Essential Guide to Letters of Recommendation for IMG Preliminary Surgery

Understanding the Role of Letters of Recommendation in Preliminary Surgery

For a US citizen IMG and American studying abroad, letters of recommendation can be the make‑or‑break factor in matching into a prelim surgery residency—often even more so than for US MD graduates. When programs review applications, they know little about your school or grading system, but they absolutely understand a strong US‑based surgical LOR.

For a preliminary surgery year, program directors are looking for:

• Evidence that you function safely and reliably in a surgical environment
• Proof of your work ethic, team skills, and teachability
• A credible outside voice that says, “We trusted this person in our ORs and on our service, and you can too”

Because preliminary positions can be competitive and are often used as a pathway to categorical surgery, radiology, anesthesia, or other specialties, your residency letters of recommendation must convince programs that you are worth investing in.

This article breaks down exactly how to get strong LOR as a US citizen IMG applying in preliminary surgery: who to ask, when to ask, how to help your writers, and how to maximize the impact of each letter.

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What Program Directors Want from Surgical LORs

To write a strong, credible LOR, an attending must be able to speak to specific behaviors that matter in surgery. Programs reading your letters will look for several core themes.

Core Competencies Highlighted in Strong Surgical LORs

The best letters for a prelim surgery residency usually cover:

1. Clinical reliability

   • Shows up on time (or early)
   • Follows up on tasks
   • Manages pages and tasks without dropping responsibilities

2. Work ethic and grit

   • Stays late when needed
   • Voluntarily takes on extra patients or consults
   • Remains composed during demanding OR days

3. Surgical interest and potential

   • Enthusiasm for the OR
   • Steady hands, attention to sterility and detail
   • Learns from feedback, improves technique even within a short rotation

4. Teamwork and communication

   • Works well with residents, nurses, and ancillary staff
   • Communicates concisely on rounds and sign‑out
   • Responds professionally even under stress

5. Professionalism and integrity

   • Honest, accountable, and reliable
   • Treats patients and staff respectfully
   • Cultural sensitivity—often a strength for an IMG

6. Comparison with peers

   • “Top 10% of students I’ve worked with in the last 5 years”
   • “One of the strongest sub‑interns on our service this year”

Program directors don’t just want adjectives; they want stories that back them up—and those come only when the letter writer knows you well.

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Who to Ask for Letters: Priorities for the US Citizen IMG

One of the most important questions is who to ask for letters when you’re an American studying abroad and may have limited US clinical exposure.

Priority #1: US‑Based Surgeons from Recent Rotations

For preliminary surgery, the most impactful letters come from US surgeons (MD or DO) who have observed you:

• On a sub‑internship / acting internship (AI) in general surgery
• On a core surgery rotation at a US hospital
• On a surgical subspecialty rotation (e.g., trauma, vascular, colorectal, SICU, cardiothoracic)

Ideal writers:

• Attending surgeons (especially if they are core faculty or program leadership)
• Surgical program director or associate program director (if they know you directly)
• Division chief or department chair (only if they supervised you clinically, not just met you once)

For a US citizen IMG, these US letters help reassure programs that you’ve been evaluated in the same environment as their own graduates.

Priority #2: US Academic Medicine or Subspecialty Faculty

If you have limited pure general surgery exposure, letters from:

• Surgical subspecialties (e.g., orthopedic surgery, neurosurgery, urology)
• Critical care / anesthesia with strong surgical interaction (e.g., SICU, trauma anesthesia)

can still be very valuable, especially if they emphasize:

• Your OR performance
• Your critical care knowledge
• Your teamwork and communication

Priority #3: Research Mentors (Preferably Surgeons or Clinician‑Scientists)

A research mentor can write a powerful letter if:

• You worked with them closely (≥ 3–6 months)
• You demonstrated productivity, initiative, and reliability
• The research is related to surgery or perioperative care

For a prelim surgery residency, a research letter:

• Should not replace all clinical letters
• Works best as a supplement (e.g., 1 research letter + 2–3 clinical surgical letters)

Priority #4: Non‑Surgical Clinical Faculty (If Necessary)

When surgical letters are limited, strong internal medicine or ICU letters can still help, especially if they:

• Emphasize complex inpatient care
• Highlight your reliability, communication, and independent functioning
• Directly mention why you would succeed in a surgical training environment

If you must use a non‑surgical letter, make sure at least two letters are clearly surgical or perioperative.

