US LOR vs Home Country LOR for Residency: Which is Better for IMGs?

Ask a group of international medical graduates (IMGs) about letters of recommendation and the same worries come up. Do I really need a letter from a US attending to match? Will letters from my home country hurt my application? Do residency program directors actually prefer American recommendations?

The honest answer? It depends on the letter in question. A US LOR can demonstrate your experience in the American healthcare system while a letter from your medical school/hospital from another country typically cannot. However, a detailed home country letter will help your application, whereas a vague US letter will do little to nothing. There are rules associated with programs and specialties, so one answer does not fit all.

We’ll review the differences between these letters, when each of them can help, and how to choose the right mix for you!

What is a Letter of Recommendation (LOR) for US Residency?

The LOR is a letter that is written by a doctor or faculty member who is familiar with your work. Your USMLE scores do not tell residency program directors how you interact with patients or work as part of a healthcare team. A strong LOR helps program directors assess your clinical performance, professionalism, and ability to work with others. 

There are typically three different types you will encounter:

• Clinical letters are a report of your work during a rotation or job.
• Academic letters are from medical school faculty, e.g., department chair or clerkship director.
• A specialty-specific LOR is a letter that recommends you for one specialty and explains why you are a good fit for it.

The programs receive letters via ERAS, the AAMC’s application service. You begin by making a request in MyERAS and the ERAS Letter Request Form is sent to the author. Your letter writer submits the recommendation through the AAMC Letter Writer Portal using the Letter Request ID generated in MyERAS. You can then track the letter’s status and assign it to your selected programs.” Once the author uploads the letter, you can assign it to the programs you are applying to. 

You’ll also decide whether to waive your right to read each letter. A waived letter is confidential, and ECFMG says this tells programs your author could write openly.

US LOR vs Home Country LOR: Key Differences

The biggest difference is what each letter can prove. A US LOR comes from a US attending physician who saw your US clinical experience (USCE), so it shows how you worked in the American system. A letter from a home-country supervisor often covers a much longer stretch of your work.

Feature	US LOR	Home-country LOR
Author	US attending physician or faculty	Home-country attending or faculty
Clinical setting	US healthcare environment	International healthcare environment
Clinical exposure	May show familiarity with US clinical practice	Shows experience in your home healthcare system
Clinical assessment	Can describe performance during USCE	Can describe longer-term clinical performance
Specialty relevance	Can be tailored to your US residency specialty	Can be tailored to your intended specialty
Familiarity with US training	Author may understand US residency expectations	Author may need guidance on US residency competencies
Value to application	Provides US-based clinical observations	Provides evidence of clinical ability and professional qualities

This table is not a ranking! A US attending who saw you for 2 weeks may have little to say, a consultant who supervised you for a year may be able to provide more detailed examples of your clinical abilities.

If your author is trained outside of the US, provide them with the Core Competencies from the ACGME. The six core competencies include patient care, medical knowledge, and professionalism, among other areas. This is the framework that is already utilized in US programs, and your consultant can explain your patient care in those terms as a US attending would. Include the list with your CV, and it will make it easier for them to write something specific.

Are US LORs Better Than Home Country LORs for Residency?

Sometimes, but only when the author knows your work well.

A US letter has a few clear advantages. The author has watched you in a US clinical setting, so they can comment on how you talk with American patients and teams. Many of them also know what programs expect from a first-year resident.

Home-country letters still matter, though. Your supervisor may have worked with you for months or years, long enough to describe how your medical knowledge and clinical reasoning grew over time.

ECFMG has three points of guidance worth following:

• If you have US clinical experience, program directors may expect a letter from someone in that program.
• If your letters come from outside the US, ask authors to evaluate your skills in terms of your ability to succeed in US residency training.
• If possible, avoid letters about experiences more than two years old.

So a US attending who directly supervised you can offer evidence a home-country supervisor can’t. On the other hand, a consultant who supervised you for months may give a fuller picture of your abilities than a US physician who observed you briefly. In the end, each program’s requirements should guide your choice.

Can IMGs Match With Home Country LORs?

Yes. IMGs can apply with letters from physicians in their home countries, and no universal ERAS rule says every IMG needs a US LOR. Individual programs can set their own requirements, though, and no type of letter guarantees an interview or a match.

