Your Ultimate Guide to Letters of Recommendation for PM&R Residency

Understanding the Role of Letters of Recommendation in PM&R for Caribbean IMGs

Letters of recommendation (LORs) are one of the most powerful components of your PM&R residency application—especially as a Caribbean IMG. Programs use them not only to verify your clinical skills, but also to judge your professionalism, teachability, and “fit” for physiatry.

As a Caribbean medical school residency applicant, you may worry that your school name is unfamiliar or carries bias. Strong, specific, and credible letters can significantly counterbalance this. When a respected PM&R attending clearly states, “I would gladly accept this applicant into my own residency program,” it reassures program directors far more than any school label can.

For Caribbean IMGs, the goals of your PM&R letters of recommendation are to:

• Demonstrate that you can perform at the same level as U.S. MD/DO students
• Show that you understand what PM&R is and are genuinely committed to physiatry
• Provide credible evidence of your clinical skills, work ethic, and professionalism
• Bridge any concerns about training quality at a Caribbean medical school

The rest of this guide focuses on exactly how to achieve that—who to ask, when to ask, what your letters should say, and how to position yourself for a successful physiatry match.

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How Many Letters and What Types Do PM&R Programs Prefer?

Most PM&R residency programs through ERAS allow up to 3–4 letters. In practice, you should aim for:

• Total letters: 3–4
• At least 2 letters from PM&R attendings (strongly preferred)
• 1 letter from internal medicine, neurology, or another core specialty that highlights your clinical thinking and reliability
• Optional 4th letter: Research mentor (especially if PM&R or neuro/MSK related), program director, or sub-internship supervisor

For a Caribbean IMG, a powerful combination looks like:

1. PM&R LOR #1: From a U.S.-based PM&R attending at a teaching hospital where you did an elective or audition rotation
2. PM&R LOR #2: From another PM&R attending (ideally at a different site or on a different service: inpatient rehab, consults, or outpatient MSK)
3. Core Specialty LOR: From an internal medicine, neurology, or orthopedics attending (ideally in a U.S. setting)
4. Optional “bonus” LOR: From a research mentor or department chair (especially helpful if you did PM&R research, even small projects, or quality improvement)

If you are counting on a strong SGU residency match (or a match from another Caribbean school like Ross/AUC), these letters—especially from U.S. PM&R faculty—will often matter as much as your school’s name. Many successful SGU residency match stories in PM&R involve at least two excellent, detailed physiatry letters.

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Who to Ask for Letters (and Who to Avoid)

Knowing who to ask for letters is just as important as how you perform on rotation. Caribbean IMGs often have fewer built-in contacts in U.S. hospitals, so you must be strategic.

Priority #1: U.S.-Based PM&R Attendings Who Know You Well

For a physiatry match, your best letters usually come from:

• PM&R attendings at ACGME-affiliated hospitals
• Physiatrists actively involved in residency training
• Rotation or sub-internship supervisors who directly observed you in clinic, on consults, or on inpatient rehab

Ideal PM&R letter writers:

• Supervised you closely for at least 2–4 weeks
• Saw you interact with multiple patients, families, therapists, and the rehab team
• Witnessed your growth over time (from the first day of rotation to the last)
• Have a reputation for being engaged with teaching and residency selection

When planning electives—as a Caribbean medical school residency applicant—intentionally seek out rotations where:

• PM&R attendings are known to work with IMGs
• There is an affiliated PM&R residency
• The department explicitly states that students can request letters of recommendation

Priority #2: Core Specialty Attendings With U.S. Experience

If you cannot secure three PM&R letters, a strong non-PM&R letter can still help you:

• Internal Medicine: Shows your ability to manage complex, multi-morbid patients (highly relevant for inpatient rehab)
• Neurology: Supports your approach to stroke, spinal cord injury, TBI, and neuromuscular disease
• Orthopedics or Sports Medicine: Useful if you are targeting outpatient MSK or sports-focused PM&R programs

These attendings help demonstrate:

• Solid medical knowledge and clinical judgment
• Dependability, work ethic, and professionalism
• Ability to coordinate care with allied health professionals

Priority #3: Research Mentors or Department Leadership

Consider a research or departmental letter if:

• The project is related to PM&R, neurology, MSK, pain, or disability
• The mentor is a well-known physiatrist or academic physician
• You had a sustained role (not just data entry or one-week involvement)

A research letter is especially valuable if:

• You need to strengthen your academic profile as a Caribbean IMG
• You are applying to academic or university-based PM&R programs
• You want to show long-term commitment to physiatry beyond one rotation

Who to Avoid as Your Primary Letter Writers

Even if they know you well, these are usually weak or supplemental letters:

• Non-physician providers (PTs, OTs, NPs, PAs) — great mentors, but not primary letter writers for residency
• Basic science professors from early pre-clinical Caribbean coursework
• Physicians who only worked with you for a short time (1–3 clinic days)
• “Famous” faculty who barely know you and can’t provide specific examples

If you must choose between a big-name physiatrist who barely knows you and a lesser-known attending who observed you daily and supports you strongly, choose the latter. PM&R program directors prefer honest, detailed letters over empty prestige.

