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In the Zone

August 09, 2020
by Mark David Siegel

Hi everyone,

As darkness fell on Wednesday evening, I entered the zone. With the electricity out at home (courtesy, Isaias), my pupils dilated (courtesy, my ophthalmologist), and 42 letters of recommendation to write for fellowship, I resolved to finish before going to sleep. It was just me, the computer, and an incandescent lamp. Nothing else existed until 2AM, when I posted the last letter and headed out into the night.

If you’re going to push into the wee hours, it should be for a good cause, which it was. Thankfully, it’s easy to write glowing letters for talented residents. It was more or less an accolade festival, with no need to exaggerate. You’re an uncommonly talented group.

With the letters out, I thought you’d want to see what they look like. Look over my template below, with comments in italics. The goal is to help fellowship directors answer the most important questions: what kind of clinician, teacher, and investigator are you? How likely are you to succeed in academic medicine? How will you contribute to their field? What kind of citizen will you be?

Whether you’re about to start interviewing or just starting to contemplate your future, it’s worth a look.

Good luck to the candidates!


August 9, 2020

Dear Fellowship Director:

I’m pleased to offer this recommendation for Dr. NAME, who is applying to your SPECIALTY fellowship. NAME is currently a PGY2/PGY3/Chief Resident/recent graduate in/from the Yale Traditional Internal Medicine Residency and as her Program Director, I am well-positioned to assess her qualifications. NAME has waived her right to review this letter, which is written according to AAIM guidelines.[1]

Program Description

The Yale Traditional Internal Medicine Residency Program, located in New Haven, CT, trains 141 residents annually. Our trainees include many of the country’s most accomplished young physicians. Residents rotate at Yale-New Haven Hospital and the West Haven Campus of the VA Connecticut Healthcare System, both major referral centers listed among the top hospitals in the US. Trainees spend one-third of their time in ambulatory settings. Inpatient rotations include general internal medicine and specialty experiences in hematology, oncology, geriatrics, nephrology, cardiology, infectious diseases, and liver diseases. Residents spend approximately six months in ICUs and six months pursuing electives. Special program features include a three-month Research-in-Residency elective, a six-week International Health elective, and opportunities to earn Distinctions in Education, Global Health & Equity, Investigation, and Quality Improvement & Physician Leadership. Most trainees participate in residency governance, program evaluation, recruitment, and/or one or more special interest groups and committees. We aim to provide residents with the skills and opportunities needed to become leaders in academic medicine. Approximately 80% of our residents pursue fellowship training upon graduation, and most of the others secure academic positions in outpatient or inpatient general internal medicine.

Clinical Competency

  • Patient Care: NAME has mastered (I would not recommend you for fellowship if untrue) the clinical skills expected of a resident at her level of training. These faculty and peer comments are representative: I copy and paste quotes from MedHub evaluations, which characterize your clinical performance. I do not include suggestions for improvement, which are solely meant for feedback.
  • Medical Knowledge: NAME has achieved competence/excels in medical knowledge in all content areas. I usually choose “excels” because most of you study hard and read widely, which shows at report, on rounds, on ITEs, etc.
  • Interpersonal and Communication Skills:
    • Communication: NAME is proficient/excels in communication with team members, patients, and family members. Here, I copy and paste quotes reflecting how you communicate, particularly with nurses and patients. The best quotes reflect the ability to listen, collaborate, use jargon-free speech, and show compassion.
    • Written Documentation: NAME has achieved independence in/mastered the ability to communicate clearly in progress notes, histories, and discharge summaries. Most of you have mastered this skill by the time you apply for fellowship. I would not recommend you for fellowship if you haven’t achieved at least achieved independence in your documentation, though most of you have mastered this skill- writing notes that are succinct, accurate, meaningful, and free of inaccuracies and outdated information (i.e., no detritus from copying and pasting).
    • Teaching Activities: NAME: Here, I add quotes attesting to teaching and leadership skills. Most come from interns, speaking to your devotion to teaching and coaching, ability to lead effective rounds, and to role model professional behavior.
  • Systems-Based Practice: NAME has achieved competence/excels in team leadership skills, interdisciplinary team interactions, and transitions of care. Self-explanatory, with quotes if available.
  • Practice Based Learning and Improvement: As we expect of all residents, NAME has become proficient in/mastered the ability to respond to feedback and self-assess to enhance her performance. I would not recommend you if you were not at least proficient at listening to and responding to feedback. Masters of PBLI actively seek out and embrace feedback.
  • Professionalism: NAME usually/always completes chart documentation in a timely manner, arrives at meetings and conferences on time, and promptly responds to calls from teammates and patients. This year, everyone got “always!”

Scholarly Contributions: Here, I highlight research projects, abstracts, presentations, and publications. For those of you focusing on education, I focus on activities such as curriculum and program development. For those of you focusing on quality improvement and patient safety, I will focus on those efforts.

Extracurricular Contributions: This is where I highlight your contributions to the program. These can include membership on committees (Executive Council, PEC, Education, Welcoming, Wellness, Diversity and Inclusion, 28-hour call, POCUS, GMEC, Resident-Fellow Senate, etc.), writing (The Beeson Beat, Capsules), leading Distinctions and interest groups (Women in Medicine, subspecialty journal clubs), sports (The Beeson Bombers), arts (Arts Night), service (Refugee Clinic), peer support (Peer Mentor, Call-a-Friend), etc.

Special Skills: Here I highlight advanced degrees, research skills, languages, and special hobbies, if present. Not everyone has “special skills,” so I delete this line if absent.

Special Recognitions: Here I highlight awards, grants, membership in honorary societies, selections for Chief Residency, and Distinctions to be awarded at graduation. Not everyone has “special recognitions,” so I delete this line if absent.

Performance-related Concerns: Thankfully, I wrote “none” for everyone this year.

Suitability as a Candidate for Fellowship Training:[2] NAME is an adjective candidate for training in SPECIALTY. See the footnote below. Reflecting the talent pool this year, as well as the impressive array of accomplishments and contributions to our program, everyone was rated as “exceptional” or “outstanding.”

In summary, NAME’s performance at Yale has been adjective (my #1 adjective is “superb”). On a personal note, she is add text (e.g., “warm,” “compassionate,” “funny,” “generous,” “creative,” “kind,” etc.). I’d be thrilled/ecstatic if she were to remain at Yale for fellowship (true for everyone this year) but have no doubt she will make adjective (“major,” “outstanding,” “important,” “lasting,” etc.) contributions to the program fortunate enough to recruit her. She has adjective (“significant,” “outstanding,” “unlimited,” etc.) potential to succeed in academic medicine and richly deserves my adjective (most commonly: “strongest and most enthusiastic”) recommendation.


Mark D. Siegel, MD

1 Alweis R, Collichio F, Milne CK, et al. Guidelines for a Standardized Fellowship Letter of Recommendation. Am J Med 2017; 130:606-611

2 Candidates are denoted as “exceptional,” “outstanding,” “excellent,” or “good,” based on their clinical performance, scholarship, and extracurricular contributions:

  • Exceptional: Superb clinical performance plus extraordinary scholarly/extracurricular contributions.
  • Outstanding: Superb clinical performance plus significant scholarly/extracurricular contributions.
  • Excellent:
    • Proficient clinical performance plus significant scholarly/extracurricular contributions or
    • Superb clinical performance without significant scholarly/extracurricular contributions.
  • Good: Proficient clinical performance without significant scholarly/extracurricular contributions.
Submitted by Mark David Siegel on August 09, 2020