Essential IMG Residency Guide: Mastering Pre-Match Communication in EM

Understanding Pre-Match Communication in EM as an IMG

Pre-match communication for an international medical graduate (IMG) in emergency medicine (EM) is both an opportunity and a potential minefield. Used wisely, it can help you clarify program fit, demonstrate professionalism, and occasionally open doors to pre-match offers or strong ranking support. Used poorly, it can create red flags, ethical concerns, or even NRMP violations.

For EM, where communication skills, teamwork, and professionalism are core competencies, how you communicate before the match can significantly influence how programs perceive you.

This IMG residency guide will walk you through:

• What “pre-match communication” actually includes
• Which types of messages are appropriate (and which are risky)
• How to handle pre-match offers and early commitment pressure
• Best practices for email, phone, and in-person communication
• Concrete templates and examples tailored to emergency medicine

Throughout, we’ll focus on the specific realities and expectations facing international medical graduates seeking emergency medicine residency positions in the U.S.

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1. The Landscape: Rules, Culture, and Expectations

1.1 What Counts as “Pre-Match Communication”?

Pre-match communication includes any contact with a program before the official Match results are released, outside of your application itself. This may involve:

• Emails to:
  • Express interest before or after an interview
  • Ask follow-up questions
  • Provide updates (USMLE scores, new publications, rotations)
• Phone calls:
  • Clarifying logistics (rarely necessary beyond what the coordinator provides)
  • Very rarely, direct calls to PDs or APDs (program directors/associate program directors)
• In-person interactions:
  • At conferences (ACEP, SAEM, EMRA events)
  • On away/audition rotations
• Online/virtual communication:
  • ERAS/Thalamus messages, interview portal messages
  • Program socials (Zoom meet & greets, online open houses)

Not all communication is equal. Some is routine and expected (e.g., thank-you emails); some is high-stakes (e.g., discussions about pre-match offers and early commitment).

1.2 The NRMP and Ethical Boundaries

Most EM residencies participate in the NRMP Match and must follow its policies. The key concepts to know:

• Programs cannot require or ask you to reveal:
  • How you will rank them
  • Whether a program is your “#1”
• You cannot ask programs directly how they will rank you.
• No one can ask you to commit to ranking them first, verbally or in writing, as a condition of receiving an interview or ranking consideration.

However, expressions of interest are allowed. Programs and applicants may say:

• “You are ranked highly within our program.”
• “I plan to rank your program very highly.”

These are statements of interest, not binding commitments.

1.3 Special Considerations for IMGs in EM

For an international medical graduate entering emergency medicine, pre-match communication can be especially important because:

• You may need to clarify visa sponsorship (J-1 vs H-1B, willingness to sponsor, institutional limits).
• Some EM programs have limited or no history of taking IMGs; communication can help you identify IMG-friendly programs.
• You often can’t rely on U.S. medical school advisors to advocate for you; your communication is your advocacy.

At the same time, IMGs can sometimes feel pressured:

• To aggressively “sell themselves”
• To chase pre-match offers in a way that may conflict with their long-term goals
• To over-communicate, which can backfire and appear unprofessional

A core principle: Professional, concise, and honest communication will always serve you better than aggressive or emotional outreach.

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2. Types of Pre-Match Communication and How to Use Them

2.1 Before Interview Invitations: Showing Interest Without Spamming

Sending pre-interview interest emails can sometimes help, especially for:

• Programs with a known IMG track record
• Regions where you have strong geographic ties (family, previous work, spouse’s job)
• Emergency medicine programs where your profile closely matches their mission (e.g., global health, underserved care, EMS, toxicology interest)

However, EM is highly competitive and busy; many programs receive hundreds or thousands of emails. Over-emailing is counterproductive.

When it can make sense to email pre-interview:

• You are a strong potential fit:
  • Significant EM-related research or global EM background
  • Prior EM clinical experience in the U.S.
  • Specific connection to their institution or region
• You have new information that isn’t in ERAS (e.g., improved USMLE/Step scores, newly passed Step 3 when visa issues are relevant).

Key principles:

• One concise email is enough.
• Address it to the program coordinator and/or program director.
• Avoid attachments if possible; refer them to ERAS.

Example pre-interview email (IMG, EM focus):

Subject: Emergency Medicine Applicant – [Your Name], IMG – Continued Interest

Dear Dr. [PD Last Name] and [Program Coordinator Name],

My name is [Your Name], an international medical graduate from [School, Country], applying to Emergency Medicine this cycle. I am writing to express my strong interest in the [Program Name] EM residency.

I am particularly drawn to your program because of [1–2 specific, concrete features: e.g., strong simulation curriculum, high-volume trauma center, support for IMGs, global health opportunities, EMS exposure, etc.]. My recent clinical experiences in U.S. emergency departments at [Institution(s)] have reinforced my commitment to a career in EM.

