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Letters of Recommendation and Dean's Letter Information for IMGs
What’s in a Letter?
A letter of recommendation is a key piece of information for any NRMP Match applicant, but especially important for the IMG. Letters of recommendation for US applicants often are partly just to make sure that a candidate that looks “good on paper” isn’t crazy, or doesn’t have any hidden flaws that have not been mentioned elsewhere in the application. US faculty members are well trained at reading applications from medical schools for which they are already familiar with, and reading thru exam scores for the USMLE. They are also very familiar with the curriculum and general training of US medical students.
If you are an international student, chances are high that your evaluator knows nothing about your medical school, your curriculum, your years of training, or your clinical competency. For the IMG, the letter of recommendation becomes even more crucial.
The purpose of the IMG letter of recommendation includes making sure you are well trained and ready for residency in the United States. Ideally this letter will describe you from a clinical perspective, including your familiarity with the US hospital system, your ability to make diagnostic decisions based on clinical and laboratory data, your ability to work as a team, and your ability to communicate with patients. The best letters will also make direct or indirect comparisons to US equivalents and perhaps even rate you as above a comparable US medical student/resident.
Who Should Write Your Letters?
First of all, the best letters will be from US faculty members. Letters from back home will only be helpful if your professor happens to be a world authority on a subject and is well known around the world as “the man” in your field. Otherwise, be sure your letter comes from a US faculty member.
This is for several reasons. First, residency admissions committee members always look first for the letterhead of the stationery the letter of recommendation is written on. They look to see if your letter came from Big Name University, USA, or Small Town Hospital Doc. There is going to be a level of trust when it comes to reading a letter, so if the reader does not personally know the letter writer (true in most cases) they will weigh the letters comments more heavily if it is from a big name institution. So you’ll want the most well known person to be writing your letters.
US faculty members are also more likely to be better letter writers. They will know what residency committee readers are looking for in a candidate and be able to write a more relevant letter for you. This will include information on your clinical competency as a member of a US medical team.
Letters written from professors at home are less desirable for a number of reasons. First, they are unfamiliar with the structure, function, and purpose of a residency letter of recommendation. Also, US readers will probably not know who your letter writer is, or even the university or hospital they are coming from. As explained above, they will not know how reliable your letter is coming form an unknown entity. Also, the tone of the letters is important, and culturally, letters written from US writers will probably be stronger, more direct, and more positive (hopefully) then more “polite” letter writers from back home.
Try to be sure to get letters from faculty, and the higher the better. Full professors will be more impressive when residency committees review your letter, and chief residents the least impressive. If you’re really in a pinch, a chief resident’s letter will suffice if you use that letter primarily to apply to the same institution for that same institution.
If you must have a letter written for you from your home country, make sure that it is relevant, explaining your clinical abilities, and that it is up to date. Don’t submit a letter that is several years old, or one where you have not worked with the letter writer in many years. Additionally, it should compare your abilities and training with the training expected of residents in the US and explain your qualifications to be a resident in the US. Ideally this letter will originate from a country with similar training and clinical practice as the US.
When Should You Ask for Your Letter?
Generally speaking the sooner the better! This is for several reasons. First of all, you never know when someone is out of town or will leave the hospital, so you want to be sure you nail down your letter writers early. That will give them little excuse not to write it, or to have to scramble for a deadline in order to get you a letter. Second, it gives the writer some additional time to write a strong letter.
If you’re going to be asking for a letter from a faculty member whom you are not currently working with, then ask in the spring of the year you are applying (unless you have already asked for the letter previously), and then you can remind that person periodically to write the letter as the deadline approaches.
How Do You Ask for a Letter of Recommendation?