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How Many Letters and What Mix Do You Need?

Most programs allow 3–4 LoRs in ERAS. For a preliminary surgery year, a strong configuration for a US citizen IMG would be:

Ideal mix (3 letters):

1. General surgery attending from a US rotation (sub‑I or core surgery)
2. Another US general surgery or surgical subspecialty attending
3. Surgical ICU / trauma / research mentor (preferably a surgeon or intensivist tied to surgery)

Stronger mix (4 letters):

1. General surgery attending (primary writer, knows you best)
2. Another general surgery or subspecialty attending
3. Surgical ICU or trauma attending
4. Research mentor or non‑surgical inpatient attending who knows you extremely well

Many program directors report that:

• 2 strong US surgery letters are “must‑have” for prelim surgery
• A third or fourth can add depth but cannot compensate for weak core surgical letters

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How to Get Strong LOR as a US Citizen IMG: Step‑by‑Step

Being an American studying abroad adds extra pressure to prove yourself during limited US time. You can’t leave letters to chance. You need a deliberate strategy.

1. Design Your Rotations with Letters in Mind

When planning US clinical experiences:

• Prioritize surgical rotations at teaching hospitals with residency programs
• Choose rotations where:
  • You will be on the same team for at least 3–4 weeks
  • There is a clear supervising attending who works with students
  • You can get into the OR and onto daily rounds

If possible, arrange:

• 1–2 months of general surgery (or surgical subspecialty)
• 1 month of SICU or trauma
• Optional: 1 month of research or clinical elective involving surgery

These rotations will become the foundation for your strongest letters.

2. Make Yourself “Letter‑Worthy” on the Rotation

Before worrying about who to ask, ensure you perform at a level that inspires strong letters. On each surgical service:

• Arrive early: Pre‑round thoroughly, know vitals, labs, overnight events
• Own your patients:
  • Prepare concise presentations
  • Anticipate questions about management (fluids, antibiotics, DVT ppx)
• Be visible in the OR:
  • Arrive early, help set up, know the patient and indication
  • Read beforehand about the procedure and anatomy
• Be proactive but not intrusive:
  • Ask, “How can I be most useful to the team today?”
  • Offer help with notes, orders (as allowed), dressing changes, discharge summaries

Remember: letters are based on stories—the extra consult you volunteered to see, the time you caught a critical lab, the night you stayed late to help close a complex case.

3. Signal Your Interest in a Letter Early (But Professionally)

If you know you’re targeting prelim surgery:

• Early in the rotation (within the first week), let your attending and residents know:
  • You are a US citizen IMG interested in preliminary surgery
  • You hope to match in the US and are seeking mentorship
• This doesn’t mean asking for a letter immediately, but it sets expectations:
  • They’ll observe you more intentionally
  • They’ll understand why you’re asking more questions or seeking feedback

Example script (for a brief discussion with an attending):

“Dr. Smith, I wanted to share that I’m a US citizen IMG applying for a preliminary surgery position this cycle. I’m very interested in surgery long‑term, and I’m hoping to learn as much as I can from this rotation. I’d really appreciate any feedback on how I can grow into someone you’d feel comfortable recommending.”

4. Ask the Right Person, the Right Way, at the Right Time

Who to Ask

Ask attendings who worked closely with you, not those who barely know you. Good signs:

• They’ve seen you multiple days in the OR and on rounds
• They’ve given you feedback or teaching directly
• Residents tell you, “Dr. X likes working with you”

If a resident or fellow is your main supervisor:

• Ask if they think the attending knows you well enough to write a strong letter
• Sometimes the attending will ask the resident to draft talking points, which is common and acceptable

When to Ask

Best time: Last week of your rotation, after you’ve demonstrated consistent performance.

