How to Obtain Strong Letters of Recommendation for EM Residency

Why Letters of Recommendation Matter So Much for US Citizen IMGs in Emergency Medicine

For a US citizen IMG (American studying abroad), letters of recommendation can make or break your emergency medicine residency application. Program directors know far less about your school, clinical grading, and exam rigor than they do for US MD/DO students. In that context, your emergency medicine letters of recommendation (LORs) become some of the most trusted signals of your readiness and fit for the specialty.

In emergency medicine specifically:

• EM is team-based and high-stress; programs want proof of how you function on the ED team, not just scores.
• Many programs screen applicants by number and quality of EM-specific letters, often preferring SLOEs (Standardized Letters of Evaluation) when available.
• For an American studying abroad, strong, detailed letters from US-based EM attendings help convince programs you can succeed in a US training environment.

This article walks you through how to get strong LORs, who to ask for letters, how to overcome IMG-specific challenges, and how to strategically use your letters to maximize your chances in the EM match.

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Understanding EM Letters: SLOE vs Traditional LOR

Before planning, you need to understand what emergency medicine programs are actually looking for.

The SLOE: Emergency Medicine’s “Gold Standard” Letter

In EM, the most valued letter is the Standardized Letter of Evaluation (SLOE). It’s a structured form created by the Council of Residency Directors in Emergency Medicine (CORD).

Why programs love SLOEs:

• They use a standardized format, making it easy to compare applicants.
• They explicitly rate you on:
  • Clinical performance
  • Work ethic & reliability
  • Teamwork & communication
  • Professionalism
  • Overall potential as an EM resident
• They place you in ranked categories (top 10%, top 1/3, middle 1/3, etc.).
• They include a global assessment (how highly they would rank you on their own list).

For US citizen IMGs, SLOEs are especially valuable because they:

• Show how you perform in a US emergency department.
• Level the playing field with US MD/DO applicants.
• Help programs look beyond your school’s name and country.

Key point: If at all possible, aim for at least 2 SLOEs from US EM rotations, ideally at sites that regularly write SLOEs.

Traditional LORs: Still Valuable, But Secondary in EM

A traditional letter of recommendation is free-form — a narrative written entirely by the letter writer. In EM, these are usually considered less powerful than SLOEs, but they still matter, especially for US citizen IMGs who may have limited SLOE opportunities.

Types of traditional LORs for EM:

1. EM faculty non-SLOE letter

   • Written by an EM attending, but not in SLOE format.
   • Can be strong if detailed and specific, especially from a US institution.

2. Non-EM clinical letters (e.g., internal medicine, surgery)

   • Demonstrate clinical skills, reliability, professionalism, and work ethic.
   • Useful as supplemental letters or if you lack enough EM-specific letters.

3. Non-clinical letters (research, leadership)

   • Less important than clinical letters, but can highlight unique strengths (research productivity, leadership, advocacy).

Hierarchy for EM programs (in most cases):

1. SLOEs from EM rotations (especially academic EM programs)
2. EM faculty non-SLOE letters (US-based)
3. Strong clinical letters in other specialties (US-based > international)
4. Non-clinical letters (research, volunteering, etc.)

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How Many Letters You Need and the Ideal Mix for EM

Most EM programs require 3 letters and allow up to 4 in ERAS. For a US citizen IMG, your goal is to present:

• Enough EM-specific evaluation
• Evidence of strong clinical performance in US settings
• A picture of you as a reliable future EM resident

Recommended Letter Strategy for US Citizen IMGs Applying to EM

Ideal scenario:

• 2 SLOEs from US EM rotations (ideally “home” rotation + an away/audition rotation)
• 1 traditional clinical LOR (preferably EM, but IM or surgery is acceptable)
• Optional 4th letter:
  • Another EM-related letter
  • A research letter tied to EM or acute care
  • A stellar internal medicine or critical care letter

If you cannot secure 2 SLOEs:

• Aim for:
  • 1 SLOE from any US EM rotation
  • 1 EM non-SLOE letter from another US EM attending
  • 1 strong clinical letter (US-based if possible, in IM/surgery/ICU)
  • 4th optional letter as above

Programs understand that not every American studying abroad has the same access to EM SLOE-writing institutions, but you must demonstrate at least some US-based evaluation from EM settings if you want a realistic shot at an EM match.