I understand how competitive this process is and how many applications you review. Should my background align with your program’s needs, I would be truly honored to be considered for an interview.

Thank you very much for your time and consideration.

Sincerely,
[Full Name, Credentials]
AAMC ID: [Number]
ECFMG Certified
[Phone] | [Email]

Do not send follow-up “checking in” emails every week. If a program is interested and has capacity, the first email is enough.

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2.2 After the Interview: Thank-You Emails and Continued Interest

In EM, thank-you emails after interviews are common but not strictly required. They rarely determine your rank position, but they can:

• Reinforce a positive impression
• Clarify your interests and fit
• Provide an avenue to express genuine alignment with the program’s values

Best practices post-interview:

• Send thank-you emails within 24–72 hours.
• Short, specific, and sincere (5–8 sentences).
• Avoid ranking promises or emotional pressure (“I will be heartbroken if I don’t match here”).

Example post-interview thank-you:

Subject: Thank You – [Your Name], EM Interview on [Date]

Dear Dr. [Interviewer Last Name],

Thank you for taking the time to speak with me during my interview at [Program Name] on [Date]. I especially appreciated our discussion about [specific topic—e.g., ED flow, global health, toxicology, ultrasound training].

Learning more about your high-acuity clinical environment and the support you provide to residents, including [specific program feature], strengthened my interest in your program. As an IMG with strong commitment to [patient population, academic EM, underserved care, etc.], I believe [Program Name] is an excellent fit for my training goals.

I am very grateful for the opportunity to interview and to learn about your department.

Sincerely,
[Full Name]

You may send a separate email to the program director expressing overall gratitude and interest, again without promising rank order.

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2.3 Post-Interview Updates and “Love Letters”

In EM, some applicants send “love letters” to their top-choice programs stating that they plan to rank them highly or even first. This area is ethically gray but currently common. For IMGs, this must be handled with extra care.

Considerations:

• It is potentially helpful to communicate genuine strong interest to your true top 1–3 programs.
• Never send “You are my #1 choice” messages to multiple programs. That is unethical.
• Use language that is honest but not coercive.

Safer phrasing options:

• “Your program will be ranked very highly on my list.”
• “I believe [Program Name] is an excellent fit, and I am strongly interested in training there.”

Use this sparingly; one or two key messages near the end of interview season is more effective than multiple repetitive emails.

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3. Pre-Match Offers, Early Commitment, and the EM Landscape

3.1 What Are Pre-Match Offers?

A pre-match offer is when a program offers you a residency position outside of the NRMP Match process, typically in writing, with an expectation that you will accept or decline before the Rank Order List deadline.

In EM, most ACGME-accredited programs participate in the NRMP Match and do not routinely offer out-of-match contracts. However, pre-match offers can still arise in:

• Some community-based EM programs
• Programs in less competitive regions
• Programs with unfilled positions or specific IMG recruitment pathways
• Certain non-NRMP or SOAP-like situations in previous cycles

As an international medical graduate, you may feel excited—this looks like security in a very competitive process. But you must carefully evaluate the risks, ethics, and long-term implications.

3.2 Legal and Ethical Considerations for Pre-Match Offers

Key points:

• If a program participates in the NRMP Main Match, they are expected to fill positions through the Match, except under very narrow, NRMP-approved circumstances. Broad use of pre-match offers can violate NRMP rules.
• If a program is outside the Match for EM positions, they might legally offer contracts directly, but you must still consider:
  • Visa sponsorship details and timelines
  • Contract length, salary, benefits, and ACGME accreditation
  • Whether completing this residency will make you board-eligible in EM

Before accepting any pre-match offer, ask:

• Does this EM position participate in the NRMP Match or is it formally outside the Match?
• Is the residency ACGME-accredited in Emergency Medicine?
• Will completion make me ABEM (or AOBEM) board-eligible?

3.3 Evaluating Early Commitment vs Waiting for the Match

If you receive a pre-match offer or strong pressure to commit early, weigh:

Advantages of early commitment:

• Guaranteed position (if the contract is legitimate, EM, and accredited)
• Reduced stress—no need to worry about Match outcomes
• More time to plan relocation and visa processing

Risks and downsides:

• You may close doors to stronger programs you might have matched into.
• Some IMGs accept pre-match spots at programs with:
  • Poor training environments
  • Limited procedures or critical care exposure
  • Weak educational structure, minimal board pass support
• Hard to back out: withdrawing later can severely damage your reputation and even affect your ability to get licensed or matched elsewhere.

