Essential Guide for Non-US Citizen IMG: Letters of Recommendation in Preliminary Surgery

Understanding the Unique LOR Needs of a Non-US Citizen IMG in Preliminary Surgery

Letters of recommendation (LORs) can make or break a surgery application, and this is even more true for a non-US citizen IMG applying to a prelim surgery residency. Program directors know that many foreign national medical graduates have strong test scores, so LORs become one of the key ways to judge:

• Operative potential
• Work ethic and reliability
• Cultural and communication fit in a US surgical team
• Ability to function safely in a fast-paced, high-acuity environment

As a non-US citizen IMG, your letters also help mitigate concerns about your clinical readiness in the US system, your visa status, and how easily you will adapt to the culture of American training programs.

This article focuses specifically on letters of recommendation for preliminary surgery applicants, with a special emphasis on the non-US citizen IMG and foreign national medical graduate. You’ll learn:

• How prelim surgery differs from categorical surgery in terms of LOR expectations
• Who to ask for letters (and who not to ask)
• How to get strong LORs from US experiences even if they’re short
• How to support your letter writers with evidence and structure
• How to handle mixed US and home-country letters strategically

Throughout, you’ll see practical steps and scripts you can start using immediately.

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What Program Directors Want to See in a Prelim Surgery LOR

Program directors reading your file in October or January are scanning quickly. Your LORs must answer a few critical questions about you as a preliminary surgery year candidate:

1. Can this person function safely on day one?

   • Recognizes sick vs stable patients
   • Knows when to call for help
   • Has basic clinical judgment and accountability

2. Will this resident show up and do the work?

   • Reliability on call and in the OR
   • Professionalism with nursing staff and consultants
   • Stamina and resilience in a demanding environment

3. Is this someone I would trust in my operating room?

   • Situational awareness
   • Respect for hierarchy and safety
   • Interest in learning and self-improvement

4. For a non-US citizen IMG or foreign national medical graduate:

   • Can they communicate clearly in English with patients and team?
   • Will they adapt to the US system and electronic medical records?
   • Do they understand US professional norms (documentation, handoffs, phone etiquette, etc.)?

A strong LOR for prelim surgery should therefore be:

• Behavior-based: concrete examples instead of vague praise
• Contextualized: explains the clinical setting and level of supervision
• Comparative: compares you to peers in a meaningful way
• Aligned: clearly supports your application to surgery, even if prelim-only

When you think about how to get strong LOR, your goal is to create situations where attendings can genuinely observe and later describe these qualities.

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Who to Ask for Letters in Preliminary Surgery: Priorities and Strategy

A central question for every non-US citizen IMG is: who to ask for letters to support a prelim surgery application?

1. US Clinical Experience (USCE) Letters: Highest Priority

For a non-US citizen IMG applying to prelim surgery, strong LORs from US surgeons are especially valuable. These reassure programs that you can function in their environment.

Best sources:

• US general surgeons who directly supervised you
  • Sub-internships / acting internships in surgery
  • Surgical clerkships with substantial responsibility
  • US-based observerships that were truly hands-on (where allowed)
• US surgical subspecialty attendings
  • Trauma/acute care surgery
  • Vascular, colorectal, thoracic, transplant, etc.
  • ICU rotations led by surgeons or surgical intensivists

If you have more than three strong surgery letters, that’s excellent—but you still typically submit only:

• 3–4 total LORs (ERAS allows up to 4 per program)

For prelim positions, a minimum of 2 letters from US surgeons is ideal. If you can get 3, even better.

2. Non-US Surgical Faculty: Still Very Valuable

As a foreign national medical graduate, you may have excellent clinical and research relationships in your home country. These can absolutely help—especially when:

• The letter writer is a senior surgeon (e.g., department chair, program director, professor)
• They can compare you to many years of trainees
• They can give strong, specific detail about your clinical and operative performance

These letters are especially useful if:

• You lack enough US surgical exposure to produce 2–3 solid US letters
• Your home institution is well-known or respected internationally
• Your mentor can describe longitudinal performance across several rotations or years

3. Non-Surgical Letters: When They Help (and When They Don’t)

Non-surgical LORs should be used selectively, especially for a prelim surgery residency.

