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Factors Influencing Residents’Pursuit of Urology FellowshipsDrew A. Freilich, Hiep T. Nguyen, and John L. Phillips
OBJECTIVE To assess the predictors of residents’ pursuit of fellowship training by surveying current urologyresidents and recent graduates. Postgraduate fellowship training of urologists could be animportant source of urologic physician-scientists and continued innovation in urologic care.
METHODS A Web-based survey was electronically mailed to urology residents and recent graduates ofurologic residency. Variables concerning sex, marital status, debt load, research and clinicalexposure, publications, and postgraduate careers were recorded.
RESULTS Of the 71 respondents, 46 (65%) were married and 45% had children/dependents. Of the69% who applied for fellowship, the “most important” factors influencing the pursuit offellowship were intellectual appeal (82%), mentors (79%), the desire for an additional pointof view for surgical training (58%), and the desire to pursue a career in academics (52%).Forty of those completing a fellowship (87%) versus two of those completing residency alone(13%) would pursue a career in academics. Residents with a mentor were 20 times morelikely to pursue a urology fellowship. A shorter residency (5 years), encouragement by aprogram director, and manuscript publication during residency were also independentpredictors.
CONCLUSION Mentorship, a shorter residency, and manuscript publication during residency were independentpredictors of pursuing fellowship training. Debt load, age, marital status, and a desire to pursuea career in academic medicine were not significant factors. UROLOGY 78: 986–993, 2011.
© 2011 Elsevier Inc.ttrahtftipp
Each year, a significant number of graduating urol-ogy residents pursue fellowship training. Manytraining programs are phasing from 6- to 5-year
rograms. The possible reasons include to attract morepplicants or offset the increasing duration of fellowshipsrom 1 to �2 years in duration. As part of this transition,raining programs might change various aspects of tradi-ional urology residencies (ie, a second year of generalurgery or dedicated research time) and also identifyritical education opportunities and experiences. Addi-ionally, concern has been raised within the urologyommunity as to whether current training models willeet the future clinical needs in the United States.1
Fellowship training provides the graduate urologist withan additional opportunity to subspecialize and devoteextended time to research and, thus, might promote agreater tendency to become an academician.
Although fellowship training is valued, there is a lackof a global assessment of the social, financial, clinical,and intellectual factors influencing residents’ pursuit of
From the Department of Urology, New York Medical College, Valhalla, New York; andDepartment of Urology, Children’s Hospital, Boston, Massachusetts
Reprint requests: John L. Phillips, M.D., Department of Urology, New York MedicalCollege, Mungar Pavilion, 4th Floor, Valhalla, NY 10595. E-mail: john_phillips@
nymc.eduSubmitted: May 2, 2011, accepted (with revisions): May 28, 2011
986 © 2011 Elsevier Inc.All Rights Reserved
urology fellowships to guide chairpersons and programdirectors in deciding the best methods to nurture a resi-dent’s career in a targeted fashion. Data are availablefrom other medical and surgical specialties assessing fac-tors, such as mentorship, debt load, sex, and publicationvolume, that influence residents’ career patterns,2-10 buthere is a paucity of such data in urologic studies. Withinhe urology studies, it has been reported that dedicatedesearch time, manuscript authorship, and volume weressociated with the pursuit of fellowship training.6,11 Weypothesized that other factors contribute to the decisiono pursue fellowship and that an identification of suchactors could further assist programs in optimizing theirraining culture. We surveyed current urology chief res-dents, fellows, and recent graduates to assess variousarameters as potential predictors of urology residentsursuing fellowship training.
MATERIAL AND METHODS
An institutional review board-approved, 35 question, Web-based survey (Survey Gizmo, Boulder, CO) was electronicallymailed to all urology program directors, their senior, chiefresidents, and graduates from training programs in the UnitedStates during 2007 to 2009 (Appendix 1). A secondary mailingto the urology residency program directors as listed with the
Society of University Chairpersons and Program Directors was0090-4295/11/$36.00doi:10.1016/j.urology.2011.05.068
DO(t
also used. All responses were anonymous. Statistical analyseswere performed using Stata, version 11.0 (StataCorp, CollegeStation, TX). Univariate analysis was performed using Fisher’sexact test and the chi-square test, when appropriate. Multivar-iate analysis was performed with stepwise logistic regressionanalysis. The data were considered statistically significant atP � .05.
