skip to main content
international guides

Letters of Recommendation: The IMG Playbook

How to secure strong US-based LORs when you don't have a US medical school network: timing, ask scripts, and relationship-building strategy.

Review date
Mar 2026
Reading time
11 min read
Author
Dr Kola Tytler MBBS CertHE MBA MSt MRCGP
On this page
IMG pathwayThis guide is updated for 2026 regulations (UK/US/Aus/Can). Always verify with official bodies.

Key points

  • LORs from US-based physicians who have <strong>directly observed your clinical work</strong> carry the most weight.
  • Start building relationships <strong>months before</strong> you need the letter — a last-minute ask produces a generic letter.
  • Quality of clinical exposure matters: one attending who watched you manage patients > a department chair who shook your hand once.
Letters of recommendation are the qualitative heart of your ERAS application. For IMGs, they are also the component with the highest difficulty — you do not have the built-in network that US medical students have. This means you must be deliberate about creating opportunities for US physicians to observe your clinical competence.
1

Step 1 — Understand what programs want to see

Most programs want: at least one LOR from a US physician in your target specialty, one from a physician who supervised you clinically, and one from someone who can speak to your character/work ethic. 'Strong' means the writer describes specific clinical scenarios where they observed your performance — not generic praise.
2

Step 2 — Create observational opportunities (USCE)

Clinical rotations, externships, and research collaborations are the primary vehicles. During any US clinical exposure, your goal is not just to learn — it is to be observed making clinical decisions. Volunteer to present patients, suggest differentials, and discuss management plans. Make your thinking visible.
3

Step 3 — Build the relationship before the ask

Identify 2–3 attendings early in your rotation who are engaged teachers. Be reliable, prepared, and curious. Follow up on interesting cases. Ask for feedback on your clinical reasoning. After 2–4 weeks of consistent interaction, the LOR ask becomes natural rather than awkward.
4

Step 4 — Make the ask properly

Ask in person first: 'Would you be comfortable writing a strong letter of recommendation for my residency applications?' The word 'strong' matters — it gives them an out if they cannot write an enthusiastic letter. If they say yes, follow up with an email containing: your CV, personal statement, a summary of cases you worked on together, and the ERAS LOR upload timeline.
5

Step 5 — Make it easy for the writer

Provide a one-page 'LOR briefing sheet': your target specialties, 2–3 specific clinical encounters they could reference, your key strengths, and deadlines. Busy attendings write better letters when you reduce their cognitive load.
6

Step 6 — Follow up and confirm upload

Send a polite reminder 2–3 weeks before the ERAS deadline. After upload, send a thank-you note. If you match, send an update. These relationships are long-term professional assets.

Red flags in LORs

A short, generic letter ('Dr X is a hard worker and I recommend them') can actively hurt your application — program directors read hundreds of these and know what a 'checkbox letter' looks like. If an attending seems reluctant or non-committal when you ask, thank them and move on. A polite 'no' is better than a lukewarm letter.

LOR briefing sheet contents

  • Your full name and AAMC ID.
  • Target specialty and program types (academic vs community).
  • 2–3 specific clinical encounters the writer could reference.
  • Your key strengths (clinical reasoning, communication, reliability).
  • ERAS Letter ID and upload instructions.
  • Deadline for upload.

Official Sources

AAMC — Letters of recommendation guidelines for ERAS
Your learning path

Save your place and choose what comes next

sign in to save your learning
Work through this guide (12 steps)

Use the actions from this article to track what you have worked through.

Sign in using the reading controls above to save your steps.

  • Most programs want: at least one LOR from a US physician in your target specialty, one from a physician who supervised you clinically, and one from someone who can speak to your character/work ethic. 'Strong' means the writer describes specific clinical scenarios where they observed your performance — not generic praise.

    Return to this section

  • Clinical rotations, externships, and research collaborations are the primary vehicles. During any US clinical exposure, your goal is not just to learn — it is to be observed making clinical decisions. Volunteer to present patients, suggest differentials, and discuss management plans. Make your thinking visible.

    Return to this section

  • Identify 2–3 attendings early in your rotation who are engaged teachers. Be reliable, prepared, and curious. Follow up on interesting cases. Ask for feedback on your clinical reasoning. After 2–4 weeks of consistent interaction, the LOR ask becomes natural rather than awkward.

    Return to this section

  • Ask in person first: 'Would you be comfortable writing a strong letter of recommendation for my residency applications?' The word 'strong' matters — it gives them an out if they cannot write an enthusiastic letter. If they say yes, follow up with an email containing: your CV, personal statement, a summary of cases you worked on together, and the ERAS LOR upload timeline.

    Return to this section

  • Provide a one-page 'LOR briefing sheet': your target specialties, 2–3 specific clinical encounters they could reference, your key strengths, and deadlines. Busy attendings write better letters when you reduce their cognitive load.

    Return to this section

  • Send a polite reminder 2–3 weeks before the ERAS deadline. After upload, send a thank-you note. If you match, send an update. These relationships are long-term professional assets.

    Return to this section
  • Return to this section
  • Return to this section
  • Return to this section
  • Return to this section
  • Return to this section
  • Return to this section

United States · Applications · Article 7 of 9