The Challenges of External Letters for Promotion: Academic Family Medicine’s Attempts to Address the Issue

The Challenge of Finding Enough People Willing to Write External Letters

The idea of creating a sort of “letter writers’ bureau” has been raised several times over recent years to STFM. A similar structure exists in emergency medicine.¹ In the spring of 2022, STFM agreed to pilot a voluntary letter writers’ bureau, modeled after the emergency medicine example, through the STFM Faculty Development Collaborative. To date, 69 individuals have volunteered to write letters through the letter writer’s bureau. STFM is currently surveying pilot members about their participation.

The Challenge of Fairly Sharing the Burden

At the 2020 ADFM conference, a small group gathered to discuss the challenge of recruiting letters of support for academic promotion—specifically how it often falls on chairs to find multiple arms’-length letter writers. In response, ADFM queried our membership about the extent of this challenge for them. On the 2020 Annual Survey (n = 94, 57% response rate), 77 departments (82%) said their institutional promotion process require external “arm’s-length” review letters. Of those 77 departments, most requests were sent by the chair (48, 62%) though about one-third were sent by someone at the school/university (22, 29%).

After this, ADFM created a virtual space and listserve for those interested in collaborating on this faculty promotions/letter writing challenge. The initial engagement was limited, however, so in summer 2021, we put out a call for anyone interested in coming together to brainstorm solutions. Ideas from this group included creating a form where departments could both sign up for letter writing requests and offer to write (a “swap” style), sharing templates, and ways to advocate internally in our institutions to change the promotion requirements. Due to logistical constraints and a lack of data on the scope of the issue, the additional ideas have not been implemented; however, the ADFM Board did advise that more data be gathered and continue to consider the challenge.

On our 2023 survey (n = 70, 43% response) we asked some follow-up questions about the number of required external letters, people contacted, and faculty up for promotion. Taken together, and extrapolating based on the response rate, there are approximately 500 faculty members up for promotion in a given year in family medicine who require external letters for promotion. It takes an average of 7 contacts to get 1 letter, and an average of 3 letters are required. This means that over 10,000 requests for external letters might be sent just in the discipline of family medicine in a given year.

Making Sure Those Who Agree to Write External Letters Deliver Appropriate Letters

Given the institution-specific criteria required in each letter for promotion, an additional challenge is that some letter writers may not write a letter with the required information, or in the correct format, which might delay the promotion process. In early 2021, STFM launched their Virtual Coaching program, and included an option for portfolio review and promotion letter writing to help address some of these challenges. STFM members who are interested in being a coach or receiving coaching can learn more at: https://connect.stfm.org/virtualcoaching4/getstarted

An Alternative for Consideration

The main intent of the external letter is to have someone who does not know the individual up for promotion assess whether they believe the person meets the criteria and whether they would be promoted to a similar rank at their own institution. The substantial amount of time required to review a long dossier and then distill it into a multi-page document that speaks to the institution’s specific promotion criteria is an excessively burdensome way to answer these questions.

What if instead of asking for this time consuming “book report”–style letter, the institution instead requested a yes/no answer to the question: “Would this person be promoted similarly at your institution?” This question could be accompanied by an optional comment box that allowed for no more than a short paragraph.

To take this idea further, what if medical schools adopted a policy whereby they only asked for the answer to this question and in kind, their faculty were only allowed to supply the answer to this one question, when asked for an arm’s-length recommendation? Would this make such a policy contagious, saving time for those doing outreach to find letter writers, those writing the letters, and the Faculty Promotions Committee who really just need a single question answered? Recognizing that the promotions policies of a university are not within control of a department of family medicine, but that this is a real issue for many of our members and ostensibly those in other disciplines as well, this potential approach to internal advocacy is an idea we share for consideration. Changing requirements for “arm’s-length” letters for promotion could ultimately save our members hundreds of hours of time each year, time they could be spending doing important work that is meaningful to students and patients.