Essential Guide to Letters of Recommendation for US Citizen IMGs

Why Letters of Recommendation Matter So Much for US Citizen IMGs

For a US citizen IMG or American studying abroad, letters of recommendation (LORs) can make or break your internal medicine residency application. Programs know less about your school, your grading system, and your clinical rigor than they do for US MD/DO applicants. That knowledge gap puts extra weight on what trusted US physicians say about your clinical performance.

In internal medicine—where teamwork, communication, and clinical reasoning are key—strong residency letters of recommendation help programs answer three essential questions about you:

1. Can this applicant take care of complex adult patients safely and thoughtfully?
2. Will they be reliable, teachable, and pleasant to work with at 3 a.m. on call?
3. Do I trust this attending’s judgment enough to bring this applicant into our team?

For a US citizen IMG aiming for the IM match, LORs serve as a critical “translation tool” that converts your international education into language US program directors understand. This article will walk you through how to get strong LORs, who to ask for letters, timing, content, and strategy—specifically tailored to internal medicine and to American students studying abroad.

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Understanding Internal Medicine LORs as a US Citizen IMG

How Many Letters Do You Need—and From Whom?

Most internal medicine residency programs ask for 3 letters of recommendation, plus the MSPE/Dean’s Letter submitted separately by your school. Some programs allow or accept up to 4; more than 4 is rarely helpful and may dilute your strongest letters.

For a US citizen IMG applying to internal medicine residency, a typical strong LOR mix is:

• 2–3 Internal Medicine letters
  • At least 2 should be from internal medicine attendings who directly supervised you in patient care.
  • Ideally, at least 1 from a US-based IM attending (especially important for US citizen IMGs).
• 1 additional clinically strong letter
  • Another internal medicine attending
  • Or, a related field: cardiology, pulmonary/critical care, endocrinology, geriatrics, hospitalist medicine, etc.

If you have a significant US clinical experience (USCE) block, a US IM letter almost always carries more weight than a letter from an unfamiliar international institution—even if the international faculty know you longer.

Why Internal Medicine–Specific Letters Matter

Internal medicine residency programs want to see letters that speak directly to:

• Your ability to care for complex adult patients with multiple comorbidities
• Clinical reasoning and diagnostic thinking
• Professionalism, reliability, and work ethic
• Teamwork with nurses, residents, and other staff
• Communication with patients and families
• Readiness for intern-level responsibility

A generic “this student was good in clinical rotations” letter is far less helpful than one saying, for example:

“As a sub-intern on our general medicine service, she independently managed 8 patients, presented daily on rounds, and consistently generated thoughtful differential diagnoses with evidence-based plans.”

That sort of narrative is what sets apart strong internal medicine residency letters of recommendation.

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Who to Ask for Letters (and Who Not To)

Ideal Letter Writers for US Citizen IMGs

When you think about who to ask for letters, prioritize how well they know your clinical work over how famous or “big name” they are. For the IM match, a moderately well-known attending who supervised you closely and writes richly detailed letters is far more valuable than a department chair who barely remembers you.

Top priority IM LOR writers:

1. US Internal Medicine Attendings Who Supervised Direct Patient Care

   • From:
     • Inpatient general medicine wards
     • Sub-internship (“acting intern”) rotations
     • US-based electives at academic or large community hospitals
   • Why they matter:
     • They can compare you to US MD/DO students
     • They understand US clinical expectations and culture
     • PDs trust their frame of reference

2. Internal Medicine Subspecialty Attendings (US-based)

   • Cardiology, GI, nephrology, infectious disease, heme/onc, pulm/CC, etc.
   • Especially strong if:
     • You had significant direct patient care responsibilities
     • You presented cases, wrote notes, or participated in consults regularly
   • Less useful if it was shadowing only.

3. International Internal Medicine Attendings Who Know You Very Well

   • Particularly:
     • Course directors
     • Chiefs of service
     • Long-term clinical mentors
   • They are especially valuable when they:
     • Describe your growth over time
     • Provide specific details of your clinical decision-making and professionalism
     • Compare you to your class or past graduates who matched in the US

Secondary Options (Use When Needed)

If you cannot secure enough strong IM letters, consider:

• US hospitalists in community hospitals where you did hands-on USCE
• Non-IM but closely related attendings (e.g., emergency medicine, family medicine)
  • Make sure they:
    • Worked with you clinically
    • Can comment on hospital-based internal medicine skills: acute care, stabilization, admission workups, etc.

