Turning US Clinical Experience Into a Strong Letter

A strong letter from US clinical experience comes from a physician who supervised you closely, saw you work over enough time to judge you, and is willing to describe specific things you did. Length of placement and price are poor predictors of that. This guide covers how to set up the conditions that make a good letter possible, without pretending you can control the result.

For the general rules on who to ask and how many letters to use, read letters of recommendation. This page focuses on getting a letter out of USCE in particular.

Why letters are the point #

The 2024 NRMP Program Director Survey found specialty-specific letters of recommendation among the key interview considerations (84% of respondents, mean importance 4.2 out of 5). For many IMGs, USCE is the only practical way to obtain a letter from a US physician who has seen them in a clinical setting. A certificate or attendance record is useful for your records, but it does not carry that weight.

What makes a letter strong #

Programs read many letters, and strong ones tend to share these features. This is common practice and our opinion, not an official standard.

Supervision time, not just weeks #

Two physicians can both host you for four weeks and give very different letters. In one case you work with a single attending daily; in the other you rotate among many people who barely learn your name. When you choose a placement, ask:

• Who will I work with each day?
• Will one physician evaluate me, or several?
• Will the evaluation be written, and can it become a letter?
• Is the experience in a setting where I will see patients and discussions often enough to be remembered?

The AMA's observership template describes the preceptor completing a formal evaluation of the observer and the observer recording hours with the preceptor. Evaluation forms are helpful, but they are not the same as a letter.

During the placement #

You cannot control the outcome, but you can make it easier for the physician to know you.

• Be on time, prepared and visible. Read about the patients you see. Ask thoughtful questions at appropriate moments.
• Follow the rules exactly. Do not exceed what an observer or visitor may do. A supervisor who has to restrain you is not going to praise your judgment.
• Ask for feedback early. Then act on it, and let the supervisor see that you did.
• Take notes on specifics. After each day write down cases, learning points and any feedback. These help the physician later, and they help you write a clear summary.
• Show professionalism with everyone. Staff, nurses and residents often influence what attendings think.

Asking for the letter #

1. Ask in person or by email near the end of the placement, while you are fresh in their mind. Ask directly: "Would you be able to write me a strong letter of recommendation for residency applications?" That wording gives them an easy way to decline.
2. Offer a short packet. A CV, your personal statement draft, target specialty, ERAS deadlines and a few bullets listing cases or tasks you worked on with them. Keep it to a page or two.
3. Explain the process. Letters are uploaded by the writer through the ERAS system using a request you generate. See the ERAS timeline for when materials are due, and check AAMC's current ERAS instructions for letter requests.
4. Give a deadline that is realistic. Physicians are busy. Ask early, then remind politely once or twice.
5. Say thank you, and update them on where you end up.

What to avoid #

• Do not pay for a letter or for a placement on the basis that a letter is included. The decision belongs to the physician, and a letter that was promised for payment is not independent. Programs may treat it with suspicion, and ECFMG's irregular behavior policy takes false or misleading submissions seriously.
• Do not ghost-write and forge. A physician may ask for bullet points. They should not be sending a letter you wrote under their name without their own review and consent.
• Do not collect letters you will not use. Some letters are never submitted, and sending too many weakens the application.
• Do not overstate the relationship in your ERAS entries or personal statement.

If you did not get a good letter #

Not every placement yields a strong letter, and that is normal. Options include building more supervised experience with a different physician, asking faculty from your own school or a research mentor who knows you well, or using the time for other parts of the application. Do not use a weak letter just to have one.

Using the experience in your application #

Even without a letter, describe the experience honestly in the experiences section: setting, dates, your role and what you learned. Never present observation as hands-on care. Programs value accuracy.