How to get good letters of recommendation: Part 1

letters of recommendation

Letters of recommendation (LOR) are an essential part of the residency application. They are letters written by physicians who know you personally, who can vouch for your work and can recommend you as a candidate for residency programs. Residency programs generally require 3 or 4 letters to be included in your application.

The importance of these letters cannot be underestimated. In the 2014 program director survey, 86% of all residency programs cited LORs as important for interview selections, with an average importance rating of 4.2 out of 5 (5 being most important). To put it in context, it was just as important the USMLE Step 1 and Step 2 CK scores (both 4.1 importance) and the medical student performance evaluation (4.0). For the purpose of ranking applicants after interviews, the same survey shows that 74% of programs cited LORs as important with a 4.1 importance rating.

If you look further at the survey, you will see that “perceived commitment to a specialty” and “evidence of professionalism and ethics” also are regarded as being very important by residency programs. Ideally, these two factors are discussed by your letter writers in your LORs.

International medical graduates may not have had any exposure to the concept of the LOR prior to applying to residency programs in the US. It is extremely important for IMGs to understand how to get good LORs in order to be competitive for interviews and for the match.

This article is the first of a two-part series on how to get good letters of recommendation. This article will cover:

  1. Contents of good LORs vs bad ones
  2. Who you should ask to write LORs for you
  3. What information you should provide your letter writers with

In the next article, I will discuss more practical tips on getting good LORs as well as discuss when to ask for LORs. Please feel free to let me know what you think about these articles!


The best way to understand the contents of good LORs is to start by considering what the readers will impressed by. The readers are residency program directors, faculty and residents who want to know about you, your abilities and whether or not you will work well with other residents in the program and serve your patients well.

The best letters:

  • are written by senior, well-known physicians in the field (ideally in the US) such as program directors, clerkship directors and high-ranking medical school faculty
  • highlight your strengths very well in concrete ways (i.e. contents are not vague or formulaic)
  • highlight your commitment to the specialty you’re applying for
  • are written by physicians in the specialty you’re applying for (although there are some advantages of having letter writers from different specialties)
  • demonstrate your excellent professionalism and high ethical standards

There are some guidelines published by various US medical schools to help faculty physicians write good letters. For example, the University of California, San Francisco website has succinct instructions for faculty. There is a sample letter to help faculty on the University of Illinois website. You can easily google other resources that may be helpful for you and your letter writers to get an idea of what good LORs look like.

Bad letters of recommendations, on the other hand:

  • are generic
  • do not highlight your clinical abilities (letters from observerships may end up this way, because your letter writer may not have had opportunity to observe your clinical skills. Click here to read more about observerships)
  • point out very significant flaws or “red flags”
  • have spelling mistakes and contain significant grammatical errors
  • are not written on professional letterhead


Simply put, you should ask physicians who are most familiar with your clinical abilities, interpersonal skills, professionalism/ability to work in a team and your work ethic. As an IMG, the first decision you need to make is whether or not you want to ask physicians in your home or in the US to write LORs for you. No matter what you may have heard by your peers or read on the internet, I don’t think there is a simple answer for everybody. Some say you must have every letter written by US physicians, while others may advise otherwise. The individual decision for you would be based on your understanding of who would be able to provide the best LOR contents for you.

As an example, all of my three letter writers were Australian physicians. This made sense for me as I had been working for a few years in Australia after graduating from medical school and the three physicians I asked knew me very well. I also figured (although I had no actual data to back up my assumption) that US physicians considered Australian medical training to be similar to theirs, and so my experience in the Australian medical system was very valuable to highlight.

I wanted to apply for psychiatry residency programs in the US. My letter writers were the director of the psychiatry training program, the head of an inpatient psychiatry unit and the director of the emergency department where I worked (in addition to my skills in psychiatry, I wanted to make sure that my medical knowledge, skills and abilities were emphasized in my application). I felt that letters from 3 senior physicians who intimately knew my work and could vouch for my ability were much more valuable than a more generic letters by a U.S. physicians who I shadowed during a short U.S. observership experience. In my case, the letters authored by these Australian physicians were helpful for me in getting interviews to programs (I received good feedback from those who interviewed me about my LORs).


