How to Stand Out During USCE as an IMG to Secure a Strong Letter of Recommendation
- Ash Eighaei Sedeh MD
- Apr 27
- 14 min read
For international medical graduates (IMGs), securing U.S. clinical experience (USCE) is a major milestone in the residency journey. However, completing a rotation is only part of the equation. To maximize your opportunity, you must leave a strong and memorable impression on your attending physician or preceptor, strong enough that they are willing to write you an impactful letter of recommendation (LoR).
In this guide, we explain actionable strategies IMGs can use to distinguish themselves during clinical rotations and secure high-quality LoRs that meaningfully strengthen their residency applications.
If you need help finding verified U.S. clinical rotations tailored to your specialty of interest, explore our available placements [HERE] or contact us at usce@imgrotations.com.
Table of Contents
Why Strong Letters of Recommendation Matter for IMGs in the U.S. Residency Match and how to stand out during USCE
As an IMG, one of the most powerful assets you can bring to your U.S. residency application is a strong, U.S.-based LoR. While academic scores and clinical experience are critical, program directors consistently rank LoRs among the most decisive factors when granting interview invitations.
In this guide, we explain why high-quality LoRs matter so much, how they influence your candidacy, and what makes a letter truly impactful for your Match journey.
The Critical Role of Letters of Recommendation and how to stand out during USCE
Every year, the National Resident Matching Program (NRMP) releases the Program Director Survey, which outlines the most important criteria for selecting applicants. Across specialties, U.S.-based letters of recommendation consistently rank near the very top, alongside USMLE scores and clinical experience.
Program directors rely on LoRs because:
They offer third-party validation:
A respected physician's endorsement speaks volumes about your competence, reliability, and readiness for residency-level responsibilities.
They demonstrate U.S. healthcare familiarity:
A U.S.-based LoR assures programs that you have adapted to the American medical system, patient communication norms, and documentation standards.
They provide insight into soft skills:
Clinical knowledge is expected. What sets candidates apart are traits like professionalism, teamwork, communication, work ethic, and resilience, qualities often highlighted in strong letters.
In competitive specialties and IMG-heavy applicant pools, a high-quality LoR can be the tipping point between receiving an interview and being overlooked.
What a Strong U.S.-Based LoR Achieves
A personalized, well-written LoR from a board-certified U.S. attending can:
1. Validate Clinical Competence
Strong letters affirm that you are clinically capable, can formulate differential diagnoses, present cases effectively, and participate meaningfully in patient care. This validation is essential for IMGs whose medical training may otherwise be unfamiliar to U.S. program directors.
2. Demonstrate Professionalism, Communication, and Work Ethic
Programs seek residents who are dependable, empathetic, and team-oriented. A good letter highlights these soft skills, showcasing your ability to interact with patients, colleagues, and multidisciplinary teams professionally.
3. Strengthen Your ERAS Application Credibility
A U.S. attending’s endorsement enhances the overall credibility of your application. It shows that you have succeeded in an American clinical environment, which carries greater weight than letters written solely by faculty abroad.
4. Differentiate You from Other IMG Applicants
Many IMGs present similar academic achievements, Step scores, and extracurricular activities. What sets you apart is not just what you know but who can vouch for how you apply that knowledge in real-world U.S. clinical settings.
Programs notice when a letter is detailed, personalized, and enthusiastically supportive—especially when compared to generic or template-style letters that offer little insight into the applicant’s true strengths.
Not All Letters Are Equal
It is crucial to understand that not every letter holds the same value:
Generic letters that merely state you "participated" in a rotation without elaborating on your strengths will not help you stand out.
Brief letters that lack personal anecdotes, specific examples, or expressions of strong endorsement may actually weaken your application.
Non-U.S. letters are useful, but they do not carry the same weight as letters from U.S.-licensed, board-certified physicians familiar with American healthcare standards.
A truly effective LoR reflects a genuine relationship built during your U.S. clinical
experience, with the physician able to confidently comment on your capabilities, potential, and character.
Ready to take the next step toward a stronger Match application? Visit www.imgrotations.com or email us at admin@imgrotations.com to get started.