You can also send a follow‑up email 1–2 weeks after the rotation, but it’s better if the initial ask is in person.

How to Ask

The most important phrase is: “Would you feel comfortable writing me a strong letter of recommendation?”

Example in‑person script:

“Dr. Smith, I’ve really valued working with you this month and I’m applying for a preliminary surgery residency this cycle. I was wondering if you’d feel comfortable writing me a strong letter of recommendation based on my performance on this rotation.”

If they hesitate or say something neutral like “I can write you a generic letter,” that’s a red flag—thank them politely but don’t rely on that letter as one of your core surgical LORs.

A “yes” should ideally sound like:

• “Absolutely, I’d be happy to”
• “Yes, you’ve done well and I can speak to your work here”

5. Provide a Helpful “Letter Packet”

Once an attending agrees, make it easy for them to advocate for you. Email them within 24–48 hours:

• A polite thank‑you
• Your CV
• A draft personal statement (or at least a paragraph about your goals)
• A short bullet‑point summary of:
  • What you did on the rotation (types of cases, responsibilities)
  • Specific things you’re proud of (with gentle language)
  • Any notable feedback you received

Example email structure:

• Subject: LOR Request – [Your Name], Preliminary Surgery Applicant
• Brief thank‑you and reminder of who you are (include rotation dates)
• Attach documents
• Provide your AAMC ID and ERAS instructions (once available)
• Politely mention deadline (e.g., “Ideally by early September if possible”)

Bullet‑Point Sheet Example

Include items such as:

• Managed 5–8 patients daily on the general surgery service under supervision
• Pre‑rounded independently and presented on morning rounds
• Assisted in OR for laparoscopic appendectomies, cholecystectomies, hernia repairs
• Stayed late on multiple occasions to help close cases and complete notes
• Received feedback from residents on clear presentations and strong follow‑through

Don’t exaggerate; the purpose is to jog the writer’s memory, not script their letter.

6. Handling Logistics in ERAS

As a US citizen IMG, you’ll upload letters via ERAS like any other applicant:

1. Register for ERAS and obtain your AAMC ID
2. Generate Letter Request Forms for each writer
3. Email or hand these forms to your writers
4. Track submission status in ERAS and send a gentle reminder 2–3 weeks before your target application date if the letter is still pending

Aim to have all letters uploaded by the time you submit ERAS, ideally by mid‑ to late September.

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Special Considerations for US Citizen IMGs and American Studying Abroad

Being a US citizen IMG comes with unique challenges—but also some advantages you can leverage.

1. Addressing Concerns about Training Background

Program directors unfamiliar with your overseas school may worry about:

• Grading standards
• Clinical exposure
• Communication skills and cultural adaptation

Your letters can directly address these:

• Ask writers to comment on how you compare to US MD students they’ve supervised
• Encourage them (through your bullet points) to mention:
  • “Performing at or above the level of our US students”
  • “Communicates clearly with patients and staff”
  • “Adapted quickly to our system and EMR”

2. Using Your US Citizenship Strategically (But Honestly)

Being a US citizen IMG removes some visa concerns but does not erase academic ones. However, you can emphasize in your personal statement and in communications:

• You have no visa restrictions
• You are fully committed to building your career in the US
• You are geographically flexible, especially as a preliminary surgery candidate

Your letters, in turn, can show that:

• You’ve already integrated successfully into US clinical teams
• You behave professionally and responsibly—no “risk” for the program

3. If You Have Limited US Clinical Experience

If you only have:

• 1–2 US clinical rotations
• Mainly home‑country or non‑US letters

Then:

• Prioritize getting the strongest possible letters from those limited US rotations
• Add 1–2 non‑US letters from surgeons who know you intimately, but recognize they may carry less weight
• Make sure your US letters explicitly address:
  • Your adaptability
  • Your clinical reasoning
  • Your comparison to US students

In such cases, a preliminary surgery year can itself become your US “credential”—but you need strong enough letters to get that first chance.

