Essential IMG Residency Guide: Navigating Pre-Match Communication in Internal Medicine

Understanding Pre-Match Communication for IMGs in Internal Medicine

Pre-match communication is one of the most confusing and anxiety‑provoking parts of the IM match process for any international medical graduate. You may receive emails, calls, or messages from programs that sound encouraging—but not entirely clear. You might wonder: Is this a pre-match offer? Are they expecting an early commitment? How should I respond without harming my chances elsewhere?

This IMG residency guide will walk you through:

• What “pre-match communication” actually means in the current NRMP era
• How it relates to the old “pre-match offers” system
• Common types of messages you may receive from internal medicine residency programs
• How to interpret and respond to them strategically
• Ethical and NRMP‑compliant behavior to protect your chances and your reputation

While the focus is on internal medicine residency, the principles apply broadly to other specialties as well, with specific nuances where relevant.

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1. What Is Pre-Match Communication Today?

1.1 Historical perspective vs. current reality

Before the modern NRMP system was widely adopted and enforced, many programs—especially community internal medicine residency programs—would offer “pre-match positions” to candidates outside of the NRMP Match. These offers:

• Came before rank list certification
• Required an early commitment from the applicant
• Removed the position from the Match if the applicant accepted

Today, most ACGME-accredited internal medicine residencies participate in the NRMP Match, and many states and institutions discourage or prohibit binding pre-match offers. However, pre-match communication still exists, just in a different form:

• Programs still signal interest before and after interviews
• Some non-NRMP or SOAP-like pathways may have early offers
• Misunderstandings about “verbal offers” or “strong signals” can confuse applicants

For an international medical graduate, understanding the difference between genuine offers (rare in NRMP programs) and interest signals (common, but not binding) is crucial.

1.2 NRMP rules you must know

The NRMP rules are designed to protect both applicants and programs. Key principles:

• No one can require you to reveal your rank order list.
• Programs and applicants may express interest but cannot demand a commitment.
• Any promise that violates NRMP policies (e.g., “If you rank us #1, we will rank you #1”) is not enforceable and may be reportable.
• The Match result is binding, not any conversation before it.

For most IMGs in internal medicine residency, your interactions with programs before Match Day will be part of program communication before match, not formal pre-match contracts.

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2. Types of Pre-Match Communication You May Encounter

Understanding what specific messages mean is the foundation of this IMG residency guide. While each program is unique, most communication falls into a few recognizable patterns.

2.1 Invitation and logistics communication

These are straightforward:

• Interview invitations and scheduling
• Instructions about virtual vs. in-person interviews
• Travel or reimbursement details (if applicable)
• Follow-up thank-you replies after you send a thank-you note

These do not represent pre-match offers or early commitment requests. They’re simply operational.

2.2 “We are very interested in you” emails

These are usually sent:

• After your interview
• Sometimes after rank lists are discussed (but before certification)
• Often by the program director (PD), associate PD, or chief residents

Common phrases:

• “You are among our top candidates.”
• “We will rank you very highly.”
• “We really enjoyed meeting you and we hope you will rank us highly.”
• “We look forward to the possibility of working together.”

How to interpret them:

• They are positive signals, but not guarantees.
• Programs sometimes send similar messages to many strong candidates.
• Some programs send no such messages at all, even to their top-ranked applicants.

For an IMG in the IM match, such messages are encouraging—but should not change your rank list if another program is genuinely a better fit.

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2.3 Direct phone calls from PDs or faculty

Some internal medicine programs still use phone calls as a strong signal of interest. These may come:

• On the same day as your interview or shortly after
• Near the end of interview season, when programs are finalizing rank lists

Common scenarios:

• PD calls you to say you’re a “great fit”
• A faculty member or chief resident calls to answer any additional questions
• They may casually ask where you plan to rank the program

Interpretation:

• This is usually a stronger interest signal than a general email.
• Still, under NRMP rules, it is not binding, even if they imply you are “very high” on their list.
• Some programs use these calls routinely; others never do.