EM-Specific Nuances for Letter Timing

• Most programs want recent letters (within 12 months of applying).
• For EM, it’s best if your SLOEs are from your 4th-year rotations right before ERAS submission.
• That means planning your US EM rotations for late spring, summer, or early fall of the application year.

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

The question of who to ask for letters is crucial. Not all letters are equal, even if the writer is a well-known physician.

Priority 1: EM Attendings Who Have Directly Supervised You

For EM letters (SLOE or traditional), your primary targets should be:

• EM attendings who:
  • Worked with you multiple shifts
  • Observed your clinical reasoning, efficiency, and bedside manner
  • Saw you handle multiple patients and evolving situations
  • Can comment on your teamwork and communication with nurses and consultants

Programs care less about the title (e.g., “Chair,” “Program Director”) and far more about how well the writer actually knows your work. A detailed letter from a mid-career attending who supervised you closely is far better than a vague letter from a department chair who barely remembers you.

Priority 2: Site/Rotation Directors and Program Leadership

For SLOEs, you often do not choose the individual letter writer—instead, the clerkship director or site director signs the SLOE, often with input from multiple faculty members. As an IMG, this can actually help you:

• Multiple faculty evaluations are synthesized.
• One mixed/average interaction is balanced by others where you excelled.
• The SLOE reflects your performance across the rotation, not one isolated day.

If you do have a choice of whom to list as your primary evaluator, consider:

• Who gave you the most feedback?
• Who saw you improve over time?
• Who seemed supportive and invested in your future?

Priority 3: Strong US Clinical Supervisors in Other Specialties

If SLOEs or EM-specific letters are limited, your next best option is:

• Internal medicine ward attending who saw you manage multiple complex patients.
• Surgery or trauma attending who watched you in acute, high-stakes situations.
• ICU attending who can comment on your critical care skills and calm under pressure.

These letters can still be powerful for an emergency medicine residency if they explicitly comment on:

• Your performance in time-sensitive or high-acuity situations.
• Your teamwork with nurses, residents, and ancillary staff.
• Your communication with patients and families under stress.
• Your ability to prioritize and multitask.

When (and When Not) to Use Non-Clinical Letters

Letters from research mentors, volunteer coordinators, or academic advisors can be:

• Helpful add-ons if they show standout qualities (leadership, work ethic, resilience).
• Less valuable than clinical letters for EM decision-making.

Use them as:

• A 4th letter rather than substituting a key clinical letter.
• Strategic support if you have a special focus (e.g., EM research, global health, ultrasound).

Avoid:

• Letters from family friends or physicians who have not supervised you clinically.
• Generic character references without detailed, firsthand observations.

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How to Get Strong LORs as a US Citizen IMG in EM

Knowing how to get strong LOR is just as important as knowing who to ask. The quality of your letters is built during the rotation, not at the moment you ask.

Step 1: Excel Clinically on Your EM Rotations

Every detail of your daily performance can end up in your SLOE or EM letter. As an American studying abroad, you are constantly being compared to US students on the team.

Focus on:

• Reliability & professionalism

  • Arrive early; stay late when appropriate.
  • Offer help rather than waiting to be asked.
  • Treat nursing staff and ancillary team with consistent respect.

• Active engagement

  • See patients proactively (within the framework allowed).
  • Present concisely and clearly.
  • Ask thoughtful but not excessive questions.

• Ownership of patients

  • Follow lab results, imaging, and consultant recommendations.
  • Reassess patients; update the attending promptly with changes.
  • Disposition patients with a clear plan and explanation.

• Growth mindset

  • Respond well to feedback (especially critical feedback).
  • Show improvement over the course of the rotation.
  • Demonstrate resilience during challenging shifts.