If you are going to be on a clinical rotation from which you hope to earn a letter of recommendation, then you want to schedule a meeting with the highest ranking person you can which will have contact with you. This could be the clerkship director, your ward attending, or in some cases the department chair. Introduce yourself, and your international training, and talk about how you plan to pursue training in residency in the US. During this meeting be sure to ask what it will take for you to earn an outstanding letter of recommendation for residency. Doing this early will allow enough time for the attending to keep an extra eye on you during the weeks you will be on the rotation so they can remember the small details to write that letter for you. You don’t want to wait until the very end, when the attending may not have been aware of the long hours you were putting in, or the extra effort you showed during your rotation. Asking early will give you the best chance of the best letter possible.
Generally you should try to ask your letter writers in a way that gives them “wiggle room” if they don’t feel like they can write you the best letter possible. You can ask your potential letter writer if they feel they can write you an outstanding letter of recommendation. Asking over email or over the phone is also ok, because actually it may allow them to more politely say no. Any letter that the writer feels pressured into writing will not be nearly as positive as one they really want to write for you.
If you’re lucky someone may offer to write a letter of recommendation for you! In these cases even if you already have enough letters of rec, ALWAYS accept these offers, since these will be strong letters. You can always save this letter for later, if one of your other letters is not very good, or if you decide to apply to the same institution as the letter writer. Homegrown letters are always nice!
Give Your Writers Some Extra Ammunition
It can be very helpful to give your letter writer a copy of your CV or a personal statement, so your writer knows more about your background. It may also be helpful to explain your training. If you have 6 years of clinical experience in the field, be sure that your letter writer knows that. If you have already been a house officer in your country, make sure they know that! Also, describe briefly your clinical/residency training (if any). US professors want to know exactly how many years you did your rotations for in your country and how much of that training is applicable in the US.
This also lets your writer know what specialty you are applying for and WHY. If you are still unsure what residency you are applying for, then ask for MORE than one! It is ok to ask your writer to write a letter for internal medicine and family practice. It takes very little extra time for them to do this (you can pick and choose which institution gets each letter) and it is much better for them to appear to have a customized letter for you than a generic one that is good for any residency.
I’m Still Waiting!
If it’s been more than three weeks since asking your letter writer for their recommendation and you haven’t heard back, you can politely and gently remind them to do so. There are several ways to do this. You can send a thank you note that acknowledges the writers time and effort in writing the letter. You can also email or call to see if the writer needed any additional information to write the letter. A quick reminder may be all they need to get cracking on your letter!
What’s a Dean’s Letter?
US medical students have a Dean’s letter written for them that usually consists of some background information on the candidate (undergraduate summary—brief, career interests), a summary of the student’s performance of the preclinical years, a collection of subjective and objective (exam) data from clinical rotations, a summary of the class rank of the student, and finally a statement of recommendation for the student.
Typically the Dean’s letter is much longer than the usual recommendation letter and it is not uncommon for them to be 3-5 pages in length. They often also include scoring statistics for the medical student’s class (e.g. class rank information, overall grading statistics of the class, percentages of students earning the highest grades.) If your medical school Dean is not familiar with writing one of these letters, you may want to give them an outline of the above items and ask that they be covered. If your school does not rank your students, then a statement regarding your abilities relative to the average student in your class is recommended. (e.g. Mr.X is superior compared to the other students in his class)
Finally most Dean’s letters end with a statement saying something to the effect that “Mrs. Y will be an outstanding physician in X specialty and we give her our highest recommendation.” This statement is sometimes regarded as one of the most important statements in the entire letter and gives insight into how the Dean views the particular candidate.
Write Your Own Letter!
Some medical students are given the chance by their professors to write their own letters of recommendation for their professors to sign. It is not uncommon for this to happen in areas where the letter writer is not familiar with how to write an appropriate letter of recommendation or simply does not have time. Given this opportunity you may decide to write the letter yourself, or you may provide a bullet list of items which you suggest the letter writer cover. For example, you may want them to mention your clinical abilities on the medical ward, your attentiveness to patient care, or your years of OR experience in your home country which will be applicable in the US. If you have the difficult task of writing your own letter, be sure to ask someone read thru it to make sure it’s appropriate for a residency letter of recommendation.