A Comprehensive Guide to Letters of Recommendation for US Citizen IMGs in EM-IM

Understanding the Role of Letters of Recommendation for US Citizen IMGs in EM-IM

For a US citizen IMG or an American studying abroad, letters of recommendation (LORs) can make or break your application to Emergency Medicine–Internal Medicine (EM-IM) combined programs. Because program directors cannot reliably compare your school’s reputation or grading system to US schools, they lean heavily on trusted voices—your letter writers—to understand your clinical skills, professionalism, and fit for a demanding dual specialty.

EM-IM programs are small, highly selective, and they expect you to be competitive for both emergency medicine and internal medicine. Your residency letters of recommendation must therefore convince programs of three things:

1. You can handle the acuity and pace of emergency medicine.
2. You have the depth, reasoning, and follow-through expected in internal medicine.
3. You will thrive in a five-year combined training environment and are committed to this path.

For a US citizen IMG, strong, credible letters can help reduce concerns about training location, perceived variability in clinical exposure, or unfamiliar grading scales. In many cases, they are the single most important “context” tool programs use to interpret your application.

In this guide, you’ll learn:

• How many letters you need and what EM-IM programs are actually looking for
• Who to ask for letters (and who not to ask)
• How to get strong LORs as a US citizen IMG with limited US clinical time
• How to support your writers so they can advocate powerfully for you
• Specific EM-IM–focused strategies and example approaches

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How Many Letters You Need and What EM-IM Programs Expect

Core Numbers and Types of Letters

Most EM-IM combined programs participate in ERAS and follow similar letter expectations to categorical EM and IM, with their own twist. Always check each program’s website, but a generally safe strategy is:

• Total letters to upload in ERAS: 4
• Letters to assign to EM-IM programs: 3–4 (ERAS allows up to 4 per program)

A competitive EM-IM letter mix for a US citizen IMG typically looks like:

1. 1 Standardized Letter of Evaluation (SLOE) from an EM rotation

   • Preferably from a US-based academic EM program (home or away rotation)
   • Group SLOE from the department/committee is best; individual EM faculty SLOE is acceptable if that’s what the site provides.

2. 1 traditional letter from an internal medicine attending

   • Ideally from an inpatient ward or ICU rotation in the US
   • Should speak to your diagnostic reasoning, longitudinal care, and professionalism.

3. 1 additional EM or IM letter

   • Another SLOE or strong EM LOR; or
   • Another IM letter (ward/ICU, not purely outpatient if possible).

4. 1 “flex” letter

   • Could be from:
     • Combined EM-IM faculty (gold standard if available)
     • Subspecialty rotation showing EM-IM-relevant skills (ICU, cardiology, pulmonary/critical care, hospitalist, trauma surgery)
     • A long-term mentor or research PI closely involved in your clinical or academic work (less ideal if zero clinical exposure).

For EM-IM, programs like to see at least:

• One clearly EM-focused letter
• One clearly IM-focused letter
• Evidence you understand and are committed to the dual path, which can be woven into either.

What Programs Read Between the Lines

Beyond generic praise, EM-IM programs look for:

• Clinical readiness: Can you function at or above the expected level of a new intern in a busy ED or medical ward?
• Adaptability and resilience: EM-IM is five intense years. Do you handle pressure, feedback, and long hours?
• Intellectual curiosity and depth: Particularly valued on the internal medicine side; EM-IM wants residents who think beyond quick dispositions.
• Teamwork and communication: How you work with nurses, consultants, and patients under pressure.
• Commitment to EM-IM: Do you understand the realities of combined training, or are you indecisive between EM and IM?

For a US citizen IMG, programs also scan letters carefully for:

• Direct comparison to US-trained students when possible
• Explicit reassurance about your clinical performance across different systems
• Evidence of success in a US clinical environment (if you have US rotations)

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Who to Ask for Letters (and Who to Avoid)

Understanding who to ask for letters is just as important as understanding how to get strong LOR. As a US citizen IMG, you may feel pressure to “collect” letters from anyone willing—but strategy matters more than volume.

Highest-Yield Letter Writers for EM-IM

1. Emergency Medicine Faculty (especially academic EM)
Ideal writers:

• Program director, associate/assistant PD, or clerkship director in EM
• Site/rotation director at a US academic EM department
• Senior EM faculty who directly supervised you for multiple shifts

Why they matter:

• EM-IM programs rely heavily on EM assessments for combined spots.
• A SLOE from a US EM rotation is often seen as more informative than a generic letter from a non-EM specialty.

