Essential Guide for US Citizen IMGs: Letters of Recommendation for Med-Peds Residency

Why Letters of Recommendation Matter So Much for US Citizen IMGs in Med-Peds

For a US citizen IMG (American studying abroad), letters of recommendation (LORs) can make or break your medicine-pediatrics (Med-Peds) application. Program directors know less about your school, may not recognize your grading system, and can’t easily compare your training environment to US medical schools. Your letters become one of the strongest ways for them to assess:

• How you perform in US clinical settings
• Your readiness for residency in both medicine and pediatrics
• How you compare to US MD/DO students rotating at the same sites
• Whether you have the professionalism, communication, and adaptability to thrive

For Med-Peds specifically, letters can also help answer a critical question:
“Does this applicant understand what Med-Peds is and really want this specialty?”

Strong, specific, and credible letters reassure programs that you’re not just “hedging bets” between internal medicine and pediatrics, but that you are actually committed to the combined training pathway.

In this guide, we’ll walk through how to get strong LORs as a US citizen IMG applying to Med-Peds, including:

• Who to ask for letters and how many you need
• How to plan your rotations as an American studying abroad
• Exactly how to ask for strong letters and what materials to provide
• How to secure at least one Med-Peds–specific letter
• Common pitfalls IMGs make—and how to avoid them

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How Many Letters, and What Kind Do Med-Peds Programs Prefer?

Most medicine-pediatrics residency programs participate in ERAS and follow similar patterns to categorical internal medicine and pediatrics programs, but with some nuances.

Typical Requirements

Most Med-Peds programs will require 3 letters of recommendation, sometimes 4 maximum in ERAS. You should always check each program’s website, but a competitive mix for a Med-Peds applicant often looks like:

• 1 letter from a Med-Peds physician (ideal)
• 1 letter from an Internal Medicine faculty member
• 1 letter from a Pediatrics faculty member
• Optional 4th letter: another IM, Peds, or Med-Peds attending, or a strong research/longitudinal mentor

Some programs will accept or even encourage a Chair’s letter (Department of Medicine or Pediatrics). For most US citizen IMGs, though, strong clinical letters from US attendings carry more weight than generic departmental letters written by someone who doesn’t know you well.

Priority for US Citizen IMGs

As a US citizen IMG applying to Med-Peds, you should prioritize:

1. US clinical experience letters over non-US letters
2. Med-Peds or categorical IM/Peds letters over other specialties
3. Direct supervisors over “big names” who barely knew you

Non-US letters (e.g., from your home school abroad) can still be included, but they are generally supporting letters, not your core anchors.

Example Letter Mix for a Strong Med-Peds IMG Application

Suppose you’re an American studying abroad in Ireland, planning a Med-Peds residency match:

• Letter 1: Med-Peds attending from a 4-week US Med-Peds elective, commenting on both your adult and pediatric care
• Letter 2: Internal Medicine inpatient attending from a US core or sub-internship rotation
• Letter 3: Pediatrics inpatient or outpatient attending from a US core or sub-internship rotation
• Letter 4 (optional): Longitudinal primary care preceptor (IM, Peds, or Med-Peds) or a research mentor who supervised you closely

This structure shows clear commitment to Med-Peds, strong US clinical evaluations, and breadth across both disciplines.

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Who to Ask for Letters of Recommendation (and Who Not To)

Understanding who to ask for letters is just as important as how you perform on rotations. The best letters come from people who:

• Supervised you directly in clinical care
• Observed your performance over a sufficient time (at least 2–4 weeks)
• Can compare you to US medical students and interns
• Can comment specifically on your readiness for residency

Ideal Letter Writers for a Med-Peds Applicant

1. Med-Peds Attendings

   These are gold for your medicine pediatrics match. A Med-Peds attending can speak on how you function in both adult and pediatric settings, your understanding of the combined specialty, and your fit with the Med-Peds culture (flexibility, breadth, complex chronic care, transitions, etc.).

   If you can do a Med-Peds elective or sub-I in the US, make this a top priority for letter writers.

