Is it important to have LORs from US for competitive specialties?

I know having LORs is important. However, for the competitive specialties no one cares whether you have hands-on experience or not for an IV, right? Does it make any change?
If you wanna try your luck for these specialties, which one is more important: hands-on experience and LOR from US or having your names on 5+ research in Q1-2? What do you think?