2.4 Suggestive or borderline NRMP-violating communication

Occasionally, programs or individuals may stray too close to improper language, especially with IMGs who may not know the rules. Examples:

• “If you rank us #1, we will match.”
• “We are planning to rank you to match if you also rank us highly.”
• “Can you promise you will rank us #1? Then I can tell the committee to put you at the top.”

These statements are problematic because:

• They pressure you for an early commitment, which is not allowed.
• They can be misleading—programs also rank many others highly.
• They may lead to ethical or NRMP issues if formalized.

You are not obligated to answer questions about your rank order list. You can respond politely without disclosing your exact plans.

2.5 True pre-match offers (rare in NRMP IM programs)

In some exceptional scenarios—more common outside categorical internal medicine, in non-NRMP programs, or in certain transitional or preliminary tracks—you may encounter:

• A direct statement like:
  • “We are offering you a position outside the Match if you commit now.”
  • “We do not participate in NRMP. We’d like you to sign a contract for next year.”

If you encounter a true pre-match offer:

1. Confirm whether the program participates in the NRMP Match for that track.
2. Ask for written details: start date, salary, benefits, visa sponsorship, accreditation status.
3. Understand that accepting a non-NRMP position may remove you from the Match or limit your participation, depending on the situation and rules.

For most IMGs in internal medicine residency, especially categorical IM positions, you will not receive a legitimate pre-match contract—you will mainly navigate pre-match communication, not pre-match deals.

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3. How to Respond to Pre-Match Communication Strategically

Your goal as an international medical graduate is to:

• Maintain professionalism
• Preserve your options
• Comply with NRMP and ethical rules
• Optimize your chances of a successful IM match

Below are practical approaches to different scenarios.

3.1 General rules for all communication

1. Be timely

   • Respond within 24–48 hours to any significant email or call.
   • Delayed responses may be interpreted as disinterest.

2. Be professional

   • Use clear, respectful language.
   • Check grammar and spelling.
   • Use professional salutations (e.g., “Dear Dr. Smith”).

3. Be honest but non‑committal when needed

   • You can express interest without making promises.

4. Document important exchanges

   • Save emails, note phone conversations, and keep a log.
   • This helps you recall details when finalizing your rank list.

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3.2 Responding to “We are very interested in you” messages

Example email from a program:

Dear Dr. Ahmed,

It was a pleasure meeting you during your interview at XYZ Internal Medicine Residency Program. Our team was very impressed with your clinical experiences and your dedication to underserved populations. We believe you would be an excellent fit for our program and plan to rank you highly.

We hope you will consider ranking our program favorably.

Best regards,
Program Director

A good IMG response:

Dear Dr. [Last Name],

Thank you very much for your kind message and for the opportunity to interview at [Program Name]. I truly enjoyed meeting the faculty and residents and was particularly impressed by [specific aspect: e.g., the strong ambulatory curriculum and supportive learning environment].

I remain very interested in your program and will give it serious consideration when finalizing my rank list.

Sincerely,
[Your Name], MD

Key points:

• You acknowledge their interest.
• You confirm your interest.
• You avoid promising any rank position.

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3.3 Handling phone calls about your rank intentions

Scenario: The PD calls and says:

“We were very impressed with you, and we think you’re an excellent fit here. We hope you’ll rank us highly. Do you know where you’ll be ranking our program?”

Recommended approach:

1. Stay calm and appreciative.
2. Do not feel forced to give a specific number.
3. Use neutral but positive language:

Example response:

“Thank you so much, Dr. [Last Name]. I truly appreciated the opportunity to interview and learn more about [Program Name]. I am still finalizing my rank list, but your program is definitely among my top choices. I value the strong inpatient training and supportive culture that I observed.”

You can personalize this:

• If the program is genuinely your first choice, you may say:
  • “Your program is one of my top choices and is under very serious consideration to be ranked #1.”
• If it is not your top choice, avoid lying or making promises. It’s better to be slightly vague but honest.

