Essential Guide to Residency Letters of Recommendation for Caribbean IMGs

Understanding the Role of Letters of Recommendation for Caribbean IMGs in Clinical Informatics

For Caribbean medical graduates aiming for a career in Clinical Informatics in the United States, letters of recommendation (LORs) can be the difference between being screened out and earning an interview. This is especially true if you are coming from a Caribbean medical school residency pipeline like SGU, AUC, or Ross and you’re targeting competitive, tech-forward programs that value data-driven care, health IT training, and innovation.

Clinical informatics is still a relatively small and specialized field. Program directors often rely heavily on residency letters of recommendation to understand:

• Your clinical competence and reliability as an intern or resident
• Your potential to succeed in a data- and technology-focused environment
• Your communication skills and professionalism
• Your trajectory: interest in informatics, quality improvement, and health IT

As a Caribbean IMG, you may already feel you need to overcome biases about “Caribbean medical school residency” applicants. Strong, targeted letters that speak directly to your abilities, your performance in U.S. clinical settings, and your potential in informatics can counteract those biases.

In this guide, we will walk step-by-step through:

• How LORs are used in both residency and clinical informatics fellowship
• Who to ask for letters (and who not to)
• How to get strong LORs as an IMG from a Caribbean school
• Specific strategies to highlight your interest in clinical informatics and health IT training
• How to handle SGU residency match and similar pathways strategically using letters

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What Program Directors Look For in Letters (Residency and Clinical Informatics)

Residency LOR expectations and clinical informatics fellowship expectations overlap but are not identical. Understanding this difference helps you guide your letter writers.

Core Expectations for Any Residency Letter of Recommendation

For preliminary or categorical residency positions (Internal Medicine, Family Medicine, etc.), program directors usually want letters to comment on:

• Clinical competence: history/physical exam skills, diagnostic reasoning, management decisions
• Work ethic and reliability: punctuality, follow-through, ability to carry a patient load
• Communication and teamwork: collaboration with nurses, residents, attendings, patients
• Professionalism: integrity, responsiveness to feedback, respect, handling of conflicts
• Readiness for internship: Can this person safely manage patients with indirect supervision?

As a Caribbean IMG, you especially need LORs that reassure PDs about:

• Your adaptability to U.S. hospital systems
• Your cultural competence and communication with diverse patient populations
• Your performance compared with U.S. grads on the same rotations

When your letter writers use comparative language (“in the top 10% of students I have supervised in the last 5 years,” “stronger than most U.S. graduates I work with”), they help overcome assumptions related to training background.

Additional Expectations for Clinical Informatics–Oriented Letters

If you are already thinking about a clinical informatics fellowship or an informatics-focused career, you want LORs that, at minimum, hint at your strengths in:

• Systems thinking: seeing patterns in workflows, identifying process gaps
• Data literacy: comfort with data, quality metrics, basic statistics, dashboards, or EHR reports
• Technology comfort: EHR proficiency, interest in clinical decision support, order sets, etc.
• Innovation and problem-solving: involvement in QI projects, EMR optimization, or health IT tools
• Interdisciplinary collaboration: working with IT, nursing, pharmacy, or data analysts

Ideally, at least one letter will explicitly mention your interest in “clinical informatics,” “health IT,” “data-driven care,” or “quality improvement,” even if you’re applying now to a traditional residency.

Key Point: As a Caribbean IMG aiming for informatics, your letters should first prove you are a safe, reliable clinician—and then show that you’re already thinking beyond the single patient to systems and data.

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Who to Ask for Letters (and How to Get Strong LORs as a Caribbean IMG)

Many Caribbean IMGs struggle with “who to ask for letters.” This question is even more important when you’re thinking ahead to clinical informatics.

