by Pedram Mizani, MD, MHSA, family physician and chief clinical officer of the AmeriClerkships Medical Society

Published in Residency Program Alert* on February 2018.

In the 2017 Main Residency Match, nearly one out of every four postgraduate year (PGY) 1 residency positions were filled by international medical graduates (IMG), more than half of whom required U.S. visa sponsorships (National Residency Matching Program, 2017). The continued addition of non-U.S. physicians to key primary care and surgical fields is a positive sign that at least these residency specialties will continue to diversify, a key element in providing culturally sensitive primary care in the U.S.

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Published with permission from HCPro/Residency Program Alert. Also published on HCPro.

* About Residency Program Alert: Residency program managers in all specialties are challenged to effectively manage their programs as accrediting agencies focus on outcome measures, the core competencies, proper documentation, resident supervision, and program, faculty, and resident evaluation. Add to those responsibilities the challenge to prepare for site visits, develop budgets for your program, and mitigate legal risks. Residency Program Alert is the source you need to confidently meet these challenges. This monthly resource provides residency managers with essential tips, tools, and best practices from the most well-respected, in-the-trenches experts. Dr. Pedram Mizani, the AmeriClerkships’ Chief Clinical Officer, is a writer and contributors to Residency Program Alert.

In the 2017 Main Residency Match, nearly one out of every four postgraduate year (PGY) 1 residency positions were filled by international medical graduates (IMG), more than half of whom required U.S. visa sponsorships (National Residency Matching Program, 2017). The continued addition of non-U.S. physicians to key primary care and surgical fields is a positive sign that at least these residency specialties will continue to diversify, a key element in providing culturally sensitive primary care in the U.S.

However, the benefits of promoting a culturally diverse resident population come with the challenging responsibility of judging all IMG applicants fairly. By properly identifying and aligning the skills and qualities they present in their Electronic Residency Application Service (ERAS) application packages with what your residency programs value most, you can find the best match. This challenge is typically greatest when evaluating non-U.S. citizen/resident IMGs, especially those who choose to support their own candidacies with foreign letters of recommendation (LOR).

We must also take a moment to define “foreign,” as this term has not been clearly defined by residency programs. While to some, “foreign” may be a euphemism for third-world countries whose native languages are not English, I define it as any LOR generated by a non-U.S. licensed physician pertaining to a non-U.S. experience, and being submitted to U.S. medical residencies for consideration.

LORs have always been an important part of any U.S. medical residency application package, but perhaps are more so now because residency selection committees are under pressure to visualize the type of resident an IMG may be outside of United States Medical Licensing Examination (USMLE) board scores and minor application flaws. However, one medical school study found that 73% of directors of American residency programs considered LORs from a foreign country to be useless (Gayed, 1991).

With so much pressure mounting to invite the candidates who they think will fit in and do the best, residency programs are putting greater value on LORs (or lack thereof) in each application. In fact, in the National Residency Matching Program’s (NRMP) 2016 Program Director Survey, “letters of recommendation in the specialty” was ranked as the second most popular and important criteria when offering residency interviews among all specialties, with only USMLE Step 1/COMLEX Level 1 score ranking higher (National Residency Matching Program, 2016). Because this survey did not delineate if “letters of recommendation in the specialty” was purposefully stated this way to include foreign LORs, the following pros and cons of foreign LORs pertain to their U.S. medical residency relevancy.

Pro: They tell a lot about what a candidate perceives as acceptable communication standards

A foreign LOR is most likely unwaived, so the applicant has seen it, and by virtue of having submitted it to your program, is telling you that he or she approves of the content and writing style. This can be useful to see if the candidate takes great pride and care to communicate accurately and in proper English, or if he or she sees nothing wrong with a poorly written LOR (foreign, or from a U.S. clinical experience).

Pro: They give a glimpse into the type of healthcare environment the candidate is coming from

In nearly every non-English-speaking country, undergraduate, medical education, and PGY-1 are combined as one MD program, virtually guaranteeing that the medical graduate will immediately give back to the community as a licensed general practitioner. Knowing this can help you avoid erroneously concluding that six or seven years of medical education is abnormal and assuming that there were unwanted gaps in an IMG’s medical education.

Pro: They may help explain gaps during (or more likely after graduating from) medical school abroad

If written objectively, a foreign LOR can help account for any perceived gaps, especially if a few years have passed since the candidate graduated from medical school. The best-case scenario is that the writer was an IMG’s hospital or clinic employer.

Pro: They may come from a healthcare environment similar to that of the U.S.

This does not happen often, but some IMG candidates submit LORs from U.S. physicians whom they’ve worked with on U.S. military bases abroad. This is often the case if the non-U.S. citizen/resident was employed by a foreign physician employer contracted to provide local physicians who speak the native language of that country in our bases (e.g., Iraq). In Japan, the U.S. Air Force offers a one-year unaccredited fellowship program to practicing Japanese-speaking physicians who wish to rotate through all core specialties, as well as electives, in a U.S. healthcare environment in their own backyard.