Strong SLOEs often emphasize progress and trajectory: “Started at X level, but by the end of the rotation was performing at Y level comparable to top US seniors.”

Step 2: Signal Early That You’re EM-Bound

Especially as a US citizen IMG, you don’t want to be perceived as “shopping around” for any specialty. Early in the rotation:

• Tell your attendings and residents that you are committed to EM.
• Share that you’re a US citizen IMG planning to apply to emergency medicine residency programs in the US.
• Ask what EM programs look for in students and how you can improve during the month.

This:

• Encourages faculty to observe you more intentionally.
• Puts “residency letters of recommendation” on their mental radar early.
• Increases the likelihood that someone will advocate for you during SLOE discussions.

Step 3: Ask for Letters the Right Way

Timing and phrasing matter.

When to ask:

• Toward the end of the rotation, when the faculty have seen your full performance.
• If possible, 1–3 weeks before you leave, so there’s time to write.

How to ask:

Use a direct but respectful approach, ideally in person:

“Dr. Smith, I’ve really appreciated working with you this month. I’m applying to emergency medicine residency this cycle as a US citizen IMG, and your feedback has been very helpful. Would you feel comfortable writing me a strong letter of recommendation for EM?”

Key phrase: “strong letter of recommendation”.
If they hesitate or say something vague (e.g., “I can write you a letter”), consider whether to seek letters elsewhere as well. A non-enthusiastic writer might produce a lukewarm letter that hurts more than it helps.

What to provide:

• Updated CV.
• Personal statement draft, if available (even rough).
• A brief summary of:
  • Why you’re choosing EM.
  • What you see as your strengths.
  • Any specific experiences you shared with that attending (e.g., “the septic shock case on night shift”).
• Clear instructions and deadlines (ERAS letter portal, due date, how many programs you plan to apply to).

Step 4: Be Organized and Respect Their Time

Emergency physicians are busy. Help them help you:

• Enter letter writers into ERAS early.
• Politely remind them 2–3 weeks before ERAS deadlines.
• One additional reminder is acceptable; beyond that, be cautious not to pester.

If a letter is delayed:

• Have backup letters lined up if possible.
• You can submit your ERAS application with some letters pending; they can be uploaded later, but earlier is better for programs that review applications in waves.

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Addressing Common IMG-Specific Challenges in EM Letters

As a US citizen IMG, you face some unique obstacles in building a competitive EM letter portfolio. You can’t change the fact you trained abroad, but you can control how convincingly your letters support your candidacy.

Challenge 1: Limited Access to US EM Rotations

Rotations at SLOE-writing EM programs are competitive and often prioritize US MD/DO students.

Practical strategies:

• Apply early for away rotations (VSLO/VSAS or direct institutional applications).
• Target:
  • Community EM programs affiliated with academic centers.
  • Hospitals known to accept IMGs and write SLOEs.
• Ask your school or IMG networks for lists of EM-friendly sites and prior placements.

If you can’t secure multiple SLOE sites:

• Maximize the one EM rotation you do get in the US.
• Supplement with:
  • EM letters from non-SLOE US EM physicians (e.g., elective or observership settings with direct supervision).
  • Strong IM/surgery letters that highlight acute care performance.

Challenge 2: Non-US Clinical Culture and Communication Differences

Program directors may worry about how smoothly you’ll adapt to US ED culture and communication.

Your letters should:

• Emphasize clear, concise presentations.
• Highlight teamwork with nurses and consultants.
• Comment on your adaptability to US systems (e.g., EMR, ED flow, consult etiquette).
• Note your professional communication with patients/families in potentially stressful situations.

You can prime this by:

• Asking for specific feedback on how you’re doing with communication.
• Letting your attendings know that this is a priority for you as a US citizen IMG.

Challenge 3: Bias and Unfamiliarity with Your Medical School

PDs may not know your school’s reputation or grading system and may carry unconscious biases.

Your letters should:

• Focus on direct performance comparisons:
  • “Comparable to our top US MD seniors”
  • “Performed at or above the level of our average EM-bound student”
• Include rank statements, if allowed:
  • “Top 10% of students I’ve worked with in the last 5 years”
• Highlight your ability to quickly adapt to a new system.