How to Prepare Before Your U.S. Clinical Rotation Begins
For IMGs, it is important to stand out during USCE as it offers an invaluable opportunity to demonstrate clinical skills, adapt to the U.S. healthcare system, and build relationships that can lead to strong letters of recommendation. However, the foundation for success is laid long before your first day on-site.
In this guide, we outline essential steps to help you prepare effectively for your USCE, so you can make a strong and lasting impression from the start.
Why Preparation Matters
Rotations move quickly, and supervisors form early impressions. Arriving prepared shows respect for the opportunity, confidence in your skills, and a professional attitude that can set you apart from the beginning.
Proper preparation allows you to:
Maximize clinical learning
Demonstrate initiative and professionalism
Minimize avoidable mistakes
Focus on building strong relationships with attendings and staff
Investing time in pre-rotation preparation is one of the most strategic moves you can make toward securing strong evaluations and letters of recommendation.
Key Steps to Prepare Before Your Rotation
1. Review Common Clinical Topics
Before your rotation begins, review core material related to the specialty you will be working in. Focus on:
Common diagnoses and presenting complaints
Basic management principles and first-line treatments
Physical examination techniques
Common diagnostic tools and laboratory tests
If you are rotating in internal medicine, for example, ensure you can confidently manage cases like chest pain, shortness of breath, and altered mental status. For pediatrics, review immunization schedules and common pediatric emergencies.
Brushing up on relevant clinical topics ensures you can participate actively and intelligently during patient discussions.
2. Complete All Administrative Paperwork Early
Many U.S. hospitals and clinics require documentation before you can start. Common requirements include:
HIPAA certification (Health Insurance Portability and Accountability Act compliance training)
Immunization records, including proof of COVID-19 vaccination, MMR, Hepatitis B, and Varicella
Tuberculosis screening, typically within 3-6 months of the start date
Background check or police clearance report
Completing and submitting all paperwork early demonstrates responsibility and helps avoid administrative delays that could jeopardize your rotation start date.
At IMG Rotations, we help guide students through this process to ensure smooth onboarding.
3. Set Specific Goals for the Rotation
Define personal and professional goals before you arrive. Ask yourself:
What skills do I want to improve (e.g., case presentations, diagnostic reasoning, communication)?
What professional attributes do I want my preceptor to observe (e.g., teamwork, punctuality, initiative)?
What specialty-specific knowledge do I want to strengthen?
Clear goals will keep you focused throughout the rotation and help you track your growth. They also make it easier to seek meaningful feedback from your preceptor along the way.
4. Understand the U.S. Healthcare System and Documentation
U.S. hospitals and clinics may differ significantly from your home country’s systems in areas such as documentation, workflows, and patient-centered care expectations.
Before starting:
Learn the SOAP note format (Subjective, Objective, Assessment, Plan)
Familiarize yourself with basic EMR (Electronic Medical Record) navigation if possible
Understand patient confidentiality, autonomy, and informed consent standards
Study common clinical workflows, such as admission orders, discharge summaries, and interdisciplinary rounds
Demonstrating familiarity with U.S. standards will increase your credibility and help you integrate smoothly into clinical teams.
Professionalism and Punctuality Are Non-Negotiable During U.S. Clinical Rotations
Clinical rotations in the United States offer IMGs an invaluable opportunity to showcase their medical knowledge and adapt to the expectations of the American healthcare system. However, beyond clinical ability, the single most important factor that determines success during USCE is professionalism.
While knowledge can be acquired over time, professionalism is a quality that supervisors expect to see immediately. In this guide, we outline key expectations for professionalism and punctuality, and explain why they are essential for making a strong and lasting impression.
Why Professionalism Matters
Residency programs seek candidates who are not only clinically competent but also trustworthy, respectful, and dependable. As an IMG, you are under close observation during rotations, and even minor lapses in professionalism can overshadow academic strengths.
Program directors value applicants who:
Communicate respectfully
Act ethically and confidentially
Demonstrate reliability and maturity
Integrate smoothly into multidisciplinary teams
Professionalism builds credibility. It establishes the trust necessary for supervisors to write strong letters of recommendation and advocate for you during the residency Match process.
Key Expectations for Professionalism During Rotations
1. Always Arrive Early
Punctuality is a basic yet critical standard in U.S. clinical practice. Students are expected to arrive:
At least 15-20 minutes before the scheduled start time.
