The Ultimate Guide to Letters of Recommendation for US Citizen IMGs in Preliminary Medicine

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

For a US citizen IMG (American studying abroad), letters of recommendation (LORs) carry outsized weight in the residency application—especially when you’re applying for a preliminary medicine year (prelim IM).

Program directors know less about your school, your grading system, and the rigor of your clinical training compared with US MD/DO schools. Strong, credible letters help them answer the question:

“Can this applicant function safely and reliably as an intern in my program?”

Because prelim IM spots are often used by future anesthesiologists, radiologists, neurologists, and others who need one clinical year, programs want residents who are:

• Clinically dependable
• Professional and easy to work with
• Strong team players who can handle a high volume of floor work
• Comfortable with bread-and-butter internal medicine

Your residency letters of recommendation are one of the best tools to demonstrate this. For many US citizen IMGs, strong LORs can help offset:

• Lesser-known medical schools
• Step attempts or gaps
• Limited US-based clinical experience

This article will walk you through:

• Who to ask for letters (and who not to)
• How to get strong LORs as a US citizen IMG
• How many and what type of letters are ideal for prelim medicine
• Practical scripts, timelines, and strategies tailored to Americans studying abroad

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Understanding What Makes a Strong LOR for Prelim Internal Medicine

Before you chase letters, you need to know what program directors actually want to see—especially in the prelim IM context.

Core Qualities Programs Look For

A strong prelim IM LOR should clearly demonstrate that you:

1. Can function at intern level (or close to it)

   • Efficient progress notes and orders
   • Safe clinical judgment; know when to ask for help
   • Basic management of common IM issues (CHF, COPD, DKA, sepsis)

2. Are reliable and professional

   • Shows up early, stays late when needed
   • Completes tasks thoroughly
   • Communicates clearly with nurses and consultants

3. Are a positive team member

   • Works well with residents, nurses, and staff
   • Accepts feedback gracefully
   • Doesn’t create drama, even when stressed

4. Are adaptable as a US citizen IMG

   • Adjusted quickly to US healthcare system
   • Familiar with EMR, documentation expectations, cultural norms
   • Demonstrated growth from earlier rotations

When reading letters, PDs are asking:

“If this person walked onto our wards July 1, would my seniors feel relieved or anxious?”

Your letters must clearly answer “relieved.”

Characteristics of a Strong Letter (vs. a Weak One)

Strong LOR:

• Writer has worked directly with you, ideally supervising you clinically
• Includes specific examples of your performance
• Uses comparative language (e.g., “among the top 10% of students I’ve worked with”)
• Addresses work ethic, fund of knowledge, communication, and professionalism
• Written on institutional letterhead, with academic title and contact information
• Explicitly recommends you for internal medicine training (even if it’s prelim)

Weak LOR:

• Generic phrases (“hard-working,” “pleasant”) with no concrete examples
• Author barely remembers you and keeps the letter vague
• Sounds like a template used for all students
• Short (less than half a page) or clearly rushed
• Comes from someone outside clinical medicine who can’t assess residency readiness

For a US citizen IMG trying to break into competitive prelim IM programs, two strong, detailed IM letters (preferably from US academic hospitals) can be more valuable than four generic ones.

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Who to Ask for Letters of Recommendation (and Who to Avoid)

Choosing who to ask for letters is one of the most strategic decisions you’ll make. As a US citizen IMG in prelim medicine, your goal is to build a LOR set that is:

• US-based (whenever possible)
• Internal Medicine-heavy
• Written by people who have directly seen you on the wards

Priority #1: US Internal Medicine Attendings from Core or Elective Rotations

For prelim internal medicine, this is your gold standard:

• Teaching attendings on inpatient IM services (wards, step-down, sometimes ICU)
• Subspecialty IM attendings (cardiology, GI, nephrology, etc.) who worked with you closely
• Attendings from US clinical electives or sub-internships (“sub-Is”)

These letters carry weight because:

• They know what intern-level performance looks like
• They understand US training expectations
• PDs view their assessments as more directly comparable