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3.4 Dealing with borderline or inappropriate pressure

If a program says something like:

“If you can promise to rank us #1, we can try to ensure we rank you to match.”

You can respond by reframing:

“I deeply appreciate your confidence in me and your interest. As required by the NRMP, I cannot commit to a specific ranking position during the interview season, but I can say that I am very interested in your program and it will be strongly considered when I finalize my list.”

If you feel uncomfortable or believe the program is violating NRMP rules, you may:

• Consult a trusted advisor (IMG mentor, dean’s office, or a residency advising service).
• Review NRMP policies directly.
• Consider whether this behavior reflects a program culture you want to join.

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3.5 Responding to a true pre-match offer or non-NRMP position

If a program outside the Match offers you a confirmed position (especially relevant for some community hospitals, research positions, or non-ACGME posts):

1. Clarify:

   • Is this ACGME-accredited?
   • Do they sponsor visas (J-1/H-1B) if you need one?
   • How many previous IMGs have matched into IM residency from this pathway?

2. Ask for written details:

   • “Could you please send me a written description of the position, including contract terms, length of appointment, and accreditation status?”

3. Consider consequences:

   • Will accepting this offer remove you from the Match?
   • Is this position a direct route into internal medicine residency or just a gap-filling job?

4. Take time:

   • You can say:
     • “Thank you for this offer. This is an important decision for me. May I have a few days to carefully review the details before giving you an answer?”

Always weigh: short-term security vs. your long-term IM residency goals.

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4. Building a Communication Strategy as an IMG in the IM Match

Instead of reacting randomly, plan your overall strategy for program communication before match.

4.1 Pre-interview communication

• Email professionalism:

  • Use an email address with your name (e.g., firstname.lastname@gmail.com).
  • Maintain a professional signature:
    • Name, degree (MD/MBBS)
    • Medical school
    • ERAS AAMC ID
    • Contact info

• Respond quickly to invites:

  • For popular internal medicine programs, interview spots fill fast.
  • A quick, polite acceptance signals reliability.

• Asking about pre-match or early offers?

  • Avoid directly asking, “Do you offer pre-match positions?” for NRMP IM programs—it may sound uninformed.
  • Instead, if unsure about a non-NRMP track, ask:
    • “Does this position participate in the NRMP Match, or is it filled outside the Match?”

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4.2 Post-interview thank-you notes and follow-up

While not mandatory, thoughtfully crafted thank-you notes can:

• Reinforce your interest
• Keep you memorable among many IMGs in a large applicant pool
• Open the door for further conversation

Basic structure for a thank-you email:

• Subject: “Thank you – [Your Name], [Interview Date]”
• Greeting: “Dear Dr. [Last Name],”
• 1–2 sentences: appreciation for the interview
• 1–3 sentences: highlight specific aspects you liked (curriculum, culture, research)
• Closing: polite and concise

Avoid:

• Overly emotional language (“It is my lifelong dream to match at your program and I will be devastated otherwise”).
• Stating rank positions (“I will rank you #1”)—unless you are absolutely certain and willing to stand by that; even then, it carries little formal weight.

4.3 Post-interview interest letters

Some IMGs choose to send letters of interest or, rarely, letters of intent:

• Letter of interest:
  • States that you are very interested in the program
  • Appropriate if it is among your top choices
• Letter of intent:
  • States the program is your absolute first choice and you plan to rank it #1
  • Use sparingly and honestly—only one such letter

Keep in mind:

• Programs are not obligated to respond.
• Some may even ignore such letters entirely due to high volume.
• Misusing letters of intent (promising multiple programs #1) is unethical and can damage your reputation if discovered.

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4.4 Protecting your mental health and expectations

For international medical graduates, especially those with visa needs, pre-match communication can create emotional highs and lows:

• Positive emails or calls may raise your expectations.
• Silence from a program you loved can feel discouraging.

Important mindset points:

• Lack of communication does not mean rejection. Many IM programs send no interest emails but still rank IMGs highly.
• “We will rank you highly” does not guarantee a match. Other candidates receive similar messages.
• The only final answer is on Match Day.