These can still significantly help your application, especially when they complement strong IM letters.

Who NOT to Ask for LORs (or Use Cautiously)

Even if they seem impressive on paper, avoid or de-prioritize:

• Physicians who barely know you
  • “He was on my service for 2 weeks; I think he did fine”–type letters are weak.
• Shadowing-only supervisors
  • Without notes, orders, presentations, or clinical responsibilities, they have little to say about your performance.
• Basic science professors with no clinical observation
  • Exception: If you did substantial research under them and need a research letter in addition to strong clinical letters (but not as your primary IM letters).
• Family friends / personal doctors
  • Perceived as biased, and they rarely have objective comparison to other students.
• Letters from non-physicians (unless specifically requested, e.g., for combined research tracks)
  • Program directors prioritize doctor-to-doctor evaluations.

If you’re wondering who to ask for letters, start by listing attendings who:

• Saw you regularly over several weeks
• Trusted you with meaningful responsibilities
• Gave you feedback and saw improvement
• Reacted positively to your initiative and questions

Those are your best initial targets.

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

1. Plan Early—Before You Step onto the Ward

For an American studying abroad, the most high-yield time to secure strong letters is during US clinical experiences, especially core internal medicine and sub-internship rotations. Before starting:

• Clarify your goal:
  Tell yourself: “This rotation is not only for learning; it’s also for earning one of my top internal medicine residency letters of recommendation.”
• Research your attendings:
  • Look them up on the hospital website
  • Note their roles (program leadership, clerkship directors, researchers)
  • Identify who is likely to be able to compare you to other students and talk to PDs

Go in with an intentional plan to:

• Be visible
• Be reliable
• Ask for feedback frequently

2. Stand Out Clinically (in Authentic Ways)

Strong letters come from strong impressions. As a US citizen IMG, you want attendings to think:

“This student performed at the level of, or above, my typical US MD student.”

Concrete behaviors that help:

• Preparation

  • Pre-read common IM topics: chest pain, shortness of breath, sepsis, DKA, heart failure exacerbation
  • Know the basics of:
    • Taking a focused history
    • Presenting succinctly
    • Writing an assessment and plan

• Work Ethic and Reliability

  • Arrive early; stay engaged until work is done (within reason)
  • Always close the loop: if you’re asked to follow up a lab or imaging, circle back and report
  • Volunteer appropriately:
    • “Would it be helpful if I called the family to update them?”
    • “Could I try writing the initial note for this patient for you to review?”

• Clinical Reasoning

  • Don’t just report data—interpret it:
    • “Given his risk factors and EKG changes, I’m concerned about NSTEMI over unstable angina and would start …”
  • Admit uncertainty:
    • “I’m considering pneumonia vs. pulmonary edema, but I’m not sure which is more likely. Could we review this together?”

• Teamwork and Professionalism

  • Be kind and respectful to nurses, clerks, and housekeeping
  • Help co-students when done with your own work
  • Own mistakes and learn from them

These habits give attendings rich material for a strong LOR and are especially important when you’re trying to stand out as a US citizen IMG.

3. Signal Early That You Are Interested in IM

Attendings are much more likely to advocate for you if they see your genuine interest in internal medicine:

Ways to show this:

• Mention early in the rotation:
  “I’m a US citizen IMG planning to apply to internal medicine residency next cycle, especially interested in [e.g., cards/hospital medicine]. I’d really appreciate any feedback on how I can perform at the level of a strong IM applicant.”
• Ask targeted questions about:
  • Internal medicine lifestyle and career paths
  • Fellowship training
  • How they chose their subspecialty

This primes them to think of you as “one of ours” rather than just another rotating student.

4. Ask for Feedback During the Rotation

Don’t wait until the last day to discover what your attending really thinks. Mid-rotation, ask:

• “Could I get some honest feedback on how I’m doing compared to other students at my level?”
• “What could I do in the remaining time on this rotation to be operating at the level of a strong IM residency applicant?”

Use their feedback immediately, then ask again later:

• “You suggested I work on more concise presentations. Can you let me know if you’ve seen improvement?”

This not only improves your performance but also signals coachability, a major theme in strong LORs.