2. Internal Medicine Faculty (inpatient or ICU)
Ideal writers:

• Ward attending on general inpatient IM service
• ICU or step-down attending
• IM clerkship director or sub-I director

Why they matter:

• They can speak to your clinical reasoning, follow-through, and multi-day patient management—key for IM credibility.

3. Faculty with EM-IM or EM/IM/CC backgrounds

If you can find:

• A combined EM-IM trained physician
• An EM physician with strong internal medicine or critical care practice
• A dual-boarded or hospitalist EM physician

They can uniquely speak to your fit for dual training and your understanding of both practice environments.

Medium-Yield but Sometimes Necessary Writers

4. US Subspecialty Faculty in Relevant Fields

Examples:

• Critical care (medical, surgical, neuro)
• Cardiology, pulmonology, nephrology (for complex inpatient care exposure)
• Trauma surgery with heavy ED interface

Use these when:

• You lack enough EM or IM letters from US-based experience
• The subspecialty attending directly supervised you, knows you well, and can describe your performance in detail

5. Long-Term Mentors or Research Supervisors

Use cautiously, and only if:

• They know you very well
• There is a clinical or applied component to your work, or they can speak credibly to your professionalism, reliability, and growth
• Their letter would complement, not replace, clinical LORs

They are best as a 4th “bonus” letter, not as a substitute for EM/IM clinical letters.

Low-Yield or Problematic Letter Writers

You should generally avoid using:

• Very senior “name” faculty who barely know you
  • Generic letters with big titles but no specifics are a red flag.
• Non-clinical basic science faculty as primary letters
  • They rarely help much for EM-IM unless you have a unique, relevant research story.
• Family friends, community physicians who didn’t supervise you clinically
  • Programs can easily tell when the relationship isn’t based on structured clinical evaluation.
• Letters from your home country only, when you have US clinical evaluations available
  • Home-country letters can be valuable context but shouldn’t overshadow US clinical evaluations if you have them.

If you must use home-country letters (for example, if US clinical access was limited), choose:

• A department chair or training director
• A faculty member who supervised you closely in an ED or ward setting
• Someone who can explicitly compare you to previous graduates who went on to train in the US or other competitive systems

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

The core question behind every LOR is: “How do I convince this attending to write me a specific, enthusiastic, comparative letter?” For a US citizen IMG or American studying abroad, you also want them to address any perceived gaps from your IMG status.

1. Maximize Your Performance on Key Rotations

Before you think about who to ask for letters, focus on becoming an outstanding student on:

• US EM rotations (home or away/audition)
• US IM rotations (ward or ICU)
• Any rotation where you might want a future letter

High-yield behaviors on EM rotations:

• Show up early, prepared, with a pattern: see patients quickly, present succinctly, document clearly.
• Ask for feedback early in the rotation: “I’m hoping to be competitive for EM-IM; are there specific skills I can focus on this week to get there?”
• Volunteer (within reason) for higher-acuity or complex cases when invited.

High-yield behaviors on IM rotations:

• Own your patients—know every detail of their history, meds, studies, and follow-up.
• Present clearly, synthesize problems, and propose plans rather than just listing data.
• Show reliability: daily follow-through, calling consults, updating families, closed-loop communication.

2. Signal Your EM-IM Interest Early

On both EM and IM rotations, let your attendings know:

• You are a US citizen IMG
• You are applying specifically to EM-IM combined programs (and possibly also to categorical EM or IM, depending on your plan)
• You are hoping to demonstrate readiness for combined training and would value feedback on where you stand

This does two things:

• It frames your performance in the context of a high bar (combined training).
• It prompts attendings to think about you as a potential EM-IM fit while they observe you.

3. Choose the Right Moment to Ask

Aim to ask for a letter near the end of a rotation when:

• You’ve had substantial direct contact (multiple shifts or >1–2 weeks of ward time)
• You’ve already demonstrated improvement over time
• You have at least informal feedback that is positive

A practical script:

“Dr. Smith, I’ve really appreciated working with you this month. I’m a US citizen IMG applying to Emergency Medicine–Internal Medicine combined programs and trying to build a strong set of letters. Based on what you’ve seen of my performance, would you feel comfortable writing me a strong letter of recommendation for EM-IM?”

