USCE Letter of Recommendation for IMGs
For US physicians writing for an IMG after an observership or hands-on rotation: what you can claim, what programs read for, and a constructed sample.
USCE Letter of Recommendation for IMGs
Write only what you saw. After an observership, that means how the graduate reasoned aloud, presented, prepared and worked with your team; after a hands-on rotation, it adds the patients they managed under you. The AMA's IMG section describes an observership as "strictly a shadowing experience with no hands-on patient contact."
An observership letter that claims hands-on skills the graduate could not have performed discredits both of you. The graduate's own application describes the same weeks as an observership, so the two documents disagree. The honest letter is also the useful one: ECFMG tells IMGs that program directors "may expect to see an LoR from someone in that program who can speak about your experience and describe how you performed in a U.S. clinical setting." How someone performs in a US setting includes how they reason on rounds and how they work with a US team, and you saw that directly. This page is for the US physician who agreed to write. The graduate's side of the request is in asking for a US clinical letter as an IMG, and every residency letter guide sits in our medical school and residency essays hub.
Every ECFMG and AMA page quoted below was checked on November 7, 2026. AAMC's ERAS pages refused our automated request that day (HTTP 403), so this page does not quote ERAS upload rules; the graduate sends you the ERAS letter request, and its instructions govern the upload.
Observership, externship or rotation: what your letter can claim
The AMA's observership FAQ draws the line by status: "International students studying outside the United States may be able to apply for an externship. International graduates can only apply for an observership." By that description, a graduate who has finished medical school abroad comes to you as an observer unless your hospital hired them into a supervised clinical role. Hospitals publish their own limits; the applicant-side page linked above quotes one university's observer guideline.
| What the IMG did with you | What you saw and can describe | Verbs that fit | Verbs to cut |
|---|---|---|---|
| Observership | Answers when you questioned them on rounds, case presentations at conference, preparation, English with the team, punctuality | "discussed", "presented", "explained", "prepared", "asked" | "managed", "examined", "admitted", "performed" |
| Externship or rotation with patient responsibility (as a student) | All of the above, plus histories, exams, notes and plans you reviewed | "examined", "presented their patients", "wrote notes I co-signed" | "independently managed" |
| Research or a non-clinical role | Work habits, analysis, writing, teaching | "analyzed", "drafted", "led" | anything clinical |
Our view: in an observership letter, every sentence should pass one test: could you have seen this from where you stood? "When I asked her the differential for new hyponatremia on rounds, she gave four causes and the test to order first" passes. "She has excellent clinical skills" fails, because the observer could not exercise them.
The countercase: some graduates come to you after a hands-on rotation, a research year with clinical duties, or a role your hospital created for them. Then describe the patient care, and name the role in the first paragraph so the reader knows why you could see it.
The relationship paragraph does most of the work
Our residency letter rubric's first check is "Whether the letter establishes the writer's basis for judgment - role, clinical setting, time period, and direct observation - and whether every later claim stays inside that vantage." For an IMG letter, that paragraph carries more weight than usual, because the reader cannot assume the graduate was on your team the way a US student on a clerkship is.
Put four facts in the first two sentences: your role, the setting, the exact dates, and how often you worked with the graduate. "She observed on my inpatient medicine team at [Hospital name] from March 1 to March 26, 2027, and was with me on rounds four days a week" lets the reader judge everything that follows.
Dates, recency and the salutation
ECFMG's guide to asking for letters (last updated May 20, 2025) sets three expectations that change how you write:
- Recency: "If possible, avoid submitting LoRs regarding experiences that took place more than two years before your application." Put the dates in the letter, so the reader sees the experience is recent.
- Salutation: "Your letter writer should begin the letter with a general salutation, such as “Dear Program Director,” or “To whom it may concern:”. Letters should not be addressed to specific programs or program directors."
- Contact: "Program directors may contact LoR authors during the application screening process." Write only what you would repeat on the phone.
If the graduate is still deciding between specialties, ask which ones before you write the closing; the residency letter of recommendation sample covers one letter for two specialties.
Constructed example: the inflated paragraph
Constructed example, written by us, not a real recommendation letter. Context (invented): Dr. R. Hakimi, an internal medicine attending, hosted Dr. Karima Kruger, MBBS, for a four-week inpatient observership.