5. How and When to Ask for a Letter

The best time to ask is usually:

• Toward the end of the rotation, when:
  • They have seen your work over several weeks
  • Your best efforts and improvements are fresh in their mind

How to phrase the ask in person:

“Dr. Smith, I’ve really appreciated working with you on this rotation and I’m committed to applying to internal medicine residency as a US citizen IMG. Would you feel comfortable writing me a strong letter of recommendation for my IM applications?”

That word “strong” is important. It gives them an exit if they can’t write one:

• If they say yes enthusiastically → good sign.
• If they hesitate or say they can write a “standard” or “generic” letter → you should consider not using that letter.

6. Provide a Helpful LOR Packet

Once they agree, make it easy for them to write concretely about you. Send:

• Updated CV
• Personal statement draft (even if preliminary)
• Transcript or exam score summary (if appropriate)
• Brief cover email including:
  • Your name, school, and status as a US citizen IMG
  • Your target specialty (internal medicine) and any specific interests
  • Dates and type of rotation you did with them
  • 3–5 bullet points of things you did on the rotation that they observed (no exaggeration)

For example:

• Managed 5–8 patients daily on the inpatient medicine service
• Independently presented new admissions and daily follow-ups on rounds
• Took initiative in updating families and coordinating with nursing staff
• Demonstrated growth in concise presentations and diagnostic reasoning
• Consistently arrived early and stayed until all patient tasks were completed

This “memory jog” helps them write a detailed, personalized letter—exactly what you want when you’re figuring out how to get strong LORs.

7. Waive Your Right to View the Letter

Always waive your right to see the letter in ERAS. Programs expect LORs to be confidential; non-waived letters may be viewed as less candid, and some attendings are less frank if they know you can read it.

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Content and Structure of a Strong IM LOR (What PDs Look For)

You can’t write the letter yourself, but understanding what makes a strong internal medicine LOR helps you:

• Choose the right writers
• Provide them with useful information
• Recognize when you’re setting them up for success

Key Elements Program Directors Like to See

1. Context and Relationship

   • How long and in what capacity the attending worked with you:
     • “I supervised her directly for 4 weeks on the inpatient general medicine service…”
   • What type of learners they usually work with:
     • “I work with US MD, DO, and IMG students and residents throughout the year…”

2. Comparative Statements

   • Strong letters don’t just say you’re “good”; they place you in context:
     • “She performed in the top 10% of students I have worked with in the last 5 years.”
     • “He demonstrated clinical reasoning skills comparable to my first-year residents.”

3. Specific Clinical Examples

   • Stories are powerful:
     • A difficult patient you managed
     • A complex diagnostic challenge you helped solve
     • A time you showed professionalism under pressure

4. Core Internal Medicine Competencies

   • Clinical reasoning and problem-solving
   • History-taking and physical exam skills
   • Documentation and presentations
   • Professionalism and reliability
   • Teamwork and communication
   • Compassion and patient-centered care

5. Growth and Coachability

   • PDs value applicants who can learn quickly:
     • “After feedback that his presentations were lengthy, he rapidly improved and was soon one of the most concise and organized presenters on the team.”

6. Clear Endorsement Statement

   • Strong closing paragraph, such as:
     • “I recommend her without reservation for an internal medicine residency position and would be delighted to have her as a resident in our own program.”

Red Flags or Weak Signs in LORs

• Vague or generic language: “He was good, punctual, and eager to learn.”
• Over-emphasis on personality only, with little clinical detail
• Short letters (e.g., < half a page) with minimal specifics
• Faint praise: “I believe he will do fine in a residency program”
• No comparative statements, or “average among peers” language

For US citizen IMGs, who already face extra scrutiny, you want to avoid any letter that feels lukewarm or generic.

