IMGs comprise one-third of the neurology residents in the US. The selection process for residency is increasingly challenging as little objective data is provided to programs. The NRMP 2024 survey reported LORs are one of the most important factors in selecting applicants to interview and rank. LORs for IMGs may be of poorer quality and/or contain bias. This has not been studied in neurology.

A total of 2,438 LoRs were identified. IMGs were less likely to have LORs from US physicians (79.98% IMGs vs 100% UMGs, p < 0.001). IMGs were also less likely to have LoRs from a Neurologist (62.29% IMGs vs 66.90% UMGs, p < 0.022), and less likely to have LORs attesting clinical skills (70.28% IMGs vs 88.86% UMGs, p < 0.001). Presence of a US Neurologist’s clinical letter was significantly higher for UMGs than IMGs (62.32% vs 32.38%, p < 0.001). Although not statistically significant, word count was higher for UMGs, and US applicant letters had more positive language than IMGs (p = 0.07).