Navigating the Electronic Residency Application Service (ERAS) as an International Medical Graduate (IMG) is a challenge and can be daunting initially. This is particularly true when it comes to one of the most important parts of the application, your letters of recommendation (LORs).
This guide will provide you with all the info you need to secure strong letters of rec and bolster your chances of matching successfully in the US. Whether you’re just starting your journey or are in the midst of application season, this post will provide valuable insights and practical tips for obtaining good LORs for your application. Let’s get started!
This post is part of our “Guide for IMGs” blog series! Check out these other posts as you gear up to apply for US residency programs:
🔎 How to Find IMG-Friendly Residency Programs
✏️ Our Top USMLE Tips & Tricks for IMGs Applying to US Residencie
What is a letter of recommendation? (LOR)
A letter of recommendation is a formal document written by a professional, usually an attending physician or research principal investigator PhD equivalent, who has supervised or worked closely with you in a clinical, academic, or professional capacity.
The letter’s general aim is to vouch for your qualifications, character, and abilities, in a professional or academic context. In this case, the LOR is used to support your application for a spot in a residency program, providing insights that are not evident from resumes or grade transcripts alone.
LORs often will (and should) include specific examples of the applicant’s skills, achievements, and attributes, as observed by the recommender, helping the recipient (usually a residency program director) to gauge the applicant’s suitability for the position or program they’re applying to.
Why LORs are Critical for IMGs
A glowing letter of recommendation is pivotal for IMGs applying via the ERAS process because it provides a credible and personalized endorsement of their clinical skills, professionalism, and suitability for the residency program. A good LOR should illustrate who you are, how you can be a positive influence, and make productive contributions to the program you’re applying to.
Given that IMGs often come from diverse educational and healthcare backgrounds, a strong letter can bridge gaps in understanding and highlight their qualifications, adaptability, and competence to a US residency program. It helps program directors assess the candidate’s performance in a clinical setting, and reassures them of the applicant’s competence and readiness to thrive in the US residency environment.
What are the differences between LORs from US and foreign doctors?
For IMGs, LORs from US doctors will often hold greater weight compared to those from foreign medical professionals.
LORs from US doctors are typically written in a way that’s consistent with the expectations and standards of the American healthcare system, providing program directors with a more relevant evaluation of the applicant’s abilities and potential fit. These letters more readily demonstrate that the IMG applicant has adapted to the US clinical environment and has been positively assessed by US-based professionals.
In contrast, letters written by foreign doctors, while valuable and often personalized, may not fully convey the applicant’s suitability for residency in the States due to differences in medical training and healthcare practices. Generally speaking, LORs from outside the US hold less weight than LORs from US clinical experiences, although in my book, a stellar LOR from abroad outweighs a poorly written US one.
How do I find a US doctor to write me a letter of rec?
As to which American doctors you can ask to write a letter, your clinical preceptors are often good people to ask once you’ve completed a rotation with them. LORs from doctors outside of the US, such as those from your home country can still be valuable, especially if they’re from renowned institutions and respected professionals.
However, LORs from US doctors are often preferred because they align more closely with the expectations and standards of US residency programs. Thus, letters from US doctors should be an important part of your ERAS application and supplemented with letters from foreign physicians to provide a holistic portrayal of the applicant.
Can I use LoRs from various specialties?
Yes, you can ask an hematologist attending to write you an LOR for family medicine. In fact, for certain fields such as radiology, it’s often advisable to have an LOR from outside the field to help gauge an applicant’s patient-facing skills. Just make sure your letter writer knows which specialty you are applying for!
How many letters do I need?
Between three and four. ERAS allows you to assign 3-4 letters per program, however you could have 20 LoRs in your pocket and use different letters for various reasons, for instance if you plan to dual-apply.
What are the different types of LORs?
Clinical vs. Academic LORs
Clinical LORs
These letters focus on your performance in clinical settings, highlight your patient care skills, application of medical knowledge, and clinical acumen.
They should provide specific examples of your interactions with patients, your ability to work within a healthcare team, and your competence in various clinical or procedural tasks.
Academic LORs
By contrast, academic LORs emphasize your curiosity, academic achievements, research experience and/or institutional awards and recognition. These letters are particularly useful if you have been involved in significant research projects, academic coursework, teaching activities, or received national awards or renown.
They should highlight your critical thinking, ability to conduct research, and contributions to the academic community.
Of course, there can be aspects of your academic prowess in your clinical letters and vice versa. The delineation is for practical purposes only and not absolute.
Specialty-Specific vs. General LORs
Specialty-Specific LORs
These are written by professionals in the specialty you’re applying for, and demonstrate your specific interest and competence in that field. They should provide detailed accounts of your skills and experiences relevant to the specialty, making a compelling case for your application.