Reasonable non-surgery options:

• Surgical ICU run by anesthesiology or critical care
• Emergency medicine in a trauma-heavy setting where you handled surgical patients
• Internal medicine where you demonstrated strong clinical care for surgical co-management patients
• Program director or dean’s letter-style LOR when they know you very well

Try to limit non-surgical letters to one unless you truly have no access to surgical mentors. A file with two or three non-surgical letters for a prelim surgery year can raise concern about your genuine interest in surgery.

4. Red Flags in Choosing Who to Ask

Avoid or be careful with:

• Short-term, low-contact mentors
  • Example: An attending you shadowed twice in clinic with no direct patient care
• Very junior faculty who barely know you
  • They may write generic letters lacking comparison or authority
• Famous names with weak knowledge of you
  • “Name recognition” does not overcome a vague, two-paragraph letter
• Non-physician letters (nurses, patients, administrators)
  • These can be valuable for your own growth but are rarely useful as formal LORs

Bottom line: A detailed letter from a mid-level attending who supervised you closely is almost always better than a generic letter from a famous professor who barely remembers you.

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How to Get Strong LORs as a Non-US Citizen IMG in a Short Time

Many non-US citizen IMGs face the same problem: rotations and observerships in the US are often brief—4 to 8 weeks. To produce powerful LORs from that limited time, you must be deliberate from day one.

1. Set Up the Rotation Intentionally

Before or on day 1:

• Email your attending or rotation coordinator:
  • Introduce yourself as a non-US citizen IMG pursuing a prelim surgery year
  • Share that you hope to obtain residency letters of recommendation from US surgeons
  • Express that you plan to work very hard and would value feedback

This primes them to watch you more closely and consider your performance in the context of a potential LOR.

2. Behaviors That Lead to Strong Surgical LORs

During the rotation, focus on behaviors attendings consistently comment on in letters:

Clinical performance:

• Know your patients deeply: labs, imaging, overnight events, plan
• Present concisely and logically on rounds
• Be proactive: anticipate orders, pre-round thoroughly, follow up on results

Professionalism & reliability:

• Arrive early, leave late when appropriate
• Offer help to interns and residents without being asked
• Communicate clearly and respectfully with nurses and ancillary staff

Commitment to surgery:

• Volunteer for cases, including less glamorous ones
• Read about upcoming procedures and discuss with the team
• Ask thoughtful, case-based questions that show you’re studying

Adaptation to US culture:

• Learn EMR workflows quickly
• Use SBAR and closed-loop communication
• Document clearly and thoroughly if allowed

3. Ask for Feedback Before Asking for a Letter

Two to three weeks into the rotation (or halfway):

You:
“Dr. Smith, I’m very grateful for the chance to work with you. I’m applying to preliminary surgery positions as a non-US citizen IMG and want to make sure I’m progressing well. Could you share any feedback about my performance and what I can improve in the coming weeks?”

This serves three purposes:

1. It signals maturity and coachability.
2. It gives you a chance to correct any issues before the attending forms a final impression.
3. It lets you gauge how enthusiastic they might be as a letter writer.

If the feedback is mostly positive and specific, they’re more likely to be a good LOR writer.

4. How to Ask for a Strong LOR (Not Just Any LOR)

Near the end of the rotation:

You:
“Dr. Smith, I’ve really valued working with you. I’m applying to prelim surgery residency programs in the US as a non-US citizen IMG. Would you feel comfortable writing a strong letter of recommendation for me that specifically supports my application to preliminary surgery positions?”