Fully prepared with necessary equipment (e.g., white coat, stethoscope, notepad).
Arriving early shows respect for the clinical team’s time, allows you to review patient charts beforehand, and ensures you are ready to participate fully from the beginning of rounds or clinical activities.
Late arrivals are noticed quickly and can damage your credibility irreparably.
2. Dress Appropriately and Maintain Professional Grooming
First impressions are often visual. Dress code expectations include:
Business casual attire (dress shirts, slacks, modest skirts or dresses)
Clean, ironed white coat without stains or excessive wear
Polished, closed-toe shoes appropriate for clinical environments
Professional grooming, including clean, neat hair and minimal accessories
Avoid excessive fragrances or distracting clothing styles
A polished appearance conveys seriousness, attention to detail, and respect for the patient environment.
3. Respect Privacy and Confidentiality
Strict adherence to patient confidentiality is mandatory. Expectations include:
Complying fully with HIPAA guidelines at all times.
Never discussing patient information in public areas such as elevators, cafeterias, or waiting rooms.
Keeping written notes and records secure and inaccessible to unauthorized individuals.
Refraining from taking unauthorized photographs or recordings under any circumstances.
Respect for patient privacy reflects ethical maturity and understanding of U.S. legal standards.
4. Be Courteous and Professional in All Interactions
Regardless of rank or title, treat every person in the clinical environment with respect, including:
Addressing patients, attendings, nurses, and staff formally (e.g., "Dr. Smith," "Ms. Johnson") unless invited otherwise.
Listening actively and attentively without interrupting.
Maintaining a positive, solution-oriented attitude even in high-stress situations.
Showing gratitude for feedback, even if critical.
Professional courtesy fosters a collaborative environment and demonstrates emotional intelligence.
5. Stay Until Dismissed
Unless explicitly excused by your supervising physician:
Do not leave early, even if clinical activities seem to be winding down.
Offer to assist with tasks or charting if you finish assigned duties early.
Remain available for debriefing sessions, teaching opportunities, or patient handoffs.
Leaving without permission is seen as unprofessional and may be reflected negatively in evaluations.
First Impressions Are Lasting
Supervising physicians often form early impressions that heavily influence mid-rotation feedback, end-of-rotation evaluations, and letters of recommendation.
Being:
Punctual
Appropriately dressed
Courteous
Engaged
Respectful of patient confidentiality
will distinguish you in the minds of attendings and preceptors. Professional behavior tells programs that you are prepared to shoulder the responsibilities of residency training.
Ready to take the next step toward a stronger Match application? Visit www.imgrotations.com or email us at admin@imgrotations.com to get started.
Clinical Engagement: Be Proactive, Not Passive During U.S. Clinical Rotations
Securing a USCE is a crucial step for IMGs, but completing a rotation passively will not maximize its value. Supervising physicians consistently notice and remember students who are actively engaged, curious, and invested in patient care.
Clinical engagement is about more than attendance, it is about how you participate in the learning environment. In this guide, we share key strategies to demonstrate proactive engagement and stand out during your rotation.
Why Active Engagement Matters
Residency program directors seek applicants who demonstrate initiative, curiosity, teamwork, and critical thinking. Strong clinical engagement:
Enhances your learning experience
Builds trust with your supervising physicians
Strengthens your letters of recommendation
Increases your confidence and professional development
Passive observation may fulfill minimum requirements, but active participation is what transforms a clinical rotation into a powerful career-building opportunity.
Ways to Show Engagement During Clinical Rotations
1. Volunteer to Present Cases
Whenever appropriate, offer to present patient cases during rounds or team meetings.
Key tips for effective case presentations:
Keep presentations concise and structured, typically following a SOAP format (Subjective, Objective, Assessment, Plan).
Focus on clinical reasoning, not just listing data. Explain your thought process behind differentials and management decisions.
Practice beforehand if you are nervous, but remain flexible if asked questions during your presentation.
Case presentations show that you are actively processing clinical information, not merely observing it.
2. Ask Relevant and Thoughtful Questions
Engaged learners demonstrate intellectual curiosity. During rounds or discussions:
Ask about diagnostic reasoning (e.g., "How did you decide to order this imaging study?")