These letters are absolutely necessary for any speciality program you apply to. For instance, if you plan to match into ophthalmology, you may want at least two specialty-specific LORs from ophthalmologists who you rotated with, and another general letter from a general surgeon, or someone in internal medicine.
If you plan to apply for neurology, you’d want two letters of recommendation from neurologists and your third from an internist or family physician. These are general guidelines that help to optimize your application and maximize your chances. Of course, you can choose to have three LORs from the specialty, but a healthy balance can lead to a more complete portrayal of the applicant.
For more personalized tips on your application, meet with a residency advisor like myself for a free consultation!
General LORs
These are broader in scope and can speak to your overall abilities and character, making them suitable for applications to multiple specialties.
They are particularly useful if you’re applying to more than one specialty, or if the letter writer cannot speak specifically about one specialty but can provide a strong endorsement of your overall qualifications.
Personal vs. Professional LORs
Personal LORs
These letters come from individuals who know you well on a personal level and can speak to your character and personal qualities.
While not typically required, they can provide additional context about your personal attributes such as integrity, work ethic, interpersonal skills, and help to supplement your application.
Professional LORs
These are your standard letters from preceptors or supervisors in a professional setting who can attest to your medical knowledge, skills, and professional behavior. They should focus on your performance in clinical settings, including your reliability, teamwork, and ability to overcome challenges and accept responsibilities.
Professional LORs are absolutely essential and can’t be replaced with personal ones, only supplemented.
Who should write your letter of recommendation?
Attending Physicians
Ideally, these should be physicians who have closely supervised your clinical work and can provide a detailed evaluation of your clinical skills. Their letters are often the most impactful because they have direct knowledge of your capabilities in a clinical setting.
Attendings possess a high level of credibility and authority within the medical field. Their extensive experience and established reputation lend significant weight to their evaluation and recommendation for you. As seasoned practitioners, attending physicians can provide specific, detailed examples of your performance in a clinical setting, offering an authoritative assessment of your capabilities and readiness for residency.
Additionally, their familiarity with the demands and expectations of residency programs ensures that their recommendations are aligned with the criteria that residency program directors prioritize, making your application more compelling.
Letters from attendings are typical and carry the most weight. Other letters from nonclinical faculty are discussed below and can be used to supplement your application, but they should not be used as replacements.
Academic Professors
A professor writing your LOR is a boon because he/she can provide a detailed and credible evaluation of your academic performance, intellectual capabilities, and dedication to the field of medicine.
Professors often have a comprehensive understanding of your theoretical knowledge, critical thinking skills, and ability to engage with complex medical concepts. Their academic perspective can highlight your strengths in research, coursework, and scholarly activities.
Research PI
A research principal investigator (PI) can write your LOR, providing a credible and insightful evaluation of your research skills, scientific curiosity, and dedication to advancing medical knowledge.
As leaders of research projects, PIs have closely observed your ability to design and conduct experiments, analyze data, and contribute to scientific discussions. Their perspective can highlight your strengths in critical thinking, problem-solving, and your capacity for independent and collaborative work in a research setting.
Additionally, PIs understand the importance of evidence-based practice in medicine and can attest to your potential to integrate research findings into clinical practice, making their recommendation a valuable addition to your residency application.
To summarize, you must have professional letters of recommendation written by at least some attending physicians you have rotated with in order to maximize your chances at securing a residency interview. The others are icing on the cake. Nice to have in addition, but not meant to replace those essential LORs.
How do you request a letter of recommendation as an IMG?
Timing Your Request
Keep in mind attendings, professors, and researchers are all busy people. Ask them early for a letter and follow up tactfully. Don’t pester and annoy your letter writers, trust me that does not bode well. However, don’t let things fall through the cracks either.
Timing your request for an LOR is crucial to ensure you receive a strong and thoughtful endorsement. Start planning out your letters early by identifying potential recommenders during your clinical rotations or research projects. The requirements vary by residency program, but most require three letters, so plan accordingly.
You did well on your clinical rotation in pediatrics, and you want to apply to a pediatric program? Great, then use that rotation’s preceptor as a letter writer. You want to apply for family medicine instead? That’s fine too, you can still use that pediatrics letter writer.
Aim to request your LOR at least three months before the application deadline, giving your recommenders ample time to reflect on your performance and write a detailed and personalized letter.
If you’re asking for a letter from an attending physician or PI you’ve recently worked with, it’s best to make the request at the end of your rotation or project, while your contributions and achievements are still fresh in their mind.
Additionally, consider the overall timeline of your application process. For residency applications through ERAS, ensure you request your letters well before the ERAS opening date to allow enough time for your recommenders to complete and upload the letters. It’s also important to follow up with gentle reminders as the deadline approaches if the letter hasn’t been submitted yet. This respectful approach not only increases the likelihood of receiving a strong LOR, but also demonstrates your professionalism and organizational skills.