Who to Ask for Letters: Priority List

1. U.S. Clinical Supervisors in Core Specialties

   • Attendings on Internal Medicine, Family Medicine, Pediatrics, or Surgery rotations
   • Ideal for residency application letters if you are seeking those specialties
   • Best if they have directly observed your clinical work for at least 3–4 weeks

2. Program Directors, Clerkship Directors, or Site Directors

   • Particularly impactful if they know you well
   • Good for both residency and future clinical informatics fellowship if they can speak to your growth, leadership, or QI efforts

3. Subspecialty or Elective Attending with Informatics/QI Involvement

   • Example: an attending who is an EHR champion, a quality officer, or has a formal title in clinical informatics
   • Highly valuable if you want a letter that speaks to health IT training potential and informatics aptitude

4. Research Mentor (Especially If Informatics, Data, or QI Focused)

   • Good supplemental letter, especially for clinical informatics fellowship applications later
   • Should comment not only on research skills but also on professional behavior, persistence, and collaboration

5. Non-U.S. or Non-Clinical Letters (Use Sparingly)

   • May be used supplementally (e.g., a strong letter from Caribbean faculty) but should not replace U.S. clinical LORs in most residency applications

Who Not to Rely On (Or Use Only as Extra)

• Family friends, alumni from your Caribbean medical school who never supervised you clinically, or non-physician administrators
  • They rarely carry weight unless they directly supervised your performance in an academic or clinical context.
• Letters from observerships only, unless the observer had significant and frequent contact and truly assessed you.
• Non-healthcare employers unless part of a specific dual degree or informatics role; they can be a 4th “supplemental” letter but not core.

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How to Get Strong LORs (Not Just Generic Ones)

Knowing how to get strong LOR letters is a skill in itself. As a Caribbean IMG, you must be proactive and intentional.

1. Start Building Relationships Early

On every U.S. rotation:

• Identify 1–2 attendings who see your work consistently.
• Ask early for feedback: “Is there anything I can do to perform at a higher level on this rotation?”
• Demonstrate growth by acting on feedback and checking back: “I’ve tried to improve my presentations the way you suggested—does this look better?”

Strong letters often come from attendings who have seen you improve and can describe your trajectory in detail.

2. Signal Your Career Interests

If you are interested in clinical informatics:

• Mention it during the rotation: “I’m very interested in clinical informatics and health IT training; I hope to work on EHR optimization or data-driven QI in my career.”
• Look for ways to engage informatics-related tasks:
  • Helping streamline order sets
  • Working with QI teams
  • Suggesting simple EHR workflow improvements

This way, when the attending writes your LOR, they can authentically comment on your interest in informatics.

3. Ask the “Strength Question”

When asking for a letter, do not just say, “Can you write me a recommendation?”
Instead, ask explicitly:

“Would you feel comfortable writing me a strong letter of recommendation for my residency application in [specialty]? It would mean a lot if you could comment on my clinical performance and my interest in clinical informatics and quality improvement.”

This gives them an opportunity to decline if they cannot write a strong letter, which is far better than receiving a lukewarm one.

4. Provide a Helpful Letter Packet

When you ask for LORs, especially as an IMG who needs to stand out, make it easy for your writer:

Include:

• Updated CV
• Personal statement (or draft) – especially if you mention interest in clinical informatics or health IT
• A 1-page “LOR highlights” sheet:
  • Dates of your rotation
  • Specific patients or cases you worked on that went well
  • Projects or QI/EHR initiatives you were involved in
  • Reminders of your contributions (e.g., “Developed a prototype Excel dashboard to track clinic no-show rates”)

Politely state:
“I’ve attached a brief summary of my experience with you to make writing the letter easier; please feel free to use or ignore as you see fit.”

5. Give Plenty of Time and Gentle Reminders

• Aim for 4–6 weeks before your submission deadline.
• Follow up professionally:
  • One friendly reminder 1–2 weeks after request (if no response)
  • Another reminder 1–2 weeks before your target submission date

This is especially important if you’re trying to position yourself for an SGU residency match or similar Caribbean medical school residency funnels that have many applicants: delayed letters can hurt you in programs that review early.

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Crafting Letters That Highlight Clinical Informatics Potential

You can’t write your own letters, but you can shape what your writers know about you and what they choose to emphasize.

