Essential Guide to Letters of Recommendation for Non-US Citizen IMGs

Why Letters of Recommendation Matter So Much for a Non‑US Citizen IMG

For a non-US citizen IMG or foreign national medical graduate applying to internal medicine residency, letters of recommendation (LORs) are often the most powerful part of the application after your USMLE scores. Program directors routinely say that residency letters of recommendation help them answer three core questions:

1. Can you function safely and effectively in a US clinical setting?
2. Do trusted US physicians believe you will be a good resident?
3. Are you specifically interested in internal medicine, not just “any” residency spot?

As a non‑US citizen IMG, you often face extra unknowns in the eyes of programs: different medical school systems, different grading structures, variable clinical exposure, and sometimes language and communication questions. Strong, detailed LORs from US-based internal medicine physicians directly reduce those doubts.

In the NRMP Program Director Survey, Internal Medicine PDs consistently rank LORs in the specialty as a top factor in interview selection and ranking. For a non‑US citizen IMG, they can tip the balance between “maybe” and “interview invite.”

This article explains how to get strong LORs, who to ask for letters, and how to strategically use your letters to support a successful IM match.

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The Basics: What Makes a Strong Internal Medicine LOR?

Before you chase letter writers, you need to know what a strong IM recommendation actually looks like. Program directors are looking for evidence, not just praise.

A high-impact internal medicine LOR for a non‑US citizen IMG usually has:

1. Clear Clinical Context

The reader should immediately understand:

• Where you worked with the writer (e.g., “Inpatient general medicine wards at XYZ University Hospital”)
• How long they supervised you (e.g., “4-week sub-internship in July 2024”)
• In what role (student, sub-intern, observer, research assistant, etc.)

This context is especially important for foreign national medical graduates because PDs need to know whether the assessment is from direct US clinical observation (gold standard) or something more distant.

2. Specific, Observed Behaviors

Strong letters are rich in specific examples, such as:

• “She independently presented 10–12 new admissions per week with organized, hypothesis-driven assessments.”
• “He identified a subtle ST-segment elevation on an ECG that led to urgent cardiology consultation.”

Generic comments like “hard-working,” “smart,” and “pleasant” are almost useless unless paired with detail. As a non‑US citizen IMG, specificity proves that your performance is not just being judged kindly—it is being directly compared to US grads.

3. Comparative Statements

Program directors want to know how you compare to typical US students or residents the writer has seen:

• “Among the international medical students I’ve worked with in the past five years, she ranks in the top 5%.”
• “His clinical reasoning and efficiency are on par with our own categorical PGY-1 residents.”

These statements are particularly powerful if they come from faculty at well-known US hospitals or academic centers.

4. Evidence of “Fit” for Internal Medicine

As you’re targeting internal medicine residency, the letter should emphasize IM-specific qualities:

• Love for diagnostic reasoning and longitudinal care
• Comfort managing complex, multi-morbid patients
• Teamwork in multidisciplinary inpatient services
• Enthusiasm for teaching, evidence-based practice, or quality improvement

A strong IM letter should leave the reader thinking: “This person really belongs in internal medicine.”

5. Professionalism and Communication

For a non‑US citizen IMG, PDs often worry about:

• Language/communication with patients and team
• Cultural adaptation to US healthcare
• Reliability and professionalism

Good LORs address these directly:

• “Her spoken and written English were clear and fluent; patients consistently reported feeling well understood.”
• “Despite being new to the US system, he quickly learned our EMR and documentation standards and was consistently on time and prepared.”

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Who to Ask for Letters (and Who to Avoid)

One of the most common questions is: who to ask for letters to maximize your chance of an IM match? The answer is strategic, not random.