Example:
You’re an American studying abroad who completed:

• 8-week inpatient IM elective at a large community hospital in New Jersey
• 4-week cardiology elective at an academic center

Ideal approach:

• Get one letter from your inpatient IM team attending
• One from the cardiology attending if they worked with you repeatedly and directly

Priority #2: Residency Program Leadership (if they supervised you)

Letters from:

• Program Director (PD)
• Associate Program Director (APD)
• Clerkship Director in Internal Medicine

…can be powerful if:

• They supervised you clinically or directly reviewed your performance
• They can speak to your reliability and “fit” for internal medicine

However, avoid letters from PDs who barely know you but are writing as a favor. Title alone does not rescue a vague letter.

Priority #3: Strong US Clinical Electives in Other Core Fields

If you’re short on IM letters, you can use:

• Family medicine attending who supervised you in an inpatient or strong outpatient setting
• Emergency medicine attending who saw you manage acutely ill patients
• Surgery or anesthesia attendings who worked with you extensively and can describe your work ethic and teamwork

These are better than a weak IM letter written by someone who barely remembers you.

When to Use a Letter from Your Non-US Medical School

As a US citizen IMG, you may have:

• A department chair or course director from your home institution who knows you very well
• A strong IM letter from a non-US setting with detailed examples of performance

These can be valuable as supplemental letters, especially if:

• The writer has a well-recognized academic reputation
• The letter is detailed and enthusiastic

However, at least 2 letters should be from US-based physicians if you want to compete well for prelim IM positions.

Who Not to Ask (or Use Only as Extras)

Even if they like you, these letters usually carry limited weight:

• Research mentors with no clinical supervision of you (unless applying to very research-heavy programs and they know you well)
• Non-physician professionals (PhDs, nurses, administrators) unless they co-write with a physician and focus on professional attributes
• Family friends, community members, or political figures
• Letters from specialties completely unrelated to patient care (e.g., radiology) where they didn’t see you in a clinical team role

You might still collect these if they’re strong, but they should supplement, not replace, your core IM-focused letters.

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How Many Letters Do You Need for a Prelim Medicine Application?

Most internal medicine prelim programs accept:

• Up to 3 or 4 letters in ERAS
• Some allow an additional “optional” letter via supplemental systems or email

For a US citizen IMG applying to prelim IM, an ideal distribution is:

Target Set: 3 letters (core set)

1. US Internal Medicine attending – inpatient or sub-I, ideally at a teaching hospital
2. Second US Internal Medicine or IM subspecialty attending who supervised you closely
3. Third clinical letter
   • Could be:
     • Another US IM attending
     • US family medicine / EM / surgery attending with strong clinical exposure to you
     • A strong non-US IM letter if it’s powerful and specific

Optional 4th Letter (if allowed and strong):

• Research mentor in IM or another specialty who can comment on your professionalism, persistence, and academic potential
• Department chair letter if it adds new, meaningful information (not just a generic summary)

Quality always beats quantity.
Three detailed, specific, enthusiastic LORs are far better than three strong plus one obviously generic or weak letter.

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How to Get Strong LORs as a US Citizen IMG: Step-by-Step Strategy

1. Plan Early: Map Letters to Rotations

As an American studying abroad, you may have limited US rotation slots. Treat each one as a letter opportunity.

Before your US rotations:

• Identify which rotations are most likely to yield strong IM letters (inpatient IM, subspecialties with close supervision, sub-Is)
• Set a goal: “I want 2 strong US IM letters and at least 1 additional clinical letter by ERAS opening.”

Bring an updated CV and brief personal statement draft with you to US rotations. You’ll need them later.

2. Perform Intentionally on Rotations

To position yourself for strong residency letters of recommendation, focus on:

• Reliability: Be on time, prepared, and follow through on tasks
• Visibility: Present patients, volunteer for admissions, and ask to follow complex cases
• Teachability: Ask questions, accept feedback, and show improvement over time
• Ownership: Know your patients thoroughly—labs, imaging, social context, discharge plan

Make sure attendings see your growth. Many will hesitate to write a strong letter for someone who stayed on the margins of the team.

