Do FMGs Need US Letters of Recommendation for a Residency Position?

Kohei Hasegawa, MD


January 19, 2011


I am an international medical graduate and am planning to do my residency in the United States after I finish Step 2. Should my letters of recommendation be from the United States or can they come from my directors in my country?

Response from Kohei Hasegawa, MD
Senior Resident, Harvard Affiliated Emergency Medicine Residency, Massachusetts General Hospital; Brigham and Women's Hospital, Boston, Massachusetts

The importance of the letter of recommendation (LOR) cannot be overemphasized for any residency or fellowship applicant, especially the foreign medical graduate. These letters give the residency committee more than simply a US Medical Licensing Examination (USMLE) score through which to get to know you.

In the United States, opportunities for career advancement are frequently based on the recommendations of others. This may be a new idea for you. If you are an international student, the members of the committee will likely have little understanding of your medical school, curriculum, or quality of training. One purpose of the LOR is to make sure that you are well-trained and ready for residency in the United States. Therefore, the LOR must describe you from a clinical perspective, your personality, your ability to work as a member of a team, and your ability to communicate with patients and colleagues. Letters describing your ability will go a long way in getting doors opened to you during interview season.

The best person to write your LOR would be an American faculty member, especially one who has a strong bond with the residency committee. Letters from your country could also be very helpful if the writer has a personal bond with the committee or was a graduate of the residency program to which you are applying. There are several reasons for this. First, residency admissions committee members always look first for the letterhead on which the LOR is written. There is a level of trust when it comes to reading a letter. A reader who does not personally know the writer will weigh, intentionally or unintentionally, the letter's comments more heavily if it is a US institution. Second, faculty members from US schools know what the committees are looking for in a candidate and they will be able to write a more relevant letter for you. For similar reasons, letters from faculty in your country are less desirable. They might be unfamiliar with the structure and purpose of a LOR and the residency admission committee would not know how reliable your letter is, coming from an unknown entity.

If possible, you should try to get at least 1 LOR from a US faculty member. You can accomplish this by asking a faculty member from the US who works in your country, or by working as an exchange student, observer, or researcher in the United States (even for a short time).

Residency committees usually ask you to submit a letter from your program director if you are already in a residency or fellowship program in your country. They suppose that the director knows best who you are and how you work. Therefore, you must have at least 1 letter written for you from your program leadership. It should be acceptable even if the letter comes from a foreign physician. Unique to the field of emergency medicine in which I am training, letters of recommendations from emergency medicine faculty are written on a standardized form. The Standardized Letter of Recommendation (SLOR), downloadable from the Council of Emergency Medicine Residency Directors, documents information about the student's performance in the emergency medicine clerkship, qualifications, and global assessment. At the end, the letter writer can provide free-text comments. You should make sure to look at the requirements for the specialty to which you are applying because the details may not be known to advisors at schools in other countries.

If you need another letter from your program, avoid letters from occasional preceptors, residents, and fellows. Given the choice between a junior faculty member who knows you well and a senior faculty member who knows you less well, choose the one who knows you better.

Good luck!