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What Makes a Strong PM&R Letter of Recommendation?

Understanding how to get strong LOR is essential. A good letter states that you were “hardworking and interested.” A strong letter proves that you can function like an intern on a PM&R team and are a great fit for physiatry.

Core Elements of a Strong PM&R LOR

Look for letters that highlight:

1. Direct Observation and Context

   • Length and type of rotation: “4-week inpatient rehab rotation at a major academic center”
   • Level of responsibility: “Acted at the level of a sub-intern; independently presented patients”
   • Diversity of experiences: inpatient rehab, consults, procedures, spasticity clinics, EMG observation, etc.

2. Clinical Reasoning and Patient Care Skills

   • Quality of H&P and rehab-focused assessments (function, goals, team involvement)
   • Ability to create practical rehab plans, not just medical diagnoses
   • Engagement in interdisciplinary rounds with therapists, case managers, and nurses

3. Core PM&R Qualities
   PM&R is team-based, patient-centered, and often longitudinal. Programs want to see:

   • Patient communication skills, especially with those who have chronic disability
   • Empathy, patience, and respect for patients and families
   • Maturity in managing chronic pain and functional limitations
   • Comfort collaborating with PT, OT, SLP, nursing, social work, and prosthetists

4. Professionalism and Reliability

   • Punctuality, preparation, and follow-through on tasks
   • Response to feedback and evidence of growth during the rotation
   • Honest comments about integrity, accountability, and teamwork

5. Explicit Advocacy for Your Physiatry Match
   The best letters contain clear endorsement phrases, such as:

   • “I would rank this student in the top 10% of students I have worked with in the last 5 years.”
   • “I would be pleased to have this applicant as a resident in our PM&R program.”
   • “I recommend them without reservation for a PM&R residency position.”

Example: Strong vs Weak Language

• Weak: “She was punctual and worked hard. She is interested in PM&R.”
• Strong: “During her 4-week inpatient rehab rotation, she consistently arrived early, pre-rounded independently, and presented concise, organized assessments. She demonstrated an impressive ability to integrate functional goals into the medical plan and often took the initiative to communicate with PT and OT to coordinate care.”

The second example gives clear, observable behaviors—exactly what program directors look for.

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How to Earn Strong Letters During PM&R Rotations (Especially as a Caribbean IMG)

Letters are not won in the last week of a rotation—they are built from your daily behavior. As a Caribbean IMG, you may feel pressure to “prove yourself” quickly. Use that motivation strategically.

Before the Rotation: Set Yourself Up for Success

1. Clarify Expectations Early

   • Email the attending or coordinator 1–2 weeks before the rotation
   • Ask about dress code, start time, and any reading they recommend
   • Let them know you are a Caribbean IMG interested in a PM&R residency and hope to earn a letter based on strong performance

2. Review Core PM&R Topics
   Before starting, read up on:

   • Basics of inpatient rehab (FIM/IRF-PAI concepts, discharge planning)
   • Common diagnoses: stroke, SCI, TBI, amputations, deconditioning
   • Musculoskeletal exam basics: gait, range of motion, strength testing

3. Understand the System

   • Learn how to use the hospital’s EMR efficiently
   • Know the hospital’s rehab services (inpatient, consults, outpatient)
   • If at a site known for SGU residency match success or other Caribbean IMG training, research previous IMG residents; this may help with networking and expectations

During the Rotation: Behaviors That Lead to Strong LORs

Focus on daily habits that make you stand out:

1. Be Actively Involved in Patient Care

   • Volunteer to see new consults and follow-ups
   • Pre-round and know your patients’ overnight events, labs, and therapy notes
   • Present clearly, with an emphasis on function and rehab needs, not just diagnosis

2. Show PM&R-Specific Thinking
   When you present a case, consistently mention:

   • Functional status (transfers, gait, ADLs)
   • Rehab potential and goals
   • Barriers to discharge and your ideas to address them
   • Coordination needs (e.g., family training, equipment needs)

3. Be a Reliable Team Member

   • Offer to help with notes, calls, or discharge summaries when appropriate
   • Communicate clearly and respectfully with nursing and therapy staff
   • Follow up on tasks you’re assigned and close the loop

4. Ask for Feedback—and Use It

   • Ask your attending midway through the rotation: “Is there anything I can improve to better prepare for residency in PM&R?”
   • Implement feedback quickly; attendings notice growth and maturity
   • If feedback is critical, respond professionally and thank them

5. Signal Your Interest in a Physiatry Match

   • Attend PM&R conferences, journal clubs, or grand rounds if allowed
   • Express your long-term goals: inpatient vs outpatient focus, subspecialty interests (SCI, brain injury, pain, sports, pediatrics)
   • Ask about their career path and what they look for in PM&R residents

When and How to Ask for the Letter

Timing:

• Ask in the last week of your rotation, after you’ve had time to show your capabilities
• If you’re unsure how they view your performance, you may preface with:
  “Based on my performance this month, do you feel comfortable writing a strong letter of recommendation for my PM&R residency applications?”