Inquire about treatment decision-making (e.g., "Why was this antibiotic chosen over another?")
Clarify clinical guidelines (e.g., "When is anticoagulation indicated in atrial fibrillation for this age group?")
Keep questions respectful and concise. Avoid interrupting patient interactions, and choose appropriate times (such as post-round debriefings) to ask deeper questions.
Insightful questions reflect genuine interest in learning and clinical growth.
3. Offer Help Whenever Appropriate
Take initiative by asking if you can assist the team with:
Chart reviews or updating the electronic medical record (if permitted)
Patient education or counseling under supervision
Gathering supplies or preparing documentation for procedures
Organizing rounds lists or assisting with clerical tasks during downtime
Small, thoughtful acts of assistance show teamwork, maturity, and initiative. They also build goodwill with residents, nurses, and attending physicians.
4. Take Initiative in Independent Learning
Clinical rotations expose you to diverse conditions and management strategies. Make the most of these encounters by:
Reviewing cases at home after clinic or rounds
Reading current guidelines or consensus statements related to your patients
Preparing questions or mini-reports to discuss with your preceptor the next day
For example, if you encounter a case of heart failure, you might read the latest ACC/AHA heart failure guidelines and discuss nuances of guideline-directed medical therapy with your attending.
Demonstrating follow-up learning shows that you are committed to professional growth beyond mandatory duties.
Enthusiasm and Intellectual Curiosity Set You Apart
Enthusiasm for learning and a proactive mindset leave lasting impressions. Supervising physicians are far more likely to write strong, personalized letters of recommendation for students who:
Display passion for patient care
Show interest in understanding complex cases
Embrace feedback with humility
Pursue clinical excellence actively rather than passively
In a competitive Match environment, these qualities can make the critical difference in both evaluations and ultimate residency offers.
Build Relationships Through Communication During Your U.S. Clinical Rotations
Securing a USCE is a crucial milestone for IMGs. However, success is not determined solely by clinical performance, it is also shaped by the relationships you build with your supervising physicians.
Strong, personalized letters of recommendation (LoRs), which are vital for the residency Match, often come from attendings who feel a genuine connection with the student. Building that connection starts with proactive, professional communication.
In this guide, we highlight practical strategies for fostering strong relationships during your rotation, ensuring you leave a lasting and positive impression.
Why Communication Matters
In the busy clinical environment, it is easy for students to become passive observers or fade into the background. Communication helps you stand out in a positive way.
Clear, respectful communication:
Builds trust with your supervising physicians
Encourages mentorship and coaching
Demonstrates emotional intelligence and maturity
Paves the way for strong, personalized letters of recommendation
Effective communicators are perceived as more professional, engaged, and capable, qualities highly valued by residency programs.
Strategies to Build Stronger Relationships Through Communication
1. Seek Feedback Early
Do not wait until the end of your rotation to find out how you are performing. Around the midpoint of your rotation:
Politely ask your attending or resident for constructive feedback.
Frame your request positively:"I would really appreciate any feedback you have on how I can improve and be more helpful to the team."
Seeking feedback shows that you are coachable, self-aware, and invested in your growth. It also invites your preceptor to observe you more closely, which can lead to a more detailed and supportive LoR.
2. Demonstrate Visible Growth
Feedback is only valuable if you act on it. After receiving suggestions:
Apply changes immediately to your presentations, documentation, or clinical reasoning.
Thank your preceptor for their guidance.
Ask follow-up questions if you need clarification on expectations.
When preceptors see tangible improvement in your performance, they recognize your work ethic, resilience, and dedication, critical attributes for a successful resident.
Demonstrated growth not only strengthens your relationship but also provides concrete examples that can be included in a strong LoR.
3. Communicate Your Career Aspirations
At an appropriate time, often after rapport has been established, share your professional goals with your attending.
For example:
"I am planning to apply for internal medicine residency and hope to eventually pursue a cardiology fellowship."
"My long-term goal is to practice outpatient pediatrics in underserved communities."
Understanding your aspirations helps your preceptor:
Tailor clinical teaching to your interests
Provide career-specific advice
Write a more personalized LoR that speaks to your future goals
Students who communicate openly about their ambitions are perceived as focused, driven, and serious about their career paths.