To stay grounded:

• Focus on what you can control: interview performance, professionalism, and a realistic rank list.
• Seek support from mentors, IMGs who recently matched, or peer groups.
• Limit over-analysis of every sentence in PD emails; read them once or twice, then move on.

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5. Crafting a Rational Rank List Despite Pre-Match Signals

Ultimately, the purpose of understanding pre-match communication is to help you build a rank order list aligned with your goals, not to be manipulated by flattering messages.

5.1 Prioritize program fit over flattery

Consider:

• Educational quality (inpatient/ambulatory balance, board prep)
• Visa sponsorship reliability (J-1 vs. H-1B, institutional history with IMGs)
• Fellowship outcomes (if you aim for cardiology, GI, etc.)
• Resident well-being and call schedule
• Location, cost of living, family needs

Use pre-match communication as additional data, not the main factor.

Example:

• Program A sends no post-interview email but has strong training and good IMG outcomes.
• Program B sends a very flattering email but has weaker board pass rates and no fellowship history.

For long-term success in internal medicine, you may reasonably rank Program A higher, despite less communication.

5.2 Understand how the algorithm works

The NRMP algorithm:

• Favors applicant preferences first, then program preferences.
• You should rank programs in true order of your preference, not based on perceived likelihood of matching.

Therefore:

• You don’t “waste” a high rank on a reach program.
• You shouldn’t downgrade a dream program just because they didn’t call you.

Pre-match communication can:

• Help you interpret realistic interest
• Confirm that a program sees you as a good fit

But your rank list should primarily reflect where you genuinely want to train.

5.3 Special considerations for IMGs needing visas

For an international medical graduate requiring a visa:

• Pre-match communication about visa sponsorship is essential. Ask directly if not clearly stated:
  • “Does your program sponsor J-1/H-1B visas for residents?”
  • “Have you sponsored visas for IMGs in the past 3 years?”

Programs may:

• Be enthusiastic about your application but unable or unwilling to sponsor your visa type.
• Give you mixed signals if their GME office has strict policies.

In your rank list:

• Prioritize programs with clear, reliable visa history.
• Take “We love you but we’re not sure about the visa” as a yellow flag.
• Use pre-match communication to clarify this early, not in February.

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FAQ: Pre-Match Communication for IMGs in Internal Medicine

1. Are pre-match offers still common for internal medicine residency in the US?
For categorical internal medicine residency programs that participate in the NRMP, true pre-match offers are now rare and generally discouraged. Most positions are filled through the regular Match. You will mainly receive interest signals (emails, calls) rather than binding offers. Some non-NRMP or special tracks may still offer positions outside the Match—these should be carefully evaluated.

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2. If a program tells me I am ranked highly, does that mean I will match there?
Not necessarily. Programs often rank more candidates highly than they have positions, and they may send similar messages to many applicants. Being “ranked highly” is a positive sign, but your match result will depend on how many candidates ahead of you rank the program and how your own rank list aligns. Never assume a match is guaranteed based solely on pre-match communication.

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3. Can I tell multiple programs that I will rank them #1 to improve my chances?
You can, but you should not. This is considered dishonest and unethical. While the NRMP algorithm doesn’t read your emails, misleading PDs can damage your reputation, especially in closely connected specialties like internal medicine. If you choose to send a letter of intent, send it to only one program and mean it.

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4. How should I respond if a program pressures me to disclose my rank list or commit early?
You are under no obligation to reveal your rank order list. You can respond politely:

“According to NRMP rules, I cannot commit to a specific ranking during the interview season, but I am very interested in your program and will give it serious consideration when finalizing my list.”

If you feel the pressure is inappropriate or persistent, discuss it with a mentor or advisor, review NRMP rules, and decide whether this behavior affects your interest in that program.

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By understanding the difference between pre-match communication and actual pre-match offers, and by responding strategically and ethically, you can navigate the IM match process as an international medical graduate with greater confidence and clarity—focusing on what truly matters: finding the best internal medicine residency program for your long-term success.