Mastering Letters of Recommendation for MD Graduates in Prelim Medicine

Understanding Letters of Recommendation for a Preliminary Medicine Year

For an MD graduate aiming for a preliminary medicine year (prelim IM), letters of recommendation can significantly influence your allopathic medical school match outcome. Even if your ultimate goal is another specialty (neurology, anesthesiology, radiology, dermatology, etc.), your preliminary medicine application has to stand on its own—and that includes strong, targeted residency letters of recommendation.

This article explains how letters work specifically for a Preliminary Medicine application, how many you need, who to ask for letters, and how to get strong LOR that support both your categorical specialty goals and your prelim IM year.

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1. Why Letters Matter So Much for a Prelim Medicine Year

1.1 The unique role of prelim medicine in your training

A preliminary medicine year is a one-year internal medicine internship. It is often required for:

• Neurology
• Anesthesiology
• Radiation oncology
• PM&R
• Dermatology
• Ophthalmology
• Some radiology pathways
• Certain specialties that want an intern year with strong inpatient exposure

Because the prelim year is short and intense, programs want applicants who can:

• Function safely and efficiently on an inpatient medicine team
• Handle night float, cross-coverage, and rapid clinical decision-making
• Work well with multidisciplinary teams
• Communicate effectively and respectfully under pressure

Your MD graduate residency application needs to show that—even if your long-term specialty is not internal medicine, you are committed to being a reliable, teachable, and hard-working intern.

1.2 Why letters are especially important for prelim IM

Prelim medicine programs often receive many applications from well-qualified MD and DO graduates. Your board scores and transcript may look similar to others, so letters help programs answer:

• Can this person handle busy inpatient medicine services?
• Will they show up, do the work, and not burn out or disengage?
• Will they be pleasant to work with at 3 AM?
• Are they trustworthy with acutely ill patients and complex medical issues?

A strong letter from an internal medicine attending who has seen you on wards, night float, or ICU can strongly reassure a prelim program that you’re a safe and dependable choice.

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2. How Many Letters You Need and How to Distribute Them

2.1 Typical requirements for MD graduates

For most allopathic medical school match applications:

• ERAS allows you to assign up to 4 letters per program.
• Most programs require 3 letters, and some recommend or allow a 4th.

Because you’re applying both to:

• A categorical specialty (e.g., Neurology, Anesthesia, etc.), and
• Preliminary medicine programs

…you’ll need a flexible letter strategy that works for both.

2.2 Recommended letter mix for prelim IM

For your prelim IM applications, a typical and effective mix is:

• 2 letters from Internal Medicine attendings
  • Preferably from inpatient ward, ICU, or night float rotations
  • At least 1 should be a detailed, narrative letter from someone who worked closely with you
• 1 additional clinical letter
  • Could be from your primary specialty of interest (e.g., anesthesiology, neurology)
  • Or another core clerkship (e.g., surgery, family medicine)
• Optional 4th letter:
  • Program director letter (internal medicine or your home department)
  • Research mentor in a clinical field, if they know your clinical performance well

2.3 Coordinating letters for both categorical and prelim applications

If you are, for example, an MD graduate applying for:

• Categorical Neurology, and
• Preliminary Medicine

You might aim for:

• 2 Neurology-focused letters (or 1 neurology + 1 PD/department letter)
• 2 Internal Medicine letters

Then:

• Assign more neurology-focused letters to your neurology programs
• Assign more internal medicine letters to your prelim medicine programs

You do not need two completely separate letter sets; you need a core group of strong letters that you assign strategically.

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3. Who to Ask for Letters for a Preliminary Medicine Application

Choosing who to ask for letters is the single most important decision in building a strong LOR file.

3.1 Priority #1: Internal Medicine attendings

For prelim IM, you want at least two letters from Internal Medicine attendings who have:

• Supervised you directly
• Worked with you over time (not just one or two days)
• Observed you in busy, inpatient settings when possible

Ideal sources:

• Wards/teaching hospital Internal Medicine rotations
• Inpatient subspecialty rotations (e.g., cardiology, GI, heme-onc)
• ICU or step-down unit rotations with an IM attending
• Night float with an IM attending who rounds or reviews overnight work

What these attendings can speak to:

• Your clinical reasoning and problem-solving
• Your reliability (does your work get done? do you follow through?)
• Your ability to hand off safely and accurately
• Your communication with nurses, consults, families, and co-residents
• Your work ethic and resilience

3.2 Priority #2: Your categorical specialty faculty (if applicable)

If you’re an MD graduate applying to a non-IM specialty (e.g., Neurology, Anesthesiology) while also seeking a preliminary medicine year, you still want:

• 1–2 letters from your intended specialty attendings
• These letters are more critical for your categorical application
• But they can also still be useful for your prelim IM application if they highlight:
  • Your performance as a sub-intern or acting intern
  • Your inpatient skills, team function, and professionalism
  • Experience managing medically complex patients