Take UT Southwestern Family Medicine. The program asks for three letters, at least one of them from a family physician, and it states that home-country or other international LORs are considered equal in value to US LORs.

If you’re relying on home-country letters, a little preparation goes a long way:

• Ask your authors to explain your abilities in terms that apply to US residency training.
• Pick people who directly supervised your clinical work.
• Skip generic letters that only help you reach the required number.

A letter describing how you managed real patients will do far more for you than one that simply calls you hardworking and sincere.

Do Residency Programs Prefer US Attending LORs?

Some do, but a preference isn’t the same as a requirement. Many programs value USCE and letters from the physicians who supervised it. Policies vary quite a bit, as these four examples show:

• Boston University Internal Medicine lists US or Canadian clinical exposure of at least four weeks, with a letter from a supervisor, for foreign medical school graduates. That’s a requirement.
• University of Cincinnati Med-Peds says its typical international candidate has recent US clinical experience and excellent letters of reference. That’s closer to a preference.
• UT Southwestern Family Medicine prefers US clinical experience but values international letters equally with US letters.
• UT Southwestern Internal Medicine asks for one letter from the Department of Medicine chair or a designee.

A US letter also isn’t automatically a strong one. If it’s brief and general, it tells a program less than a specific letter from a long-term supervisor.

Policies change between cycles, so check each program’s website before you assign letters.

How to Get a US LOR as an IMG

Step 1: Find suitable US clinical opportunities

• Clinical electives and clinical rotations, if you’re still a student
• Externships
• Observerships
• Research with clinical faculty, where appropriate

Patient contact varies a lot across these. An observership isn’t the same as hands-on clinical experience, because you mostly watch care being delivered. Before you pay for any program, ask what you’ll be allowed to do and whether the attending usually writes letters.

Step 2: Build a professional relationship with the attending

Show up on time, prepare for rounds, speak clearly, and act on feedback. Attendings can only write about what they see, so tell them early that you hope to apply for residency.

Step 3: Ask for feedback and a strong LOR

Try asking, “Would you feel comfortable writing me a strong letter of recommendation?” The wording gives the attending an easy way out if they can’t write a personalized letter.

Not sure how to word the ask? Start from our residency LOR request email templates for IMGs.

Step 4: Provide supporting documents

• Updated CV
• Personal statement
• Specialty preference
• Brief summary of your clinical responsibilities
• ERAS Letter Request Form

Step 5: Follow up professionally

Share your deadline and leave enough time. The AAFP suggests at least four to six weeks’ notice. One polite reminder is fine if you need it, and thank them once the letter is uploaded.

Can I Apply for Residency Without US LORs?

Yes, if a program specifies one. Still, these four situations aren’t the same:

• US LOR not available: You do not have a letter from a US physician, although you may have experience in the US.
• No USCE: Programs that require clinical experience may not consider you due to this.
• USCE but no letter: You have had experience in a clinical environment within the United States, but no one there wrote a letter for you.
• International clinical experience: All your clinical experience has been outside of the US.

You may have USCE but it is not a problem if your only LOR is from your home country. Be sure to accurately describe it in your application for ERAS and utilize your best recommenders. Expect the program director to ask about the missing letter, since he/she might be expecting it. 

How Many Letters of Recommendation Should IMGs Submit?

ECFMG advises submitting at least three LORs through MyERAS. You can store more than that, but ERAS only lets you assign four to each program.

• Many programs ask for three letters, but requirements vary.
• Some specialties use standardized letters, such as the SLOE in emergency medicine.
• Some programs want a department chair letter.

You don’t have to send every program the same set, so match your letters to each program’s instructions. Take your time with this step. Once a letter is assigned to a program you’ve applied to, you can’t replace it.

For the 2027 season, authors submit letters through the AAMC Letter Writer Portal. You request and assign letters in MyERAS, but you don’t upload a waived letter yourself.

Should IMGs Submit Both US and Home Country LORs?

Often, yes, if both are strong. Together, they can show how you worked in the US and how you performed over a longer period at home, which gives programs a fuller picture. The right mix depends on your profile, and no fixed ratio works for every applicant.