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Common Mistakes to Avoid with Surgical LORs

Even strong applicants can undermine themselves with avoidable errors.

1. Settling for Generic or Weak Letters

Signs a letter may not be strong:

• The writer barely knows you
• They supervised you for only a few days
• They seem hesitant or noncommittal when you ask

As a US citizen IMG, quality beats quantity. Two truly detailed, enthusiastic surgical letters are more valuable than four generic ones.

2. Over‑Relying on Non‑Surgical Letters

For a prelim surgery residency, a letter from:

• A famous cardiologist
• A respected internist
• A non‑clinical dean

is less impactful than a letter from a moderately known but deeply involved surgeon who can describe your OR and ward performance. Use non‑surgical letters only as supplements.

3. Missing Deadlines or Poor Communication

• Failing to give writers adequate notice (at least 4–6 weeks)
• Not providing your CV or personal statement
• Not checking ERAS to confirm receipt

Programs may see missing letters as poor organization—something particularly damaging in surgery.

4. Asking Only Very Senior People Who Don’t Know You

A short, generic letter from the department chair who doesn’t remember you is weaker than a detailed letter from a mid‑career attending who worked with you daily. The depth of knowledge about you is more important than the title of the writer.

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Putting It All Together: A Sample LOR Strategy for a US Citizen IMG

Here’s how a well‑planned approach might look:

Profile:

• US citizen IMG, American studying abroad
• Did 3 months of US clinical rotations:
  • 1 month general surgery at a community teaching hospital
  • 1 month trauma surgery at a university hospital
  • 1 month surgical ICU at the same university hospital

Target LORs:

1. General surgery attending from community hospital

   • Knows you well, saw you every day in OR and clinic
   • Can describe your growth over the month

2. Trauma surgery attending at university hospital

   • Observed your performance on call and in emergent situations
   • Can comment on composure, teamwork, and interest in surgery

3. SICU attending

   • Highlights your ability to manage complex surgical patients
   • Confirms strong communication and reliability in critical care setting

4. Home‑country general surgeon (optional 4th letter)

   • Knows you for 2+ years
   • Speaks to longitudinal growth and commitment to surgery

In ERAS, you could choose:

• For most prelim surgery programs: the 3 US surgical/perioperative letters
• For programs that allow a 4th: add the home‑country surgeon’s letter to show continuity and long‑term commitment

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FAQs: Letters of Recommendation for US Citizen IMG in Preliminary Surgery

1. How many surgery‑specific letters do I absolutely need for a prelim surgery residency?

Aim for at least two strong US surgical letters, ideally from attendings who observed you clinically in the OR and on the wards. A third letter from SICU/trauma or a research mentor with close clinical observation strengthens your application further.

2. Should I ever ask a resident to write or co‑write my letter?

The letter should always be signed and submitted by an attending, but in practice many attendings ask residents or fellows for input or a draft. It’s acceptable if:

• The attending knows you and agrees to the letter
• The attending reviews, edits, and endorses the final version

You should still ask the attending, not the resident, for the letter.

3. Is a research letter useful for a preliminary surgery year?

Yes—if:

• The research is surgical or perioperative
• Your mentor supervised you closely and can comment on your work ethic and reliability
• You already have at least two clinical surgical letters

A strong research letter should be a supplement, not a substitute for clinical surgical LORs.

4. What if an attending offers a “generic” letter—should I still use it?

If someone explicitly says they can only write a generic letter, that usually means it will not help you and could even hurt by faint praise. Thank them, but prioritize letters from attendings who:

• Know you well
• Can speak in detail about your work
• Are willing to write a strong letter

As a US citizen IMG, you must use your limited US exposure to generate maximally strong, not merely average, letters.

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By approaching letters of recommendation with this level of planning and intentionality, you greatly increase your chances of securing a preliminary surgery year that opens doors—whether your long‑term goal is categorical surgery or another competitive field.