Mastering Letters of Recommendation for US Citizen IMG in Global Health

Understanding Letters of Recommendation as a US Citizen IMG in Global Health

Letters of recommendation (LoRs) can make or break your residency application—especially when you are a US citizen IMG aiming for a global health–focused residency track. Program directors routinely say that strong, specific letters carry more weight than test scores once you’re past basic cutoffs. For an American studying abroad, your letters also serve an extra purpose: they validate that you can thrive in the US clinical environment and that your global health work is meaningful, not just “medical tourism.”

This article focuses on how a US citizen IMG applying to global health, international medicine, or global health residency tracks can strategically plan, request, and maximize the impact of residency letters of recommendation. You’ll learn who to ask for letters, how to get strong LORs, what global health programs are looking for, and how to navigate common IMG-specific pitfalls.

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What Global Health Programs Look for in Letters of Recommendation

Global health–oriented residencies (e.g., internal medicine, pediatrics, family medicine with a global health residency track, or dedicated international medicine programs) are looking for both core clinical competence and global health alignment. Your letters should reflect both.

Core Competencies Every Letter Should Address

Regardless of specialty or setting, every LoR should speak to:

• Clinical knowledge and reasoning
• Reliability and professionalism
• Communication skills with patients and teams
• Teamwork and adaptability
• Work ethic and integrity

For a US citizen IMG, these letters must also implicitly answer two questions:

1. “Can this applicant function effectively in the US healthcare system?”
   Program directors want assurance that you understand US standards of care, documentation, communication norms, and interprofessional teamwork.

2. “Are the assessments comparable to US benchmarks?”
   Letters from US-trained faculty or from faculty familiar with US training systems carry extra weight because they know how to contextualize your performance.

Global Health–Specific Attributes Programs Want to See

To stand out for international medicine or a global health residency track, your letters should highlight:

• Commitment to global health
  Longitudinal engagement rather than a single short trip. Mention of multi-year involvement, scholarly work, or leadership in global health projects.

• Cultural humility and respect
  Not “saving” or “helping poor communities,” but working collaboratively with local teams, listening, and showing respect for local expertise.

• Systems thinking and public health orientation
  Understanding how social determinants, health systems, and policy affect care—and demonstrating that in your clinical and project work.

• Ethical practice in low-resource settings
  Respecting scope of practice, supervision, and local standards rather than pushing to perform procedures for your own learning.

• Resilience and adaptability
  Managing uncertainty, resource limitations, and emotionally heavy cases while still functioning as a dependable team member.

An ideal letter for a global health–inclined program explicitly connects these traits to the kind of resident you will be in their track or international medicine pathway.

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Who to Ask for Letters: Building the Right Mix as a US Citizen IMG

One of the most common questions is who to ask for letters to create the strongest, most credible application as an American studying abroad. You want a portfolio of letters that checks three boxes: US credibility, specialty alignment, and global health fit.

The “Ideal Mix” of Letters

Most residency programs allow 3–4 letters plus the MSPE/Dean’s letter. For global health–oriented applications, consider:

1. US Clinical Letter(s) – Non-negotiable

   • At least one (ideally two) letters from US-based clinical rotations (sub-internships, electives, observerships with hands-on components where possible).
   • Preferably in the specialty you’re applying to (e.g., internal medicine, pediatrics, family medicine).

2. Home/International School Clinical Letter

   • A letter from your primary hospital or medical school that shows consistent, long-term performance.
   • For US citizen IMGs, this helps contextualize your training abroad.

3. Global Health / International Medicine Letter

   • From a supervisor who saw you in a global health, international medicine, or low-resource setting or on global health research/advocacy.
   • Crucial if you’re specifically targeting a global health residency track.