Applicant profile	Suggested approach
Has 2-3 strong US LORs	Prioritize relevant US letters while meeting program requirements
Has 1 strong US LOR and several home-country letters	Combine them strategically
Has no US LOR but strong home-country supervisors	Use the strongest specialty-relevant international letters
Has extensive USCE but no US attending letter	Use strong available letters and assess whether a new US letter is feasible
Applying to multiple specialties	Obtain letters that appropriately address each specialty

If this is the case, you could apply to two specialties. ECFMG DOES NOT recommend resubmitting a letter recommending you for one of them. Use a general letter or any specialty-specific letters.

How to write a Strong US Residency LOR?

The AAMC guidelines request a specific assessment of how well you performed and prepared for residency, not a blanket recommendation. Generally, a good letter includes six elements:

• Direct observation: The author says he or she worked with you and for how long and when.
• Specific clinical examples: real-life examples: what you did and what happened.
• Clinical competence: relates to your medical knowledge and clinical reasoning.
• Professionalism: conveys reliability, responsibility, ethical behavior.
• Communication and teamwork: It has a description of how you communicate and cooperate with patients or healthcare workers.
• Specialty specific endorsement: explains why you are deserving of the endorsement in the specialty.
  

AAMC provides a clear example of what NOT to write: “She works well with others”.  

A better letter explains a situation, what you did, and the results. If your author hasn’t written for US letters before, send the AAMC guidelines to make them aware of what programs are interested in reading.

The letter should contain the following information:

• Official institutional letterhead
• The name and appointment of the author(s).
• Institutional affiliation
• Address, phone number, and email address.
• Date and signature (Electronic signature is acceptable by AAMC)

Common LOR Mistakes IMGs Should Avoid

• Choosing a recommender only for their seniority. A famous name who barely knows you adds little, so pick someone who has seen your work.
• Sending generic or repetitive letters that all say the same thing. Ask each author to focus on what they saw you do.
• Using a letter that doesn’t address your intended specialty.
• Giving your author too little time, which often leads to a rushed, general letter.
• Submitting unsigned or badly formatted letters.
• Ignoring program requirements, such as a department chair letter.
• Waiting until the application deadline to request letters. Programs aren’t guaranteed to review letters assigned after your initial application.

Frequently Asked Questions About IMG Residency LORs

Q1. Can I apply for US residency with only home-country LORs?

Yes. ERAS has no universal US LOR requirement, but some programs set their own. Check each program’s website before you apply, since a missing required letter can hurt you.

Q2. Do US residency programs prefer American attending physicians?

Some do, especially if you have USCE. Others accept international letters equally. Either way, aim for a detailed evaluation from a physician who worked with you.

Q3. Can I use an observership LOR for residency?

Yes, if the program accepts it. The attending should honestly describe what they observed, without implying you provided hands-on patient care.

Q4. How many US LORs do IMGs need?

There’s no universal number. Some programs require one or more US letters, while others require none. Read each program’s published instructions before requesting any letters.

Q5. Can I use a letter from a consultant or professor in my home country?

Yes. Choose someone who directly supervised you and can describe your clinical skills and readiness for US residency training. Ideally, that supervision happened within the past two years.

Q6. Should my LOR be specific to Internal Medicine or Family Medicine?

Yes, if you’re applying to that specialty. If you’re applying to both, request separate letters or one general letter that suits both specialties.

Q7. Can I submit more than four LORs through ERAS?

You can store more than four in ERAS, but you can only assign four to each program. Different programs can receive different combinations.

Sources

1. ECFMG: Asking for a Letter of Recommendation
2. AAMC: Guidelines for Writing a Narrative Letter of Recommendation for a Residency Applicant
3. AAMC: Letters of Recommendation, 2027 MyERAS Applicant User Guide
4. AAMC: ERAS for Letter Writers FAQ
5. UT Southwestern: Family Medicine Applicant Information
6. UT Southwestern: Internal Medicine, How to Apply
7. Boston University: Internal Medicine Residency Requirements
8. University of Cincinnati: Med-Peds Applicant Information
9. ACP: International Medical Graduates, Reference Letter Outlines
10. AAFP: How to Submit Strong Letters of Recommendation
11. AMA: Finding the Best People to Write Residency Letters of Recommendation

Disclaimer:

Articles published by IMG Helping Hands are prepared by our team using information from direct experience, publicly available resources, and educational references. AI tools may be used to assist with drafting, proofreading, and formatting; however, all content undergoes review and approval before publication.
The information provided is intended for educational purposes only. Requirements, policies, and processes may change over time. Readers should consult official sources for the most current information.