Essential Pre-Match Communication Tips for IMG in EM-IM Residency

Understanding Pre-Match Communication as an IMG in EM–IM

For an international medical graduate, the combined Emergency Medicine–Internal Medicine (EM–IM) pathway can be both exciting and intimidating. You’re applying to a niche specialty with relatively few programs, intense clinical expectations, and a competitive applicant pool. In that environment, pre-match communication becomes a critical skill—not to “game the system,” but to demonstrate professionalism, clarify mutual interest, and avoid serious ethical pitfalls.

This IMG residency guide will walk you through how to handle program communication before Match Day specifically for EM–IM. You’ll learn what is allowed, what is risky, how to respond to hints of pre-match offers or “early commitment,” and how to communicate in a way that reflects well on you as a future resident and colleague.

Throughout, remember one key principle: your integrity is more important than any single program. The EM and IM communities are small, and EM–IM combined is even smaller. Your reputation follows you.

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1. The Landscape: EM–IM for International Medical Graduates

Why pre-match communication matters more in EM–IM

EM–IM combined programs are limited in number, often with only a handful of spots per year. For an international medical graduate:

• You’re competing not only with other IMGs, but also with strong US graduates.
• Many EM–IM programs are at large academic centers that receive hundreds to thousands of applications.
• Programs may be trying to identify applicants who are both:
  • Genuinely committed to dual training, and
  • Likely to thrive in high-acuity, high-volume settings.

In this context, clear, thoughtful communication can help you:

• Demonstrate genuine interest in EM–IM rather than using it as a “backup.”
• Clarify your visa needs and any logistical issues early.
• Stand out as a mature, reliable professional who understands the NRMP rules.

IMGs and pre-match pressures

Many IMGs feel added pressure because of:

• Visa concerns (J-1 vs H-1B eligibility).
• Limited geographic flexibility (family, financial constraints).
• Fear of “going unmatched” after years of sacrifice.

This pressure sometimes leads applicants to:

• Over-interpret routine emails as “secret signals.”
• Send too many messages to programs.
• Engage in inappropriate “ranking conversations” with faculty.

Your goal is to do the opposite: communicate clearly and professionally, without anxiety or desperation showing through.

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2. What Counts as Pre-Match Communication?

Types of communication you may encounter

Before and after interviews, you may see several types of program communication before match:

1. Administrative messages

   • Interview offers, scheduling, and logistics.
   • Information about the program, rotations, or hospital.
   • These are routine and not “signals” about your rank.

2. Thank-you responses / courtesy notes

   • Short “Thank you for interviewing with us” or “We enjoyed getting to know you.”
   • These are polite, boilerplate and do not imply rank.

3. Interest or fit signals

   • “We think you would be a great fit here.”
   • “You are a strong candidate for our EM–IM program.”
   • May be sincere, but are often non-committal and not binding.

4. Stronger language or “we plan to rank you highly”

   • “We will rank you highly on our list.”
   • “We hope to work with you next year.”
   • Still non-binding under NRMP rules, even if it sounds promising.

5. Informal or explicit discussion of pre-match offers / early commitment (rare in NRMP-participating EM–IM programs)

   • “If you commit to ranking us #1, we can essentially guarantee you a spot.”
   • “We sometimes offer pre-match spots to strong candidates.”

Most EM–IM programs participate fully in the Match and do not offer pre-match contracts. If you are ever offered something that sounds like a guarantee or a backdoor deal, you must carefully consider the NRMP rules and your own ethical obligations.

The NRMP framework you must understand

As of my knowledge cutoff (late 2024), NRMP rules include:

• No program or applicant may ask the other for ranking commitments.
• You may freely express interest, including saying things like “I plan to rank your program highly.”
• No binding agreements outside the Match are allowed for NRMP-participating positions.
• Violations can lead to NRMP investigations that may affect your ability to enter residency.

Always check the current NRMP Applicant Agreement and your local regulations, as policies can change.

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3. Communicating Before the Match: Strategy and Best Practices

Your overall goals

For an international medical graduate applying to EM–IM, your pre-match communication should aim to:

1. Clarify your genuine commitment to combined training.
2. Highlight your specific suitability for emergency medicine internal medicine training.
3. Address visa and logistical questions proactively, but not obsessively.
4. Show professionalism, maturity, and integrity in all written and verbal interactions.

Think of each interaction as part of a professional portfolio—just like your letters of recommendation and personal statement.

Before the interview: outreach and signals

You generally don’t need to contact EM–IM programs before they invite you to interview, except in limited situations:

Appropriate pre-interview communication:

• You did an EM or IM rotation with their faculty and want to:
  • Politely remind them of your connection.
  • Express your interest in EM–IM specifically.
• You have a meaningful geographic or personal tie:
  • Immediate family in the area.
  • Prior research or training at that institution.
• You need to clarify visa sponsorship:
  • Their website is unclear about J-1 vs H-1B.
  • You have unusual visa circumstances.