RESULTSA total of 332 physicians were identified in the AmericanUrological Association’s member database within ourgraduation parameters. Of the 332 surveys, 71 completeresponses were received; 138 surveys were “abandoned”(respondent clicked on the link without going beyondthe introduction page) and 24 surveys were “partial”(respondent entered the survey response mode withoutcompleting the survey). The total “click through” (com-plete, partial and abandoned) response rate was unable tobe calculated owing to the inability to determine the truesample size that received the survey for participation.The mean time to complete a survey for the completeresponse group was 13 minutes (range 4-38). No dupli-cate responses were found when the 2 survey distributionmethods were compared. The univariate and multivariateanalysis results are presented in Tables 1 and 2.
emographicsf the 71 respondents, 52 (73%) were male and 19
27%) were female; 41 (58%) were 29-31 years of age in
Table 1. Univariate analysis
Variable
DemographicsSex (male)Age (�32 y)Financial debt (�$50 k)Marital status (married)Dependents (yes)Practice population (�1 million)5-y ResidencyPublished manuscript before residencyPublished manuscript during residencyAnticipated pursuing fellowship before residencyDesignated research timeEncouraged by chairpersonEncouraged by mentorRanked 1-y program higher than 2-yRanked accredited program higher than
nonaccreditedDecision factors (important/very important)
MentorIntellectual appealIncomeNeed for additional experienceDesire to pursue a career in academics
Decision factors (agree/strongly agree)Felt fellowship important to obtain desired job
Data presented as numbers, with percentages in parentheses.
he year in which they applied for fellowship or at the
UROLOGY 78 (5), 2011
beginning of their chief year (if they did not apply forfellowship). Of the 71 respondents, 48 (68%) identifiedthemselves as white, 8 (11%) as Asian, 5 (7%) as Indian,4 (6%) as black, 3 (4%) as Hispanic, 1 (1.5%) as Arabic,and 1 (1.5%) as Pacific Islander. Six had a Doctorate ofPhilosophy (8.5%); 68% of the respondents were in post-graduate year 7 or 8 from medical school. The mostrepresented American Urologic Association sectionswere North Central (21%), New York (16%), Western(14%), and Northeastern (11%). Of the 71 respondents,46 (65%) were married, 18 (25%) were single, and 32(45%) had children/dependents when they applied forfellowship (or at the beginning of their chief year if theydid not apply). Also, 37 (52%) of the 71 respondents had�$100 000 in debt (educational, mortgage, credit card).Urology training was 5 years for 41 respondents and 6years for 30 respondents. Of those who completed general
ied for Fellowship(n � 49)
Did Not Apply forFellowship(n � 22) P Value
34 (69) 18 (82) .27434 (69) 10 (46) .06525 (51) 12 (55) .5729 (59) 16 (77) .2119 (39) 13 (59) .11221 (43) 9 (41) .67232 (65) 9 (41) .054
26 10 .55345 4 .01125 10 .42627 22 .1646 16 .01345 12 .00121 3 .3730 2 .422
47 16 .01145 15 .03227 11 .12428 10 .02733 9 .004
25 14 .52
Table 2. Multivariate analysis
Variable Odds Ratio P Value
Desire to pursue career inacademics
2.46 .074
5-y Residency 5.52 .024Published manuscript during
residency5.71 .039
Encouraged by programdirector
6.47 .049
Encouraged by mentor 20.19 .01
Appl
surgery training beyond the PGY-1 year, 57% agreed/
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strongly agreed that the additional general surgery train-ing “improved your ability as an urologist.”
Research ExperienceOf the 71 respondents, 70% performed either basic sci-ence or clinical science, and 36 (51%) had publishedmanuscripts before residency. Thus, 13 (18%) had �6months of dedicated research time, 21 (30%) had 3-6months, 9 (13%) had �3 months, and 28 (39%) had nodedicated research time. Of the 71, 68 (96%) partici-pated in either basic or clinical science research duringtheir residency; 60 (85%) published an abstract or videoas either the first author or coauthor. Ultimately, 43(61%) published manuscripts as the first author and 17(24%) as a coauthor.
