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With the rapidly changing landscape of medicine, physician assistants (PAs) have solidified their role as integral members of nearly every medical field. As PAs become leaders in smaller, more specialized fields, their duties encompass skills that they had not been exposed to in the broad, comprehensive, standard PA education. Consequently, participation in postgraduate PA education has rapidly expanded to keep up with the demand for additional training. Postgraduate PA education, frequently called “residencies” or “fellowships,” offers additional specialized, hands-on, supervised clinical training along with continued didactic teaching on advanced topics. These programs offer distinct training advantages over on-the-job training. This article discusses the process of developing the Texas Children's Hospital Surgery Physician Assistant Fellowship Program and provides a framework for the development of similar programs around the country. Topics include the rationale for conception, curriculum development, applicant recruitment, and challenges along the way.