If you are allowed four letters, a strong mix might be:

• 2 US clinical letters (core specialty)
• 1 global health–focused letter (clinical or research)
• 1 letter from your home institution (considered “back-up” or submitted selectively based on program preferences)

Prioritizing US vs. International Letter Writers

As a US citizen IMG, you must demonstrate that your skills are directly translatable to US practice:

• US letters from core rotations in your specialty (e.g., IM or FM) often carry the greatest weight.
• A global health letter from a US-based faculty member (who supervised you abroad or at a US global health center) can be extremely powerful—it confirms both your clinical and global health potential in familiar benchmarks.
• If your strongest clinical push came from international mentors, that’s still valuable, but you should supplement with at least one US-based letter.

Who Not to Ask for Letters

Avoid asking for letters from:

• Faculty who barely know you or only saw you briefly.
• Non-physicians unless they co-sign with a physician (rare exceptions: public health PhDs in combined MD/MPH or research tracks, but still weaker than MD/DO letters).
• Alumni, family friends, or “famous” people who can’t comment meaningfully on your clinical performance.
• Short-term shadowing experiences with no documented evaluation.

The best LoRs are from people who can say, “I worked with this applicant extensively and can compare them to other students I have supervised from US schools.”

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How to Get Strong LORs: Strategy for US Citizen IMGs in Global Health

You don’t “get” strong letters at the end of a rotation; you build them from day one. For US citizen IMGs in particular, you’re often working against limited exposure windows in the US and need to be intentional.

Step 1: Plan Your Rotations Around Letters

Before you even start your US or global health rotations, map out:

• Which rotations are most critical?

  • US internal medicine or family medicine electives (if applying IM/FM).
  • Pediatric sub-I if aiming for pediatric global health.
  • Dedicated global health or international medicine elective.

• Which faculty are likely to be strong advocates?
  Ask residents which attendings are known for good teaching and mentorship. Try to get scheduled with them early in the year.

• Timing for ERAS
  Ensure your key rotations finish by late summer or early fall of application year so letters can be uploaded before programs start reviewing.

Step 2: Behave Like a Sub-Intern from Day One

To position yourself for a powerful letter:

• Arrive early, stay late; always be prepared for your patients.
• Take full ownership: follow up labs, call consults, know your patients’ social context.
• Volunteer for admissions, procedures (within your scope), and patient/family meetings.
• Document carefully and learn the local EMR quickly.
• Ask for feedback early: “What can I do better to function more like an intern?”

Global health–oriented programs look for residents who can function independently yet safely; your letter writers need to see glimpses of that during your rotations.

Step 3: Make Your Global Health Work Visible and Meaningful

For your global health letter:

• Don’t just show up; embed yourself in a project or sustained role (clinic, teaching, QI, research).
• Ask your supervisor how you can contribute in a way that will continue after you leave—this shows maturity and ethics.
• Keep a brief log of:
  • Cases you managed
  • Systems issues you noticed
  • Projects you contributed to
  • Interprofessional teamwork scenarios

Later, you can share this log with your letter writer to help them recall specifics.

Step 4: Ask Explicitly for a “Strong, Detailed” Letter

When you’re ready to ask:

• Do it in person or via video when possible, then follow with an email.
• Use wording like:
  “I’ve really valued working with you and am applying to internal medicine programs with a global health focus. Would you feel comfortable writing me a strong, detailed letter of recommendation that speaks to my clinical performance and suitability for a global health–oriented residency?”

This phrasing gives the faculty member a graceful way to decline if they cannot write you a strong letter, which is better than a lukewarm or generic one.

Step 5: Provide a “Letter Writer Packet”

Help your writers help you. Send:

• Your CV (highlight global health, international medicine, and leadership).
• A draft personal statement (even if not final yet).
• A short summary (1 page or less) including:
  • Your intended specialty and goal (e.g., “Internal Medicine with a global health residency track, aim to work in international medicine and health systems strengthening.”)
  • Bullet points of what you did under their supervision (number of weeks, responsibilities, notable cases, any feedback they gave you).
  • Skills or attributes you hope they can emphasize (e.g., cross-cultural communication, resourceful clinical reasoning, commitment to underserved communities).
• Any program-specific instructions (e.g., upload to ERAS, deadlines, whether the letter should address global health).