Practical rule for IMGs in EM:

Only consider a pre-match or early-commitment offer if:

1. The program is fully ACGME-accredited in Emergency Medicine and leads to EM board eligibility.
2. Visa sponsorship is clearly specified in writing and realistic for your timeline.
3. You would truly be happy training there even if it were your only option.
4. You have verified the program via:
   • Current (or recent) residents, ideally other IMGs
   • Reputation among EM physicians or advisors
   • Outcomes: board pass rates, fellowship matches, job placement

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3.4 How to Respond to a Pre-Match Offer or Early Commitment Pressure

If a program hints at or directly proposes an early commitment, adopt a calm, structured approach.

Step 1: Clarify the nature of the offer

You can respond with:

Thank you very much for your confidence in me and for discussing the possibility of an offer. To ensure I fully understand, would this position be filled outside the NRMP Match process, or through the Match? Additionally, is the position ACGME-accredited in Emergency Medicine and board-eligible upon completion?

Step 2: Ask for time

You usually do not need to answer immediately.

I am very honored by your consideration. This is an important decision for my career and for my family. Would it be possible to have a few days to review the details of the contract and confirm visa/credentialing considerations before I provide you with an answer?

Step 3: Seek independent advice

As an IMG, consult:

• EM faculty or advisors who know the U.S. landscape
• Trusted mentors from your home institution
• Current or former residents at that program (especially IMGs)
• Professional organizations (e.g., EMRA, ACEP IMG sections if available)

Step 4: Make a decision—and then commit

If you accept, do so clearly and professionally. Do not continue applying to or courting other programs if your acceptance is contractually binding.

If you decline, remain respectful:

Thank you again for considering me for this opportunity. After careful thought, I have decided to remain in the NRMP Match process and pursue all of my options there. I am very grateful for your time and for your confidence in my potential.

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4. Professional Program Communication Before Match: Do’s and Don’ts

4.1 General Email Etiquette for IMGs in EM

Do:

• Use a professional email address (e.g., firstname.lastname.md@gmail.com).
• Include your full name, AAMC ID, ECFMG number (if relevant), and contact details in your signature.
• Keep messages concise—program staff are extremely busy.
• Double-check grammar and spelling; consider having a friend review if English is not your first language.
• Reference specific program features when expressing interest.

Don’t:

• Email the same program multiple times with no new information.
• Copy-paste generic messages to 50 programs with only the name changed (errors often slip through).
• Apologize excessively for being an IMG; present your background confidently.
• Use emotional pressure (“This is my only hope,” “My entire future depends on you”).

4.2 Appropriate Reasons to Contact Programs Late in the Season

As the rank order list deadline approaches, appropriate program communication before match can include:

• Updates:
  • New publication or poster in EM
  • New Step score (particularly Step 3 for visa-sensitive programs)
  • Change in visa status (e.g., from requiring H-1B to being eligible for J-1)
• Clarification:
  • Questions about curriculum, off-service rotations, ED volume
  • Clarification of visa sponsorship type
• Expression of strong, sincere interest:
  • One well-timed, honest message to your top program(s)

Example late-season interest email:

Subject: Update and Continued Interest – [Your Name], EM Applicant

Dear Dr. [PD Last Name] and [Program Coordinator Name],

I hope you are doing well as the interview season is coming to a close. I wanted to share a brief update and reaffirm my strong interest in the [Program Name] Emergency Medicine Residency.

Since our interview on [Date], I have [passed USMLE Step 3 / presented an abstract at X conference / completed an EM rotation at Y hospital, etc.]. These experiences have further solidified my desire to train in a high-acuity, team-oriented ED environment like yours.

I continue to be particularly drawn to [1–2 specific program features]. As an IMG committed to a long-term career in Emergency Medicine in the U.S., I believe [Program Name] aligns exceptionally well with my training and career goals, and I plan to rank your program very highly.

Thank you again for considering my application.

Sincerely,
[Your Name]

4.3 Communication with Coordinators vs Faculty

Program Coordinators

• Handle logistics: interview scheduling, documents, instructions.
• Ideal contact for:
  • Schedule changes or conflicts
  • Technical issues with interview platforms
  • Clarifying deadlines and requirements

Program Directors/Faculty

• More appropriate for:
  • Expressing program-specific interest
  • Academic or curriculum-related questions
  • Addressing complex concerns such as visa nuances or late updates

When in doubt, it’s often safer to email the coordinator and CC the PD only when the content truly involves them.

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5. Strategic Tips for IMGs Navigating EM Match Communication

5.1 Presenting Your IMG Background as a Strength

In all your communication:

• Highlight resilience, adaptability, and multicultural experience.
• Emphasize your EM-specific strengths:
  • Comfort with resource-limited settings
  • Prior exposure to high-acuity emergencies
  • Language skills useful for the local population

For emergency medicine residency programs, international experience can be an asset in caring for diverse patient populations, disaster response, or global health initiatives.