What You Want Letters to Say (Even If Not Verbally Scripted)

For both residency and future clinical informatics fellowship applications, you ideally want at least one or two letters that convey:

1. You are clinically solid and safe.
   • “Excellent clinical reasoning,” “thorough yet efficient,” “reliable follow-through”
2. You think in systems, not just individual cases.
   • “Frequently asked questions about why workflows were structured as they were and suggested feasible improvements.”
3. You are data-curious and tech-comfortable.
   • “Naturally gravitated toward using EMR tools, dashboards, or data reports.”
4. You have initiative in health IT or QI.
   • “Led a small project to standardize discharge instructions using EMR templates,” or
   • “Helped identify and correct a recurring EHR order error.”
5. You are a good communicator and collaborator.
   • Critical for any informatics role where you must bridge clinicians and IT.

You can influence this by:

• Taking the initiative on informatics-adjacent tasks on rotation
• Communicating those activities clearly in your CV and “LOR highlights”
• Reminding your letter writer of specific examples (“When we worked on the sepsis alert modification…”)

Example “Highlight Sheet” Bullets for an Informatics-Focused Resident Applicant

You might send your attending something like:

• During this rotation, I:
  • Helped create a structured template in the EMR for daily progress notes on our heart failure service.
  • Analyzed 2 weeks of readmission data for our unit and presented it at morning report.
  • Identified a duplicative nursing documentation step in the EMR and proposed a streamlined alternative, which was shared with the unit manager.
  • Used a basic Excel sheet to track and visualize our team’s case load and discharge times.

Without scripting the letter, you are reminding them of concrete informatics-relevant behaviors they can honestly include.

Positioning for a Future Clinical Informatics Fellowship

Most clinical informatics fellowships expect:

• Completed residency (often in Internal Medicine, Pediatrics, Family Medicine, EM, etc.)
• Evidence of interest in and exposure to informatics, data, QI, or health IT training

Your residency letters, especially from program leadership, will later be key when you apply for a clinical informatics fellowship. Those letters should ideally reference:

• Your involvement in residency QI projects
• Any data analysis, EMR optimization, or dashboard work you did
• Your leadership or committee roles (e.g., informatics committee, EHR superuser, etc.)

As a Caribbean IMG, you may not have informatics exposure in med school. That’s okay. Use residency to build that track record and signal this goal early to mentors, so that by PGY2/PGY3 they can write targeted informatics support letters.

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Strategizing Letters Across the Timeline: From Caribbean School to Fellowship

Your strategy evolves as you progress:

Phase 1: Caribbean Medical School → Residency Applications

Primary goals:

• Demonstrate you are a safe and strong clinician in U.S. settings
• Reassure PDs about your performance relative to U.S. grads
• If possible, hint at your interest in informatics

LOR profile:

• 3–4 letters:
  • 2–3 from U.S. core clinical rotations
  • 1 from a subspecialty or elective (ideally with QI or informatics flavor)
• At least one writer who can comment on:
  • Your adaptability as an IMG
  • Your strong work ethic and growth over the rotation

Key considerations for Caribbean IMGs:

• Programs may know your school (e.g., SGU); some have prior experience with SGU residency match patterns or similar. Letters from well-known U.S. institutions or respected attendings can offset concerns about school reputation.
• Prioritize rotations at teaching hospitals affiliated with major U.S. academic centers when possible, and then get letters from there.

Phase 2: Early Residency (PGY1–PGY2) → Building Informatics Profile

Primary goals:

• Confirm your reputation as a strong intern/resident
• Begin engaging in health IT, QI, or data projects

What to do:

• Join QI initiatives, EMR optimization groups, or digital health pilots.
• Ask your chief residents or attendings which committees are informatics-focused.
• Consider electives in:
  • Quality and Safety
  • Healthcare Operations
  • Clinical Informatics (if offered)

Letters to cultivate for the future:

• Program Director or Associate PD who can speak to your clinical excellence and committee/leadership roles.
• An informatics physician or CMIO (Chief Medical Information Officer) who supervises your project.

Phase 3: Applying to a Clinical Informatics Fellowship

Now your LOR strategy becomes more targeted:

• 1–2 letters from residency leadership (PD/APD) emphasizing:
  • Clinical ability
  • Reliability
  • Overall professional conduct and leadership
• 1–2 letters from informatics mentors or project supervisors focusing on:
  • Your specific informatics activities: EHR projects, QI data analysis, CDS rules, dashboards, telehealth workflows, etc.
  • Your understanding of both clinical realities and technical constraints

Here, your question of who to ask for letters is much more about informatics credibility. A letter from a recognized informatics leader can strongly support your application.

