Early Subspecialization Alignment: How Residents Tailor Experiences Before Fellowship

Urology residency is designed to equip trainees with the skills necessary for independent practice. Over recent decades, however, the educational landscape has evolved, with fellowship-trained urologists constituting > 45% of the workforce. We examine whether residents perform a greater number of cases aligned with their intended fellowship and whether, after matching, they tailor their chief resident year to reinforce their chosen subspecialty.

We conducted a multi-institutional, retrospective analysis of Accreditation Council of Graduate Medical Education case logs from residents of 14 programs from 2010 to 2022. Cases were categorized into 5 domains: Endourology, Reconstruction, Oncology, Pediatrics, and General. Residents who pursued fellowship training were identified, and case volumes were compared between those who matched into a given subspecialty and those who entered directly into practice/other fellowships.

Of 340 residents, 199 (58.5%) pursued fellowship. Residents entering fellowship logged significantly more cases in their aligned domains: Oncology (median 274 vs 259, P = .034), Pediatrics (259 vs 186, P < .001), and Endourology (260 vs 229, P = .027). No significant difference was observed in Reconstructive Surgery (160.5 vs 154.5, P = .489). During the chief year, residents continued to align case selection with fellowship: Oncology (173 vs 136.5, P < .001), Pediatrics (13 vs 4, P = .025), and Endourology (48 vs 32, P = .003). Reconstructive case volume did not follow this trend (47.5 vs 43, P = .383).

These findings suggest that for most specialties, subspecialization seems to begin during residency, with residents aligning their operative experience with future fellowship plans. Chief year case selection seems to reflect strategic preparation for fellowship.