Example email (brief, professional):

Subject: EM–IM Application and Visa Eligibility Question – [Your Name, AAMC ID]

Dear Dr. [Program Director’s Last Name] / EM–IM Program Coordinator,

I recently applied to the [Institution Name] Emergency Medicine–Internal Medicine residency as an international medical graduate (AAMC ID: XXXXXXXX). I am very interested in combined EM–IM training because [1–2 concise reasons, ideally tied to their program’s features].

I wanted to clarify one point regarding visa sponsorship. I am currently eligible for [J‑1 / H‑1B] sponsorship. I could not find detailed information on your website and would be grateful to know whether your EM–IM program sponsors [that visa type].

Thank you very much for your time and consideration.

Sincerely,
[Full Name, Medical School, Graduation Year]

Avoid mass, generic emails. One or two well-crafted emails to programs where you have a real connection or question are enough.

After the interview: thank-you notes and updates

Thank-you notes

For most EM–IM programs, it is acceptable (but not mandatory) to send a brief thank-you email:

• To the program director.
• Optionally, to a specific interviewer with whom you had a meaningful connection.

Keep it concise:

• Express appreciation.
• Reference one concrete detail from the conversation.
• Reiterate your specific interest in EM–IM combined at that institution.

Example structure:

• 2–4 short paragraphs.
• No mention of rank order or “you are my #1.”

Post-interview updates

Consider an update if:

• You have a significant new accomplishment (new US clinical experience, publication, Step 3 pass, improved visa status).
• You want to send a single, thoughtful “interest statement” close to rank-list time.

EM–IM is small; less is more. One well-timed, content-rich message can be more effective than multiple vague emails.

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4. Interest Statements, “Love Letters,” and Rank List Etiquette

Can an IMG tell a program they are ranking it #1?

Yes, NRMP rules allow you to voluntarily share your plans, as long as:

• There’s no pressure from the program.
• No one asks you to confirm your rank order in writing.
• There is no implied or explicit contract.

But you must be extremely careful:

• Do not tell more than one program that it is your “first choice” or “ranked to match.”
• If you’re uncertain, use softer but still honest language (e.g., “I will be ranking your program very highly”).

How to phrase interest without overcommitting

Stronger commitment (only if truly #1):

“After careful consideration, your EM–IM program remains my top choice, and I intend to rank it first on my list.”

High-interest but non-committal (if it’s among your top choices):

“I will be ranking your EM–IM program very highly due to [specific reasons].”

Avoid:

• Asking how they will rank you.
• Pressuring faculty for “inside information.”
• Copy-pasting identical “you are my #1” letters to multiple programs.

Example “top choice” email (use only for a true #1 program)

Subject: Continued Strong Interest in [Institution] EM–IM – [Your Name]

Dear Dr. [PD Last Name],

I wanted to again thank you and the team for the opportunity to interview for the Emergency Medicine–Internal Medicine residency at [Institution]. The combination of high-acuity emergency care, robust internal medicine training, and your focus on [e.g., critical care, global health, ultrasound] aligns closely with my long-term goal of practicing as a dual-trained EM–IM physician.

After reflecting on all of my interviews, I have decided that [Institution] EM–IM is my top choice, and I intend to rank your program first on my rank order list. I would be honored to train in a program that values both acute resuscitation and complex longitudinal care, and I believe my background as an international medical graduate with [specific experience] would allow me to contribute meaningfully to your team.

Thank you again for your consideration.

Sincerely,
[Your Full Name, AAMC ID, Contact Info]

Only send this if you truly intend to rank them #1. Anything else is dishonest and can hurt you if it becomes known.

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5. Pre-Match Offers, Early Commitment, and Red Flags

Do EM–IM programs give pre-match offers?

Most US EM–IM programs in the NRMP do not offer non-match contracts. They fill positions through the Match like other ACGME-accredited programs. However:

• Some institutions may have non-NRMP tracks (e.g., preliminary or research positions) with separate processes.
• Applicant rumors on forums can misinterpret strong interest language as a “pre-match offer.”

For an international medical graduate, especially if you come from a system where pre-match or direct contracts are common, US processes can feel confusing. Always verify:

• Is the position part of the NRMP Match?
• Is there an official contract outside ERAS/NRMP?
• Does this communication align with the NRMP Code of Conduct?

How to recognize problematic early commitment pressure

Red flags from programs:

• “If you tell us we’re your #1, we can guarantee you’ll match here.”
• “We expect our top candidates to inform us of their rank positions.”
• “We need written confirmation that you will rank us first.”
• “We don’t usually match IMGs unless we are sure they’ll come.”

These statements may not always be outright NRMP violations, but they are ethically concerning and reflect poorly on a program’s culture.

If you encounter this:

1. Stay calm and neutral.
2. Respond with something like:
   • “I am very interested in your program and will consider it strongly when creating my rank list.”
3. Do not commit to a rank order you don’t mean to keep.
4. Document the interaction with dates and details in case you need guidance from:
   • NRMP,
   • Your medical school advisor,
   • An IMG support organization.

What if a program seems to be making a real pre-match offer?

Occasionally, you might encounter:

• Programs that fill some positions outside of NRMP (rare in EM–IM).
• Research fellowship years, observer roles, or non-standard positions framed as “pathways” to categorical spots.

