Essential Guide to LORs for Non-US Citizen IMGs in Med-Peds Residency

Understanding the Role of Letters of Recommendation in Med-Peds for Non-US Citizen IMGs

For a non-US citizen IMG applying to Medicine-Pediatrics (Med-Peds), letters of recommendation (LORs) are often the most powerful part of your application after your clinical performance. Program directors know your test scores and transcripts don’t tell the full story—especially when your medical school is outside the US system. LORs help them answer three key questions:

1. Can this applicant function safely and effectively in US clinical settings?
2. Would I trust this person to care for complex adult and pediatric patients?
3. Would this resident be a good fit for our Med-Peds culture and team?

As a non-US citizen IMG or foreign national medical graduate, you face added challenges: unfamiliarity with the US system, fewer home-institution connections, and sometimes limited US clinical experience. Strong, specific LORs can offset these disadvantages and reassure selection committees about your readiness.

This article focuses on how to get strong LORs for Med-Peds as a non-US citizen IMG—what program directors look for, who to ask for letters, how to approach letter writers, and how to make your clinical performance translate into persuasive advocacy on paper.

---

What Med-Peds Programs Look for in Letters of Recommendation

Why Med-Peds Letters Are Distinct

Med-Peds is unique because it combines two full residencies (internal medicine and pediatrics) in four years. Program directors need proof you can:

• Care for both adults and children
• Handle high cognitive complexity and system-based practice
• Work well in interdisciplinary teams
• Think and act like a lifelong learner who can bridge multiple subspecialties

Unlike categorical internal medicine or pediatrics programs, Med-Peds programs often value applicants who show:

• Flexibility moving between adult and pediatric settings
• Comfort with chronic disease management across the lifespan
• Interest in transitional care, complex care, or underserved populations

Your letters of recommendation should highlight these qualities whenever possible.

Core Qualities Programs Want to See

The best residency letters of recommendation for Med-Peds consistently emphasize:

1. Clinical competence in US-style systems

   • Ability to formulate differential diagnoses and management plans
   • Accurate and efficient documentation
   • Safe prescribing, good judgment about when to ask for help

2. Fund of knowledge and clinical reasoning

   • How you approach complex or ambiguous cases
   • Your ability to integrate pathophysiology with clinical data

3. Professionalism and reliability

   • Punctuality, responsibility for patient care tasks
   • Respect for all team members, integrity, responsiveness to feedback

4. Communication skills

   • Rapport with patients and families, including those from diverse backgrounds
   • Clarity and conciseness in presentations and written notes
   • Ability to communicate across teams (nurses, consultants, social workers)

5. Teamwork and teachability

   • Willingness to learn, accept feedback, and improve
   • Contributions to a positive team culture

6. Specific evidence of fit for Med-Peds

   • Performance in both adult and pediatric settings
   • Interest in continuity of care, transition-age youth, complex chronic conditions
   • Adaptability between different patient populations and workflows

Letters that offer concrete clinical anecdotes demonstrating these points carry much more weight than generic statements like “hardworking and enthusiastic.”

---

Who to Ask for Letters: Strategic Choices for Non-US Citizen IMGs

One of the most common concerns is who to ask for letters. For a non-US citizen IMG applying to Med-Peds, the structure of your LOR set is especially important.

The Ideal LOR Mix for Med-Peds

Most Med-Peds programs require 3 letters, sometimes allowing an optional 4th. A strong, typical mix for a foreign national medical graduate is:

1. US Internal Medicine Attending (Clinical)

   • Preferably from an inpatient or core sub-specialty rotation
   • Shows you can handle adult medicine in the US system

2. US Pediatrics Attending (Clinical)

   • Inpatient or outpatient rotation with substantial supervision and interaction
   • Demonstrates comfort with children, families, and pediatric team dynamics

3. US Med-Peds Physician (If Available) or Another Strong Attending Letter

   • A Med-Peds attending is ideal, especially someone who knows the combined culture
   • If not available, a second letter from IM, Peds, Family Medicine, or another core field is acceptable—as long as it’s strong and detailed

4. Optional 4th Letter (If Programs Allow)

   • Research mentor (if they can speak to your clinical potential, professionalism, and work ethic)
   • Strong non-US letter (only if it provides exceptional depth and detail and you are sure programs will read a fourth letter)

If you do not have access to a Med-Peds attending, it is better to have two very strong US letters from IM and Peds than a weak Med-Peds letter.