5.2 Managing Anxiety and Over-Communication

The EM match is stressful, especially for IMGs. Common pitfalls:

• Over-emailing programs to seek reassurance
• Asking for rank information directly
• Comparing yourself constantly to others on forums or social media

Practical strategies:

• Set a personal communication limit:
  • One pre-interview email (if any)
  • One thank-you and one end-of-season update per program at most
• Keep a spreadsheet:
  • Track each program, date of emails, responses, topics
• Check messages at scheduled times only; avoid sending late-night or emotional emails.

5.3 Handling Silence from Programs

Many EM programs never respond to thank-you or update emails; this is normal. Silence usually means:

• They are busy.
• They have a policy not to respond to post-interview communication.
• It doesn’t necessarily reflect your rank status.

Do not:

• Send multiple “just checking if you received my email” messages.
• Take it as a personal rejection.

Instead, focus your energy on:

• Improving your backup plan (e.g., understanding SOAP, alternative specialties if necessary).
• Preparing for possible future reapplication (if you’re an early-cycle applicant).

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6. Putting It All Together: A Step-by-Step Communication Plan for IMGs in EM

Here is a structured, practical plan for an international medical graduate navigating pre-match communication in emergency medicine:

Step 1: Before Applications Open

• Research EM programs that are:
  • IMG-friendly (check FREIDA, program websites, current resident profiles).
  • Historically supportive of J-1 or H-1B visas.
• Build a list of:
  • Top-tier “reach” programs
  • Realistic targets
  • Safety/backup EM programs (if available)

Step 2: After Applications Are Submitted

• Consider one targeted email to a small number of high-priority programs:
  • Where you have a strong geographic or academic fit
  • Where your IMG profile matches their mission
• Keep tracking responses but accept that many will not respond.

Step 3: During Interview Season

• After each interview:
  • Send a brief, tailored thank-you within 24–72 hours.
  • Note specific program features and interactions you valued.
• Update programs if:
  • You pass a major exam (especially Step 3)
  • You publish, present, or complete notable EM experiences

Step 4: Late Season / Pre-Rank List

• Identify your top 1–3 programs.
• Send one carefully written continued interest email to each, especially your true #1 program.
• Use honest, non-coercive language; do not make promises you can’t keep.

Step 5: If You Receive a Pre-Match Offer

• Verify accreditation, board eligibility, and visa sponsorship details.
• Request time to think and review the contract.
• Consult independent advisors and current/former residents.
• Decide whether this early commitment aligns with your long-term goals in EM.

Step 6: After Rank List Submission

• Avoid sending further rank-related emails.
• Focus on:
  • Completing rotations professionally
  • Preparing for transitions (e.g., relocation, clinical skills, reading EM texts)
• Maintain professionalism; the EM community is small, and reputations spread.

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FAQs: Pre-Match Communication for IMGs in Emergency Medicine

1. As an IMG, do I need to send pre-interview emails to all EM programs I applied to?

No. Mass emailing can annoy programs and dilute your message. Use targeted communication only where you have a clear and genuine connection—such as strong regional ties, previous clinical experience there, or a highly aligned academic interest. Many applicants match to EM without sending any pre-interview emails at all.

2. Can I tell more than one emergency medicine program that they are my “#1 choice”?

You should not tell multiple programs they are your #1; that is misleading and unethical. You may tell one true top program that you plan to rank them first or very highly, and you may express strong interest to others using more general language. Remember that EM is a small community; dishonesty can damage your reputation.

3. How often should I email programs after my EM interviews?

In most cases, the following is sufficient:

• One thank-you email per interviewer and/or one to the PD within a few days of the interview.
• One late-season update/interest email only if you have something meaningful to share (new exam result, publication, or genuine final expression of strong interest).

More frequent emails rarely help and may hurt your image as a future EM professional who can prioritize and communicate efficiently.

4. How do I know if a pre-match offer is safe to accept as an IMG?

Check the following before accepting:

• The position is ACGME-accredited in Emergency Medicine.
• Completion of the residency makes you board-eligible in EM (ABEM or AOBEM).
• Visa sponsorship (J-1 or H-1B) is clearly documented and feasible for your timeline.
• You have spoken with current or recent residents, preferably other IMGs, and feel confident about the training environment.

If any of these are unclear or concerning, seek further clarification and independent advice before making a decision.

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By approaching pre-match communication with structure, honesty, and professionalism, an international medical graduate pursuing emergency medicine residency can turn a stressful process into a strategic advantage—demonstrating exactly the composure, clarity, and maturity that EM programs value in their future residents.