Mastering Letters of Recommendation: A Guide for US Citizen IMGs in Surgery

Understanding the Unique LOR Needs of US Citizen IMGs in General Surgery

As a US citizen IMG (international medical graduate), your letters of recommendation (LORs) can be one of the most powerful parts of your general surgery residency application—or a major weakness if not handled correctly. Program directors consistently rank residency letters of recommendation among the top factors in the surgery residency match, second only to clinical performance and board scores.

For an American studying abroad, strong LORs do three critical things:

1. Validate your clinical ability in the US system
2. Reassure programs about your readiness for a demanding surgical residency
3. Offset concerns about unfamiliar schools, grading systems, or non‑traditional paths

This article focuses specifically on how a US citizen IMG can strategically plan, obtain, and use letters of recommendation for general surgery residency.

We will cover:

• What makes a “strong” surgery LOR for an IMG
• How many letters you need and ideal composition
• Who to ask for letters (and who not to)
• How to get strong LORs during US clinical experiences
• How to approach letter writers and what to give them
• Common pitfalls and how to avoid them
• Sample timelines and scripts you can adapt

Throughout, the lens is: US citizen IMG in general surgery, aiming to maximize match chances in a competitive specialty.

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What Makes a Strong General Surgery Letter of Recommendation?

Before focusing on how to get strong LOR, you need to know what “strong” actually looks like in the eyes of surgery program directors.

Key Features of a Strong Surgery LOR

1. Specific, performance-based detail

   • Describes exactly what you did: cases you scrubbed into, responsibilities on the service, how you handled call, notes, consults, clinic.
   • Uses concrete examples: “She independently evaluated post-op patients, identified early ileus in a complex case, and escalated appropriately.”

2. Clear comparison to peers

   • Programs want to know where you stand relative to US MD/DO students:
   • Phrases like:
     • “Top 10% of students I’ve worked with in the last 5 years”
     • “Comparable to, and in some aspects stronger than, our own US medical students”
   • For a US citizen IMG, this comparative language is extremely valuable.

3. Direct commentary on attributes vital for surgery

   • Work ethic and reliability: shows up early, stays late, owns tasks.
   • Technical aptitude: hands-on skills, comfort in the OR, potential for safe growth.
   • Teachability: accepts feedback, improves quickly, seeks learning opportunities.
   • Teamwork and communication: with residents, nurses, patients, and families.
   • Grit and resilience: thrives under pressure, handles long hours, remains calm.

4. Evidence of sustained interaction

   • Strong letters come from people who truly know you:
     • Worked with you for at least 2–4 weeks (ideally longer).
     • Observed you directly in the OR, wards, and/or clinic.
   • Weak letters sound generic, as if they could have been written for anyone.

5. Written by the right type of author

   • Program directors and selection committees give more weight to:
     • US academic surgeons (especially general surgeons)
     • Department chairs or program directors
     • Faculty at ACGME-accredited programs
   • This is particularly important for US citizen IMGs, because these letters “translate” your ability into familiar US-based standards.

What a Weak or Damaging LOR Looks Like

• Generic: “She was punctual and hard-working” with no concrete examples.
• Vague: “He will be successful in any field he chooses” (doesn’t commit to surgery).
• Faint praise: “With adequate supervision, he did reasonably well.”
• Backhanded: “She improved after early difficulties with professionalism.”
• Lukewarm closing: “I recommend him for consideration.” (Instead of “highest recommendation” or “strongest level of recommendation.”)

As a US citizen IMG aiming for a general surgery residency, you want every letter to be clearly and unmistakably strong, not just acceptable.

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How Many Letters You Need—and the Ideal Mix for US Citizen IMGs

Most general surgery programs in ERAS accept 3–4 letters of recommendation. You are not required to submit the same letters to every program; you can tailor which letters go where.

For an American studying abroad, a very strong combination is:

• 2 letters from US general surgeons at ACGME-accredited institutions
• 1 additional US clinical letter (surgery or another core specialty)
• Optional: 1 “bonus” letter (research, department chair, or additional surgeon)

Priorities for Letter Composition

1. At least two US-based letters from general surgeons

   • These are the backbone of your surgery residency match application.
   • Ideal sources:
     • Faculty from US general surgery electives or sub-internships (Sub-I’s)
     • Surgeons from audition rotations at target programs
     • Faculty whom you worked closely with for 4 weeks or more

2. One letter from your strongest US clinical experience (if not surgery)

   • Could be:
     • ICU, trauma, or emergency medicine with heavy surgical overlap
     • Internal medicine or other field where you excelled and had real responsibility
   • This letter should still explicitly support your choice of general surgery.

