Essential Strategies for US Citizen IMGs to Secure Strong LORs

As a US citizen IMG (International Medical Graduate), your letters of recommendation (LORs) can make or break your residency application. Program directors often rely heavily on letters to judge whether an American studying abroad is prepared for US clinical training. While you can’t change where you went to school, you can control how strategically you build, request, and use your letters.

This guide breaks down exactly how to get strong LORs as a US citizen IMG: who to ask for letters, how to plan your clinical experiences, what your letters should say, and how to avoid common pitfalls.

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Why Letters of Recommendation Matter So Much for US Citizen IMGs

For an American studying abroad, your application may raise a few questions for program directors:

• Has this applicant adapted to US-style clinical practice?
• Can they communicate effectively with patients and staff in the US health system?
• Will they function safely and efficiently in a busy residency program?
• Are they “rankable,” not just on paper but on the wards?

Residency letters of recommendation are one of the primary ways programs answer these questions.

What Program Directors Look For in IMG Letters

Most PDs want letters that:

• Come from US-based attending physicians
• Are written after direct clinical observation
• Provide specific examples of your clinical performance
• Comment on work ethic, professionalism, communication, and teamwork
• Include comparisons to US medical students or interns
• Show that the writer would work with you again or hire you

For a US citizen IMG, strong US clinical letters help “de-risk” your application by proving you can thrive in their environment.

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Planning Ahead: LOR Strategy Timeline for US Citizen IMGs

Strong letters don’t happen by accident. You need a timeline and a deliberate approach.

18–24 Months Before Applying: Big-Picture Planning

If you’re an American studying abroad early in medical school:

• Understand LOR expectations early

  • Review ERAS and NRMP data for your target specialty.
  • Talk to recent US citizen IMG graduates from your school about what worked for them.

• Align electives with letter needs

  • Plan for US clinical experience (USCE) before your application cycle.
  • Prioritize core specialties (internal medicine, surgery, pediatrics, family medicine, psychiatry) even if they’re not your final choice—you may still need these letters.

• Research key programs and mentors

  • Identify hospitals that regularly host IMGs and produce strong LORs.
  • Check if your school has agreements or affiliations for US rotations.

12–15 Months Before Applying: Secure US Clinical Rotations

At this stage, your focus is to set up the experiences that will generate your letters:

• Book US rotations (electives/observerships/externships)

  • Prefer hands-on electives where you can write notes, present patients, and join rounds.
  • Avoid purely shadowing if possible—these rarely yield impactful letters.

• Prioritize timing

  • Aim for rotations 6–12 months before ERAS submission so letters are recent but ready in time.
  • Try to complete at least one rotation in your intended specialty in this window.

• Think strategically about settings

  • Academic centers are ideal, but strong community programs with residency training are also excellent.
  • What matters most: a supervising physician who truly knows your work and is accustomed to writing residency letters of recommendation.

6–9 Months Before ERAS: Performance and Relationship-Building

Now you’re in your critical USCE window. Your daily performance directly shapes your LOR quality.

• Arrive early and consistently prepared

  • Know your patients thoroughly.
  • Read about common conditions on the service.
  • Show initiative but not overconfidence.

• Signal your goals early

  • In the first week, tell your attending:
    “I’m a US citizen IMG planning to apply to residency in [specialty] next cycle. I’m hoping to earn a US-based letter of recommendation through this rotation, and I’d be very grateful for any feedback on how I can improve.”

• Seek mid-rotation feedback

  • Ask: “How am I doing compared with other students at my level? What should I improve before the end of the rotation?”
  • Then act on that feedback visibly.

• Demonstrate reliability and professionalism

  • Be on time (early), responsive, respectful to everyone.
  • Follow through on every task you’re assigned.
  • Avoid complaining or gossip.

This is how you become the student attendings want to write about.

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Who to Ask for Letters (and Who Not To)

Understanding who to ask for letters is especially critical for US citizen IMGs. Below is a prioritized framework you can use.

Priority #1: US Attending Physicians in Your Target Specialty

For example, if you’re applying to internal medicine:

• US-based internal medicine attendings who directly supervised you
• Preferably at institutions with ACGME-accredited residency programs
• Ideally someone who has worked with many US medical students and residents

Why they matter: These letters are most directly relevant to residency in terms of skills, expectations, and comparability.

Example:
You completed a 4-week internal medicine sub-internship at a community teaching hospital in New York. The attending who staffed your patients daily, watched you present, and gave feedback on your notes is an ideal letter writer.

Priority #2: US Clinical Attending in a Related Core Specialty

If you don’t have enough letters from your target field, the next strongest are from:

• Core specialty attendings (IM, FM, surgery, peds, psych, OB/GYN, EM)
• Who can comment on your clinical performance, even if not your exact specialty

Example:
An internal medicine attending letter can still be valuable if you’re applying to neurology or psychiatry. They can speak to your clinical reasoning, documentation, and professionalism.

Priority #3: US Program Directors or Department Chairs Who Know You Well

Titles impress, but only if the writer truly knows you and can be specific.