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Logistics, Timing, and Strategy for the IM Match

When to Gather Letters

Typical timeline for a US citizen IMG targeting the IM match:

• 4–18 months before ERAS opens

  • Complete key internal medicine and subspecialty rotations (ideally including USCE)
  • Identify potential letter writers and ask near the end of each rotation

• 3–6 months before ERAS submission

  • Follow up with any attendings who haven’t uploaded letters
  • Decide which 3–4 letters will be your primary ones for internal medicine residency

• September (ERAS submission)

  • Ensure at least 3 letters are uploaded early in the season
  • It’s okay if a 4th arrives a bit later, but earlier is more advantageous

Handling Multiple Letters and Program-Specific Strategies

ERAS allows you to assign different combinations of letters to different programs. Strategic tips:

• For categorical internal medicine programs:

  • Prioritize:
    • 2–3 IM clinical letters
    • 1 additional (IM or closely related) letter as needed

• For preliminary or transitional year positions:

  • IM letters still help a lot
  • If you have a strong letter from a related specialty (e.g., surgery for prelim), you can swap one letter accordingly

If you have:

• 2 strong US IM letters
• 1 strong international IM letter
• 1 strong subspecialty/research letter

You might:

• Use the 3 IM clinical letters as core for most programs
• Add the subspecialty/research letter for more academic or research-heavy programs

Following Up Without Being Annoying

Attendings are busy; polite reminders are normal and expected.

Example email 4–6 weeks after your initial request if the letter isn’t in ERAS yet:

Subject: Gentle Reminder – LOR for Internal Medicine Residency

Dear Dr. Smith,

I hope you’re doing well. I wanted to kindly follow up regarding the letter of recommendation you kindly agreed to write for my internal medicine residency applications. ERAS is now open and I’m planning to submit my application by [date].

If there’s any additional information I can provide to help, I’d be happy to do so. Thank you again for your support and for the opportunity to work with you on the wards.

Sincerely,
[Your Name]

One follow-up after 4–6 weeks, and possibly a final reminder closer to your submission date, is reasonable.

What If You’re Late or Missing Strong Letters?

If you’re a US citizen IMG and find yourself close to ERAS opening without strong internal medicine letters:

1. Prioritize a late but high-quality US IMCE rotation over a quick, low-quality one.
2. Consider delaying your application by a year if:
   • You have no meaningful US IM letters
   • Your only letters are from brief or low-responsibility experiences
3. Use the year to:
   • Obtain robust US clinical experience in internal medicine
   • Build relationships with attendings
   • Secure truly strong LORs and possibly research experience

It’s better to enter the IM match with strong letters once than to reapply multiple times with weaker ones.

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FAQs: Letters of Recommendation for US Citizen IMGs in Internal Medicine

1. How many US letters do I really need as a US citizen IMG?

Aim for at least one strong US internal medicine letter, though two is significantly better. A competitive portfolio might be:

• 2 US internal medicine attendings (wards, sub-I, subspecialty with real responsibility)
• 1 international internal medicine attending who knows you very well
• Optional 4th: subspecialty, research mentor, or another IM letter

Programs understand that not all US citizen IMGs can get 3 US IM letters, but the more strong US-based evaluations you have, the more reassured they feel about your readiness.

2. Are letters from my home country’s famous professors helpful?

They can be helpful if:

• The professor directly supervised your clinical work
• They write specifically about your patient care, reasoning, and professionalism
• They provide strong comparative statements (e.g., “top 5% of students I have worked with”)

However, a famous name that barely knows you is less useful than a mid-level attending who can describe your day-to-day clinical performance in detail. For internal medicine residency, substance beats status.

3. Should I get a research letter if I’m applying to internal medicine?

A research letter is valuable if:

• You’ve done substantial research (months to years)
• The mentor knows you well and can describe:
  • Your work ethic
  • Initiative
  • Critical thinking
• You’re applying to academic IM programs or those with research tracks

However, do not replace core clinical IM letters with only research letters. Ideally, research letters are supplements, not substitutes. Your primary letters must demonstrate clinical readiness.

4. Can I use the same letters if I apply to both internal medicine and another specialty?

You can, but it’s not ideal. Internal medicine LORs are tailored to IM-specific skills. If you are truly dual-applying:

• Try to obtain at least:
  • 2 strong IM letters
  • 1–2 letters tailored to the other specialty
• Coordinate with letter writers:
  • Some are willing to write two versions of the letter (one addressed generally, one emphasizing the other specialty)

If you must reuse the same letters, ask your attendings to keep them general enough to be appropriate for more than one specialty, though this may slightly dilute their IM-specific focus.

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Thoughtful, detailed, and strategic letters of recommendation are one of the most powerful tools you have as a US citizen IMG aiming for an internal medicine residency. By choosing the right letter writers, standing out clinically, asking effectively, and managing logistics well, you significantly strengthen your chances in the IM match—and present yourself as the kind of colleague your future program will be excited to train.