2. Internal Medicine Attendings (especially inpatient or sub-I)

   Strong IM letters should speak to:

   • Your clinical reasoning and differential diagnosis
   • Your ability to manage complex adult patients with chronic diseases
   • Your work ethic, reliability, and role on the team
   • Your communication with patients, nurses, and interdisciplinary staff

   Sub-internship (acting internship) supervisors are especially powerful because they can say, “This student functioned at the level of an intern.”

3. Pediatrics Attendings (inpatient, NICU, PICU, or continuity clinic)

   Peds letters should highlight:

   • Your communication with children and families
   • Your comfort with developmental and behavioral issues
   • Your bedside manner and family-centered care
   • Your adaptability and emotional resilience in pediatric care

4. Longitudinal Clinical Mentors

   This might be a faculty who worked with you repeatedly in clinic, in a research project with clinical relevance, or in a quality improvement (QI) project. They can comment on your growth over time, professionalism, initiative, and commitment to underserved or complex patient populations.

Who to Avoid as Primary Letter Writers

• Famous faculty who barely know you
  A short, generic letter from a national “big name” is less valuable than a long, detailed letter from a local attending who supervised you closely.

• Non-clinical basic science faculty
  Unless they supervised you in a substantial research or longitudinal program and can speak to your professionalism and work ethic in depth, their letters won’t carry the same weight as clinical ones.

• Residents or fellows alone
  They may help draft the letter, but the final LOR must be signed and submitted by an attending. A letter directly from a resident usually won’t be accepted.

• Non-US clinical letters as your only or primary letters
  These can supplement your application, but US citizen IMGs need US-based clinical letters to show how they perform in this environment.

Practical Strategy for a US Citizen IMG

If you’re an American studying abroad with limited US rotation time:

• Plan at least two US core or sub-I rotations (one Internal Medicine, one Pediatrics) early enough to get letters before ERAS opens.
• Add one Med-Peds elective at a program that has a Med-Peds residency if at all possible.
• Before each rotation starts, identify which attendings are likely letter-writers and show them consistent engagement, reliability, and improvement.

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How to Get Strong LORs: Step-by-Step Strategy for US Citizen IMGs

Knowing how to get strong LORs is as important as knowing who to ask. As a US citizen IMG, you may feel at a disadvantage compared to US MD/DO students—but the same principles apply, with even more emphasis on preparation and professional follow-through.

1. Start Planning Early

Aim to have your core letter strategy mapped out 6–9 months before the application cycle:

• Decide how many Med-Peds vs IM vs Peds letters you’ll target
• Schedule US rotations with enough buffer before ERAS submission
• Research which programs and hospitals have Med-Peds attendings and combined programs
• Clarify each school’s process for uploading ERAS letters (some sites are slow)

2. Perform Intentionally on Every Rotation

Even if you’re not yet sure you’ll ask a specific attending for a letter, act as if you will. That means:

• Showing up on time (or early) every day
• Reading about your patients and anticipating plan changes
• Presenting organized, concise, and thoughtful assessments
• Being proactive in helping the team (notes, follow-up labs, calling consults where appropriate)
• Asking for feedback mid-rotation and adjusting your approach

When attendings see rapid improvement after feedback, it stands out—and they’ll often comment on it in letters.

3. Signal Early That You May Request a Letter

About halfway through a rotation—once you’ve shown your work ethic and reliability—say something like:

“Dr. Smith, I’m a US citizen IMG applying to Medicine-Pediatrics next cycle, and I’m hoping to collect strong letters of recommendation from attendings who have worked closely with me. If by the end of this rotation you feel you know my work well enough, I’d really appreciate being considered for a letter.”

This does three things:

1. It tells them you value their opinion.
2. It encourages them to pay closer attention to your performance.
3. It gives them space to decline gracefully if they don’t feel they can support you strongly.

4. Explicitly Ask for a “Strong Letter”

At the end of the rotation, during your final feedback meeting or shortly afterward, you should ask directly:

“Dr. Smith, I really enjoyed working with you and learned a lot on this rotation. I’m applying to Med-Peds residency this fall, and I was wondering if you would feel comfortable writing a strong letter of recommendation on my behalf.”