I have discussed some potential benefits of asking non-US based physicians to write your LORs. If you are planning to ask a physician in your home country to write your LORs, there are some potential negatives to consider also:

  • your letter writer will likely have zero idea about writing a LOR for US residencies, with regards to conventional formatting or knowing what exactly it should contain. They will also have no idea about how to submit it (they will need clear, succinct instructions from you)
  • your letter writer may not have a good command of English (thus the letter may have errors in spelling and grammar)
  • your letter writer and the foreign country medical system will likely be completely unknown to those who evaluate your residency application (there are some exceptions)

There are some more things to consider if you decide to ask a non-US based physician to write your letters:

  • avoid asking writers who are not familiar with your current abilities and skills (e.g. faculty you may have worked with over 2 years ago)
  • consider not waiving your right to view the letter (although some would argue that you should always waive your right to see the letter). You may want to look at the letter before submission to ensure that it appears to be written in line with expected standards for LORs. Be aware that LOR writers specify whether or not you waived your right or not. Be forewarned that programs may consider it a “red flag” if you have not waived your right to see the letter as they may be concerned that the writer may have felt that they could not be completely honest.


Keep in mind what I wrote earlier:

you should ask physicians who are most familiar with your clinical abilities, interpersonal skills, professionalism/ability to work in a team and work ethic

It is generally challenging for IMGs to have in-depth contact with physicians in the clinical settings in the US. Thus getting compelling LORs from these physicians can be challenging.

The US physicians you can ask include:

  • physicians you had contact with during external medical school rotations. These letter can be strong although you need to keep in mind that you don’t want too much time to have elapsed from your rotation to the time that you are applying (to ensure that the writers can comment on your current skills and knowledge)
  • physicians you did an observership with (generally weaker letters in terms of highlighting your clinical and patient-care abilities)
  • physicians you had contact with during an IMG-externship (variable strength of letters)
  • physicians you did research with


  • CV: highlights your accomplishments and provides other factual information that can help your letter writer
  • copy of your personal statement that you are submitting, if available (I did not do this myself)
  • the specialty you’re considering. If you’re considering multiple specialties, you may want to ask your letter writer to write a more generic letter that can be used for multiple specialities (although this may weaken your letter) or ask your writer to write multiple specialty-tailored letters (painful for your writer, but will lead to stronger letters for you)
  • information about deadlines and how to submit the letter (information about the LOR Portal)

In summary, in order for you to get good LORs, it is very important to first understand what good letters should contain. This will help you to figure out who you should ask to write letters for you. You also need to know what information you need to provide to help them write compelling letters. I will discuss more tips on getting good LORs in my next article, as well as considering the issue of when you should ask for LORs.

Was this article helpful for you? Please feel free to comment or sent me an email.

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2 Replies to “How to get good letters of recommendation: Part 1”

  1. zhaleh

    Thank you for sharing your experiences.

    I am an IMG student, and I am passing my last term of ENT residency in my country.
    I want to participate in USMLE about 3 months later,of course after my board exam.
    This is my plan:
    Step 1 ….April 2018
    2 ck….. june 2018
    2 cs pending
    2 month observership or clerkship
    I have some questions:
    -Do you think it is a good plan?or What is wrong?
    -Which LOR is prepare for me?( observership with a head and neck fellowship in toronto or clerkship?)

    • Shinji Post author

      Congratulations for almost finishing your ENT residency! Looking at your plan, the timeline is quite tight. Unless you have an excellent knowledge of basic sciences, I think studying for 3 months for the USMLE Step 1 is not enough time (I imagine that you will be spending all of your time on your board exam before this). Then 2 months to study for the Step 2 CK is also very tight. Given ENT is a narrow specialty, I think it may be prudent to give yourself more time to study as the topics covered in the USMLE Step 2 CK are very broad (eg you will need good knowledge of ObGyn and pediatrics). With regards to LORs, in general hands-on clinical experience in a clerkship is more valuable than an observership in my opinion. Depending on your country of training, I would also consider including a LOR from your residency program director/senior attending who can vouch for your cinical skills and professionalism.


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