Example behaviors that lead to strong letters:

• Offering to write drafts of notes and orders for the resident to review
• Staying late during a busy admission night without being asked
• Following up on pending results and proactively updating residents and nurses

3. Ask the Right Attending, the Right Way, at the Right Time

When to ask:

• Ideally near the end of the rotation, after you’ve had time to demonstrate growth
• Not on the very last day in a rushed hallway conversation—try to schedule a quick meeting

How to ask (phrase it to protect yourself):

Instead of:

“Can you write me a letter for residency?”

Say:

“Dr. Smith, I’ve really valued working with you this month. I’m applying to internal medicine, mostly for preliminary medicine positions, and I was hoping to ask if you’d feel comfortable writing me a strong letter of recommendation based on my performance on this rotation.”

This wording:

• Gives the attending permission to decline if they can’t be enthusiastic
• Helps you avoid letters that are lukewarm or generic
• Signals that you care about strength, not just the number of letters

If they hesitate or say something like:

“I can write you a letter, but I don’t know how strong it will be…”

Take that as a sign to accept politely but not use it as one of your primary letters.

4. Provide Supporting Materials

Once they agree, immediately offer materials to make their job easier and improve the letter’s quality:

Send a concise email with:

• Updated CV
• Draft of your personal statement (even if preliminary)
• Summary of your work with them:
  • Dates of the rotation
  • The kind of service (inpatient IM, cardiology, etc.)
  • 3–5 specific cases or situations that showcase your strengths
• Your ERAS AAMC ID
• The deadline by which you hope the letter will be uploaded

Example email snippet:

Dear Dr. Smith,

Thank you again for agreeing to write a strong letter in support of my applications for preliminary internal medicine positions. I’ve attached my CV and a draft of my personal statement. I’ve also included a brief summary of my time on your rotation and a few cases that particularly stood out to me.

ERAS will send you a direct link to upload the letter using my AAMC ID: XXXXXXXX. If possible, I’d be grateful if the letter could be submitted by [target date], as many programs start reviewing applications soon after ERAS opens.

Sincerely,
[Your Name]

5. Emphasize Prelim Medicine Context (Quietly)

Although a prelim IM year is still internal medicine, you can subtly guide letter writers to highlight aspects that appeal to prelim PDs:

You might say:

“I’ll mostly be applying for a preliminary medicine year, so program directors will be especially interested in my ability to function as a reliable intern on busy inpatient services.”

This can prompt them to comment on:

• Your ability to handle multiple patients
• Resilience under pressure
• Teamwork with residents and nurses
• Efficiency and organization

6. Manage Timelines and Follow-Up Professionally

Timeline guidelines:

• Ask for letters 4–8 weeks before you need them submitted
• ERAS typically opens for letter uploads in late spring/early summer for a September application submission
• Aim to have all LORs uploaded by mid-September at the latest

Follow-up strategy:

• If you haven’t seen a letter marked as “Received” in ERAS 2–3 weeks before your target deadline, send a polite reminder:

Dear Dr. Smith,
I hope you’re doing well. I just wanted to gently follow up about the letter of recommendation for my preliminary internal medicine applications. ERAS shows it as still pending, and I wanted to see if there’s any additional information I can provide.

I truly appreciate your time and support.
Best regards,
[Your Name]

Keep follow-ups respectful—attendings are busy, and reminder emails should feel like assistance, not pressure.

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Tailored Tips for US Citizen IMGs: Maximizing Letter Impact

Emphasize Your US Clinical Adaptation

As a US citizen IMG, you want letters that explicitly address your adjustment to the US system:

Ask your letter writer (subtly) to consider including:

• Your familiarity with US EMR systems
• Comfort with US hospital workflows
• Communication skills with US patients and multidisciplinary teams
• Growth over the rotation as you adapted to expectations

Language like:

“Despite being an international medical graduate, [Name] adapted quickly to our system and functioned at the level of a strong US senior medical student, sometimes approaching intern-level responsibility.”

