency immediately.

Your goal is not just to collect four acceptable letters. Your goal is to curate a small set of targeted, detailed, and comparative LORs that collectively answer the program director’s core questions:

1. Can this applicant function safely and effectively as a new EM–IM resident?
2. Will this applicant thrive and grow with feedback?
3. Do trusted faculty specifically recommend this person for EM–IM training?

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How Many Letters You Need and From Whom

General Requirements for EM–IM Applicants

Most EM–IM combined programs participate in the NRMP and use ERAS, and will list their preferred letter composition on their websites. Requirements vary, but common patterns include:

• 3–4 total letters of recommendation
• At least 1–2 letters from Emergency Medicine faculty
• At least 1–2 letters from Internal Medicine faculty
• Often, programs strongly prefer that at least one letter writer has worked with you in a U.S. academic setting (critical for IMGs or MD graduates who trained abroad)

Some programs will also detail whether they prefer:

• An EM Standardized Letter of Evaluation (SLOE) (sometimes required)
• Traditional narrative letters in addition to, or instead of, a SLOE
• A departmental or chair letter in Internal Medicine

Always cross-check each program’s official website and ERAS listing, then build your LOR strategy to meet the strictest set of requirements you’re likely to face.

Ideal Letter Mix for EM–IM Combined Programs

For an MD graduate pursuing EM IM combined residency, a strong template would be:

• 1 EM SLOE from a home or away EM rotation (if available)
• 1 EM faculty letter (if you cannot obtain a SLOE, aim for at least one detailed EM letter)
• 1–2 Internal Medicine letters, ideally:
  • One from a general IM attending on inpatient wards
  • One from an IM subspecialist or continuity clinic attending
• Optional: 1 additional letter from:
  • A research mentor in EM, IM, or a related area
  • A chief resident or fellowship-trained faculty (co-signed by an attending)
  • A prior residency or prelim-year program director (if you’re a re-applicant or MD graduate from a prior year)

Most EM–IM programs will only review 3–4 letters, so prioritize quality and relevance over quantity.

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Who to Ask for Letters and How to Choose Strategically

A core part of learning how to get strong LORs is making strategic decisions about who to ask for letters, rather than chasing the biggest academic title you can find.

Prioritizing Clinical Evaluators Over Big Names

Program directors consistently say they prefer:

• A detailed letter from a faculty member who knows you well clinically

  over

• A vague letter from a nationally known professor who barely worked with you.

A practical hierarchy (from most to least valuable) often looks like:

1. EM faculty who directly supervised you on clinical shifts, especially core faculty or APDs/PDs.
2. IM ward attendings who saw you manage multiple days of inpatient care.
3. Continuity clinic or ambulatory IM preceptors.
4. Longitudinal research mentors in EM or IM who can comment on your clinical reasoning and professionalism.
5. Department chairs or senior leaders who co-sign a letter primarily drafted by someone who knows you well.

Characteristics of Strong Letter Writers

When deciding who to ask, look for attendings who:

• Have observed you multiple times (ideally over at least 2–4 weeks).
• Saw you handle sick patients, complex diagnostics, and interprofessional collaboration.
• Have a reputation for writing strong letters (peers, residents, or advisors can sometimes guide you).
• Seemed invested in your growth—gave you feedback, discussed career plans, or praised your work.

Red flag evaluator types:

• Faculty who only worked a single shift or day with you.
• Attendings who gave you very lukewarm feedback or seemed disengaged.
• Someone who has major time constraints and may only produce a brief, generic letter.

How to Ask: Timing and Approach

Ask early—ideally:

• Near the end of each key rotation (EM and IM) while you’re still fresh in their minds.
• At least 4–6 weeks before ERAS submission, earlier if possible.

How to phrase the ask (in person or via email):

• “I have really valued working with you this month and your feedback has been very helpful. I’m applying to EM–IM combined residency programs. Would you feel comfortable writing me a strong letter of recommendation for my application?”

