The end of residency marks the first off-ramp for a clinical urologist, who has been on a medical education and training pathway for, typically, a decade or more. The decision to pursue a fellowship should therefore not be taken lightly. There are enormous financial, personal, and practice-pattern consequences in pursuing fellowship training and it is, unlike residency, not a necessary step to practice most aspects of urology. The year(s) of fellowship training, however, can be extremely engaging and fruitful, and may even provide supplemental skills and opportunities that extend one’s career duration and satisfaction well beyond the length of a fellowship.

When I speak with residents considering fellowship training, particularly in my field of urologic oncology, I always recommend starting from a big-picture perspective: why are you pursuing a fellowship? There are many reasonable and equally valid reasons to do so—developing new clinical or research skillsets, attaining more repetitions in certain procedures, building a basis for future specialized referrals or job opportunities. I always knew that I wanted an academic career with a prostate cancer academic focus. While it may not have been impossible to attain this with only residency training, a fellowship expanded the skills that I had to be successful in this type of role, as well as career opportunities.

When choosing a program, it is important to look at alumni of fellowship programs to see what you might reasonably expect when you are done—do people take academic jobs or private jobs? Do they end up in locations that are desirable? Are they seeing the types of patients that you want to see? When I was choosing among Society of Urologic Oncology fellowships, I scoured academic faculty sites in geographic locations of interest to me. I found that many of the people who had careers I wanted to emulate had trained at the National Cancer Institute and I focused my efforts on training there myself. While many programs were supportive of my career goals—and may have indeed been phenomenal places to train—there is always a calculated risk (admittedly with potential huge upside) in being a trailblazer at a program that has a traditionally different focus. It is worth using the alumni network as a surrogate measure for the type of infrastructure, training, and mentorship you might receive at a program to set you up for the next step in a career.

Fellowships tend to have strengths and weaknesses. It is important to find a program with strengths that align with one’s reasons for pursuing fellowship. For example, in urologic oncology there are only a handful of programs in which trainees do a large number of retroperitoneal lymph node dissections for testis cancer, a high-risk procedure with a great deal of nuance. Trainees who want to position themselves to see a high volume of these patients in practice should seek one of these programs. While some programs may be more well-balanced than others, it is important to prioritize skills and training that align with a desired future practice.

Finding a program that will allow for the augmenting of skills is an important aspect of fellowship choice. Barring personal limitations requiring geographic or programmatic stability, this is a justification for seeking a fellowship outside of a home program. There are many different ways of approaching disease processes and cases and it is sometimes hard to understand the breadth of these approaches within 1 institution. As an example, I felt very comfortable performing transperitoneal open radical or robotic partial nephrectomies after residency, but would not have had the confidence to perform robotic retroperitoneal or open flank partial/radical nephrectomies. While residency case logs would suggest I did not need more kidney cases, I knew selecting a fellowship that would allow me to gain experience with these techniques would round out my clinical practice. There are many similar examples in urologic oncology, such as learning to perform robotic cystectomies if residency training only utilized open approach, or obtaining technical pearls to perform intracorporeal urinary diversion if never performed previously.

A similar rationale can be applied to augmenting of research skills. Trainees come from a variety of backgrounds—some may have PhDs and others may have scarcely touched a retrospective chart review. It is important to find a program that has both the infrastructure and mentorship to improve on areas of weakness that will be necessary in one’s career. I prioritized clinical trial design as a skill to improve in fellowship and knew the National Cancer Institute had support systems for trial design, regulatory approvals, and statistical analysis that would help me learn best practices as I wrote trials.

One critical element of fellowship choice—perhaps the most important—is geography. Many people stay at the institution where they train or in a nearby region. It is not unreasonable to discuss internal job opportunities after fellowship at the time of a fellowship interview. Further, it is hard to be successful in any job unless you (and partner, if applicable) are satisfied with life outside of the hospital. Access to friends, family support, and activities that round out your life can only enhance a fellowship experience. A “perfect” fellowship in a location that does not work for one’s life will only end up as a tally mark in years of training toil, rather than a transformative and enriching experience.

Ultimately, the choice of fellowship is highly personal and the considerations are varied. Working backwards from an understanding of future career and practice goals can help define priorities and provide a guiding light for finding the best program fit.