Priority #1: US Internal Medicine Faculty Who Supervised You Clinically

For a non‑US citizen IMG, the most valuable LORs typically come from:

• US internal medicine attendings who directly supervised you during:
  • Sub-internship/acting internship
  • Core internal medicine clerkship (if you did some training in the US)
  • Inpatient electives (wards, ICU, cardiology, GI, etc.)
• Core faculty or program leadership (PD, APD, Chief of Service) who saw you in action

These letters show that you can function in the US system and that IM specialists believe in your potential.

Ideal number:

• At least 2–3 strong US internal medicine letters if possible

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Priority #2: Subspecialty IM Faculty (Cardiology, Pulmonology, etc.)

If your best clinical work was with subspecialty internal medicine attendings (e.g., cardiology, nephrology, infectious disease), their letters are also very valuable, especially if:

• The rotation was hands-on (not pure observership)
• They directly observed your patient care, presentations, and decision-making
• They can compare you to US students or residents

These are still considered internal medicine letters by most programs.

Priority #3: Research Mentors (in Internal Medicine)

Research mentors can be excellent writers, especially if:

• You had a long-term, close working relationship
• They saw you regularly, not just via email
• You had tangible output (abstracts, posters, publications, QI projects)

However, if their only exposure to you is academic (no clinical observation), their letter should be supplementary, not your only clinical evidence.

Lower Priority / Situational Letters

• Non-IM specialties (e.g., surgery, radiology, pathology)
  Useful only if:
  • They are exceptionally strong letters
  • You have limited IM letters and need a credible clinical reference
• Non-US faculty from your home country
  These can help show long-term excellence and leadership, but:
  • They are less persuasive than US clinical letters for IM match
  • Use 1 strong home-country letter if you lack enough US exposure, but not more than 1–2 in most cases

Who Not to Ask (Usually)

Avoid letters from:

• People who barely know you or supervised you very briefly
• Politically powerful but clinically distant figures (e.g., dean who never saw you clinically)
• Family friends or physicians with conflicts of interest
• Observership-only supervisors who had no true clinical assessment (unless they meaningfully interacted with you and can give detailed, behavior-based feedback)

For a non‑US citizen IMG, the perception of “real” supervision is critical. Program directors can tell when a writer is stretching.

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

Knowing how to get strong LORs is as important as knowing who to ask. As a foreign national medical graduate, you may have cultural or language barriers, but you can still follow a structured, professional process.

Step 1: Plan Early and Backwards from ERAS Deadlines

Timeline suggestions:

• 6–12 months before ERAS opens

  • Identify target US clinical rotations (sub-I, electives, observerships with real engagement)
  • Aim to complete at least 1–2 key IM rotations by June–July before you apply

• End of each rotation

  • If you performed well and built rapport: ask for the letter immediately, while your performance is fresh in their mind

• 2–3 months before ERAS submission

  • Follow up with gentle reminders
  • Upload all letters into ERAS (through writers) or your institution’s system

Step 2: Perform Deliberately to Earn a Strong Letter

LORs reflect your daily behaviors. During your US IM rotations, consciously demonstrate:

• Ownership: Know your patients better than anyone else, anticipate needs, follow up on labs and consults
• Work ethic: Arrive early, stay as needed, help the team
• Communication: Present clearly, write concise notes, update families respectfully
• Curiosity: Read about your patients, ask thoughtful questions, apply evidence
• Professionalism: Be reliable, respond promptly, respect boundaries and hierarchy

A good rule: behave every day as if your attending will later have to justify choosing you over someone else for residency.

Step 3: Ask the Right Way: “Can You Write Me a Strong Letter?”

When asking for residency letters of recommendation, how you ask matters.

Near the end of a rotation (or after a major project milestone), approach your potential writer:

“Dr. Smith, I’m planning to apply for internal medicine residency, and I have really valued working with you on this rotation. Based on your observation of my work, would you feel comfortable writing a strong letter of recommendation for my residency applications?”

This phrasing:

• Gives them an honest exit if they don’t feel they can write strongly
• Signals that you care about quality, not just collecting letters

If they hesitate or seem non-committal (“I can write something” vs. “absolutely”), it may be better to avoid using that letter.