That phrase—“strong letter of recommendation”—is important. It gives the faculty member a graceful opening to say no if they can’t write you a supportive letter. If they hesitate, consider asking someone else.

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What Makes a Letter “Strong” for EM–IM

To understand how to get strong LORs, it helps to know what program directors actually look for once they open the letter.

Core Content Program Directors Want to See

For an EM–IM applicant, strong residency letters of recommendation will usually include:

1. Context of the relationship
   • Rotation type and setting (ED, inpatient wards, ICU, clinic)
   • Duration (number of weeks, approximate number of shifts or days)
   • Level of responsibility you held
2. Comparative statements
   • “Among the top 10% of students I’ve worked with in the last 5 years”
   • “One of the strongest MD graduates I have supervised on the wards”
   • “Comparable to our incoming EM–IM residents”
3. Specific clinical examples
   • A critically ill ED patient you stabilized and presented clearly
   • A complex IM admission where you synthesized a broad differential
   • How you handled a challenging sign-out, family discussion, or overnight call
4. Core competency evaluation
   • Medical knowledge and clinical reasoning
   • Procedural skills and comfort with acutely ill patients
   • Communication and teamwork with nurses, consultants, and patients
   • Professionalism, reliability, and ability to accept feedback
5. Evidence you fit EM–IM specifically
   • Ability to balance acute resuscitation with longitudinal problem-solving
   • Curiosity across organ systems, not just “one complaint, one diagnosis”
   • Resilience in high-volume environments
6. Clear endorsement
   • “I give my strongest recommendation for Dr. X for an EM–IM combined residency.”
   • “I would be thrilled to have this individual as a resident in our program.”

EM-Specific vs IM-Specific Strengths

Because you’re applying to both emergency medicine and internal medicine simultaneously, your letters collectively should show:

• From EM letters

  • Comfort managing undifferentiated patients with limited information.
  • Ability to prioritize and resuscitate the sickest patients.
  • Efficient workflow, multitasking, and decision-making under pressure.
  • Team leadership and communication during codes, traumas, and sign-outs.

• From IM letters

  • Thoughtful differential diagnoses and evidence-based management plans.
  • Ownership of patients across multiple days on service.
  • Skills in coordinating with consultants and discharge planning.
  • Attention to follow-up, comorbidities, and chronic disease management.

A classic EM–IM-supportive comment might be:

“Dr. Patel demonstrated the rapid prioritization and crisis management expected in EM, while also consistently thinking in an internal medicine framework—anticipating complications, considering long-term care needs, and following through on workups beyond the immediate ED disposition.”

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How to Set Yourself Up for Strong Letters (Before You Ask)

The foundation of a powerful LOR is how you perform on rotation. As an MD graduate, you might have some advantages—prior clinical exposure, maturity, or work experience—but you need to show current, up-to-date skills and work habits.

On EM Rotations: Behaviors That Lead to Great Letters

On your EM shifts, aim to demonstrate:

• Ownership of patients
  Don’t just “shadow” cases. Ask to pick up patients, formulate plans, and place orders (with supervision).

• Situational awareness
  Keep track of:

  • Which patients are pending radiology or labs
  • Who needs re-evaluation
  • Which rooms may need rapid turnover

• Urgency and safety balance

  • Know when to ask for help quickly.
  • Recognize red-flag presentations (chest pain, shortness of breath, altered mental status, sepsis).

• Team-oriented behavior

  • Communicate clearly with nurses and techs.
  • Offer help when others are overloaded (placing IVs, checking vitals, updating families).

• Receptive feedback style

  • Request targeted feedback: “Do you have any suggestions on how I presented that chest pain case?”
  • Demonstrate you incorporate feedback on subsequent shifts.

On IM Rotations: Behaviors That Lead to Great Letters

On your internal medicine rotations, focus on:

• Thorough, organized admissions

  • Comprehensive history and physical exam.
  • Prioritized problem list and clear assessment/plan.
  • Evidence-based reasoning with appropriate guidelines or literature.

