Advice for an M4: Neurology vs Radiology route for Neurointerventional career or Neurosurgery Chances

[trundlethegreat]

Hey guys, soon to be M4 here (US DO) looking for some advice. I hope everyone is staying safe and I just wanna say thanks to all of you busting your ass in the COVID fight. I posted this on the reddit-residency sub but figure this is a good place too:

For the last 3 years I've worked hard to build a resume that would make Neurosurgery a possibility. I've understood from day one though that matching isn't guaranteed, even with the best scores and research. This is evident in the most recent match, where it looks like only 3/18 DO's who ranked NSG programs matched. Obviously I don't know their resumes or whatever, but the 4-5 NSG residents I've talked to say that a back-up plan is absolutely necessary for anyone applying. Originally that plan was to scramble into a prelim surgery spot. I know it starts with how bad I want to be a neurosurgeon. I love studying the brain, but general Neurology didn't cut it. The ability to be a lot of folks' last hope, operate on and treat all aspects of the nervous system both brain and spine, as well as build relationships with sick patients, do research and teach, get into biotech and AI, and work globally are all reasons for why I want to do NSG. I'm willing to do research after graduation or prelim years, but it seems that still may not cut it.

I know connections are of the utmost importance and I was going to have to depend highly on sub-internships at away institutions because my school doesn't have a hospital system, let alone a home NSG program. I was planning on doing at least 7-8 sub-I's. Now, with all the coronavirus stuff and all my rotations being canceled, I'm having to re-evaluate my plan. Currently, I do not have any NSG letters. I've been doing research at a large academic MD institution nearby and have thought about asking for a letter there, but I'm still building that relationship and am unsure how much it'd help because they can't attest to my clinical and surgical skills.

I've been in a major funk trying to figure this out. I'm down to three potential paths and thus have two questions. I really appreciate any advice in advance, since my school is ill-equipped to provide guidance for my particular situation. This is under the assumption that I'm unable to get NSG letters before ERAS. Maybe things will change, but we gotta make decisions with limited info and I'm just trying to plan ahead in case they don't.

Path 1: Stay the course, apply with little optimism of matching with no departmental letters, and then do a prelim surgery year and just apply NSG again next year. Do whatever sub-I's I can this year and blow their socks off.

Path 2: Apply NSG with DR as a backup and go the neuro-interventional radiology route. I'd still have to do the prelim year and if I'm just absolutely hating the DR/IR route for whatever reason, try to find a NSG spot later.

Path 3: Apply NSG with Neurology as a backup and go the interventional neurology route. This appears to be an emerging field with less fellowship opportunities than the radiology route, but I'd be focused on neurological disease from day one.

Question 1: I've thought about it long and hard, and after 3 unsuccessful matches I'd probably say F it and go another route. The DR-ESIR or Neurology routes are easier to match into it seems and I'd hate to give up multiple years when I could have been doing something I'd potentially love. Can anyone speak to whether a neuro-interventional career can satisfy these goals?

Question 2: Let's say I keep the NSG dream alive but decide the international neurology/neuroradiology route checks off enough boxes. Considering I want to work on the nervous system and have relationships with my patients, does Path 2 or 3 make more sense?

For reference, I got a 26X on Step 1 (step 2 tbd), am top 10% in class with honors in all clinical rotations, doing a dual degree MBA and have 10+ abstracts, pubs, posters, etc. with a few of them in NSG. No first-author pubs in NSG but a couple are in the works.

Sorry for the long post, but any help at all would be just fantastic let me tell ya.

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[slowthai]

One very high yield thing I would recommend is reaching out to the DOs that just matched neurosurg and also going back at least 5+ years. They can really help with planning and setting you up for success.

 

[bobjonesbob]

As you outlined in your post, the main question is how bad do you want to be a neurosurgeon? You can't even really answer this until you've at least done an elective and ideally a couple sub internships. Your most viable options are probably:

1. Continue on your current path. Try to get rotations at the program you are doing research with and any other nearby programs. Secure as many letters as possible. If you can't do any subis, your app is probably tanked but who knows. This will be a weird year and it doesn't really cost you anything to apply even if you have a subpar app (other than the application fees). Given you likely won't match you have to have a solid contingency plan to continue research or move on to another field.

2. Try to land a 1-2 year research position. Once again most viable option will be with the program you are already working with. The main question is funding. They probably won't be able to pay you so you either need your own money (great if you or your family have it) or need to maintain student status to keep getting your loans. That might require doing MSCR, MPH, or MBA. Look and see if these are offered at your current research institution or other places you could move to. Your school may be able to help you with this or find other ways you can continue to get your federal loans.