Attitude Toward FellowshipThirty-five (49%) anticipated or strongly anticipatedpursing a fellowship when they applied for urology resi-dency. Fourteen (20%) did not anticipate or strongly didnot anticipate pursuing fellowship. Forty-six (65%) an-ticipated or strongly anticipated pursing a fellowshipwhen they were junior urology residents, and those whodid not anticipate or strongly did not anticipate haddecreased to nine (13%). Ultimately, 49 respondents(69%) applied for fellowship training. The most impor-tant factors influencing the pursuit of fellowship (impor-tant/very important) were intellectual appeal (82%),mentors (79%), the desire for an additional point of viewfor surgical training (58%), and the desire to pursue acareer in academics (52%). In contrast, the least impor-tant factors (a little important/not at all important) werefamily/work hours (45%), perceived need to be compet-itive in the job market (42%), prestige (38%), the needfor more experience (35%), and income opportunities(34%).
Fellowship ApplicationForty-nine respondents (69%) applied for a urology fel-lowship. Forty-six (94%) received a match/appointmentto a fellowship. Respondents applied to laparoscopy/en-dourology (n � 13), pediatrics (n � 13), reconstructive/female (n � 12), oncology (n � 11), infertility/sexualmedicine (n � 4), and trauma (n � 2). Exposure to therologic subspecialties as detailed in Figure 1 was not aignificant factor. Thirty-two (45%) did or will rank anccredited fellowship program higher “based solely on itsccreditation status.” Twenty-four (34%) did or will rank-year fellowships more highly than programs 2 or 3 yearsn duration “based solely on the fact that the fellowshipas shorter in duration.” Among those not applying for
ellowship, the reasons cited were “Did not feel necessaryo perform the surgeries you wanted to” (n � 12), “Didot want to be a resident anymore (ie, tired)” (n � 11),Needed income” (n � 7), and “Family/significant otherommitments” (n � 7). The decision factors are further
etailed in Figure 2.988
ractice Patternshirty respondents (42%) currently practiced or antici-ated practicing in a city with a population �1 million,ourteen (20%) in a city with a population of 500 001-100 000, twelve (17%) in a city with a population of 20001-500 000, and twelve (17%) in a city with a popula-ion of 50 000-200 000. Forty (87%) of those completing
fellowship are or will pursue a career in academicsompared with two (13%) of those completing residencyno fellowship). Eleven respondents who were not fel-owship trained agreed/strongly agreed that “not beingellowship trained hindered finding a desired job, salary,r location,” but seventeen disagreed/strongly disagreed.n contrast, 20 of those who were fellowship trainedgreed/strongly agreed that “being fellowship trained as-isted in finding a desired job, salary, or location,” and 5isagreed/strongly disagreed.
COMMENTWe present what we believe to be the first global assess-ment of the factors influencing urology residents’ pursuitof fellowship training. Our data suggest that factors pre-viously reported in the nonurology data to affect resi-dents’ career decision making, such as age, marital status,dependents, debt load, and the desire to pursue a careerin academic medicine were not significant factors. How-ever, a shorter (5-year) residency, manuscript publication
Figure 1. Exposure to urology subspecialties.
Figure 2. Decision factors.
during residency, and encouragement by a program di-
UROLOGY 78 (5), 2011
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rector or a mentor were each independent factors posi-tively associated with urology residents pursuing fellow-ship training.
Some program directors believe that debt load is animportant factor they are unable to control in regard towhich residency applicants and graduates will pursuefellowship training and possibly a career in academicmedicine. Because the average student graduates from anAmerican medical school with $140 000 in debt and hasan average income of $43 266 as a resident, it is under-standable that financial considerations might play a moresignificant role in career and the pursuit of fellowshiptraining of some residents more than others.12 Althoughit has been reported that the debt load affects the selec-tion of specialty and career plans in other medical andsurgical fields, it did not prove to be a significant decisionfactor for urology residents.13 One possible hypothesis forhis finding is the average salary of a urologist tends to bereater than the national average for physicians, possiblyllowing for more flexibility in career planning and aiminished effect of debt on the pursuit of fellowshipraining.14
Although there are numerous hypotheses for why res-idents from shorter residencies (5-year) are more likely topursue fellowship training, our sample size was too smallto fully assess the possible causes. It could be that resi-dents from shorter-length training programs felt thegreater availability of time to pursue fellowship training;however, the lack of significance of age argues againstthis hypothesis. We found no significant difference in thenumber of respondents from 5-year versus 6-year trainingprograms reporting the perceived need for extra surgicalexperience despite their shorter training duration (P �.43). Perhaps a future assessment of this factor would beaugmented by reassessing this factor in conjunction withthe residents’ case volume.