• Longitudinal follow-through

  • Following up on results consistently.
  • Anticipating discharge needs, social barriers, and outpatient follow-up.
  • Communicating effectively with interdisciplinary team members.

• Dependability

  • Always prepared on rounds.
  • Reliable with tasks and follow-up.
  • Available and responsive to pages/calls.

• Academic curiosity

  • Looking up key questions about your patients.
  • Presenting short, focused teaching points or reading around your cases.

Directly Supporting Your Letter Writers

Once you know who you’ll ask for letters, you can subtly help them write stronger ones by:

• Asking them early in the rotation what they look for in a strong student/resident.
• Requesting mid-rotation feedback and adjusting your performance accordingly.
• Letting them know you are aiming for EM–IM combined and are particularly interested in:
  • Managing high-acuity patients safely.
  • Integrating acute care with longitudinal thinking.

This transparency helps them observe you with those goals in mind and later write a more tailored letter.

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The Logistics: Requesting, Managing, and Submitting LORs

What to Provide Your Letter Writers

When you ask for a letter, support your writer by giving them a concise, organized packet. Include:

• Your CV (updated, with clinical experiences, research, leadership).
• Personal statement (draft or near-final) for EM–IM.
• List of programs or program types you’re applying to (EM–IM combined, and possibly categorical EM or IM).
• Brief bullet points of:
  • Patients or cases you worked on together that you feel show your strengths.
  • Roles you held (e.g., “led morning sign-out once per week,” “served as team leader on rapid responses”).

You can phrase it as:

“To make this as easy as possible, I’ve attached my CV, personal statement, and a brief list of cases we worked on together that I found particularly educational. Please feel free to ignore or use any of this if it’s helpful.”

ERAS Mechanics and Waiving Your Right to View Letters

In ERAS, you will:

1. Create a separate entry for each letter writer.
2. Generate an ERAS Letter Request Form with a unique Letter ID for each LOR.
3. Send the form to your letter writers (by email or printed).
4. Waive your right to view letters (strongly recommended).
   • Program directors expect that strong letters are confidential.
   • Waiving your right signals trust in your writers and reduces concerns about editing influence.

Handling Timing, Delays, and Gentle Reminders

Letter writers are busy, and delays are common. Protect yourself by:

• Asking early and stating your preferred due date, slightly earlier than ERAS submission (e.g., ask for 2–3 weeks before you upload applications).
• Sending a polite reminder about 1–2 weeks before the deadline:
  • Thank them for agreeing to write.
  • Re-attach the ERAS form if needed.
  • Briefly restate your gratitude and timeline.

If you’re worried a letter may not be completed in time, consider:

• Having back-up letter writers.
• Prioritizing letters from those with a record of on-time responses (ask peers or advisors).

Programs can often see when letters were uploaded, but a slight delay is usually acceptable. Just ensure at least 2–3 strong letters are in by the time interview invitations roll out.

MD Graduate Considerations (Re-applicants, Gaps, or Extra Time)

If you’re applying as an MD graduate one or more years after finishing medical school, programs will want reassurance that your clinical skills are current and strong.

Consider:

• Getting fresh letters from:
  • A recent clinical position (e.g., hospitalist assistant, research associate with some clinical involvement, prelim or transitional year).
  • Observerships or externships (ideally with hands-on or supervised participation, if allowed).
• Having at least one writer explicitly address your timeline:
  • Explaining what you did after graduation.
  • Affirming that your skills and knowledge are appropriate to start residency now.

If there are gaps, your LORs can help programs understand that these periods were productive and intentional, not evidence of burnout or inability to match.

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Common Mistakes and How to Avoid Them

Even strong applicants make avoidable errors with residency letters of recommendation. Watch for these pitfalls:

1. Waiting Too Long to Ask

Delaying your request until just before ERAS submission can lead to:

• Rushed, superficial letters.
• Stressful last-minute scrambling.
• Some letters never getting uploaded.