Using the phrase “strong letter of recommendation” is important. If they hesitate, seem lukewarm, or suggest someone else instead, take that as a sign to look elsewhere for a primary letter.

5. Provide a Brief, Organized Letter Packet

Once they agree, send a professional email within 24–48 hours:

Subject: Letter of Recommendation Request – [Your Name], Med-Peds Residency Applicant

Attach:

• Your CV (updated and clearly formatted)
• A draft of your personal statement, even if still evolving
• A one-page summary of:
  • Your long-term career interests (e.g., complex chronic care, transitional care, underserved populations)
  • Why you’re drawn to Med-Peds specifically
  • 3–5 patients or situations from that rotation that highlight your strengths
• Your ERAS AAMC ID and instructions or link for letter upload
• A reminder of the deadline you’re targeting (ideally 2–4 weeks before ERAS opens)

This packet helps your letter writer craft a detailed, personalized, and Med-Peds–aligned letter, which is especially important when your home institution is abroad and less familiar to them.

6. Gently Follow Up (Without Harassing)

Faculty are busy, and letters can fall off their radar. It’s reasonable to:

• Send a friendly check-in 2–3 weeks after your initial request
• Send another reminder 2 weeks before your internal deadline if it’s still not uploaded

Always be polite, appreciative, and concise. If they still haven’t submitted close to the final deadline, you may need to activate an alternate plan with another potential writer, if available.

7. Waive Your Right to View the Letter

ERAS will ask if you want to waive your right to see each LOR. For residency letters, the expectation is that you waive your right, signaling that the letter is candid and not edited by you. Programs often view non-waived letters with suspicion.

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Med-Peds–Specific Considerations for LORs

For Med-Peds, letters do more than say “this person is competent.” They help programs answer: “Is this applicant truly a Med-Peds person?”

What a Med-Peds Program Looks for in Letters

Across your letters, programs want to see:

• Ability to handle complexity
  Patients with multiple chronic conditions, psychosocial challenges, or care transitions.

• Breadth of interest across age groups
  Evidence that you enjoy and are capable of caring for both adults and children—not just tolerating one of the two.

• Adaptability and resilience
  Med-Peds residents constantly switch between adult and pediatric services. Letters that mention your flexibility and rapid learning curve are powerful.

• Teamwork and communication
  Med-Peds often functions in interdisciplinary, primary care, and hospitalist settings. Comments about your collaboration with nurses, social workers, therapists, and families carry weight.

• Commitment to continuity and long-term care
  Many Med-Peds physicians focus on transitional care, complex chronic illness, or underserved populations. If you have experience in those realms, make sure letter writers know about it.

How to “Coach” Your Letters (Without Writing Them Yourself)

You cannot—and should not—write your own LOR. But you can influence its content by giving your writer:

• Your Med-Peds specific career goals (e.g., complex care, global health, primary care for people with developmental disabilities, hospital medicine spanning both IM and Peds)
• Specific examples of patients or cases that demonstrate:
  • Multisystem thinking
  • Transitional care issues
  • Working with adolescents becoming adults
  • Follow-up in both pediatric and adult settings

For example, in your summary page, you might include:

“If helpful, you might recall Mr. J, the 22-year-old with congenital heart disease transitioning from pediatric to adult care; I really appreciated your feedback on balancing his cardiology needs with his mental health and social concerns. That case strongly reinforced my interest in Med-Peds and transitional care.”

This triggers the attending’s memory and helps them write a richer, more specific letter.

Balancing Letters for Med-Peds vs Categorical Programs

Many US citizen IMGs apply to both Med-Peds and categorical Internal Medicine or Pediatrics as parallel strategies. You can usually reuse letters across both, as long as:

• The letter is strong and detailed
• It speaks broadly to your clinical capabilities in adult or pediatric medicine

However, for your Med-Peds–focused programs:

• Try to have at least one clearly Med-Peds–focused letter
• Ensure your other letters do not strongly imply that you’re only interested in categorical IM or Peds (e.g., “She is one of the strongest future internists I’ve worked with” without mentioning interest in Med-Peds or pediatrics at all)

If an attending asks directly, “Are you applying to Med-Peds or categorical?” answer honestly, but explain your rationale and primary preference clearly.