Prioritizing US Clinical Experience Letters

For non-US citizen IMGs, US clinical letters are often critical:

• They reassure programs that you can function in US hospitals/clinics.
• They provide direct comparison with US graduates.
• They validate your Step scores and transcript with real-world performance.

If you have limited US clinical experience, maximize the impact of what you do have:

• Ask for letters from core rotations (IM, Peds, Family Medicine) over very short observerships in niche subspecialties.
• Long-term experiences (4–8 weeks) usually yield stronger, more detailed letters than brief observerships.

When Non-US Letters Still Matter

A letter from your home institution (outside the US) can add value when:

• The writer is a senior faculty member or department chair who knows you very well.
• The letter offers longitudinal insight over years of training.
• It highlights leadership, academic excellence, and professional maturity.

However, such letters should supplement, not replace, US letters—especially for a non-US citizen IMG targeting competitive programs.

---

How to Get Strong LORs: From Clinical Performance to Persuasive Letters

Step 1: Plan Early and Intentionally

As soon as you know you are interested in Med-Peds:

• Map out at least two US rotations that will allow you to work closely with internal medicine and pediatrics attendings.
• If possible, arrange one rotation at an institution with a Med-Peds program or at least Med-Peds-trained faculty.
• Identify potential letter writers 2–4 weeks into the rotation, not on the last day.

Keep a running list of attendings who:

• Give you direct feedback
• Allow you to manage patients with increasing independence
• See you in multiple settings (inpatient + clinic, or multiple weeks on service)

These are the people most likely to write a strong, detailed letter.

Step 2: Perform Like a Future Resident, Not Just a Student

Your day-to-day behaviors are the raw material for your letters. Program directors pick up on very specific comments from faculty. To strengthen your future LORs:

On Internal Medicine rotations:

• Take responsibility for follow-up: labs, imaging, consultations.
• Present cases with concise, organized structure:
  • Chief complaint → focused history → problem-based assessment/plan.
• Show your ability to handle complex adults: CHF, COPD, DM, sepsis, etc.
• Anticipate next steps (“If the MRI is negative, our next step would be…”).

On Pediatrics rotations:

• Demonstrate comfort communicating with children and parents.
• Be meticulous about dosing, weight-based calculations, and growth parameters.
• Show sensitivity to developmental stages and family dynamics.
• Engage actively with child life, nursing, and allied health staff.

Across all rotations:

• Be on time, every time. Reliability appears in many strong letters.
• Ask for feedback mid-rotation and show visible improvement.
• Offer to help the team while respecting your role and supervision boundaries.
• Maintain professional behavior with patients, families, and staff—even during stress.

Step 3: Ask the Right People, the Right Way

When you’re thinking about who to ask for letters, focus less on titles and more on how well they know your clinical work.

A solid attending LOR is better than a vague letter from the department chair who barely interacted with you.

When asking, use this specific question:

“Do you feel you know my clinical work well enough to write a strong letter of recommendation for my Med-Peds residency application?”

This phrasing gives the writer an opportunity to decline if they cannot write a strong letter. If they hesitate or seem unsure, do not push; choose another writer.

Step 4: Provide a Helpful Letter-Writing Packet

Even an enthusiastic writer can only write a strong LOR if they have enough information. When they agree, send a concise, organized packet:

• Updated CV (with dates, roles, and responsibilities clearly listed)
• Personal Statement Draft (even a rough draft, especially if Med-Peds focused)
• USMLE/Step scores and brief explanation of any gaps (if relevant)
• Transcript or performance evaluations (if they don’t already have them)
• Specific Med-Peds talking points, for example:
  • “I am applying to Med-Peds because I’m interested in caring for adolescents and young adults with chronic childhood-onset conditions.”
  • “I hope to work in a setting that combines adult and pediatric hospital medicine.”