For US-based faculty, clarify that you are a US citizen IMG and briefly explain your path as an American studying abroad—they can subtly address any concerns about your transition back to the US system.

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Crafting Letters That Highlight Global Health–Relevant Strengths

You don’t write your own letters, but you can shape what goes into them by the way you present your experiences and by what you request your recommenders emphasize.

Attributes to Highlight for Global Health Tracks

When you speak with your letter writers or send them your summary, you can mention that global health–oriented programs value:

• Cultural humility and communication
  Example request: “If appropriate, I’d appreciate if you could comment on how I worked with patients from different backgrounds and with interpreters.”

• Adaptability in low-resource or unfamiliar settings
  Example: “I tried to be resourceful in managing patients when certain diagnostics weren’t available; if you observed that, it would be helpful to mention.”

• Long-term commitment to underserved populations
  Especially if you’ve worked with migrant populations, indigenous communities, or underserved US groups.

• Ethical decision-making in global settings
  Respecting local protocols, working within my scope, and collaborating with local providers.

Concrete Examples Your Letters Should Include

Program directors trust letters that contain specific stories rather than generic adjectives. Good examples:

• A time you navigated a complex social determinant of health (e.g., medication access, transportation, immigration status).
• A case where you coordinated with local nurses, community health workers, or interpreters to build a realistic discharge plan.
• Your contribution to a quality improvement or public health project (e.g., vaccination outreach, HIV retention in care, maternal mortality review).
• How you negotiated cultural differences respectfully when making care recommendations.

Encourage your writers indirectly by reminding them of such episodes in your summary email: “During the rotation, I especially remember the case of Ms. X, the patient with advanced heart failure who lived three hours away; I worked with the CHW team to coordinate follow-up…”

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Practical Tips, Timing, and Common Pitfalls for US Citizen IMGs

Timing Your Letters for ERAS and Global Health Tracks

• Ask 4–8 weeks before you need the letter uploaded.
  Faculty are busy; this courtesy increases the chance of a thoughtful letter.

• Request letters immediately after rotations while you’re still fresh in their mind, even if you won’t apply until the next cycle.
  They can save and later upload when ERAS opens.

• Check program requirements
  Some global health residency tracks prefer or require at least one letter speaking to:

  • Work in low-resource or international settings
  • Research or MPH/public health experience

Handling Red Flags or Gaps in an IMG Context

If you anticipate concerns (extended time to graduate, exam failures, gaps for research or global service):

• Choose letter writers who know the context and can speak to your growth.
• They can say, for example:
  “Although he took an extra year to complete an MPH, this additional training has significantly enhanced his systems-level understanding, which was evident in how he approached patient care and QI projects.”

For US citizen IMGs, letters that frame non-traditional paths as deliberate and valuable are particularly important.

Avoiding Common Mistakes in Letter Strategy

1. Only non-US letters
   This is a major red flag. Even if your global health experiences are abroad, secure at least one strong US clinical letter.

2. Letters from “big names” who don’t know you
   A generic letter from a famous global health leader is weaker than a detailed letter from a mid-career clinician who worked closely with you.

3. Ignoring program fit
   Global health tracks vary: some emphasize international field work, others focus on local underserved care and policy.
   Your letters should align with how you present yourself in your personal statement and ERAS entries.

4. Not waiving your right to see letters
   Always waive your right in ERAS. Program directors give more weight to confidential letters.

5. Last-minute scrambling
   Late letters raise questions about organization and professionalism. Start planning your letter strategy at least 6–9 months before you apply.

Sample Email Template for Requesting a Letter

You can adapt this to your situation:

Subject: Request for Residency Letter of Recommendation

Dear Dr. [Name],

I hope you are well. I wanted to thank you again for the opportunity to work with you on the [service/rotation] from [dates]. I learned a great deal about [brief, specific insight].