Pay attention to their reaction:

• If they say yes enthusiastically (“Absolutely,” “I’d be happy to,” “You’ve done very well”): great.
• If they hesitate (“I can write you a letter,” “I don’t know you that well yet”): consider this a warning sign; you may want to prioritize another writer.

Asking for a “strong” letter gives them a graceful way to say no if they do not feel comfortable.

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Supporting Your Letter Writers: What to Provide and How to Guide Them

Once an attending agrees to write, your next job is to make it easy for them to write a powerful, specific letter. This is especially critical for a non-US citizen IMG, who may need help showcasing US readiness.

1. Materials to Send Your Letter Writers

Email them:

• Your updated CV (highlight US and surgical experiences)
• Personal statement draft for surgery (even if prelim-focused)
• USMLE/COMLEX scores (if you’re comfortable sharing)
• List of programs or types of programs you’re aiming for
• ERAS timeline and deadline (be specific: “ERAS opens to programs on September X; I hope letters can be uploaded by…”)

For an IMG with multiple systems, add:

• Brief summary of your home-country training (internship, residency, rotations)
• Any visa context they should be aware of (only if relevant and you’re comfortable)

2. Provide a Short “Brag Sheet” with Concrete Examples

Instead of generic statements, send a one-page “highlights” document with specific behaviors they may have seen:

• “On call, I evaluated X number of new consults and presented them to you.”
• “We worked together on Y complex case where I assisted with Z steps.”
• “You gave me feedback about my presentations on rounds, and I implemented…”
• “Examples of my commitment: staying late for emergency OR, reading about conditions overnight and discussing with the team.”

Frame this not as telling them what to write, but as reminding them of moments they personally observed.

3. Gently Emphasize What Matters Most for Prelim Surgery Programs

Without scripting the letter, you can share what program directors value:

“Because I’m primarily applying to prelim surgery year positions, letters that comment on my:

• Clinical judgment and safety
• Work ethic and ability to function on a busy team
• Communication skills and professionalism
• Readiness to adapt to US surgical training

would be especially helpful.”

Most attendings will welcome this guidance, especially if they don’t often write letters for IMGs or for prelim surgery applications.

4. Following Up Without Being Pushy

Give your writer at least 3–4 weeks before the ideal upload date.

If the letter is not uploaded within 2 weeks of your requested deadline:

You:
“Dear Dr. Smith,
I hope you’re doing well. I wanted to gently follow up about the residency letter you kindly agreed to write for me for preliminary surgery programs. ERAS opens to programs on [date], and it would be ideal to have the letter uploaded by then. Please let me know if there’s any additional information I can provide.

Thank you again for your support,
[Name]”

If they remain non-responsive, you may need to adjust your strategy and confirm letters from other attendings.

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Balancing US and Home-Country Letters: Strategy for the Non-US Citizen IMG

As a foreign national medical graduate, you often have a mix of US and international experiences. The key is to structure your LOR portfolio in a way that reassures programs about both your clinical depth and your adaptability to the US system.

1. Ideal LOR Mix for a Prelim Surgery Applicant

If possible, aim for:

• 2 letters from US surgeons (general or subspecialty)
• 1 letter from a home-country senior surgical mentor who knows you very well
• Optional 4th letter: US or home-country ICU/EM/trusted mentor, if truly strong and relevant

This mix shows:

• US readiness and performance
• Longer-term surgical development
• Strong support in multiple clinical environments

2. When You Have Limited US Clinical Experience

If you only have one solid US surgery LOR:

• Make that letter as strong and detailed as possible by supporting the writer
• Add 2 strong home-country surgical letters from senior faculty
• Consider a US non-surgery letter (e.g., ICU, EM) that highlights your adaptation to the US system and communication skills

In your personal statement and interviews, be proactive about explaining:

• Why your US time is limited (visa, cost, availability)
• What you learned from your US rotation(s)
• How your home-country experience prepared you clinically and emotionally for US training

3. What Home-Country Writers Should Emphasize

You can gently guide home-country letter writers to focus on:

• Your clinical breadth and autonomy (especially helpful if you’ve had more responsibility than typical US graduates)
• Your operative experience (assisting, performing under supervision, understanding anatomy and perioperative care)
• Your comparative standing: “top 5% of over 100 trainees,” etc.
• Your professionalism, integrity, and teamwork over years, not weeks

This helps US program directors feel more comfortable that you can handle the intensity of a prelim surgery residency, even if your US observation time was short.