You may also include a short bullet list of things they observed that you hope can be mentioned, such as:

• “Led family meeting for complex pediatric patient with social issues.”
• “Managed multiple adult patients with complex comorbidities on busy ward.”
• “Consistently sought feedback and demonstrated measurable improvement in presentations and notes.”

Do not script the letter or demand specific wording; instead, gently remind them of concrete examples they already witnessed.

Step 5: Respect Timing and Logistics

• Ask 4–8 weeks before deadlines whenever possible.
• Clarify the exact submission method:
  • ERAS system (most common)
  • Institution-specific portal for VSLO or away rotations
• Follow up politely if the letter is not uploaded 2 weeks before your target date.

A short, respectful reminder email might say:

“Dear Dr. [Name],
I hope you are doing well. I wanted to kindly check in about the letter of recommendation for my Med-Peds residency application. ERAS opens for program review on [date], and I plan to finalize my applications by [date]. Please let me know if there is any additional information I can provide.
Thank you again for your support.
Sincerely,
[Your Name]”

---

Med-Peds-Specific Considerations for Non-US Citizen IMGs

Highlighting Both Adult and Pediatric Strengths in Your LOR Set

Program directors will look across all your letters to see if you are balanced:

• Does one letter show strong adult medicine skills and another strong pediatric performance?
• Do any letters explicitly state that you would be well suited for combined training?

Consider briefing at least one letter writer about your Med-Peds goal and asking if they feel comfortable commenting on your fit for combined training.

You might say:

“I’m specifically applying to Medicine-Pediatrics because I enjoy caring for both adult and pediatric patients, especially those with complex chronic conditions. If you feel comfortable, it would be very helpful if you could comment on any observations related to my adaptability between age groups or my potential fit for Med-Peds training.”

Addressing Common IMG Concerns Through Your Letters

As a non-US citizen IMG, program directors may wonder:

• Can you adjust to the pace and expectations of US residency?
• Are your communication skills strong enough for complex patient interactions?
• Do you understand US medical culture, interdisciplinary teamwork, and patient safety standards?
• Will you require visa sponsorship, and is it worth it for the program?

Your letters can help answer these questions by including statements like:

• “I have no hesitation recommending [Name] for a Med-Peds position and would gladly have them in our own residency program.”
• “[Name] functioned at or above the level of our US medical students and sub-interns.”
• “[Name] demonstrates excellent spoken and written English communication and works effectively with patients, families, and staff.”

You cannot control exactly what is written, but by performing strongly and explaining your goals clearly, you can encourage these themes to appear.

Visa Status: What Belongs in a Letter?

Typically, visa details should not be the focus of an LOR. Your letter writers do not need to discuss your visa category or immigration status.

However, they can appropriately mention:

• Length of time they’ve known you in the US system
• Your reliability and commitment (which reassures programs that sponsoring you is worthwhile)
• Your potential to become an asset to the US healthcare workforce long-term

Administrative details about your visa will be handled in other parts of your application and by program coordinators, not through LORs.

---

Practical Examples and Sample Phrases for Strong Med-Peds LORs

While you must never write or alter your own letters, it is helpful to understand what strong content typically looks like. This allows you to shape your performance and your conversations with faculty appropriately.

Example 1: Adult Medicine Emphasis for a Med-Peds Applicant

A strong internal medicine LOR might include phrases like:

• “As a sub-intern on our general medicine service, [Name] managed a demanding census of complex adult patients, including individuals with decompensated heart failure, COPD exacerbations, and uncontrolled diabetes.”
• “[Name] consistently produced well-organized, problem-based assessments and plans and demonstrated sound clinical reasoning, particularly when managing multi-morbidity.”
• “I would rank [Name] in the top 10% of international medical graduates I have worked with in the past five years, and I believe they will excel in a rigorous Med-Peds program.”

Example 2: Pediatric Emphasis Highlighting Med-Peds Fit

A strong pediatrics LOR might include:

• “[Name] quickly built rapport with both children and parents, explaining diagnoses and plans in clear, developmentally appropriate language.”
• “They displayed special interest in adolescents with chronic illness transitioning to adult care, asking thoughtful questions about long-term outcomes and coordination with adult providers.”
• “Given their ability to move comfortably between developmental stages and manage complex care, I believe [Name] is particularly well suited for Medicine-Pediatrics training.”