3. When to include non-US or home-school letters

   • As a US citizen IMG, non-US letters are often viewed as “extra,” not core.
   • Use them if:
     • You had a unique role (e.g., leading surgery research or acting as chief intern).
     • The writer knows you exceptionally well and can speak to leadership, character, and sustained performance.
   • These work best as your 3rd or 4th letter, never the primary clinical letter.

4. SOAP/backup specialty considerations

   • If you’re applying to a backup specialty (e.g., prelim surgery, internal medicine):
     • Keep at least 3 strong surgery-focused letters for categorical and prelim surgery.
     • Consider 1 neutral or slightly broader letter that can fit both surgery and IM if needed.

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Who to Ask for Letters—and Who Not To

One of the most common questions is: who to ask for letters as a US citizen IMG trying to enter general surgery?

Best-Case Scenarios: Ideal Letter Writers

1. US academic general surgeon with direct supervision of you

   • Example: The attending you worked with most on your US general surgery Sub-I.
   • What makes them ideal:
     • They saw you operate, pre-round, write notes, present patients.
     • They can compare you to US students, interns, and residents.
     • Their name and institution carry weight.

2. General surgery program director or associate program director

   • Especially powerful if:
     • You rotated at their program.
     • They worked with you clinically (not just met in an office).
   • Even brief but intense exposure (e.g., on call, in trauma activations) can yield a strong letter if your performance was excellent.

3. Trauma/acute care surgeons or surgical intensivists

   • Trauma and SICU rotations often give you higher responsibility:
     • Managing post-op patients
     • Participating in resuscitations
     • Presenting in multidisciplinary rounds
   • These letters showcase critical care thinking that is very relevant to general surgery.

4. Surgeons with roles in recruitment or education

   • Clerkship directors, site directors, or faculty in charge of Sub-I’s:
     • They’re used to writing residency letters of recommendation.
     • They know what selection committees want to hear.
   • They might systematically compare you against cohorts, which is beneficial.

Good but Secondary Choices

1. Non-surgical US physicians who supervised you closely

   • Strong examples:
     • ICU/EM faculty who saw your procedural skills and crisis management.
     • Internal medicine attendings who saw your work ethic and ownership.
   • These letters are especially useful as a 3rd or 4th letter, supporting your overall clinical excellence.

2. Research mentors (surgical field preferred)

   • Valuable if:
     • You had a substantial, sustained role (months to years).
     • You produced abstracts, posters, or publications.
     • Mentor can speak to:
       • Analytical ability
       • Independence
       • Persistence and scholarly mindset
   • Use them as an additional letter, not instead of clinical letters.

Who Not to Rely On

• Very senior people who barely know you

  • Department chairs, chiefs, or famous surgeons who met you twice:
    • Name recognition helps only if they can write a truly personalized letter.
    • A generic “I support this candidate” with no detail is actually harmful.

• Family friends or unofficial shadowing experiences

  • Even if they’re surgeons or program directors:
    • Shadowing is not the same as supervised clinical performance.
    • Programs know when an LOR is based on casual observation or personal relationship.

• Non-physician letters as primary LORs

  • Letters from PhDs, nurses, or administrative staff can be powerful supplements but:
    • They rarely carry enough weight alone for a competitive surgery residency match.
    • If included, they should complement, not replace, physician letters.

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How to Get Strong LORs as a US Citizen IMG in General Surgery

The core challenge for a US citizen IMG is not only “who to ask for letters,” but how to create the conditions where faculty want to write you an outstanding LOR.

Step 1: Strategically Choose US Clinical Rotations

As an American studying abroad, you have to be deliberate with where and how you rotate.

Prioritize:

• AGCME-accredited general surgery programs
  • Especially institutions with a track record of interviewing or matching IMGs.
• Rotations where students are truly integrated into the team
  • You present on rounds, write notes (if allowed), scrub into cases, attend conferences.
• Sub-internships (Sub-I) or audition rotations
  • These are essentially “month-long interviews.”
  • Faculty expect to evaluate your residency potential and often expect to write LORs.

Avoid:

• Observerships with minimal hands-on involvement.
• Rotations where students aren’t allowed in OR or on rounds.
• Short 1–2 week exposures that don’t allow meaningful assessment.