Personal Connections Lead to Stronger Letters
Supervising physicians are far more likely to write strong, detailed, and enthusiastic letters of recommendation for students they:
Feel personally connected to
Have observed growing and succeeding during the rotation
Understand beyond surface-level interactions
Building relationships through communication makes you memorable for the right reasons and significantly enhances your residency application profile.
Final tips from IMG Rotations
Technical knowledge and clinical skills are essential during U.S. clinical rotations, but personal relationships built through respectful communication often make the difference between an average and an outstanding evaluation.
By seeking feedback early, demonstrating improvement, and sharing your professional goals, you position yourself for stronger mentorship, more personalized support, and ultimately, better residency Match outcomes.
At IMG Rotations, we not only secure high-quality USCE but also mentor students on how to make the most of every opportunity.
Ready to secure your next clinical rotation and strengthen your Match application? Visit www.imgrotations.com or email us at admin@imgrotations.com to get started today.
Ask Thoughtfully for Your Letter of Recommendation During U.S. Clinical Rotations
A strong LoR is one of the most critical components of your U.S. residency application. For IMGs, a personalized, supportive LoR from a U.S.-based attending physician can significantly boost credibility and differentiate your application in a competitive Match environment.
However, obtaining a strong letter does not happen automatically. It requires thoughtful timing, professional communication, and careful preparation. In this guide, we discuss best practices for requesting your LoR to maximize your chances of receiving a powerful endorsement.
Why Your Approach Matters
Even if you perform well during a clinical rotation, a poorly timed or casually delivered request for LoR can result in a weak, generic, or delayed letter. Preceptors are busy professionals, and how you ask directly impacts their willingness and ability to write a strong, detailed LoR.
By being proactive, respectful, and organized, you set the stage for a positive response and a letter that truly reflects your capabilities.
Best Practices for Requesting Your LoR
1. Ask 1-2 Weeks Before the Rotation Ends
Timing is crucial. The best time to ask is approximately:
One to two weeks before the end of your rotation
After you have demonstrated your clinical skills, professionalism, and engagement
Requesting early gives your preceptor:
Enough time to reflect on your performance
Flexibility to draft the letter without feeling rushed
The ability to write while your strengths are still fresh in their memory
Waiting until the last day or after you leave may result in a weaker or delayed letter.
2. Be Specific and Polite in Your Request
When asking, be clear and respectful. Use language such as:
"Dr. Smith, it has been a privilege to learn under your supervision. Would you feel comfortable writing me a strong letter of recommendation for U.S. residency programs?"
This approach:
Gives the preceptor an easy way to decline if they do not feel they can strongly support you
Ensures you only collect letters from supervisors who are enthusiastic about endorsing you
Reinforces that you value a strong, personalized recommendation, not just a generic endorsement
Being direct yet courteous shows professionalism and maturity.
3. Provide Supporting Materials
Make the process easier for your preceptor by offering:
Your updated CV highlighting clinical, academic, and leadership experiences
A draft personal statement (even if incomplete) that outlines your goals and values
A list of residency programs you plan to apply to, if requested
Specific points you would appreciate being mentioned, such as particular clinical strengths or areas of growth
Supporting documents help your preceptor craft a more detailed, compelling letter aligned with your personal and professional narrative.
4. Follow Up with Gratitude
After your preceptor agrees to write the letter and completes it:
Send a sincere thank-you email expressing appreciation for their time and support
Consider sending a handwritten thank-you note for an even more personal touch
Acknowledging their effort:
Leaves a lasting positive impression
Reflects maturity and professionalism
Strengthens your relationship for future networking and mentorship opportunities
A simple, thoughtful gesture can set you apart in a highly professional environment.
Never Assume a Letter Is Automatic
One of the most common mistakes IMGs make is assuming that clinical rotation participation alone will result in a LoR. Always remember:
Letters are earned through clinical performance, professionalism, and communication
Explicitly requesting a strong letter ensures that the attending knows your intention and can prepare accordingly
Building rapport during the rotation increases the likelihood of receiving an enthusiastic, personalized letter
Ready to take the next step toward a stronger Match application? Visit www.imgrotations.com or email us at admin@imgrotations.com to get started.