Although residents who published a manuscript duringresidency (first author or coauthor) were almost sixfoldmore likely to pursue fellowship training, we did not finda significant difference in manuscript publication rates asa function of the length of dedicated research time. Wehypothesize that residents with an interest in pursuingfellowship and/or a career in academics might be morelikely to conduct research and publish beyond their ded-icated research time. Our data differs from the assessmentof Hellenthal et al11 of the correlation between dedicatedesearch time and publication volume among urologyesidents. They reported that the number of publicationser resident was not different between residents with 3onths of research and those with 6 months, but resi-
ents with �6 months were significantly more produc-ive.
Mentorship was the most important factor we identi-ed in residents pursing fellowship. Residents who werencouraged by a mentor to pursue fellowship trainingere 20-fold more likely to do so compared with an only
.5-fold increase when encouraged by their program di-UROLOGY 78 (5), 2011
ector. Encouragement by a chairperson was not a signif-cant influence. The importance of mentorship has alsoeen demonstrated in other medical fields.3 Mentorsave the potential to encourage residents to examine aubspecialty of urology they might not have had muchxposure to or, conversely, to cultivate their interest in aubspecialty of urology they are drawn to. In the largestublished assessment of mentorship, Cain et al15 sur-eyed �5000 obstetrics and gynecology residents andellows and reported on the perceived importance ofentorship and pursuing a career in academic medicine.imilar to our data, their data demonstrated the impor-ance of mentorship. They reported a concerning findinghat 1215 (42%) of female residents believed there was aender bias in who received helpful career advice com-ared with 570 men (35.7%) who believed there was aender bias (P � .001). When considering race, 923omen (39.6%) believed there was a racial bias in who
eceived helpful career advice compared with 815 men28.6%) who did so.15 Their findings should serve as a
reminder that given the reported importance of mentor-ship on career development, it is critical for it to beprovided in a nonbiased and even manner.
Our study was limited by the small number of responsesand uncertain sample size. However, Web-based surveyshave been validated as academic research tools and havedemonstrated good reliability.16-19 Although our surveyinstrument was informally focus group tested, it was notformally validated before being distributed. It was notpossible to calculate a response rate, because it was un-known how many recipients received the electronic mailcontaining the survey link through either distributionmethod. Additionally, in neither of our distributionmethods was it possible to use reminder letters to aug-ment the response rates. The greater response rate fromthose anticipating completing/completed a fellowshipmight have resulted in a response bias. Male urologyresidents outnumber female urology residents in theUnited States. However, owing to our limited samplesize, a sex-specific statistical analysis was not possible butremains an important variable worthy of future review.As other specialties have reported different career deci-sion factors for men compared with women, this would beimportant for future research endeavors.10,20 Cain et al15
achieved a 97% response rate by administering theirsurvey assessing the importance of mentorship during theannual subspecialty examination. Perhaps, there is a rolefor various surveys to be administered in a similarlytargeted fashion to urology residents to better enablesubset analysis on a large sample size.
CONCLUSIONSWe found that encouragement by a program director,publishing a manuscript during residency, mentorship,and a shorter (5-year) residency were all independentlysignificant factors for residents pursuing a urology fellow-
ship. Factors, such as debt load, age, practice location,989
9
marital status, and a desire to pursue a career in academicmedicine, traditionally thought to affect a resident’s de-cision-making process, were not significant. Additionalevaluation with a larger sample size would help to betterassess the potential additional important factors. Thesedata could help chairpersons and program directors moldtheir resident education program to help maximize resi-dent education and cultivate potential future surgeonscientists, especially with organized mentorship opportu-nities.
References1. Lange PH. Are we training enough surgeon scientists to secure the
future of urology? AUA. News. 2008;13:1.2. Gabram SG, Hoenig J, Schroeder JW, et al. What are the primary
concerns of recently graduated surgeons and how do they differfrom those of the residency training years? Arch Surg. 2001;136:1109-1114.
3. Yang G, Zaid U, Erickson BA, et al. Urology resident publicationoutput and its relationship to future academic achievement. J Urol.2001;185:642-646.
4. Thakur A, Fedorka P, Ko C, et al. Impact of mentor guidance insurgical career selection. J Pediatr Surg. 2001;36:1802-1804.