Step 2: Perform Like a Future Intern, Not a Visiting Student

To earn a powerful letter:

• Arrive earlier than the residents
• Know your patients cold: labs, imaging, operative details, overnight events.
• Volunteer for tasks: consent forms, dressing changes, discharge summaries.
• Follow through relentlessly: if you say you’ll do something, it’s done.

Faculty are more likely to write strong residency letters of recommendation when they:

• See you function almost at an intern level.
• Hear residents praising your contributions.
• Notice nurses seeking you out because you are reliable and respectful.

Step 3: Signal Early That You’ll Need a Letter

Around week 2 of a 4-week rotation, consider briefly telling an attending:

“I’m a US citizen IMG applying to general surgery this upcoming cycle, and this rotation is really important to me. I’d really appreciate any feedback along the way, because I’m hoping to earn a strong letter of recommendation based on my performance here.”

Benefits:

• They’ll pay closer attention to your performance.
• You invite feedback early enough to improve.
• It shows maturity and goal-directed behavior.

Step 4: Ask the Right Way for a Letter

Timing: Generally the last week of the rotation, when your work is freshest.

Ask in person first if possible, then confirm by email.

Example script (in person)

“Dr. Smith, I’ve really valued working with you and the team this month. As you know, I’m a US citizen IMG applying to general surgery this fall. Based on what you’ve seen of my work, do you feel you’d be able to write a strong letter of recommendation for my residency applications?”

This phrasing does three key things:

1. Emphasizes you want a strong letter.
2. Allows them to decline gracefully if they cannot.
3. Signals professionalism and awareness of the process.

If they hesitate or answer weakly (“I can write you a letter if you need one”), thank them—but do not use that letter if you have other options. Look instead for someone enthusiastic: “Yes, I’d be happy to write you a strong letter,” or, “Absolutely, you’re one of the strongest students we’ve had.”

Step 5: Provide a Helpful, Organized “Letter Packet”

Once they agree, make it easy for them to write a detailed, positive letter.

Email them:

• Updated CV
• ERAS personal statement (or a polished draft)
• Transcript and USMLE scores (if you’re comfortable sharing)
• A one-page summary of your time on the rotation, for example:
  • Patients you followed closely
  • Cases you scrubbed in on
  • Highlights: presentations given, nights on call, extra responsibilities
• A short “brag sheet” with bullet points:
  • Your strengths (from feedback you’ve received)
  • Specific examples they might not have seen (research, leadership, service)
• Exact ERAS instructions:
  • How they’ll receive the email from ERAS to upload the letter
  • Deadlines you’re working with (be clear but reasonable)

You are not writing your own letter. You are simply reminding them of concrete examples and giving them context to make their letter stronger and more individualized.

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Practical Details: Logistics, Red Flags, and Common Pitfalls

ERAS Logistics for LORs

• Number of letters you can store: Up to 4 letters sent to each program, but you can have many more uploaded in ERAS.
• Uploading process:
  • You generate a Letter Request Form in ERAS.
  • Send the PDF (or link) to each letter writer.
  • They upload the letter directly—you do not see it.
• Waiving your right to see the letter:
  • Always waive your right.
  • Non-waived letters are viewed as less credible by programs.
• Label letters carefully:
  • In ERAS, you can add a descriptive title for each LOR:
    • “General Surgery – Dr. Smith, Trauma Surgeon, University X”
    • “ICU – Dr. Lee, Surgical Intensivist, Hospital Y”
  • This helps you assign the best combinations to each program.

Timing and Deadlines for US Citizen IMGs

• Ideal timeline (for a traditional September ERAS submission):

  • January–May: Schedule and complete US-based general surgery rotations.
  • May–July: Ask for letters at the end of these rotations.
  • August: Follow up politely if letters haven’t been uploaded.
  • By early September: Aim to have at least 3 strong letters uploaded.

• If you’re late in the cycle:

  • Prioritize US rotations that explicitly permit LORs for IMGs.
  • Consider doing a late summer/early fall rotation and updating programs mid-season with a new, strong letter.

Following Up Without Being Annoying

If a letter writer hasn’t uploaded your LOR 2–3 weeks before your target submission date:

Email something like:

“Dear Dr. Smith,
I hope you’re doing well. I’m finalizing my ERAS application for general surgery residency and wanted to gently follow up about the letter of recommendation you kindly agreed to write. Programs begin reviewing applications soon, so if possible, I’d be very grateful if you could upload it in the next week or so. Please let me know if you need any additional information from me.