I am a US citizen IMG currently attending [School], and I am applying to [specialty, e.g., Internal Medicine] residency programs with a strong interest in global health and international medicine. I was hoping to ask if you would feel comfortable writing me a strong, detailed letter of recommendation for my ERAS application.

I valued your feedback during the rotation, particularly regarding [specific skill or area you improved], and I believe your perspective on my clinical performance, teamwork, and readiness for residency would be very meaningful to programs.

I have attached my CV and a draft of my personal statement, along with a brief summary of my work on your service to assist you. Letters are submitted directly through the ERAS system; if you are willing, I can provide the ERAS Letter Request Form with upload instructions. My target deadline for having letters uploaded is [date].

Thank you very much for considering this request and for your mentorship.

Sincerely,
[Your Name]
[AAMC/ERAS ID if applicable]

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Putting It All Together: A Letter Strategy for US Citizen IMG Interested in Global Health

To summarize a practical, high-yield approach:

1. Identify your target:

   • Specialty (e.g., internal medicine, family medicine, pediatrics) plus global health residency track or international medicine focus.

2. Plan rotations intentionally:

   • At least one US core rotation in your specialty with hands-on involvement.
   • A substantial global health or international medicine experience.
   • Continuity with mentors who can see you over time.

3. Decide your letter portfolio:

   • 2 US clinical letters in your target specialty.
   • 1 global health or international medicine–focused letter.
   • 1 additional letter (home institution or research/global health mentor) as allowed.

4. Invest in relationships:

   • Show up consistently, seek feedback, and demonstrate genuine commitment to underserved and global populations.

5. Ask clearly and early:

   • Use the phrase “strong, detailed letter of recommendation.”
   • Provide a thoughtful letter writer packet.

6. Align letters with your narrative:

   • Your personal statement, CV, and letters should tell a coherent story: a US citizen IMG with a sustained, ethical commitment to global health and the skills to be an excellent resident in the US system.

Done well, your letters won’t just confirm that you’re competent; they will convince programs that you are precisely the type of resident they want in their global health residency track—clinically strong, globally aware, and ready to contribute to international medicine in a thoughtful, sustainable way.

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FAQs: Letters of Recommendation for US Citizen IMGs in Global Health

1. How many global health–specific letters do I actually need?

One strong global health–focused letter is usually enough, especially if you also discuss global health extensively in your personal statement and experiences section. Your other letters should emphasize core clinical performance in US settings. More than one global health letter can help if you are applying to highly specialized global health tracks, but not at the expense of solid US clinical letters.

2. Is a letter from a global health research mentor as valuable as a clinical letter?

A research mentor’s letter can be powerful—especially if it involves global health, implementation science, or public health—but it usually supplements rather than replaces clinical letters. Programs still prioritize letters that demonstrate your readiness to function as an intern. If your research mentor is also a clinician who has seen your patient care (e.g., on global health rounds), that’s particularly impactful.

3. What if my best global health supervisor is not US-trained or not based in the US?

A letter from a non-US global health supervisor can still be very valuable, especially if they have worked with US trainees before and can compare you to them. To strengthen this, you might:

• Ask them explicitly to compare your performance to US students or residents they’ve supervised.
• Pair that letter with robust US clinical letters to reassure programs about your readiness for the US system.

4. Should I prioritize a slightly weaker US letter over a very strong international letter?

You generally need at least one clearly supportive US letter, even if it’s somewhat less effusive than your international one. However, don’t accept a lukewarm or vaguely negative US letter just to have a US writer. If you suspect a US faculty member cannot write you a strong letter, seek another US clinical experience or another US-based mentor (such as a global health or research mentor) who knows you well.

Balancing US-based credibility with the depth of your global health experience is key. Aim for a combination that demonstrates both: you are ready to excel in US residency and you bring genuine, well-founded commitment to international medicine and global health.