5. Garibaldi RA, Popkave C, Bylsma W. Career plans for trainees ininternal medicine residency programs. Acad Med. 2005;80:507-511.
6. Woodworth PA, Chang FC, Helmer SD. Debt and other influenceson career choices among surgical and primary care residents acommunity-based hospital system. Am J Surg. 2000;180:570-576.
7. Chung KC, Lau FH, Kotsis SV, et al. Factors influencing residents’decisions to pursue a career in hand surgery: a national surgery.J Hand Surg. 2004;200J:738-747.
8. Noble J, Schendel S, Daniel S, et al. Motivations and future trends:a survey of Canadian ophthalmology residents. Can J Ophthalmol.2007;42:821-825.
9. Incorvaia AN, Ringley CD, Boysen DA. Factors influencing surgi-cal career decisions. Curr Surg. 2005;62:429-435.
10. Siddighi S, Barker M, Pancholy A, et al. Attitudes and perceptionsregarding subspecialty training in female pelvic medicine recon-structive surgery. Int Urogynecol J. 2008;19:1523-1526.
11. Hellenthal NJ, Ramírez ML, Yap SA, et al. Manuscript publicationby urology residents and predictive factors. J Urol. 2009;181:281-286.
12. AMSA student debt fact sheet 2009. Available from: http://www.amsa.org/AMSA/Homepage/About/Committees/StudentLife/DebtFactSheet.aspx. Accessed 2011.
13. Kassebaum DG, Szenas PL, Schuchert MK. On rising medicalstudent debt: in for a penny, in for a pound. Acad Med. 1996;71:1124-1134.
14. Tolkoff M. Exclusive earnings survey: how are your doing? MedicalEconomics, October 20, 2006.
15. Cain JM, Schulkin J, Parisi V, et al. Effects of perceptions andmentorship on pursuing a career in academic medicine in obstetricsand gynecology. Acad Med. 2001;76:628-634.
16. Vickers AJ, Savage CJ, Shouery M, et al. Validation study of aweb-based assessment of functional recovery after radical prosta-tectomy. Health Qual Life Outcomes. 2010;8:82-88.
17. Young NL, Varni JW, Snider L, et al. The Internet is valid andreliable for child-report: an example using the Activities Scale forKids (ASK) and the Pediatric Quality of Life Inventory (PedsQL).J Clin Epidemiol. 2009;62:314-320.
18. Matteson KA, Anderson BL, Pinto SB, et al. Surveying ourselves:examining the use of a Web-based approach for a physician survey.Eval Health Prof. Epub 2010 Dec 29.
19. Kaplowitz MD, Hadlock TD, Levine R. A comparison of Web and
mail survey response rates. Public Opin Q. 2004;68:94-101.90
20. McCord JH, McDonald R, Leverson G, et al. Motivation to pursuesurgical subspecialty training: is there a gender difference? Am ColSurg. 2007;205:698-703.
APPENDIX: 1: SURVEY
ABOUT YOU
1. What is your gender?()Male()Female
2. What is/was your age when you applied for fellowship (or ifyou did not/are not applying for fellowship, your age whenyou began your last year of residency)?
3. What is your race/ethnicity?()American Indian or Alaska Native()Asian()Native Hawaiian or Pacific Islander()Black/African American()White/Caucasian()Indian()Hispanic()Other
4. What is/was your level of debt (educational, mortgage, creditcard) when you applied for fellowship (or if you did not/arenot applying for fellowship, your debt when you began yourlast year of residency)?
()�$50,000()$50,001-$100,000()$100,001-$150,000()$150,001-$200,000()�$200,000
5. What postgraduate (PGY) year are you?6. Did you participate in either basic science or clinical re-
search PRIOR to residency?()Yes()No
7. Did you publish (clinical or basic) science abstracts or videosPRIOR to residency?
()Yes, as first author()Yes, as coauthor()No
8. Did you publish (clinical or basic) science manuscriptsPRIOR to residency?
()Yes, as first author()Yes, as coauthor()No
9. Do you have a Ph.D.?()Yes()No
10. When you applied for urology residency did you anticipatepursuing a fellowship?
()Strongly anticipated()Anticipated()Neutral()Did not anticipate()Strongly did not anticipate