Step 4: Provide a Helpful “Letter Packet”

To support your writer (and gently guide emphasis), send a concise packet including:

• Updated CV
• Personal statement draft (especially if IM-focused)
• USMLE score report (if comfortable sharing)
• Short bullet list of cases or projects you worked on together (to jog their memory)
• A brief note with:
  • Your career goals in internal medicine
  • Any specific strengths you hope they might highlight (e.g., communication, diagnostic reasoning, leadership)
  • ERAS instructions and deadlines

This is not “writing your own letter”; it is responsible, professional preparation. For a non‑US citizen IMG, it also helps the writer understand your pathway and challenges, which they can mention appropriately.

Step 5: Follow Up Professionally

If your writer agrees:

• Confirm the deadline they prefer
• One week before that date, send a polite reminder:

  “Dear Dr. Smith, I hope you’re well. I wanted to send a gentle reminder about the letter of recommendation for my internal medicine residency applications, which are due to ERAS on [date]. Please let me know if you need any additional information from me. I’m very grateful for your support.”

If you sense they are too busy or unresponsive, you may need backup writers—which is why planning early is crucial.

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How Many Letters, What Types, and How to Assign Them

Most internal medicine programs accept 3–4 LORs. As a non‑US citizen IMG, aim for a portfolio that covers:

Ideal LOR Mix for IM Match (Non‑US Citizen IMG)

Option A: Strong US Exposure

• 2 letters from US internal medicine inpatient attendings (wards, sub-I, ICU)
• 1 letter from US IM subspecialty or research mentor
• Optional 4th: Home-country IM faculty or long-term mentor

Option B: Limited US Clinical Experience

• 1–2 letters from US internal medicine rotations (even if observership but with true engagement)
• 1 strong letter from home-country IM faculty who supervised you significantly
• 1 letter from research or long-term mentor (IM-related if possible)

Specialty-Specific vs. Department-Level Letters

For internal medicine residency:

• A letter from “Program Director, Internal Medicine Residency” where you did a sub-I or elective can be especially strong, if they knew you well.
• A letter from a Chief Resident alone is usually not enough, but if co-signed by an attending or used as a supplement, it can add detail about your day-to-day performance.

Assigning Letters in ERAS

You can choose which letters go to which programs. Strategy:

• For university or academic IM programs: prioritize letters from academic IM attendings and research mentors.
• For community programs: strong clinical letters from US attendings (even at smaller hospitals) can be very persuasive.
• For programs known to value research or QI: include your research mentor’s letter.

If you have letters that vary in strength or relevance, send your best 3–4 to your most competitive programs.

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Special Issues for Non‑US Citizen IMGs: Visas, Home-Country Letters, and Gaps

Being a non‑US citizen IMG or foreign national medical graduate introduces extra details that letters can help address.

Addressing Visa and Sponsorship Concerns

Your letter writers do not control your visa, but they can help PDs feel comfortable advocating for you by:

• Emphasizing reliability and professionalism
• Highlighting commitment to internal medicine and long-term goals
• Showing you will be an asset worth the extra paperwork

Example language they might use:

“As a foreign national medical graduate, Dr. X will require visa sponsorship, but I believe the additional administrative effort will be well justified by her exceptional work ethic and contribution to patient care and education.”

You cannot dictate that they write this, but if they understand your situation, they may choose to acknowledge it in a supportive way.

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Making the Most of a Home-Country Letter

If you need to use a home-country letter:

• Choose someone who knows you extremely well:
  • Long-term internal medicine mentor
  • Department head who supervised your clinical work
• Ask them to focus on:
  • Specific cases, leadership roles, teaching activities
  • Comparisons to peers at your home institution

Their letter can show longevity, leadership, and character, complementing US letters that may be from short rotations.

