a question about LORs for fellowship application

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As far as I learned, there are some internal medicine residents who are not able to go into fellowship right after residency, either because they haven't decided on subspecialty in the second year, or was not fully prepared for the application, or need to solve some visa issue, or some other reason.
So my question is: if you get a letter of recommendation for cardiology in PGY 2 for example, but apply for cardiology fellowship after working as a hospitalist for 1 or 2 years, is this letter still useful for application? Is it considered outdated? If that is true, then how do you manage to get letters if you apply later?
Thanks in advance!

Yes, it will be "outdated". At a minimum, you'd ask the letter writer to update the letter at the end of your PGY-3. Or, you'd ask them to update it again when you actually apply -- obviously at this point they would simply change the wording to say "donaldtang graduated in 2012, and here's what I can say about his performance...".

In general, if applying for a fellowship after working, you'd want one letter from your PD, one letter from whomever your research mentor was, one letter from your job (presumably your boss), and then you'll have one more letter.

If you're planning on applying for a Cards fellowship after working, you would be really much better off working in some sort of "cardiology" position -- like a cards hospitalist, etc. That way, your letters from your gap year are cards focused also (and also helps generate more cards research opportunities)