UME/GME Program Resources

Fellowship Letter of Recommendation Guidelines

In April 2017, AAIM endorsed new standards for program director (PD) letters of recommendation (LOR) for fellowship applicants. Based on national survey results, residency program directors reported a high level of awareness (90%) and wide adoption (60%) of AAIM guidelines. 80% of fellowship program directors was satisfied or very satisfied with letters based on the AAIM guidelines as compared to 50% for other letter types. Applicant unique characteristics (e.g. level of engagement, degree of initiative) and serious performance-related issues were elements deemed most helpful.

Now in its fifth year, the AAIM Guidelines for Fellowship Applicant Letter of Recommendations have improved the educational handover from residency to fellowship. When compared to letters that did not adhere to guidelines, fellowship program directors found conforming letters to be more helpful in many areas. Programs are encouraged to fully adopt the guidelines for 2022 internal medicine subspecialty fellowship applicants.

In addition to recommendations contained in the guidelines, letter writers for 2022 fellowship applicants are encouraged to include:

  • Any changes related to the COVID-19 pandemic on the residency program curriculum, any limitations of usual opportunities, or other extenuating circumstances
  • Descriptions of a resident’s exemplary contributions to patient care during the pandemic

AAIM Program Director LORs

Published in the May 2017 issue of The American Journal of Medicine, these guidelines seek to improve reliability and efficiency through standardization, while continuing to allow advocacy and discussion of applicant characteristics. Supported by APDIM Council, ASP Council, and the AAIM Resident to Fellow Interface Committee, they reflect efforts to overcome challenges of the current LOR involving variation in terminology, length, interpretation, and meaningful comparison.

LOR Guidelines PDF

Please contact or (703) 341-4540 with questions or comments.

The Guidelines

I. Paragraph describing your program

  • Location of program, number of trainees, and number of hospitals used for rotations
  • Unique features of the program
  • Types of required inpatient and outpatient rotations, including number of critical care rotations and number of elective months
  • Percentage of residents that pursue fellowship training

II. Resident's achievement in all six core competencies

Patient Care: Resident’s cognitive input into management decisions and effectiveness of interaction in and with consultation teams, as demonstrated by:

  • Whether applicant has engaged in/become independent in/mastered clinical management. Provide a representative example/faculty comment, if possible

Medical Knowledge: As assessed by supervisors, rather than IM-ITE scores, including:

  • Whether applicant is achieving/has achieved/or excels in medical knowledge in all or specific aspects of internal medicine, with particular note made of the chosen subspecialty
  • The In-training Examination is protected data limited to learner assessment and program evaluation and items unrelated to residency that are accessible in other documents, such as USMLE scores, should not be included.

Interpersonal and Communication Skills: Effectiveness of communication with team members and patients, timeliness of written documentation, and quality of teaching junior residents and students, supported by:

  • Whether applicant is achieving/has achieved/or excels in communication with team members, patients and their families providing a representative example, if possible.
  • Examples to demonstrate whether applicant is learning/has achieved independence/has mastered the ability to communicate clearly in progress notes, histories and discharge summaries
  • Examples of assessments of their teaching activities

Systems-Based Practice: Team leadership skills, interdisciplinary team interactions, and management of transitions of care, is achieving/has achieved/or excels in to include one or more of the following:

  • Success of applicant in building team relationships
  • Examples of recognition of system errors and identification of need for system improvements
  • Identification of forces that impact the cost of health care and mitigation strategies
  • Examples of efficient transitioning of patients across health care delivery systems

Practice-Based Learning and Improvement: Willingness to accept and act upon feedback from physicians and other team members, such as:

  • Analysis of individual performance data and demonstration of self-improvements
  • Demonstration that applicant is learning/is independent in/has mastery in the skill of assessing data at point of care, including examples

Professionalism: Peer and staff interactions, completion of required tasks within expected time-frame, including:

  • Usually/always completes chart documentation in timely manner
  • Shows up for meetings and conferences on time
  • Promptly responds to calls from teammates and patients

III. Describe scholarly contributions during and prior to residency training, highlighting

  • Involvement of resident in formulation of questions regarding quality improvement, patient safety, education or clinical research
  • Types of scholarly activities (such as oral abstract presentations, peer-reviewed publications)

IV. Details that provide deeper insight and clarity about personal characteristics of the resident, such as level of engagement in assigned activities and degree of initiative, should be included

V. If applicable describe skills the resident has sought to master that are beyond the residency requirements, such as exemplary teaching

VI. If applicable, describe any performance-related extensions in training, curtailment of clinical privileges, or formal probation

VII. Provide an overall assessment of the resident’s suitability as a candidate for fellowship training in the subspecialty of choice

Standardized LOR Workgroup

  • Nancy Day Adams, MD
  • Richard L. Alweis, MD
  • Karen M. Chacko, MD
  • Frances A. Collichio, MD
  • Bhavin Dalal, MD
  • Solomon Liao, MD
  • Caroline Milne, MD
  • Elaine Muchmore, MD
  • Teresa K. Roth
  • Melanie Sulistio, MD
  • Gopal Yadavalli, MD