• Program directors you rotated with
• Associate program directors or clerkship directors who observed your work
• Department chairs who directly taught or supervised you

A brief, generic letter from a big name is less helpful than a detailed letter from a less prominent attending who really knows you.

Priority #4: Non-US or Non-Clinical Letters (Use Selectively)

These may include:

• Letters from your home country or international rotations
• Research mentors, especially if you did significant scholarly work
• Non-clinical faculty who supervised major academic or leadership projects

Use these to supplement—but not replace—strong US clinical letters.

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Who You Should Not Rely On for Primary Residency Letters

• Physicians who barely know you or only interacted briefly
• Residents or fellows (unless they co-sign with an attending)
• Family friends or personal physicians writing as a favor
• Letters from purely observational experiences with minimal interaction
• Non-physician professionals unless they supervised meaningful, relevant work

If you’re unsure who to ask for letters in a particular setting, ask your clerkship coordinator or the attending directly:
“Do you typically write residency letters of recommendation for students you work with, and would this rotation be appropriate for that?”

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What Makes a Letter “Strong” for a US Citizen IMG?

A “strong” letter isn’t just positive—it is specific, comparative, and clearly written for US residencies. As an American studying abroad, you want your letters to clearly answer: “Can this person function at or above the level of a US medical graduate?”

Key Elements of a High-Impact LOR

1. Clear context of the relationship

   • How long the writer worked with you
   • In what capacity and setting (e.g., “inpatient medicine sub-internship at an ACGME-accredited teaching hospital”)

2. Specific examples of clinical performance

   • Detailed accounts of patient presentations, procedures, or teamwork
   • Demonstrated growth over the rotation

3. Direct comparison to peers

   • “Among the top 10% of students I have supervised”
   • “Comparable to strong US medical graduates entering residency”

4. Comments tailored to IMG concerns

   • Demonstrated adaptation to US healthcare systems
   • Excellent English communication with patients and staff
   • Familiarity with EMR, documentation, teamwork structures

5. Clear, strong endorsement

   • “I would be eager to work with this student as a resident in our program.”
   • “I recommend [Name] without reservation for residency training in [specialty].”

How You Can Influence Letter Strength (Indirectly and Ethically)

You can’t write your own letter, but you can:

• Provide a well-organized CV and personal statement draft to your writer
• Include a one-page summary of:
  • Your career goals
  • The rotations you’ve done
  • Key patients or projects from their rotation they might remember
• Politely remind them of specific cases where you performed well
• Share any feedback or evaluations you received during the rotation

This doesn’t dictate content but helps writers recall meaningful details they can use.

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How to Ask for Letters of Recommendation (Step-by-Step)

Knowing how to get strong LORs is as important as knowing who to ask. Here’s a structured approach tailored for US citizen IMGs.

Step 1: Test the Waters with Performance Feedback

Near the end of your rotation:

1. Ask your attending:
   “I’ve really appreciated this rotation and your teaching. Could I ask for some honest feedback about how I’ve been doing compared to other students at my level?”

2. Listen carefully:

   • If they give strong, specific praise, they’re likely a good letter writer.
   • If feedback is lukewarm or vague, they may not write a powerful letter.

Step 2: Ask Directly and Professionally

If feedback is positive, follow up with:

“I’m a US citizen IMG applying for residency in [specialty] this coming cycle. Based on our work together, do you feel you could write a strong letter of recommendation to support my application?”

Including the word “strong” gives them a respectful way to decline if they can’t be enthusiastic.

If they hesitate or say they’re too busy or unsure, thank them and ask someone else. A neutral letter can hurt.

Step 3: Provide a Helpful LOR Packet

Once they agree, email them a concise packet:

• Updated CV
• Draft of your personal statement (if ready)
• ERAS letter request form with AAMC ID
• Brief reminder of:
  • When and where you worked together
  • Key patients, presentations, or projects
  • Your target specialties and types of programs

Subject line example:
“LOR materials – [Your Name], US citizen IMG applying to [specialty] residency”

Step 4: Clarify Logistics and Deadlines

• Confirm how they will upload the letter (typically via ERAS link).
• Provide a reasonable deadline:
  • Ideally 2–4 weeks before you plan to submit ERAS.
• Politely follow up 1–2 weeks before the deadline if you haven’t received confirmation.

Polite reminder email example:

Dear Dr. [Name],
I hope you’re doing well. I just wanted to kindly follow up about the residency letter of recommendation you graciously agreed to write for me. ERAS opens for submission on [date], and I’m hoping to have all letters uploaded by [earlier date].
Please let me know if there’s any additional information I can provide to make this easier.
Best regards,
[Your Name]

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US vs. Non-US Letters: How Many and Which to Use?

As a US citizen IMG, your goal is to maximize high-quality US clinical letters while strategically using others to support your story.

How Many Letters Do You Need?