11. When you were a junior urology resident did you anticipatepursuing a fellowship?
()Strongly anticipated()Anticipated()Neutral()Did not anticipate()Strongly did not anticipate
ABOUT YOUR RESIDENCY PROGRAM
12. Which AUA Section does your program belong to?
UROLOGY 78 (5), 2011
1
1
13. What is/was the length of your residency training?()5 years()6 years
14. Your general surgery training beyond the PGY-1 level im-proved your ability as a urologist?
()Strongly agree()Agree()Neutral()Disagree()Strongly disagree()Not applicable—did only 1 year of general surgery
15. During residency to what extent where you exposed to theurology subspecialties?
Pediatric None Minimal Adequate Significant ExcessiveOncology None Minimal Adequate Significant ExcessiveReconstructive None Minimal Adequate Significant Ex-
cessiveFemale None Minimal Adequate Significant ExcessiveLaparoscopy None Minimal Adequate Significant Ex-
cessiveRobotics None Minimal Adequate Significant ExcessiveEndourology None Minimal Adequate Significant Ex-
cessiveTrauma None Minimal Adequate Significant Ex-
cessiveInfertility/sexual medicine None Minimal Adequate-Significant ExcessiveTransplant None Minimal Adequate Significant Ex-
cessive
16. Did you participate in either basic science or clinical re-search DURING residency?
()Yes()No
17. Did you publish (clinical or basic) science manuscriptsDURING residency?
()Yes, as first author()Yes, as coauthor()No
8. Did you publish (clinical or basic) science abstracts orvideos DURING residency?
()Yes, as first author()Yes, as coauthor()No
9. Did you have designated research time during your urologyresidency?
()Yes, �3 months()Yes, 4-6 months()Yes, �6 months()No
APPLICANT STATUS
20. Did you apply for a urology fellowship?()Yes()No
21. Did you match/receive an appointment to a fellowship?()Yes()No()Unknown—application still in progress()Not applicable—did not apply
22. What was your marital status at the time you applied forfellowship (or if you did not apply for fellowship, when youbegan your last year of residency)?
()Single()Divorced/widowed
()MarriedUROLOGY 78 (5), 2011
()Engaged/living together23. Did you have any children/dependents at the time of ap-
plying for fellowship (or if you did not apply for fellowship,when you began your last year of residency)?
()Yes()No
24. Which fellowship are you applying for/currently participat-ing in/completed?
()Pediatrics()Oncology()Reconstructive/female()Laparoscopy/endourology()Trauma()Infertility/sexual medicine()Transplant()Other()Not applicable—did not apply for fellowship
25. How were important where the following factors in yourdecision to pursue a fellowship?
(Not at all important, Minimally important, Neutral,Important, Very important)
a. Income opportunitiesb. Intellectual appealc. Prestiged. Family priorities/work hourse. Role models/mentorsf. It is required to perform what you want to dŒ
g. Did not receive enough experience as a resident to feelcomfortable
h. Desire to pursue a career in academicsi. Desire for an additional point of view for surgical trainingj. Felt needed fellowship to be competitive in job market or
practice
26. You did/will rank “accredited” fellowships more highly than“nonaccredited” fellowships based solely on its accredita-tion status?
()Strongly agree()Agree()Neutral()Disagree()Strongly disagree()Not applicable—did not apply for fellowship
27. You did/will rank 1-year fellowships more highly than 2- or3-year programs based solely on the fact that the fellowshipwas shorter in duration?
()Strongly agree()Agree()Neutral()Disagree()Strongly disagree()Not applicable—did not apply for fellowship
28. If you did not apply for fellowship. Why did you not applyfor fellowship? (check all that apply)
()Did not feel it necessary to perform the surgeries youwanted
()Needed income()Family/significant other commitments()Did not want to be a resident/fellow anymore (ie,
tired)()Other()Not applicable—applied/completing/completed a fel-
lowship29. In what size city to you anticipate practicing or currently
practice?()�5,000 people()5,001-50,000 people
()50,001-200,000 people991
o
rbcustattpfmmsmh
PUS
()200,001-500,000 people()500,001-1,000,000 people()�1 million people
30. Did you/are you pursuing a career in academics?()Yes, after completing a fellowship()Yes, after completing residency (no fellowship)()No, after completing fellowship()No, after completing residency (no fellowship)()Not applicable—still in training