Explaining Gaps or Atypical Paths

If you have:

• Time gaps between graduation and application
• Periods of preparing for exams
• Family or health interruptions

You can optionally ask a trusted mentor to contextualize this in their letter, emphasizing:

• How you used that time productively (research, study, clinical observerships)
• Your motivation and persistence in pursuing internal medicine

This should be brief and not the main focus, but it can reassure programs that the gap has a reasonable explanation.

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Practical Examples: What Strong vs. Weak Letters Look Like

Here are simplified, fictional excerpts to illustrate the difference.

Weak, Generic Letter

“To Whom It May Concern,
I had the pleasure of working with Dr. A for two weeks. He was hard-working, punctual, and got along with the team. He always tried his best and showed interest in learning internal medicine. I believe he will be a good resident.
Sincerely,
Dr. X”

Problems:

• Very short duration (“two weeks”)
• No specific examples
• No comparison to peers
• Generic praise that could apply to anyone

Strong, Specific IM Letter (for a Non‑US Citizen IMG)

“To the Internal Medicine Residency Selection Committee,
I supervised Dr. A, a non-US citizen IMG from [Country], during a 4-week inpatient internal medicine elective at [US Hospital] in July 2024. Our service admitted 10–12 complex patients per day, and Dr. A consistently took primary responsibility for 3–4 patients at a time under my supervision.

From the first week, Dr. A demonstrated clinical reasoning skills comparable to our US medical students and even some interns. For example, he evaluated a 68-year-old with dyspnea and initially non-specific findings. He constructed a thoughtful differential including heart failure exacerbation, pulmonary embolism, and pneumonia, and recommended a focused diagnostic workup that quickly confirmed a PE, allowing us to start anticoagulation within hours of admission.

Dr. A’s communication with patients and staff was excellent. Although he trained outside the US, his spoken and written English were clear and professional. Several patients specifically commented that he took the time to explain their conditions in a way they understood. He integrated smoothly into the team, regularly arrived early to pre-round, and stayed late to follow up results.

In terms of overall performance, I would place Dr. A in the top 10% of international medical graduates I have worked with over the past decade and comparable to our better US senior medical students. I have no hesitation recommending him enthusiastically for a categorical internal medicine residency position.

Sincerely,
Dr. X, MD
Associate Professor of Medicine, [Institution]”

This letter addresses:

• Context and duration
• Specific examples
• Comparison to US and IMG peers
• Direct endorsement for internal medicine

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Frequently Asked Questions (FAQ)

1. How many US letters of recommendation do I need as a non‑US citizen IMG?

Ideally, aim for 2–3 strong US internal medicine letters plus 1 additional letter (US-based or home-country mentor). Programs generally accept 3–4 letters; more is not necessarily better if the extra letters are weaker or repetitive. Quality and relevance to internal medicine matter far more than quantity.

2. Is a home-country LOR useless compared to a US LOR?

Not at all. A strong home-country LOR from a senior internal medicine faculty who knows you well can still add significant value—especially for showing long-term performance, leadership, and character. However, for the IM match, US clinical letters carry more weight because they show your ability to function in the US system. Use 1 powerful home-country letter to complement (not replace) US letters.

3. Should I waive my right to see my letters in ERAS?

Yes. You should waive your right to view your LORs. Program directors may trust waived letters more because they assume the writer was more candid. If you are worried a writer might not support you, it’s better to choose a different writer than to keep non-waived letters.

4. Can I use the same letters for all internal medicine programs?

In most cases, yes. For internal medicine residency applications, you will usually use the same core set of 3–4 letters. However, you can select different combinations in ERAS. For research-heavy academic programs, include your research mentor’s letter; for others, you might prioritize purely clinical IM letters. Always ensure that the letters you send strongly support you as a future internal medicine resident.

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By understanding how to get strong LORs, who to ask for letters, and how to strategically use them as a non‑US citizen IMG, you greatly strengthen your internal medicine residency application. Thoughtful planning, excellent clinical performance, and professional communication with your letter writers can turn this often stressful part of the process into one of your biggest advantages in the IM match.