Before agreeing to anything:

1. Clarify the nature of the position:

   • Is it ACGME-accredited?
   • Does it guarantee a categorical EM–IM slot later? (Usually no.)
   • Is it separate from the NRMP?

2. Seek independent advice:

   • Speak with mentors, EM–IM faculty, or advisors familiar with US GME.
   • Join IMG-focused professional groups (e.g., ACEP International Section, APDIM or AAIM resources).

3. Consider long-term consequences:

   • Non-standard paths can be useful but may delay board eligibility.
   • Make sure any early commitment does not block you from a better NRMP-matched position.

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6. Practical Communication Tips for EM–IM IMGs

1. Tailor your message to EM–IM, not just EM or IM

Programs want to see you understand the unique nature of combined training:

• Long training (5 years).
• Balancing acute care with continuity and chronic disease management.
• Potential careers in:
  • Academic EM or IM,
  • Critical care,
  • Hospitalist or ED leadership,
  • Global emergency care.

In your emails and conversations, reference:

• Specific features of their EM–IM curriculum (e.g., ICU-focused blocks, leadership tracks).
• How your background as an international medical graduate prepares you to navigate both ED chaos and complex inpatients.

2. Communicate like a future colleague, not a desperate applicant

In all your program communication before match:

• Use professional language; avoid slang or overly casual expressions.
• Keep messages short and structured (3–6 sentences is often enough).
• Proofread for grammar and clarity; minor errors are ok, but repeated sloppy writing suggests poor attention to detail.
• Respect time:
  • Don’t send multiple follow-ups if no response.
  • Don’t message faculty through social media unless explicitly invited.

3. Handle silence and mixed signals maturely

Many EM–IM programs simply do not send post-interview signals. No news is:

• Not a rejection.
• Not a reflection of your worth.
• Simply a result of busy clinical and educational leadership.

Do not:

• Flood them with “Just checking in” emails.
• Change your rank list in response to which programs email you more often.

Instead:

• Rank programs in your true preference order.
• Accept that communication styles vary; silence is neutral, not negative.

4. Manage visa discussions factually, not apologetically

As an IMG, visa needs are a reality, not a defect.

• Mention visa status briefly and clearly when relevant:
  • “I will require J‑1 visa sponsorship.”
  • “I am currently on [visa], and I am eligible for [visa type].”
• Do not sound apologetic or defensive.
• Never attempt to hide or misrepresent your visa needs—it will cause far more problems later.

5. Use mentors to review your communication

Particularly as an international medical graduate navigating an unfamiliar system, it can help to:

• Ask an EM or IM attending, an EM–IM faculty member, or an experienced IMG to review your:
  • Sample thank-you note.
  • Interest statement to your top-choice program.
• Join virtual IMG advising sessions hosted by:
  • EM or IM organizations.
  • Your medical school alumni network.

Getting feedback on tone, clarity, and appropriateness can prevent missteps that might otherwise harm your candidacy.

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Frequently Asked Questions (FAQ)

1. As an IMG, do I need to send post-interview thank-you emails to EM–IM programs?

No, you don’t need to, and some programs explicitly state that they do not expect or read them. However, a brief, sincere thank-you email can:

• Reinforce your interest in EM–IM combined training.
• Highlight one or two specific program features you value.
• Help faculty remember you, especially in small EM–IM cohorts.

Keep it concise, professional, and free of rank discussion.

2. How many times should I email a program before the Match?

For most EM–IM programs, a reasonable upper limit is:

• 0–1 pre-interview contact (only if you have a specific question or connection).
• 1 short thank-you after the interview.
• 0–1 final interest/update email near rank-list time (especially for your top-choice or top few programs).

Avoid repeated “checking in” messages; they rarely help and may hurt.

3. What if a program director asks outright, “Where will you rank us?”

This is a gray and uncomfortable situation. You are not required to disclose your rank list. Respond with:

• “I am very interested in your EM–IM program and will be ranking it highly.”
• Or, “I am still finalizing my rank list, but your program is one of my top choices.”

You do not need to provide specific rank order. If you feel pressured, document the interaction and seek advice from an advisor or NRMP.

4. Does expressing strong interest actually change how EM–IM programs rank me?

Sometimes yes, sometimes no. Programs vary:

• Some use applicant communications as a minor positive factor when deciding final ranks.
• Others intentionally ignore post-interview contact to keep the process unbiased.

Regardless, genuine, well-written communication:

• Demonstrates professionalism.
• Signals maturity and self-awareness—qualities valued in EM–IM residents.

Just remember: never sacrifice honesty for perceived strategic benefit. Rank programs in the order you truly prefer, and let your communication reflect your actual priorities and values.

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Handled thoughtfully, pre-match communication lets you showcase yourself as more than scores and CV lines—especially crucial for an international medical graduate in a small, demanding field like emergency medicine internal medicine. Use it to highlight your readiness for dual training, your understanding of EM–IM’s unique demands, and your commitment to ethical, transparent engagement with the Match.