Pro: They may show that patient demographics treated by an IMG candidate may be similar to those seen in your residency

Many programs encourage their residents to learn medical Spanish; therefore, a foreign LOR that emphasizes an IMG’s ability to speak with patients in both Spanish and English may give an IMG candidate an edge over similarly qualified candidates.

Pro: They can indirectly tell you about an IMG’s U.S. clinical experience and residency readiness

One or more foreign LORs with too few or no recent U.S. LORs can be an indicator of an IMG candidate’s lack of recent U.S. clinical experience, which will help you decide if an invitation to interview is better suited for an IMG with a better U.S. clinical experience portfolio.

Con: Unfamiliar language or grammatically incorrect content can be distracting

Due to the sheer number of applications submitted by IMGs to primary care and surgical specialties, it’s nearly impossible to conduct the first round of vetting by looking for positives. This is why we look for negatives and red flags: The more we see, the more we tend to disqualify the candidate. Grammatically incorrect LORs—mostly seen in foreign LORs but also not uncommon in U.S. LORs—can waste valuable seconds that we could be putting into assessing a candidate’s residency readiness based on ACGME core competencies, not letter writing skills.

Con: Healthcare setting is most likely completely different than U.S. GME settings

Although it’s nice to have a colleague abroad support an IMG candidate, the experience that led to the writing of the LOR was most likely not in a setting with patients from the U.S., being treated under U.S. healthcare policies, or following protocols commonly implemented in the U.S.

Con: Fact-checking is neither timely nor efficient, and downright impossible in most cases

Many LOR reviewers in the U.S. find it quite discouraging when they are faced with challenges (e.g., time differences, missing country codes for direct phone numbers, generic email addresses that are checked infrequently, and outdated contact pages on medical school websites) when attempting to contact the letter writer about an IMG they are interested in. Just like a poorly written LOR, these issues create a red flag, and enough red flags can lead to a rejection.

Con: Most foreign LOR writers have never been trained in a U.S. GME, so they lack immediate credibility when it comes to recommending someone to enter it

There is typically no indication that an LOR writer has any experience with U.S. GME, making it nearly impossible for him or her to make a recommendation to a U.S. program based on the writer’s experiences. Therefore, it makes it difficult for an LOR reviewer in the U.S. to trust someone’s recommendation who may not have trained in the same system for which they are recommending a candidate.

Con: References to ACGME core competencies are nearly nonexistent

This is understandable, since ACGME core competencies are unique to the U.S., which is the reason why some programs refuse to consider LORs from non-U.S. experiences. A seemingly strong foreign LOR (based on a candidate’s medical knowledge or high USMLE scores) is not truly relevant to U.S. medical residency programs if it fails to address all other ACGME core competencies as we would like to see them be taught and carried out in this country.

Con: They rarely criticize or even point out weaknesses in IMG candidates

IMG candidates typically ask friends or professional colleagues from abroad to write LORs, and in general, friends and colleagues will not be critical of an IMG’s performance. In my 18 years of reviewing LORs, I have yet to come across a foreign LOR that was critical of a candidate or objective of that candidate’s performance. If all LORs are positive and subjective, then the value of an LOR quickly diminishes.

Considerations for foreign LORs

With all of that being said, foreign LORs deserve special consideration under the following conditions:

1. The LOR is written by a U.S.–licensed physician outlining experiences that took place on U.S. military bases abroad, treating patients from the U.S., using the U.S. healthcare system

2. The clinical experiences described took place in any of 70 ACGME International–accredited residency programs in Singapore, Lebanon, Oman, Qatar, United Arab Emirates, and Saudi Arabia

3. The experiences took place in non-military “American hospitals” abroad, especially if they are Joint Commission International–accredited

4. The LOR is written by a physician who supervised the IMG candidate who was responding to a humanitarian disaster

5. The LOR is written by an IMG who completed a U.S. ACGME–accredited residency program, is not licensed in the U.S., but is practicing abroad

6. The LOR is from a clinical experience in an English-only speaking medical school with a supervising medical board that has reciprocity agreements with your state medical board for purposes of licensure

7. The candidate is applying for a fellowship, advanced, or PGY-2 position in the exact same specialty as his or her field of practice (e.g., ophthalmology), and the U.S. residency or fellowship program requires the IMG’s immediate supervisor to attest to his or her performance and specialty suitability

8. The position offered is a research track and the candidate has extensive residency relevant research experience abroad

I hope you find this information useful when faced with evaluating a foreign LOR in an ERAS application to your residency program. Consider sharing this information with your residency faculty and colleagues who review residency applications for interview consideration. By truly understanding all that is entailed in residency applications submitted by IMGs and taking proactive steps to address the unique aspects of such applicants, we can improve the suitability of those whom we invite for interviews, prior to extending offers.


Gayed, N. M. (1991). Residency directors’ assessments of which selection criteria best predict the performances of foreign-born foreign medical graduates during internal medicine residencies. Academic Medicine, 66(11), 699–701. Retrieved from

National Residency Matching Program. (2016). Results of the 2016 NRMP program director survey. Retrieved from

National Residency Matching Program. (2017). Results and data: 2017 main residency match. Retrieved from