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Common Pitfalls for Caribbean IMGs and How to Avoid Them

As a Caribbean IMG, you face some specific LOR-related challenges. Address them early:

Pitfall 1: Letters That Sound Vague or Generic

Phrases like “hardworking,” “pleasant,” and “good student” without detail are weak. They may even be interpreted as coded language for “average.”

Prevention:

• Choose writers who have had enough exposure to you.
• Provide specific examples and accomplishments in your highlight sheet.
• Ask if they feel they can write a strong letter.

Pitfall 2: Over-Reliance on Non-U.S. or Non-Clinical Letters

Residency programs want to know how you perform in U.S. clinical environments. A glowing letter from a Caribbean preclinical professor does not compensate for the absence of strong U.S. clinical LORs.

Prevention:

• Prioritize getting at least 2–3 letters from U.S.-based clinical rotations.
• If you must include a Caribbean faculty letter, make it supplemental rather than primary.

Pitfall 3: Not Connecting Letters to a Coherent Career Story

If your personal statement is heavily about clinical informatics but none of your letters mention it, reviewers may doubt your commitment or see it as a last-minute buzzword.

Prevention:

• Let your letter writers know about your informatics interest.
• Share informatics-related projects and ask if they’re comfortable mentioning them.
• Ensure your CV, personal statement, and letters all tell a consistent story.

Pitfall 4: Timing Errors and Late Letters

Caribbean IMGs sometimes face unpredictable rotation schedules or visa challenges and delay asking for LORs. Late letters may mean your application is not complete during early review, decreasing your interview chances.

Prevention:

• Identify 3–4 potential letter writers at least a few months before ERAS opens.
• Ask for letters as soon as you finish a strong rotation—even if you’re not applying that year yet. Letters can often be uploaded later.
• Track submission status and send polite reminders.

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FAQs: Letters of Recommendation for Caribbean IMGs Targeting Clinical Informatics

1. How many letters of recommendation do I need for residency, and should any be informatics-focused?

Most residency programs require 3 letters, and some allow a 4th. As a Caribbean IMG:

• Aim for 3 strong U.S. clinical letters as your core.
• If you have an informatics-oriented mentor who supervised substantial work, that letter can either be your 3rd or a 4th supplemental letter.
  Even if no letter is explicitly “informatics,” you should still try to have at least one that mentions your interest in data, QI, or health IT.

2. If my school is in the Caribbean (e.g., SGU), how can I make my LORs competitive against U.S. grads?

Focus on:

• Well-known U.S. clinical sites: Letters from attendings at recognized U.S. teaching hospitals carry significant weight.
• Comparative statements: Ask writers who can compare you favorably to U.S. grads.
• Specific examples: Provide them with detailed reminders of your best cases and projects.

For students from SGU and similar schools, an SGU residency match is often supported by long-standing relationships with specific programs. Strong letters from those affiliated hospitals can make your application stand out even amid many Caribbean medical school residency applicants.

3. Do I need separate letters when I later apply to a clinical informatics fellowship?

Yes. For clinical informatics fellowships, you will typically need:

• New letters from your residency PD or APD and
• Mentors who supervised your informatics, QI, or technology projects.

Your original residency application letters are useful history but are usually not resubmitted as-is. However, the same people may write updated letters that now focus more on your informatics growth.

4. What if I don’t have any formal informatics experience—can my letters still support a clinical informatics path?

Yes. At the residency stage, programs do not expect you to be a full-fledged informatician. Your letters can still support this trajectory by emphasizing:

• Your curiosity about systems and data
• Early QI or workflow-improvement efforts
• Your comfort with technology and rapid learning

During residency, you’ll intentionally build your informatics profile—projects, committee roles, and health IT training—that will then be highlighted in fellowship letters.

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Strong letters of recommendation are one of the most powerful tools you have to overcome bias as a Caribbean IMG and to shape your path toward a clinical informatics career. By choosing the right writers, preparing them thoughtfully, and aligning your clinical work with your informatics interests, you can turn your LORs into a compelling, coherent narrative that convinces both residency and future fellowship programs that you belong in the next generation of clinician-informaticians.