The word “strong” is important. If they hesitate or downgrade the language (“I can write you a letter,” but not “a strong letter”), thank them and consider asking someone else as your primary letter writer.

4. Provide a Helpful Letter Writer Packet

To help your attendings write detailed, credible letters, give them a concise packet with:

• Your CV
• A brief, focused personal statement (EM-IM–oriented if possible)
• A 1-page “brag sheet” or bullets with:
  • 3–5 patients or clinical scenarios that showcase your skills
  • Any unique aspects of your path (US citizen IMG, American studying abroad, language skills, etc.)
  • Your reasons for pursuing EM-IM combined training
• Any program-specific details if you are asking them to highlight combined training suitability

You can phrase it as:

“I know your time is limited; I’ve put together a brief summary of my background and my interest in EM-IM to make the letter easier to write. Please feel free to use anything that’s helpful and ignore anything that isn’t.”

5. Explicitly Address Your IMG Context (Without Apologizing)

For US citizen IMG applicants, it can help to gently prime your letter writer:

• Explain briefly why you chose to train abroad (e.g., timeline, personal reasons, opportunity).
• Highlight steps you’ve taken to align with US training (USMLE performance, US clinical experience, research with US faculty).
• Ask if they can comment specifically on how your performance compares to US med students or interns they’ve worked with.

Example ask:

“If you feel it’s accurate, it would be extremely helpful if you could comment on how my performance compares to the US medical students and interns you’ve worked with. Many programs find that kind of comparison helpful for applicants like me who trained abroad.”

6. Give Plenty of Lead Time and Gentle Follow-Up

• Ask at least 4–6 weeks before you need the letter uploaded to ERAS.
• After they agree, send a follow-up email with your materials and links/instructions.
• Two weeks before your target submission date, you can send a polite reminder:

“Dear Dr. Smith,
I hope you’re doing well. I just wanted to touch base regarding the EM-IM letter of recommendation for my ERAS application. The ideal upload date is [date], but as long as it’s in by [later date], it will still reach most programs before they start reviewing. Please let me know if there’s anything else I can provide. Thank you again for your support.”

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EM-IM–Specific Tips: Aligning Your Letters With a Combined Career

Emergency Medicine–Internal Medicine is not just “half EM and half IM.” It’s a deliberate career choice with unique demands. The strongest letters for EM-IM do more than say you’re “good in the ED” or “strong on the wards”; they show you are wired for combined training.

Content Themes Your Letters Should Highlight

When you think about how to get strong LOR tailored to EM-IM, consider asking writers (where appropriate) to address:

1. Breadth and depth of thinking

   • EM side: Rapid assessment, prioritization, early stabilization.
   • IM side: Longitudinal thinking, working through complex differentials, coordinating multi-day care.

2. Comfort with acuity and complexity

   • Handling critically ill patients in ED or ICU contexts
   • Following complex patients over time (sepsis, multi-organ failure, undiagnosed systemic disease)

3. Resilience and stamina

   • Demonstrated ability to maintain performance over long shifts or rotations
   • Emotional maturity when handling bad outcomes, difficult families, or diagnostic uncertainty

4. Curiosity beyond a single specialty

   • Interest in systems of care, transitions between ED and inpatient, or continuity after ED visits
   • Reflective comments about seeing both “front door” and “long view” of medicine

You don’t tell your writers what to say, but by sharing your goals and experiences, you nudge them toward these themes.

Example Micro-Requests to Writers (Respectful, Not Prescriptive)

In your email, you might write:

“Because I’m applying to EM-IM combined programs, it’s especially helpful if programs can see how I function in both acute care and longitudinal/internal medicine–type thinking. I’ve attached a short list of patients and situations that felt particularly illustrative of that balance, in case they’re useful as you think about the letter.”

Then list 2–3 examples:

• A patient you saw in the ED, then followed on the wards
• A complex ICU patient where you helped connect ED and inpatient decisions
• A challenging case where you integrated acute resuscitation and long-term planning

Should You Have Letters Explicitly Say “EM-IM”?

Yes—when accurate, it helps. Programs want to know:

• You are not simply undecided between EM and IM
• You understand this is usually five years, not three
• You have thought about career paths (e.g., EM-IM hospitalist, ED-based observation units, critical care, administration, etc.)

A writer might include lines like:

• “Given Alex’s strong performance in both rapid decision-making in acute situations and thoughtful follow-through with complex inpatients, I believe he will be an excellent fit for Emergency Medicine–Internal Medicine combined training.”
• “I have no doubt that Priya would thrive in a rigorous five-year EM-IM residency and emerge as a leader in integrated acute and inpatient care.”