Dr. Kruger functioned at the level of a US intern on my team. She managed her patients independently, performed thorough physical examinations and demonstrated excellent clinical skills throughout the rotation.
Every claim in it is one an observer could not earn. A reader who knows the graduate was an observer stops trusting the rest of the letter.
Constructed example: the full letter, revised
Constructed example, written by us, not a real recommendation letter. Same invented writer and graduate.
Dear Program Director,
I am an attending physician in internal medicine at [Hospital name], where I lead an inpatient teaching team. Dr. Karima Kruger observed on my team from March 1 to March 26, 2027, and was with me on rounds four days a week. As an observer she did not examine or treat patients; this letter describes what I saw her do.
On rounds I question residents and students on each new admission, and I included Dr. Kruger. When I asked her the causes of new hyponatremia in an elderly patient on a thiazide, she gave four, ranked them, and named the first test to order. Her answers were at the level of the PGY-1 residents on the team.
On March 18 she presented a ten-minute case at our noon conference on discharge planning for heart failure, drawn from her house-officer work in India. She answered questions from two attendings clearly, and our residents asked her for her slides.
She arrived before pre-rounds every day, read about each new admission the night before, and asked the residents good questions without slowing the team. Her English on rounds and at conference was clear and professional.
I have hosted six international medical graduates as observers. Dr. Kruger is the strongest of them in clinical reasoning and preparation. I recommend her for residency training in internal medicine without reservation.
Sincerely, R. Hakimi, MD, Attending Physician, Department of Medicine, [Hospital name]
The body, from "I am an attending physician" to "without reservation", is 224 words. The first paragraph states the role, setting, dates and the observer limit. Each later claim is something the writer saw from rounds or conference. The comparison names its group, six observers, and does not compare her with residents' patient care she could not provide.
USCE letter checklist for writers
- Confirm the graduate's role: observer, extern or employee.
- State your role, the setting, the dates and how often you worked together.
- For an observer, cut every verb that implies patient care.
- Give two or three dated moments you saw: a question on rounds, a presentation, preparation.
- Compare with a group you can name, with its number.
- Use "Dear Program Director" or "To whom it may concern".
- Close with the specialty, or with "residency training" if the graduate is applying in more than one.
Questions about writing a USCE letter
Can I write a letter after only a two-week observership?
Yes, if you can describe specific moments. If you cannot recall two, tell the graduate a short letter would not help them, and suggest the attending who saw more.
Should I compare the graduate with US residents?
Only on what you saw both do, such as answering questions on rounds. Do not compare their patient care with residents who carried patients they could not.
The graduate sent me a draft. Should I use it?
No. Write the letter yourself from your own notes. The guide for when you are asked to write your own letter is the applicant's side of that request. In OB/GYN and some other specialties the letter is a structured form; see standardized letter forms by specialty.
Get a free review of the letter
Get a free Quick Review of the letter against GradPilot's residency letter of recommendation rubric, which covers letters for international medical graduates. For an observership letter it checks that the first paragraph gives your role, the setting and the dates, and it flags any later claim that goes past what you could see from where you stood.
More guides for letters for international graduates:
- Asking for a US clinical letter as an IMG: the graduate's side, with a constructed one-page summary for writers.
- Observership request email for IMGs: how the graduate found the observership.
- Residency letters for SOAP and off-cycle applicants: if the graduate asks for a backup letter before Match Week.
Sources
Retrieved November 7, 2026, except where noted.
- American Medical Association IMG Section, Finding an observership FAQs (no year stated): observership as shadowing with no hands-on patient contact; externships for students, observerships for graduates.
- ECFMG, Asking for a Letter of Recommendation (LoR) (last updated May 20, 2025): US clinical letters, two-year recency, salutation, program contact with authors.
- GradPilot, Residency letter of recommendation rubric (public page): the basis-for-judgment check quoted above.
- Not retrieved: AAMC, ERAS letters of recommendation chapter (HTTP 403 to our request on November 7, 2026); no ERAS rule is quoted on this page.
Review the Letter Before It Is Submitted
See how the letter reads against the rubric for its destination.