Script Example:
“In working with you this month, I’ve really appreciated your teaching and feedback. I’m committed to pursuing a PM&R residency, and I would be honored if you could write a strong letter of recommendation on my behalf. I believe you’ve seen my clinical growth and dedication to rehabilitation medicine, and your support would mean a great deal in the application process.”

If they hesitate or seem uncertain, do not push. It is better to have fewer strong letters than more lukewarm ones.

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Logistics, ERAS, and Common Pitfalls for Caribbean IMGs

Handling Letters in ERAS

• Use the ERAS Letter Request Form for each writer
• Confirm that letters are uploaded directly to ERAS (never handled by you)
• Assign the most PM&R-heavy letters to PM&R programs; if you apply to prelim or transitional years, assign more IM/core letters there
• Make sure each letter is properly labeled (e.g., “PM&R – Dr. Smith – Inpatient Rehab Rotation”) so you do not misassign them

Waiving Your Right to View Letters

You should waive your right to view letters in ERAS:

• Programs expect this; it suggests the letter is candid
• If a writer insists on showing you a draft, that’s acceptable—but the final letter should still go directly through ERAS with your rights waived
• As a Caribbean IMG, you especially want program directors to trust that letters are unfiltered

Dealing with Timing and Late Letters

• Ask for letters at least 4–6 weeks before you plan to submit ERAS
• Send polite reminders 2–3 weeks before your target date
• If a key PM&R letter is significantly delayed, consider submitting ERAS with your available letters, then assign the additional letter as soon as it appears

Common Pitfalls for Caribbean IMGs

1. Too Few PM&R Letters

   • Aim for at least two strong PM&R LORs whenever possible
   • If your Caribbean school has limited PM&R access, aggressively seek U.S. electives or away rotations

2. Letters Only from Caribbean-Based Faculty

   • One letter from a Caribbean PM&R or core clinical faculty is fine, but U.S.-based letters carry more weight for many programs
   • Use any opportunity (SGU residency match pathways, affiliated sites, alumni networks) to arrange U.S.-based clinical experiences

3. Generic or Template-Style Letters

   • Avoid letter writers who openly state they “just use a template” and “don’t know residents’ names”
   • If your school uses a centralized LOR service, meet with the dean or writer in person and provide detailed notes about your performance

4. Not Addressing Gaps or Red Flags

   • If you have exam failures, leaves of absence, or academic issues, a supportive letter that addresses your improvement and reliability can be helpful
   • A trusted PM&R attending or program director can discuss your growth if they feel comfortable doing so

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FAQs: Letters of Recommendation for Caribbean IMGs in PM&R

1. Do I absolutely need a letter from a physiatrist to match into PM&R?

Yes, practically speaking, you do. For a physiatry match, at least one PM&R letter is essential, and two PM&R letters is strongly recommended. Programs want evidence that you:

• Understand the specialty
• Have been directly evaluated by a physiatrist
• Are a good fit for the collaborative, function-focused nature of PM&R

If your home school has no PM&R department (common for Caribbean schools), prioritize U.S.-based electives or audition rotations in PM&R specifically to secure these letters.

2. Is a letter from my Caribbean medical school worth less than a U.S. letter?

Not automatically. A detailed, enthusiastic letter from a Caribbean-based attending who worked closely with you is far more valuable than a generic U.S. letter. That said, many programs are more familiar with U.S.-based training environments, and they often prefer at least one or two letters from U.S. clinical faculty, particularly in PM&R, internal medicine, or neurology. Ideally, you will have a mix: strong Caribbean letters plus robust U.S.-based letters.

3. How many letters should I submit if programs allow four?

For PM&R residency applications, three strong letters is the minimum. A fourth letter is helpful if:

• It comes from a PM&R attending, program director, or respected research mentor
• It adds new information (e.g., research ability, leadership)
• It does not replace a core PM&R or IM/neurology letter

Avoid sending four letters if one is clearly weaker or redundant; quality outweighs quantity.

4. What if my attending asks me to draft my own letter?

This happens, especially in busy clinical environments. If it occurs:

• Be honest and professional—agree to draft a fact-based, modest version
• Emphasize specific examples of your work ethic, growth, and PM&R interest
• Avoid over-the-top language; your writer can edit and strengthen it as they see fit
• Always ensure the final letter is edited, signed, and uploaded by your attending, not you

If you are uncomfortable, you can say:
“I’d be happy to provide a detailed CV and a summary of my activities and strengths to make it easier for you to write the letter.”
Most attendings will accept that and write it themselves.

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Strong, thoughtful letters of recommendation can dramatically enhance your application as a Caribbean IMG aiming for a PM&R residency. By choosing your letter writers wisely, performing at a high level on your rotations, and understanding the logistics of ERAS and the physiatry match, you can present yourself as a capable, committed future physiatrist—regardless of where you started medical school.