…can significantly reassure program directors.

Mitigate Concerns About Your School’s Reputation

Most PDs don’t deeply understand the curriculum at overseas schools, even for Americans studying abroad. Strong LORs can fill that gap by:

• Comparing you directly to US students seen at that institution:

  “Her performance was comparable to, and in some areas surpassed, typical US MD/DO students rotating on our service.”

• Emphasizing your fund of knowledge and self-directed learning:

  “He consistently read around his patients and came prepared to discuss evidence-based management.”

Align Letters with Your Career Story (Especially if Prelim for Another Specialty)

Many US citizen IMGs apply to prelim IM spots as part of a plan to enter:

• Anesthesiology
• Neurology
• Radiology
• PM&R, etc.

Your letters should still prioritize your readiness for an IM intern year, but can briefly support your broader trajectory. Example guidance to a letter writer:

“I’ll be applying to both [specialty] and preliminary internal medicine positions. For the IM programs, they’ll mainly want to understand my ability to function well as an intern on medicine wards, but it’s also fine if you briefly comment on how my skills might translate to my long-term interest in [specialty].”

Just make sure the letter still explicitly endorses you for internal medicine training, even if prelim.

Be Strategic About Waiving Your Right to See Letters

ERAS allows you to:

• Waive your right to view the letter (recommended)
• Not waive (you retain the right to see it later)

For most US citizen IMGs, it’s best to waive your right because:

• Program directors tend to trust waived letters more
• It signals confidence that your writer will be honest and supportive

If you’re unsure about whether a writer will be strongly supportive, ask directly when you request the letter by using the “strong letter” phrase. If they express hesitation, consider asking someone else instead of keeping rights unwaived.

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Frequently Asked Questions (FAQ)

1. How many internal medicine letters do I really need for a prelim IM year as a US citizen IMG?

Aim for at least two strong internal medicine letters from US-based attendings if at all possible. Your third letter can be:

• Another IM attending
• A related specialty (FM, EM, or surgery) with strong inpatient exposure
• A powerful non-US IM letter if it’s detailed and enthusiastic

If you have a fourth letter slot, only use it for a truly strong, complementary letter (e.g., research mentor who knows you well).

2. What if I didn’t get to rotate in internal medicine in the US?

If you lack US IM rotations:

• Use the strongest US-based clinical letters you do have (FM, EM, surgery)
• Supplement with a strong non-US IM letter that describes your clinical performance in depth
• In your personal statement and interviews, emphasize your readiness for intensive inpatient work and your adaptability

You should also strongly consider arranging post-graduate US clinical experience (USCE)—observerships or externships—if time permits, and obtain updated letters for future application cycles if needed.

3. Is a department chair letter necessary for prelim internal medicine?

A chair letter is not strictly required for most prelim IM programs, especially for US citizen IMGs whose training is abroad. A generic chair letter that doesn’t know you personally may carry less weight than:

• A detailed letter from a supervising attending who worked with you clinically

If your chair letter is:

• Strong
• Specific
• From someone who truly knows your strengths

…it can be a useful supplement, but it should not replace letters from direct clinical supervisors.

4. Can I reuse the same letters for both categorical and prelim IM applications?

Yes. In ERAS, you can assign the same letters of recommendation to both categorical and preliminary IM programs. Strong IM letters that speak to your:

• Clinical ability
• Reliability
• Teamwork

…are equally valuable for both program types. Just ensure the letters recommend you for internal medicine training broadly, rather than explicitly specifying only categorical or only prelim positions.

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Carefully chosen and well-timed letters can significantly elevate your application as a US citizen IMG applying for a preliminary medicine year. Focus on:

• Getting US-based IM attendings who know you well
• Asking for strong, specific letters
• Providing clear, organized information to your writers
• Highlighting your readiness to function as a safe, dependable intern

Done well, your residency letters of recommendation can transform you from “unknown international graduate” to “trusted future intern” in the eyes of prelim internal medicine program directors.