Solution: Decide your letter strategy early in the application year and confirm letter writers by the end of key rotations.

2. Choosing the Wrong Mix of Authors

Examples of problematic mixes:

• All letters from Internal Medicine for an EM–IM combined application.
• All from outpatient settings without any acute care experience.
• Only research letters, with no one commenting on your hands-on clinical work.

Solution: Ensure you have:

• At least one EM-focused and one IM-focused letter, both clinically oriented.
• Additional letters that complement—but don’t duplicate—the same strengths.

3. Asking People Who Don’t Know You Clinically

A letter that says “I don’t know the applicant well” (or implies it by vague language) can hurt you more than help.

Solution: Only ask attendings who directly observed your clinical abilities for a meaningful period. If you love a research mentor who hasn’t seen you clinically, they can still write—but make sure they speak strongly to your reasoning, professionalism, and work ethic, not just your pipetting skills.

4. Over-directing or Ghostwriting the Letter

While it’s appropriate to share a CV and talking points, do not write your own letter. Programs can often detect artificially glowing, over-the-top language or cookie-cutter phrasing that appears in multiple documents.

Solution: Trust your writers. Provide them with helpful context and examples, then step back.

5. Ignoring Program-Specific Requirements

If a program requires an EM SLOE and you only upload traditional letters, your application may be considered incomplete or noncompetitive.

Solution: For each program:

• Check their website and ERAS listing.
• Track whether they:
  • Require or prefer SLOEs.
  • Need a department chair letter.
  • Have limits on the number or type of letters reviewed.

Keep a simple spreadsheet to track compliance.

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FAQs: Letters of Recommendation for EM–IM Residency

How many EM vs IM letters do I need for EM–IM combined programs?

Most allopathic medical school match programs in EM–IM want a balanced set. A common, flexible structure is:

• 1 EM SLOE or strong EM faculty letter
• 1 additional EM or EM–IM letter (if possible)
• 1–2 Internal Medicine letters from inpatient/general medicine attendings

Always verify individual program requirements; if one insists on a minimum of 2 EM letters or a specific SLOE, make sure to meet that threshold.

I’m an MD graduate from a previous year. Do I need new letters?

Yes, you should obtain at least one or two new letters that reflect your current clinical abilities and your activities since graduation. Programs want to know that:

• Your medical knowledge and clinical judgment are up to date.
• You’ve remained engaged in medicine (clinical, research, education, or quality improvement).
• You are ready to function as an intern now.

Older letters (e.g., from core clerkships) can still be included, but having recent, strong endorsements is important.

Should I use the same letters for EM–IM and categorical EM or IM applications?

You can often use the same EM and IM letters for both EM–IM and categorical applications, especially if those letters:

• Focus on your clinical skills.
• Endorse you for EM or IM residency broadly.

For EM–IM–specific applications, it’s helpful if at least one letter explicitly mentions EM–IM combined training and why your skills and goals fit that path. If you’re applying broadly (EM–IM, EM, and IM), coordinate with your letter writers so their endorsements don’t conflict (e.g., one letter saying you are absolutely committed only to IM, while another says you’re absolutely committed only to EM).

Do I need a department chair letter for Internal Medicine?

Some IM or EM programs request a chair or departmental letter, but many EM–IM combined residencies do not make this mandatory. It varies significantly by institution. If your home institution has a standard process for generating a chair letter (e.g., a composite letter based on multiple evaluations), it can be a useful addition—but it should not replace:

• Direct, detailed letters from faculty who personally supervised you.
• An EM SLOE, if required.

Check each program’s requirements and work with your dean’s office or advisors to decide whether a chair letter is necessary.

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Thoughtfully chosen and well-supported letters of recommendation can elevate your application from “qualified” to “standout” in the competitive EM–IM combined residency landscape. As an MD graduate, prioritize early planning, strong clinical performance, and clear communication with your letter writers so your LORs fully reflect the resident you’re ready to become.