You can encourage this by:

• Sharing with your letter writers that, as a US citizen IMG, you know objective comparative statements carry extra weight in the EM match.
• Asking (politely) if they feel able to comment on how you compare to typical US students they supervise.

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Using Your Letters Strategically in the EM Match

Once you’ve secured your letters, you need to think about how to assign and present them through ERAS.

How Many Letters to Assign Per Program

Most EM programs will read 3 letters carefully and may skim a 4th if it’s clearly relevant.

A common strategy:

• 3 core letters assigned to all EM programs:
  • 2 SLOEs (if you have them)
  • 1 strong clinical letter (EM or IM/surgery)
• 4th letter assigned if:
  • It meaningfully adds something distinct (e.g., EM research, leadership, unique niche).
  • You are concerned one of your other letters may be average.

Customizing Letter Sets (Optional but Helpful)

If you have:

• A letter from a well-known EM faculty or from a program with strong EM reputation, prioritize assigning it widely.
• A letter that speaks to a particular strength (e.g., rural EM, ultrasound, global health), you can choose to assign it selectively to programs with similar interests.

However, don’t overcomplicate this. For most US citizen IMGs:

• Focus on having 3–4 excellent, broadly assignable letters.
• Make sure all EM programs see your best SLOEs and clinical letters.

Impact on Interview Invitations

Strong SLOEs and EM letters can:

• Compensate for a less-known medical school.
• Offset borderline scores if they paint you as a safe, reliable, high-potential hire.
• Move you from “maybe” to “interview” when committees review your file.

During interviews, be prepared to:

• Discuss experiences mentioned in your letters.
• Reinforce the themes your letter writers highlighted (teamwork, resilience, growth).

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

1. How many SLOEs do I really need as a US citizen IMG applying to emergency medicine?

Aim for 2 SLOEs if at all possible. Many EM program directors informally expect 2 SLOEs for a fully competitive application. If you can get only 1, make sure it’s excellent and support it with:

• 1–2 strong EM or acute care letters (IM, surgery, ICU).
• Clear evidence in your application that you are committed to EM (personal statement, experiences).

Programs understand that IMGs have variable access, but at least 1 US EM SLOE is highly recommended.

2. I didn’t get an EM rotation at a big academic hospital. Will community EM letters still count?

Yes. A well-written SLOE or EM letter from a high-volume community ED that regularly teaches students can be very valuable. What matters most is:

• Quality and specificity of the evaluation.
• How your performance compares to their usual US students.
• Clear evidence that you can handle the pace and demands of EM.

If the community site doesn’t use official SLOEs, ask if they’re willing to use the CORD SLOE template or at least address similar domains (clinical ability, teamwork, professionalism, ranking vs. peers).

3. Can I use letters from my home country for EM residency in the US?

You can use one strong international letter as a supplement, but it should not replace US-based clinical letters if you want to maximize your EM match chances. For a US citizen IMG:

• Prioritize US clinical letters, especially from EM settings.
• If you include a home-country letter, make sure:
  • The writer knows you very well.
  • The letter is highly detailed and specific.
  • It emphasizes skills that translate directly to EM (acute care, teamwork, communication).

4. Is it okay if my letter writer asks me to draft my own LOR?

This happens, especially outside of EM or outside the US. In general:

• For SLOEs, you should not be writing your own letter; they are structured and faculty-driven.
• For traditional LORs, if a writer insists:
  • Provide them with a bullet-point summary of your experiences and strengths instead of a full draft, if possible.
  • Emphasize truthful, specific clinical behaviors.
  • Ask them to edit heavily to reflect their authentic voice and independent assessment.

Residency letters of recommendation are powerful tools in the EM match. For a US citizen IMG, they are your chance to prove that, regardless of where you trained, you are ready to thrive in a US emergency medicine residency. Plan early, choose wisely who to ask for letters, and build the kind of performance on rotations that naturally leads to strong, enthusiastic support.