Example 3: Cross-Setting Perspective (Ideal for Med-Peds Faculty)

If you have access to a Med-Peds attending who supervised you in both adult and pediatric settings, an especially powerful letter might say:

• “I observed [Name] in both our internal medicine and pediatric inpatient services. In each setting, they quickly adapted to differences in workflow, communication style, and clinical focus.”
• “Their curiosity about transition-of-care issues and long-term outcomes across the lifespan reflects the core mindset we value in Med-Peds physicians.”
• “I would be delighted to have [Name] as a resident in our own Med-Peds program and recommend them without reservation.”

Even if you never see the exact wording, your aim is to create the conditions for these kinds of statements to be true and natural for your letter writers.

---

Common Mistakes Non-US Citizen IMGs Make with LORs (and How to Avoid Them)

1. Relying too heavily on non-US letters

   • Solution: Prioritize at least 2–3 strong US clinical letters whenever possible.

2. Choosing famous names over strong advocates

   • Solution: Ask attendings who directly supervised you and can provide detailed observations, even if they are not department chairs.

3. Requesting letters too late

   • Solution: Plan ahead; ask 4–8 weeks in advance and send a complete packet promptly.

4. Not clarifying your interest in Med-Peds

   • Solution: Tell each writer explicitly that you are applying to Med-Peds and why. This allows them to tailor comments to your chosen specialty.

5. Failing to ask for a “strong” letter

   • Solution: Use the phrase “strong letter of recommendation” when asking, giving them an opportunity to decline if they can’t support you enthusiastically.

6. Not monitoring submission status

   • Solution: Track your letters in ERAS and set calendar reminders to follow up politely if needed.

---

FAQs: Letters of Recommendation for Non-US Citizen IMGs in Med-Peds

1. How many Med-Peds–specific letters do I need?

You do not strictly need a Med-Peds-specific letter to match in Med-Peds, especially as a non-US citizen IMG. However:

• At least one letter from internal medicine and one from pediatrics is highly recommended.
• A letter from a Med-Peds physician is ideal but not mandatory.
• What matters most is that your letters are strong, detailed, and from US clinical experiences whenever possible.

2. Can I use the same letters for both Med-Peds and categorical IM or Peds applications?

Yes. Many applicants apply to Med-Peds as well as categorical programs. You can use the same letters across:

• Med-Peds
• Internal Medicine
• Pediatrics

If you know you are applying to both Med-Peds and categorical programs, you can tell your writers this. Some may naturally write a more “generalist” letter that still supports all your applications.

3. What should I do if I only have observerships and no hands-on US clinical experience?

If you lack hands-on US clinical experience:

• Seek observerships or externships where you can still be observed closely by an attending.
• Choose rotations with structured evaluation and teaching.
• Ask your supervisors whether they feel they know you well enough to write a strong letter, emphasizing your clinical reasoning, professionalism, and communication—even if your hands-on role was limited.
• Supplement these with the strongest possible home-country letters, ideally from senior faculty who know you well.

Programs understand the structural barriers for foreign national medical graduates; what they need is convincing evidence of your potential, wherever that can be best demonstrated.

4. Is it ever acceptable to draft my own letter for an attending to sign?

No. You should never write or edit your own letter of recommendation. This is considered unethical in US residency applications and can seriously damage your credibility if discovered.

If a potential letter writer asks you to draft your own letter:

• Politely explain that, for US residency applications, letters need to be written by the evaluator.
• Offer to provide a detailed CV, personal statement, and bullet list of experiences and strengths instead.
• If they insist on you drafting the letter, it’s a sign they may not be the best person to write for you; consider choosing someone else.

---

Thoughtful planning, excellent clinical performance, and strategic communication with your mentors will allow your letters of recommendation to become a major strength in your Med-Peds application—even as a non-US citizen IMG. By understanding what programs look for and how to get strong LORs from the right people, you can significantly improve your chances in the Medicine-Pediatrics match.