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Common Mistakes to Avoid with Residency Letters of Recommendation

Even strong candidates weaken their application by mishandling LORs. Watch out for these pitfalls:

1. Collecting Too Many Weak Letters

Having 6–7 mediocre letters does not help. Programs will only see up to 4 per application. Focus on quality, not quantity.

2. Submitting Generic or Template-Like Letters

Red flags in letters that program directors notice:

• Overly short letters (one page or less with no examples)
• No specific cases or behaviors mentioned
• No comparison to peers (“one of the best,” “above average,” etc.)
• Letters that could have been written for any applicant

These can hurt you, especially as a non-US citizen IMG, where your LORs are a key proof of readiness.

3. Ignoring Visa or Status Questions Completely

Your letters do not need to discuss your visa status. However:

• Avoid any implication that you are “uncertain about your career direction” or “considering many specialties” if you are clearly applying to prelim surgery.
• If you have a long-term goal (e.g., categorical surgery or transitioning to another field after prelim), that can be addressed in your personal statement, not your LORs.

4. Timing Errors

• Asking for letters in October or November of application season
• Not reminding letter writers of deadlines
• Submitting applications with only 1 LOR uploaded

Aim to have at least 2–3 LORs uploaded by the time programs start reviewing applications.

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FAQs: Letters of Recommendation for Non-US Citizen IMGs in Preliminary Surgery

1. How many letters of recommendation should I submit for a prelim surgery residency?

Most preliminary surgery programs expect 3 letters, and ERAS allows you to assign up to 4 per program. For a non-US citizen IMG, a strong strategy is:

• 2 US surgery LORs (if possible)
• 1 additional strong letter (US or home-country surgery)
• Optional 4th: only if it adds new, strong information

Do not feel obligated to use four letters if your 3 best are significantly stronger than the others.

2. Is it a problem if one of my letters is from internal medicine or another non-surgical field?

One non-surgical LOR can be acceptable, especially if:

• It’s from a US-based rotation
• The writer observed you extensively
• They can speak to your clinical reasoning, teamwork, and reliability

For a prelim surgery year, try to ensure at least two letters are from surgeons. More than one non-surgical LOR can raise questions about your commitment to surgery.

3. As a foreign national medical graduate, are home-country letters still useful if I have US letters?

Yes. Home-country letters are especially valuable when:

• Written by senior surgeons who know you well
• They describe your long-term growth, clinical breadth, and operative experience
• They compare you favorably to several years of trainees

US letters demonstrate adaptation to American systems; home-country letters demonstrate depth and continuity of surgical development.

4. Should my letters focus on me as a categorical surgery candidate or as a preliminary surgery applicant?

Most letters do not need to explicitly say “preliminary” unless they are aware and want to emphasize your openness to that path. Instead, ask writers to:

• Endorse you as a strong candidate for surgical residency in the US
• Highlight qualities that are essential for any surgical resident (reliability, work ethic, judgment, teamwork)

In your personal statement and interviews, you can explain your reasons for targeting prelim surgery positions (e.g., late transition, needing US experience, timing, or long-term categorical goals).

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By choosing the right letter writers, deliberately shaping your performance on rotations, and proactively supporting your mentors with information and reminders, you can transform your LORs from a vulnerability into a major strength of your application—even as a non-US citizen IMG applying for a prelim surgery residency.

Your scores and CV get you noticed; your residency letters of recommendation can convince a program that you are exactly the kind of hard-working, adaptable team member they want on call at 3 AM.