Fellowship Letter of Recommendation (LOR) Guidelines

The AAIM Guidelines for Fellowship Applicant Letters of Recommendation have improved the educational handover from residency to fellowship. When compared to letters that did not adhere to these guidelines, fellowship program directors found conforming letters to be more helpful in many areas. These guidelines improve reliability and efficiency through standardization, while continuing to allow advocacy and discussion of applicant characteristics. Supported by APDIM Council, ASP Council, and the former  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.  Programs are encouraged to fully adopt the guidelines for internal medicine subspecialty fellowship applicants.

In addition to recommendations contained in the guidelines, letter writers for 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 former  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.

The Guidelines

  • Location of program, number of trainees, clinical setting, patient demographics, and number of hospitals used for rotations.
  • Unique features of the program (ex. specialized training offered).
  • 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.

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 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. This and other 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 assessing point of care data, to include examples.

Professionalism: Peer and staff interactions, completion of required tasks within expected timeframe, including:

  • Usually/always completes chart documentation in a timely manner.
  • Punctual for meetings and conferences.
  • Promptly responds to calls from teammates and patients.

  • Involvement of resident in formulation of questions regarding quality improvement, patient safety, education, or clinical research.
  • Types of scholarly activities (ex. oral abstract presentations, peer-reviewed publications, etc.).
  • If the resident participated in health equity-related activities, volunteered time towards the betterment of their community, or has offered expertise/assistance in outreach programs at any level, these should be articulated.  
  • Efforts to improve diversity and inclusion within their respective program should also be communicated.  
  • In addition, if the resident illustrated leadership skills in any local/national committees or volunteer groups, these should be shared
This includes curtailment of clinical privileges or formal probation, if applicable. 

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

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