Pursuing fellowship training: There are no traffic jams along the extra mile

Fellowship training typically consists of 1–3 years of additional specialized training once an individual has completed general urological residency training. These positions provide experience across a cadre of urology sub-specialties, including pediatrics, oncology, reconstruction, etc. The decision to pursue fellowship training is often multifactorial and may include gaining more experience in a particular area of urology that was not emphasized during residency, subspecialized training prior to starting an academic junior faculty position, and having the opportunity to train and learn under world leaders. Unlike the competitive urological residency-matching process, the decision to pursue fellowship training may be more difficult, even though the ability to secure a position is generally easier. Urology training in Canada has witnessed many changes over the past two decades, primarily increasing from 15 residency training positions in 2002 to 31 in 2011.¹ This has increased further to 35 positions for the 2017 Canadian Resident-Matching Service (CaRMS).² Given the enticing option of starting clinical practice after residency training vs. pursuing fellowship training, in the words of Dallas Cowboys Hall of Fame quarterback Roger Staubach, “There are no traffic jams along the extra mile.”

What effect has increasing urology positions had on future employment and the perceived need to pursue additional training? Welk et al examined the postgraduate training patterns and employment choices among Canadian urology residents from 1998–2009.¹ During this time, 258 urology residents graduated, of which 72% completed a fellowship. The most common type of fellowship training was minimally invasive surgery (MIS)/endourology (39%). The number of residents pursuing fellowship training increased over time, as did the number of individuals pursuing a graduate degree during residency/fellowship. Importantly, >98% of residents graduating during this time garnered employment, including 34% working in the academic setting and 16% practicing in the U.S (41% at academic institutions). A followup survey assessing graduating residents’ attitudes for pursuing fellowship training (84 respondents) demonstrated that residents wanted to: 1) pursue a career in academic urology (61.1%); 2) acquire marketable skills to obtain a urology staff position (64.4%); and 3) focus their practice to a specific subspecialty area (84.9%).³ A similar survey (n=71) among graduating U.S. urology residents reported comparable outcomes, in addition to residents citing intellectual appeal (82%), additional mentorship (79%), and desire for an additional point of view for surgical training (58%).⁴

Reviewing this literature, and as a current fellow, I found that my motives and goals for pursuing urological oncology fellowship training were quite comparable to my colleagues. My first inclination for pursuing a fellowship was the desire to eventually be in academic practice. Certainly, fellowship training with dedicated research time allows one the ability to pursue personal research interests and set the stage for eventual junior faculty research endeavors and securing grant funding. As has become more common during fellowship,¹ the opportunity to pursue a graduate degree (MSc) in clinical epidemiology was paramount, providing the groundwork for designing future studies, involvement in clinical trials, and acquiring a strong statistical background. Finally, the opportunity to refine my surgical skills and operate alongside leaders in the field was a significant consideration. We all learn how to perform a radical cystectomy in residency training, but seeing 3–4 different techniques and approaches in fellowship and learning additional tips and tricks will be invaluable.

Once a midlevel/senior resident decides to pursue fellowship training, there are a number of items to keep in mind. First, it is important to meet with program directors and their faculty as soon as possible. The best way to do this is to attend the subspecialty and Canadian Urological Association (CUA) and American Urological Association (AUA) annual meetings. Forming early professional relationships with these future mentors allows them to get to know you and for you to assess fellowship programs of interest. Particularly, if you are presenting research at a meeting, having fellowship program directors aware of your work is an added bonus. Second, preparing for the formal interview (and fellowship match, if applicable), it is important for residency mentors to write strong letters of recommendation highlighting your character, work ethic, research productivity, and surgical acumen. Finally, once the fellowship position is secured, identifying a research mentor at your fellowship program, and developing and refining your research project(s) early will allow you to maximize research time when fellowship commences.

There has been an increasing interest in pursuing fellowship training among urology residents for a variety of reasons. Although not crucial for obtaining employment, the decision is important and may be difficult. Nonetheless, once the decision is made, fellowship provides an excellent opportunity to subspecialize, continue to learn, collaborate, begin self-directed research projects, and take the step to a junior academic faculty position.