For IMGs, it’s crucial you get US-based letter writers, and the best way to do so is to find USCE and/or a US-based research or clinical project to participate in. By doing so, you get access to your potential American letter writer and have a chance to show off your clinical acumen and skill.
Approaching Potential Letter Writers
Approach potential writers professionally and with courtesy. Leave any sense of entitlement at home, because no one owes you a letter.
When you meet a potential letter writer, it’s helpful to explain your career goals, why you’re requesting an LOR from them, and how it’ll support your application. It’s important to communicate the significance of the LOR, and why you believe they’re the right person to write it. Again, be considerate of the timing and approach them after the rotation/project is over or nearing completion.
To help your letter writers craft a strong and relevant LOR, provide them with the following information to help them gain a better understanding of who you are:
CV and Personal Statement
Providing your letter writers with these two items is the bare minimum, as these documents will give them a comprehensive view of your background and career aspirations. Doing so helps them understand your career goals and tailor their letter accordingly.
ERAS LOR Request Form
This form includes instructions for submitting the letter. Make sure they understand the process and deadlines.
Specifics About the Programs You’re Applying To
Inform them about the specialty and types of programs you’re targeting. This can help them tailor their letter to highlight relevant skills and experiences.
What is the process of submitting an ERAS letter of recommendation as an IMG?
The ERAS submission process involves several steps.
First, you request an LOR via the ERAS system, then provide the LOR request form to your writer, who submits the letter directly to ERAS. Ensure that your writers are aware of the submission process, deadlines, and the ERAS letter of recommendation portal (LORP), which is the platform where your letter writers upload their LORs. Provide them with clear instructions and follow up as needed.
Keep in mind that in order for a letter to be uploaded to the portal, the letter must meet specific requirements such as a file size limit, formatting requirements, etc. (See the official website for more info.)
Ensuring Confidentiality
LORs are most credible when they’re confidential. Waive your right to view the letters to demonstrate trust in your letter writers. Confidential letters are generally seen as more honest and reliable. It’s recommended that letters are written on a professional letterhead and signed by the author when possible.
Special LOR Considerations for IMGs
1. Highlight your international experience.
Use your LORs to highlight the unique perspectives and skills gained from your international experience. Perhaps you can prompt your letter writer to emphasize how these experiences have prepared you for a diverse and dynamic healthcare environment. This can be a unique selling point that differentiates you from other applicants, particularly US students.
2. Address gaps in US clinical experience.
If you have limited US clinical experience, your LORs should highlight your adaptability, eagerness to learn, and any efforts you have made to gain relevant experience, such as observerships or externships. Place an emphasis on your commitment to understanding and integrating into the US healthcare system, and showcase all the work you have done stateside.
3. Align LORs with your personal statement and CV.
Ensure consistency across your application documents. Your LORs should reinforce the themes and strengths highlighted in your personal statement and CV.
For instance, if you have a heavy focus on clinical research, one of your LORs could be from a research PI to highlight that aspect. A cohesive application presents a clear and compelling narrative about your qualifications and career goals, and you certainly don’t want any discrepancies to mar your ERAS application.
4. Strategically select LORs for each program.
Select LORs that best match the specific programs and specialties you’re applying to. Tailored letters that align with the program’s focus can make a stronger impact. For example, if you’re applying to a program known for its research opportunities, an LOR highlighting your research experience can be particularly effective.
What are some common LOR pitfalls and how to avoid them?
Late Requests
Avoid requesting LORs at the last minute. This can result in rushed or incomplete letters. Plan ahead and give your writers ample time to craft a thorough and thoughtful letter. Timeliness demonstrates your professionalism and respect for the letter writer’s time.
Inadequate or Generic Letters
Generic letters that lack specific examples or insights into your abilities can weaken your application. Ensure your writers understand the importance of a detailed and personalized LOR. . Provide them with enough information (such as your resume and personal statement) that they can write a strong letter on your behalf.
Not Following Up
After requesting an LOR, follow up with your writers periodically to ensure they’re on track to submit the letter on time. Be tactful and don’t annoy your letter writers. Most often, a simple and polite reminder can prevent last-minute delays.
Finally, don’t forget to express your gratitude for your letter writer’s help, and offer any additional information they might need to get the job done.
Final Thoughts
As you navigate the process of obtaining LORs, remember to stay organized, communicate clearly with your writers, and showcase your unique strengths. Remember to carefully choose your letter writers and to showcase your dedication and effort in medicine. By following the advice in this guide, IMGs can obtain strong letters and bolster their chances of securing a residency position in the US.
Good luck getting those letters, and be sure to reach out if you need assistance!