You don’t script these sentences, but by clearly conveying your goals, you make it easier for writers to frame your fit for dual training.

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Practical Problems and Solutions for US Citizen IMGs

Problem 1: Limited or Late US Clinical Rotations

If your first US EM rotation is in August–September of application year, you may worry your SLOE will be late.

Strategies:

• Still pursue the SLOE—it’s often better for programs to see a strong SLOE that arrives a bit later than never.
• Use strong, early IM or subspecialty letters for initial review; then update programs once your SLOE is uploaded.
• If you have earlier home-country EM or IM letters: choose the most detailed and comparative ones, especially those that can reference graduates who went to US residencies.

Problem 2: No Home EM Department or Limited EM Exposure Abroad

As many international schools lack robust academic EM:

• Maximize any ED exposure you do have (even short blocks).
• Emphasize overlapping experiences: ICU, trauma services, acute admissions.
• Pursue elective EM rotations in the US as early as possible (often your final year).
• Ask your US EM attendings if they can explicitly comment on how quickly you adapted, given your home environment.

Problem 3: Concern About Bias Toward IMGs

While you cannot control individual biases, you can help letter writers address program directors’ questions:

• Ask if they can comment explicitly on:
  • Your communication skills with patients and staff
  • Your adaptability to the US system, documentation, and workflow
  • Your comparison to US graduates at their institution
• Use your US letters to demonstrate that you already function well in US hospitals, not that you are just “promising” in theory.

Problem 4: Mixed EM and IM Applications

Many EM-IM applicants also apply to categorical EM or IM. You can handle this by:

• Asking for “EM-IM and EM” letters from EM attendings, and “EM-IM and IM” letters from IM attendings.
• Uploading the same letter to EM-IM and EM programs (unless the writer insists on tailoring).
• Ensuring your writers know you genuinely value a combined path, even if you will also interview in categorical programs.

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Frequently Asked Questions (FAQ)

1. As a US citizen IMG, do I absolutely need a SLOE for EM-IM applications?
A SLOE from a US EM rotation is strongly preferred and often expected, especially for the EM component of EM-IM programs. Without any SLOE, it becomes harder for programs to benchmark you against their usual EM applicants. If you truly cannot obtain a SLOE, prioritize:

• Strong US IM inpatient letters
• Detailed letters from US acute care settings (ICU, trauma, acute admissions)
• Early communication with programs to explain your situation

But whenever possible, schedule at least one US EM rotation that can generate a SLOE before or early in application season.

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2. How should I rank my letters in ERAS or decide which 3–4 to send to EM-IM programs?
There is no formal “ranking” visible to programs, only which letters you assign. For EM-IM combined programs, an optimal mix is:

• 1 SLOE (EM)
• 1 IM inpatient or ICU letter
• 1 additional EM or IM letter (whichever is stronger)
• 1 flex letter (subspecialty or mentor) if it truly adds something unique

If you have more than four letters in ERAS, selectively assign:

• The most detailed and directly observed clinical letters
• Letters that mention EM-IM suitability or speak well to both acute and longitudinal care.

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3. Is it better to get a letter from a famous professor who barely knows me, or a lesser-known attending who worked closely with me?
For EM-IM (and most residencies), specificity beats prestige. A detailed letter from a mid-career attending who directly supervised you, describes concrete cases, and compares you favorably to peers is far more valuable than a generic paragraph from a department chair who met you twice. Name recognition only helps when paired with honest, detailed advocacy.

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4. Should I see or edit my letters of recommendation?

In the US system, residency letters of recommendation are expected to be confidential. Waiving your right to view them is standard and can increase their perceived credibility. You should not ask to read or edit the letter itself. What you should do is:

• Provide a clear, concise packet (CV, personal statement, “brag sheet”)
• Clarify your goals (EM-IM combined) and any context (US citizen IMG, American studying abroad)
• Trust your writer’s professional judgment—if they accepted after you asked for a “strong” letter, they likely support you.

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By approaching letters strategically—choosing the right writers, performing strongly on key rotations, and clearly conveying your EM-IM goals—you give program directors the context they need to see you as a capable, committed future EM-IM resident. For a US citizen IMG, strong, detailed, well-aligned letters can be the single most powerful tool to bridge the gap between “interesting candidate” and “confident interview invite.”