3.3 Additional options: Program directors and research mentors

If you have space for a 4th letter or are choosing between potential writers, consider:

Program Director / Clerkship Director Letter

• Example: Internal Medicine clerkship director, Neurology clerkship director, or your home department residency PD
• Strong if they can:
  • Place your performance in context (e.g., top 10% of students)
  • Comment on patterns of professionalism and growth
  • Reference multiple rotations or evaluation data

Research Mentor

• Reasonable if:
  • They know you well and can comment on your character and work ethic
  • They have directly observed your clinical work (best case)
  • Or your research is strongly clinical and team-based
• Less helpful if:
  • The letter is purely about research productivity with no clinical examples

3.4 Who not to prioritize

For a preliminary medicine LOR set, lower priority would be:

• Letters from non-clinical basic science faculty who never saw your clinical work
• Shadowing-only letters (particularly from outpatient private practice)
• Letters from non-physicians (PA, NP, nurse) unless explicitly allowed and extremely strong; usually better as supplemental feedback rather than main letters

If you must choose, always prioritize attendings who supervised your inpatient or high-acuity clinical care.

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4. How to Get Strong LOR for a Prelim Medicine Application

Understanding how to get strong LOR is about more than asking early. It starts with how you perform on rotations long before you request a letter.

4.1 Laying the groundwork on rotations

On your Internal Medicine and inpatient rotations, deliberately act with future letters in mind.

Behaviors that produce strong letters:

• Reliability:

  • Show up early, prepared, and organized
  • Volunteer for tasks and complete them fully
  • Double-check orders, follow up labs, and close the loop on patient issues

• Ownership of patients:

  • Know your patient’s story, labs, imaging, and plan in detail
  • Anticipate next steps and overnight issues
  • Communicate clearly with nurses and consultants

• Clinical reasoning:

  • Present structured, logical assessments and plans
  • Ask thoughtful, not performative, questions
  • Incorporate feedback into your next patient or next day’s work

• Teamwork & professionalism:

  • Be consistently respectful to all staff
  • Help co-students and interns when you can
  • Stay calm and constructive under pressure

You want attendings to naturally think: “I would be comfortable with this student as my intern.”

4.2 Asking the “right way”: the key question

When you are ready to request a letter, ask in a way that gives the attending permission to decline if they can’t write you a strong one.

Example language (in person or by email):

“Dr. Smith, I’m applying for a preliminary internal medicine year as part of my residency plans. I really valued working with you on the wards, and I was hoping you might be able to write me a strong letter of recommendation commenting on my performance as a near-intern. Do you feel you’d be able to do that?”

This phrasing:

• Signals that you care about the quality of the letter
• Allows them to decline if they don’t know you well enough
• Encourages more honest and supportive letters overall

If they hesitate or say something like, “I can write a letter,” but not specifically “strong,” consider asking another attending as well.

4.3 Timing your requests as an MD graduate

If you are approaching or have completed graduation from an allopathic medical school, be mindful of timing:

• During or right after a strong IM rotation:
  • Ideally ask in the last week of the rotation or within 2–4 weeks afterward
  • Attendings’ memories fade; earlier requests mean better details
• For graduated MDs (gap year, research year, etc.):
  • Reconnect via email; remind them of who you are and what rotation you did together
  • Provide specific dates and a brief recap of your role

Aim to have all letters requested by late summer for a typical September ERAS opening, and ideally uploaded by early–mid September.

4.4 Providing a “letter packet” to your writers

Make it easy for your attendings to write a detailed, supportive letter. Send them:

1. Your updated CV
2. Personal statement(s)
   • One for your categorical specialty
   • Optional short note or statement about why you want a strong prelim year, if different
3. ERAS letter request with the correct designation (Prelim IM vs categorical specialty)
4. A short, bulleted summary of:
   • When and where you worked together
   • Specific patients, cases, or experiences that stood out
   • Strengths you hope they can emphasize (e.g., “work ethic, clinical reasoning, ability to manage complex inpatient cases”)

Sample paragraph you might include in your email:

“We worked together on the inpatient medicine service at University Hospital in March 2025. I cared for 6–8 patients daily, including several with decompensated heart failure and sepsis. I tried to take full ownership of my patients, especially in organizing follow-up labs, coordinating with case management, and preparing for family meetings. For my preliminary medicine applications, it would be especially helpful if you could comment on my clinical reasoning, reliability, and ability to function at a near-intern level on a busy service.”

This kind of context helps attendings write more specific, impactful letters.

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5. Making Your Letters Work for Both Categorical and Prelim Applications

Many MD graduates worry about “splitting focus” between categorical and prelim programs. With some planning, your residency letters of recommendation can strengthen both.