Most programs allow up to 3–4 letters to be uploaded in ERAS per specialty. Typically:

• 3 strong letters is sufficient for most specialties
• Some highly competitive fields may expect 4

Check each program’s website—some specify:

• A required minimum number of specialty-specific letters
• Limitations on research or non-clinical letters

Ideal Mix for a US Citizen IMG

For most core specialties (IM, FM, Peds, Psych, etc.), an ideal mix might be:

• 2+ letters from US attendings in your target specialty
• 1 additional US clinical letter (from another core specialty or sub-internship)
• Optional: 1 research or non-US letter if it significantly strengthens your profile

Using Non-US or Non-Clinical Letters Strategically

Only include these if they add something essential:

• International clinical letters

  • Useful if you had substantial responsibility and outstanding performance
  • Helpful when they show leadership, autonomy, or unique experience

• Research letters

  • Strong if you’ve had significant involvement (publications, presentations)
  • Particularly important for academic or research-heavy programs

• Departmental or dean’s letters from your foreign medical school

  • Supportive background, but not a substitute for US clinical letters

If forced to choose, prioritize:

Detailed US clinical letter > Impressive title but vague letter > Extra but generic letters

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Specialty-Specific Considerations for US Citizen IMGs

While general LOR principles apply across the board, some specialties have specific expectations.

Internal Medicine

• Programs often expect at least 2 IM letters
• A sub-internship (sub-I) or acting internship letter can be very powerful
• Seek writers who:
  • Saw you pre-round, write notes, manage cross-coverage issues
  • Can compare you to US seniors or interns

Family Medicine

• FM values broad clinical exposure and community orientation
• Strong letters often mention:
  • Longitudinal patient relationships
  • Communication skills
  • Cultural competence and teamwork

Psychiatry

• Psych programs like letters that highlight:
  • Communication with patients and families
  • Maturity, empathy, and boundary awareness
  • Ability to work in multidisciplinary teams

Surgery & Procedural Specialties

• Programs focus on:
  • Work ethic, resilience, ability to function in high-stress environments
  • Technical potential (even early in training)
  • Team integration in the OR and wards

In every specialty, if you’re a US citizen IMG, make sure at least one writer explicitly affirms that your performance is on par with or better than US med school graduates they’ve worked with.

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

Mistake 1: Waiting Too Long to Think About Letters

Fix: Start planning at least a year before applying. Arrange US rotations specifically with letters in mind.

Mistake 2: Choosing Famous Names Over Familiar Mentors

Fix: Always prioritize how well the writer knows you over their title. Detailed stories beat impressive signatures.

Mistake 3: Overloading on Non-US or Non-Clinical Letters

Fix: As an American studying abroad, you must show you can work in the US system. Aim for at least 2–3 strong US clinical letters.

Mistake 4: Not Asking if the Letter Will Be “Strong”

Fix: Use that wording. It helps filter out lukewarm writers and protects your application.

Mistake 5: Neglecting to Follow Up Professionally

Fix: Track who agreed to write letters, when you asked, and when they upload. Gentle reminders are appropriate and expected.

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Final Tips: Maximizing the Impact of Your LOR Package

• Align letters with your narrative

  • If your personal statement emphasizes continuity of care, leadership, or overcoming obstacles, choose letters that reinforce those themes.

• Tailor letter selection by specialty

  • You can assign different combinations of letters to different specialties in ERAS.
  • For example: use your pediatrics attending letter only for pediatrics applications, not for psychiatry.

• Mind the timing

  • Strong letters uploaded before Sept 15 (or current ERAS opening/submission date) strengthen your early impression.
  • Late letters might miss some interview offers.

• Protect your professionalism

  • Never write your own letter or ask someone to sign a letter you drafted.
  • If someone asks you to “draft the letter for them,” you can offer bullet points of achievements, but the final letter should always be their work.

For a US citizen IMG, letters of recommendation are one of the clearest ways to prove that your training abroad has prepared you to excel here. With planning, strong clinical performance, and thoughtful choices about who to ask for letters, your LORs can become one of the strongest assets in your residency application.

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FAQ: Letters of Recommendation for US Citizen IMGs

1. How many US letters of recommendation do I really need as a US citizen IMG?

Aim for at least two strong US clinical letters, ideally three, especially in your target specialty or closely related fields. Most programs accept 3–4 letters, and for an American studying abroad, each US letter is critical evidence of your readiness to train in the US system.

2. Is an observership good enough to get a strong LOR?

Pure observerships rarely generate top-tier residency letters of recommendation because your involvement is limited. If an observer role includes substantial case discussions, presentations, or research, you might still get a useful letter—but whenever possible, prioritize hands-on electives, externships, or sub-internships where you’re directly involved in patient care.

3. Should I waive my right to see the letters in ERAS?

Yes. Program directors generally expect applicants to waive the right to view letters. Waived letters are perceived as more honest and therefore more reliable. If you don’t waive, some programs may see that as a red flag.

4. What if an attending I worked with is slow or doesn’t upload the letter?

Plan ahead so you’re not dependent on a single letter writer. If an attending is delayed:

• Send one or two polite reminder emails spaced 1–2 weeks apart.
• If there’s still no response, shift focus to other attendings who can write on time.
• Never harass or pressure a writer; simply thank them for their time and move on if needed.

Well-planned redundancy—rotating with multiple attendings and asking more than the bare minimum for letters—protects you from these situations and keeps your residency timeline on track.