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Common Pitfalls for US Citizen IMGs (and How to Avoid Them)

1. Relying Only on Non-US Letters

If your only letters are from your school abroad, programs may worry about:

• How you adapt to US healthcare systems
• Your communication with US patients and teams
• The reliability of evaluation standards

Solution: Prioritize at least 2–3 US-based clinical rotations with strong letter potential, even if it means extra effort, cost, or travel.

2. Waiting Too Long to Ask for Letters

If you wait months after a rotation ends:

• Attendings will remember less about you
• Your letter may be shorter and more generic
• They may be too busy with new students, fellows, and projects

Solution: Ask at the end of the rotation, while your performance is fresh in their mind, and send your packet immediately.

3. Not Asking for a Strong Letter

If you simply say, “Can you write me a letter?” some attendings will say yes out of politeness, even if it won’t be glowing.

Solution: Always ask if they can write a strong letter. This gives them space to bow out if they can’t fully support your application.

4. Overloading on Research Letters

Research letters can be excellent supplements, especially if you’ve done clinically relevant or outcomes-focused work. However, for a residency application—especially Med-Peds—programs prioritize clinical performance.

Solution: Limit pure research letters to 0–1 in your main three, unless the research mentor also directly supervised your clinical work.

5. Not Aligning Letters With Your Specialty Narrative

If one letter focuses only on psychiatry, another on surgery, and another on anesthesia, while your personal statement screams Med-Peds, programs may question your focus.

Solution: Ensure your core letters come from Internal Medicine, Pediatrics, and ideally Med-Peds faculty, and that your summary materials emphasize why you’re committed to Med-Peds.

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FAQs: Letters of Recommendation for US Citizen IMGs in Med-Peds

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

Aim for at least three US clinical letters, with a balance across Internal Medicine, Pediatrics, and (if possible) Med-Peds:

• 1 Med-Peds or Internal Medicine letter
• 1 Pediatrics letter
• 1 additional IM/Peds/Med-Peds or longitudinal mentor letter

If you have a stellar non-US letter (e.g., from your dean or a major clinical mentor abroad), you can include it as a fourth letter, but don’t let it replace a strong US clinical LOR.

2. What if my school abroad doesn’t offer many US rotations?

This is a common challenge for Americans studying abroad. Options include:

• Proactively seeking visiting student electives in the US (VSLO/VSAS or direct institution applications)
• Prioritizing rotations at institutions with Med-Peds programs
• Considering private or community-based US clinical experiences that allow for formal evaluation and letter-writing

Even two high-quality US rotations can be enough if your performance is excellent and your letters are strong and detailed.

3. Can I use the same letters for Med-Peds and categorical IM or Peds programs?

Yes. Most ERAS applicants use the same set of letters across multiple specialties. For a US citizen IMG applying to Med-Peds and categorical IM or Peds:

• Use your IM letter(s) for both Med-Peds and IM applications
• Use your Peds letter(s) for both Med-Peds and Pediatrics applications
• Use your Med-Peds–specific letter for Med-Peds programs and sometimes for both if it strongly supports you as an intern-level physician

Just ensure your personal statement and program-specific materials align with the specialty you’re applying to.

4. How can I tell if a letter is actually strong if I waived my right to see it?

You won’t see the content, but you can infer strength by:

• The attending’s immediate and enthusiastic response when you ask
• Their track record of supporting students in the match
• Their familiarity with US residency expectations
• Their reputation among students and residents

If an attending hesitates, seems unsure, or suggests you might be better off asking someone else, take that seriously and look for a different writer.

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Thoughtful planning, early relationship-building, and clear communication about your Med-Peds goals will give you a powerful letter portfolio. As a US citizen IMG, you’re already navigating an extra layer of complexity; turning your letters of recommendation into a genuine strength is one of the most impactful ways to stand out in the medicine pediatrics match.