DECISION-MAKING FACTORS
31. Your chairperson encouraged your pursuit of a fellow-ship?
32. Your program director encouraged your pursuit of a fellow-ship?
Your mentor encouraged your pursuit of a fellowship?a. I felt forced to pursue a fellowshipb. I was strongly encouraged to pursue a fellowshipc. I was encouraged to pursue a fellowshipd. I was supported to pursue a fellowship after requesting assis-
tancee. I was advised not to pursue a fellowshipf. I was strongly advised not to pursue a fellowshipg. I felt forced not to pursue a fellowshiph. Not applicable—never discussed/desired to pursue fellow-
shipi. Not applicable—my program director is/was my chairman
(question 32)j. Not applicable—I did not have a mentor (question 33)
FOR GRADUATES WITHOUT FELLOWSHIP TRAINING34. Not being fellowship trained hindered finding a desired
job, salary, or location?()Strongly agree()Agree()Neutral()Disagree()Strongly disagree()Unknown—currently seeking employment()Not applicable—still pursing/completing/completed
fellowship
FOR GRADUATES OF FELLOWSHIPS
35. Being fellowship trained assisted your finding a desiredjob, salary, or location?
()Strongly agree()Agree()Neutral()Disagree()Strongly disagree()Not applicable—did not pursue a fellowship()Unknown—still in training
EDITORIAL COMMENTThis report describes a survey attempting to learn those factorsthat influence urology residents to pursue fellowship training.The independent factors favoring fellowship application were a5- rather than 6-year residency, manuscript publication duringresidency, and encouragement by a mentor. The factors notsignificant were marital status, dependents, debt load, and thedesire for an academic career. With only 20% compliance,
these results are hypothesis generating rather than definitive.992
However, this effort touches on many issues related to urologictraining and raises more questions than it answers.
The percentage of residents seeking fellowships is increasing,and the reasons for this are in a state of flux. Large grouppractices are increasingly popular, and they favor fellowship-trained applicants. Urology is now more complex and “doingeverything” progressively more difficult. Many urologists domostly “office urology”; thus, there is a disconnect betweenwhat residents are trained to do and what they actually do inpractice. Subspecialization is becoming more formalized. Pedi-atric urology and, most recently, female pelvic medicine andreconstructive surgery are now accredited and certified. Uro-logic oncology could soon follow. Despite many disadvantagesto this trend (eg, “balkanization” of the specialty, manpowerdistribution issues), the popularity of fellowship training willincrease. Thus, a major question now is how to integrate fel-lowships and basic urology training and to what purpose.
This is too complex an issue to discuss comprehensively hereso I will make just a few remarks. As the demand for fellowshipsincrease and the disconnect between residency training andpractice continues, it seems important that we consider trun-cating general resident training and alter the increasingly ob-solete goal that the usual residency program should reliablyproduce urologists who operationally will “do it all.” Residencytraining could become more “individualized.” Thus, someoneinterested in urologic oncology would have a different residentexposure than someone headed for general practice or “officeurology.” Other specialties, such as general surgery, are far alongin debating these considerations.1 Of course, there are manybstacles to this concept.I believe a central reason for fellowship training should
emain the production of academicians. This would not have toe a goal of all fellowships but should be of those in academicenters. The education of those who will innovate and moverology forward is essential to the survival of our specialty. Asuch, an early �2-year research experience should be a part ofhese fellowships, because 1 year is not sufficient to reliablyccomplish enough and not usually fundable through federalraining grants.2 Of course, in practice only a few of theserainees will solidly land in academic positions, and one mightosit that research training for all is wasteful. I disagree. Evenor those ending up as pure practitioners, this research trainingakes for better and more discerning physicians, generatesore appreciation and support for the aspirating physician
cientist, and provides a necessary manpower component to theedical research enterprise. I believe the medical subspecialtiesave found this to be true.
aul H. Lange, M.D., F.A.C.S., Department of Urologyniversity of Washington School of Medicine,eattle, Washington
References
1. Pellegrini, Warshaw CA, Debas HT. Residency training in surgery inthe 21st century: a new paradigm. Surgery. 2004;136:953-965.
2. Lange PH. Genitourinary oncology and its surgeon scientists: trium-phant past, but does it have a future? Urol Oncol. 2007;25:2-10.
doi:10.1016/j.urology.2011.07.1407
UROLOGY 78: 992, 2011. Published by Elsevier Inc.UROLOGY 78 (5), 2011
