A strong Letter of Recommendation (LOR) can be the difference between a match and a miss—especially for Indian Medical Graduates navigating the US residency process. But what exactly makes an LOR impactful? And what do US attendings look for when they agree to write one?
This blog breaks it all down from the attending physician’s perspective, so you can understand, prepare, and approach your LORs strategically.
🎯 Why LORs Matter So Much for Indian Applicants
For international medical graduates (IMGs), especially from India, LORs serve as:
Validation of clinical competence by US physicians.
Proof that you can communicate and work effectively in a US clinical environment.
A measure of how well you’ll integrate into a residency team.
An opportunity to stand out when program directors compare IMGs.
👉 Bottom line: It’s not just what the letter says, but who says it—and how personally they can speak about your strengths.
🧠 What US Attendings Expect Before Writing a Strong LOR
A good LOR doesn’t come from a casual observation—it’s based on real interaction and trust. Here’s what US attendings typically expect:
✅ 1. Sustained Clinical Interaction
At least 2–4 weeks of working together during a USCE.
You should be present, punctual, and actively involved in patient discussions (even if it’s an observership).
✅ 2. Demonstration of Key Attributes
US attendings value:
Clinical reasoning and decision-making.
Communication skills with patients and the team.
Work ethic, curiosity, and willingness to learn.
Professionalism and cultural adaptability.
✅ 3. Respectful LOR Requests
Don’t assume an LOR will be offered.
Politely request it near the end of your USCE, ideally after building a good rapport.
Example phrasing:
“Dr. Smith, I’ve learned a great deal during this rotation, and I’ve truly valued your mentorship. Would you feel comfortable writing me a letter of recommendation for residency?”
📝 What Makes an LOR Strong (vs. Weak)
| Strong LOR | Weak LOR |
|---|---|
| Describes your work with specific examples | Generic praise with no context |
| Mentions your clinical ability, ethics, and character | “This student rotated with me for 4 weeks…” |
| Written by someone with US academic credibility | From a private clinic with little teaching reputation |
| Speaks to your suitability for US residency | Repeats your CV without personal input |
| Clearly states how well they know you | Vague, impersonal tone |
💡 Pro Tip: LORs from academic physicians in teaching hospitals carry more weight than those from private practitioners—unless the private practice has a strong reputation and the letter is personalized and detailed.
What Program Directors Want in an LOR
According to the NRMP Program Director Survey:
78% of PDs cited LORs as one of the most important criteria for granting interviews.
They look for:
Clinical aptitude in a US system.
Your fit within a team.
A sense of your potential as a resident.
Whether the attending would welcome you into their own program.
📥 How Many LORs Do You Need—and From Whom?
ERAS allows you to upload up to 4 LORs per program.
Ideally, have 3 LORs from US physicians, especially from:
Core specialties (Internal Medicine, Pediatrics, Surgery, etc.)
At least one academic/research or teaching hospital
One strong letter is better than three vague ones.
💬 Optional: 1 letter from your home institution (India)—preferably from a Head of Department or Dean—but this carries less weight unless the recommender is known internationally.
🧩 Tips for Indian Students to Earn Strong LORs
🔹 1. Choose the Right USCE
Prioritize hands-on electives or observerships in teaching hospitals.
Length matters—minimum 3–4 weeks with a physician is ideal.
🔹 2. Be Proactive
Discuss cases, ask insightful questions, take initiative (when allowed).
Show interest beyond the basics—read up on patient conditions, US protocols, and ethical issues.
🔹 3. Stay in Touch
A gentle email reminder when LOR season comes (around June-July).
Provide your ERAS LOR cover sheet and your CV.
🔹 4. Be Honest
Only ask for a letter if the physician seems genuinely positive about your performance.
It’s better to skip a letter than submit one that’s neutral or weak.
⚠️ Common Mistakes to Avoid
❌ Asking too early (before building a relationship) during electives/clerkships.
❌ Pushing for a letter when the attending seems hesitant.
❌ Using a “template” letter written by you—many attendings consider this unethical.
❌ Submitting old or non-relevant letters (e.g., from a lab tech or non-clinical setting).
- ❌ Using the same draft as your senior for the LOR.
🌐 Uploading LORs on ERAS
LORs must be uploaded by the letter writer or their assistant—not by you.
You provide a Letter Request Form (via ERAS).
LORs can be:
Waived (recommended): You waive your right to view the letter. This signals trust and adds credibility.
Non-waived: You can read it, but some PDs view this less favorably.
🧠 Final Thoughts
US LORs aren’t just letters—they are testimonials of trust and capability from US physicians who have seen you work. For Indian applicants, these letters help bridge the gap between different systems and prove you belong in a US residency.
“Earn them. Don’t just ask for them.”
Start early, be intentional with your USCE choices, and focus on building authentic clinical relationships that naturally lead to strong, personalized letters.
📩 Need help choosing the right USCE to earn strong LORs—or unsure how to approach attendings?
Let’s talk. I help Indian students craft a personalized roadmap to the Match, starting with clinical experience and ending with a confident ERAS application. Reach out to us at ConsultCK