Thank you again for your time and support,
[Name]”

Most faculty appreciate the reminder.

Common Pitfalls for US Citizen IMGs—and How to Avoid Them

1. Relying mainly on non-US letters

   • Fix: Prioritize US clinical rotations early and get at least 2–3 US-based LORs from surgeons.

2. Collecting too many generic letters instead of fewer strong ones

   • Quality>quantity. Programs read content, not just letter counts.
   • Better to have 3 outstanding, specific letters than 4 mediocre ones.

3. Not aligning letters with your specialty choice

   • As a US citizen IMG in general surgery, all main letters should clearly support:
     • Your commitment to surgery
     • Your suitability for a demanding surgical career

4. Not asking early enough

   • Surgeons are busy; if you wait months to ask, they may forget details.
   • Ask during the last week of the rotation, while your performance is fresh.

5. Being afraid to specify “strong” letter when asking

   • You are protecting your own application by clarifying.
   • Faculty understand this language; it’s standard in US medical education.

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Putting It All Together: Sample LOR Strategy for a US Citizen IMG

To make this actionable, here is an example plan:

Scenario

• You’re a US citizen IMG finishing med school abroad.
• You want to apply to general surgery this year.
• You have scheduled:
  • 4-week general surgery rotation at an ACGME program (April)
  • 4-week trauma/acute care surgery rotation at another US hospital (June)
  • 4-week ICU or EM rotation with strong procedural exposure (July)

Target LOR Set

1. Dr. A (General Surgery Attending, Hospital 1)

   • From your April rotation.
   • Directly supervised you in cases and on the wards.
   • Writes: “Top 10% of students I’ve worked with in 5 years; I give my highest possible recommendation for general surgery residency.”

2. Dr. B (Trauma Surgeon / Program Director, Hospital 2)

   • From your June trauma rotation.
   • Saw you during nights on call and trauma activations.
   • Emphasizes your calm under pressure and initiative.

3. Dr. C (ICU or EM Attending, Hospital 3)

   • Notes your clinical reasoning, procedural skills, and teamwork.
   • Explicitly states: “I strongly endorse him for general surgery residency.”

4. Optional: Dr. D (Home-school surgery professor or research mentor)

   • Adds depth about long-term performance, scholarly work, or leadership.

You then tailor:

• For university programs:
  • Use LORs from Dr. A, Dr. B, and Dr. D (academic and research focus).
• For community programs:
  • Use LORs from Dr. A, Dr. B, and Dr. C (clinical workhorse profile).

This strategy shows US-based clinical excellence, strong surgical potential, and consistent commitment to general surgery across different settings.

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FAQ: Letters of Recommendation for US Citizen IMGs in General Surgery

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

Aim for at least two, preferably three US-based letters for general surgery, with at least two from general surgeons at ACGME-accredited programs. Non-US or home-school letters can be useful additions, but they should not be your primary clinical LORs when targeting a surgery residency match in the US.

2. Is a letter from a big-name surgeon better than a detailed letter from a less famous attending?

A detailed, personalized letter from a less famous attending who worked closely with you is far more valuable than a generic letter from a big-name surgeon who barely knows you. Residency committees prioritize specific, credible observations over reputation alone—especially for an American studying abroad where they are trying to verify real clinical performance.

3. Should I ask for letters only from surgeons, or can I use letters from other specialties?

You should prioritize surgeons, but you don’t have to limit yourself entirely to them. A common and effective mix for a US citizen IMG in general surgery is:

• 2 letters from general surgeons
• 1 letter from another US clinical specialty where you excelled (ICU, EM, IM)
• Optional 4th letter from research or long-term mentor

Non-surgery letters should still explicitly endorse you for general surgery.

4. Can I reuse letters if I need to reapply next year?

Technically, yes—ERAS allows reuse, and some letters remain strong for 1–2 years. However, fresh clinical letters are generally preferred, particularly for IMGs. If you reapply, try to:

• Do additional US clinical or research work.
• Obtain at least one new or updated letter that reflects your recent performance and growth.

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By planning your rotations strategically, performing at an intern level, and being intentional about who to ask for letters and how to get strong LOR, you significantly improve your odds in the general surgery residency match as a US citizen IMG. Your letters can become one of the most credible, compelling components of your application—clearly signaling that you’re not just another IMG, but a well-prepared, high-potential future general surgeon.