5.1 Specialty-focused vs prelim-focused letters

Discuss your specific goals with your letter writers:

• For specialty-focused letters (e.g., radiology, anesthesia, neurology):

  • Ask them to emphasize your commitment to that specialty
  • But also mention your readiness to handle a demanding intern year

• For prelim medicine–focused letters:

  • Ask them to emphasize your inpatient internal medicine skills
  • They can still briefly mention your long-term specialty goals, framed positively

Example guidance to an IM attending:

“For my preliminary internal medicine applications, it would help if you could focus on my performance on the wards—how I handled working up admissions, my reliability in following through on tasks, and how I worked with the team. It’s also fine to mention that my intended field is neurology, but I want programs to know I’m fully committed to a strong medicine intern year.”

5.2 Customizing letter assignments in ERAS

Within ERAS, you can:

• Upload each letter once
• Then assign letters selectively to each program

Practical approach:

• Prelim IM programs:

  • 2 Internal Medicine attendings
  • 1–2 letters from your intended specialty or PD, highlighting your general clinical strengths

• Categorical specialty programs:

  • 2 specialty letters
  • 1 Internal Medicine attending letter (especially helpful if your field is inpatient-heavy or wants a strong intern year)
  • Optional PD letter

This way, each program sees letters that align with what they care about most—without you needing completely separate letter sets.

5.3 Handling weaker or older letters

If you suspect a letter may be:

• Generic
• Old (from early MS3 with limited clinical experience)
• From a rotation unrelated to internal medicine or your target specialty

Consider not assigning it, especially if you already have three strong recent letters. Quality > quantity.

If you graduated some time ago and only have older letters:

• Proactively address what you have done since graduation (research, clinical work, observerships) in your personal statement and experiences section
• If possible, obtain at least one recent clinical letter from any supervised clinical role (e.g., hospitalist service, research with embedded clinical work, observership with active participation where permitted).

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6. Common Pitfalls and How to Avoid Them

6.1 Waiting too long to ask

If you delay until the last moment:

• Attendings may be overwhelmed with other letters
• They may not remember your performance well
• Details in the letter may be generic and weaker

Solution:
Ask near the end of the rotation or shortly afterward, and send gentle, respectful reminders 2–3 weeks before your needed deadline.

6.2 Asking someone who barely knows you

A big name does not guarantee a strong letter.

Signs a letter may be weak:

• The attending rarely saw your presentations or patient care
• You only interacted with them in a lecture or conference setting
• They supervised you for a very brief period

Instead, choose someone who:

• Directly supervised your work
• Knows your personality and work style
• Can recall specific examples of your performance

6.3 Not specifying “prelim medicine” vs categorical needs

If you don’t clarify your goals, an attending might:

• Focus solely on your ultimate specialty interest
• Fail to mention your readiness for an intensive medicine intern year

Always be explicit:
“I am applying for both categorical neurology and a preliminary internal medicine year required for training.”

6.4 Forgetting professionalism around letters

Avoid:

• Asking for a copy of the letter if your institution expects waived rights (most programs prefer waived letters)
• Micromanaging content or demanding specific language
• Repeatedly pressuring attendings or sending frequent emails

Do:

• Waive your right to view letters in ERAS (this is the norm and can increase credibility)
• Send one polite reminder if a deadline is approaching
• Thank your letter writers with a short email, and later update them on your match outcome

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FAQ: Letters of Recommendation for MD Graduates in Preliminary Medicine

1. How many Internal Medicine letters do I need specifically for a prelim IM application?

Aim for at least two Internal Medicine letters from attendings who supervised you directly—preferably on busy inpatient rotations, ICU, or night float. These show prelim programs that you can function as a reliable medicine intern. Your third or fourth letter can be from your categorical specialty, a program director, or a strong clinical mentor.

2. Can I use the same letters for both my categorical specialty and my preliminary medicine applications?

Yes. ERAS allows you to assign letters selectively to programs. You can upload a set of 3–4 strong letters and then choose a slightly different combination for categorical programs vs prelim IM programs. Just make sure at least some letters emphasize your ability to succeed in a demanding preliminary medicine year.

3. Who should I prioritize if I can only get three letters?

For an MD graduate targeting a prelim IM year plus a categorical specialty, a strong three-letter set might be:

1. Internal Medicine attending (inpatient, strong clinical letter)
2. Second Internal Medicine attending or IM clerkship director
3. Categorical specialty attending (e.g., neurology, anesthesia, etc.)

If you are very limited, never skip having at least one strong Internal Medicine attending letter.

4. Is it okay if one of my letters is from research and not directly clinical?

It can be okay, especially if:

• The research is clinical and team-based
• The mentor can describe your communication, reliability, and clinical judgment
• You still have at least two clinical letters, including Internal Medicine

However, for a preliminary medicine application, research letters should be supplemental, not substitutes for clinical IM letters.

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By planning ahead, choosing the right writers, and being intentional about how to get strong LOR, you can present a compelling, well-documented case that you will thrive during your preliminary medicine year—and lay a strong foundation for success in both your intern year and your ultimate specialty.