3. Switch to rads or neurology. Rads is probably a more natural fit for people interested in neurosurgery. Many people who leave surgical subspecialties wind up in radiology. Most radiology programs are also fine with this and won't be turned off by your prior interest in neurosurgery. As far as transitioning from these into neuro IR, my impression is that it is not super competitive. It's not that it's easy - you are still going to have to work really hard, do research, network etc. - there just isn't the same kind of bottle neck as you will face applying neurosurgery as a DO. With your app, you should be able to get into a strong academic program for either radiology or neurology. At that point, there just aren't that many people interested in doing neuro IR. The lifestyle is awful compared to the average radiologist or neurologist, so if you're dedicated to it you should be able to get a fellowship spot.

Ultimately is a personal decision based on how bad you want neurosurgery and what your risk tolerance is. There are a ton of unknowns and the scheduling issues with coronavirus make it even worse. Trying to find a mentor would be a good idea if you can.

Also check out neurosurgery hub if you haven't yet. It looks like some people are putting together meetings and providing info on how to plan for this years app given the extenuating circumstances:
Nsg applicant town hall

 

[longhaul3]

Hey guys, soon to be M4 here (US DO) looking for some advice. I hope everyone is staying safe and I just wanna say thanks to all of you busting your ass in the COVID fight. I posted this on the reddit-residency sub but figure this is a good place too:

For the last 3 years I've worked hard to build a resume that would make Neurosurgery a possibility. I've understood from day one though that matching isn't guaranteed, even with the best scores and research. This is evident in the most recent match, where it looks like only 3/18 DO's who ranked NSG programs matched. Obviously I don't know their resumes or whatever, but the 4-5 NSG residents I've talked to say that a back-up plan is absolutely necessary for anyone applying. Originally that plan was to scramble into a prelim surgery spot. I know it starts with how bad I want to be a neurosurgeon. I love studying the brain, but general Neurology didn't cut it. The ability to be a lot of folks' last hope, operate on and treat all aspects of the nervous system both brain and spine, as well as build relationships with sick patients, do research and teach, get into biotech and AI, and work globally are all reasons for why I want to do NSG. I'm willing to do research after graduation or prelim years, but it seems that still may not cut it.

I know connections are of the utmost importance and I was going to have to depend highly on sub-internships at away institutions because my school doesn't have a hospital system, let alone a home NSG program. I was planning on doing at least 7-8 sub-I's. Now, with all the coronavirus stuff and all my rotations being canceled, I'm having to re-evaluate my plan. Currently, I do not have any NSG letters. I've been doing research at a large academic MD institution nearby and have thought about asking for a letter there, but I'm still building that relationship and am unsure how much it'd help because they can't attest to my clinical and surgical skills.

I've been in a major funk trying to figure this out. I'm down to three potential paths and thus have two questions. I really appreciate any advice in advance, since my school is ill-equipped to provide guidance for my particular situation. This is under the assumption that I'm unable to get NSG letters before ERAS. Maybe things will change, but we gotta make decisions with limited info and I'm just trying to plan ahead in case they don't.

Path 1: Stay the course, apply with little optimism of matching with no departmental letters, and then do a prelim surgery year and just apply NSG again next year. Do whatever sub-I's I can this year and blow their socks off.

Path 2: Apply NSG with DR as a backup and go the neuro-interventional radiology route. I'd still have to do the prelim year and if I'm just absolutely hating the DR/IR route for whatever reason, try to find a NSG spot later.

Path 3: Apply NSG with Neurology as a backup and go the interventional neurology route. This appears to be an emerging field with less fellowship opportunities than the radiology route, but I'd be focused on neurological disease from day one.

Question 1: I've thought about it long and hard, and after 3 unsuccessful matches I'd probably say F it and go another route. The DR-ESIR or Neurology routes are easier to match into it seems and I'd hate to give up multiple years when I could have been doing something I'd potentially love. Can anyone speak to whether a neuro-interventional career can satisfy these goals?

Question 2: Let's say I keep the NSG dream alive but decide the international neurology/neuroradiology route checks off enough boxes. Considering I want to work on the nervous system and have relationships with my patients, does Path 2 or 3 make more sense?

For reference, I got a 26X on Step 1 (step 2 tbd), am top 10% in class with honors in all clinical rotations, doing a dual degree MBA and have 10+ abstracts, pubs, posters, etc. with a few of them in NSG. No first-author pubs in NSG but a couple are in the works.

Sorry for the long post, but any help at all would be just fantastic let me tell ya.

Your chance of matching is indeed low right now. Honestly I think your best option, if you really want to do nsg, is to do a research year in a neurosurgery department that might conceivably take you in the match the following year. A 260 Step 1 score alone is not going to cut it, especially as a DO. Unfortunately your research output is actually below the average for matched applicants, which I think is completely absurd, but the point is it's not going to be a big wow factor either, and as a DO you need multiple wow factors. A high Step 1 score is great but only gets you so far. Connections are great and indeed crucial, but sadly when push comes to shove people may not stick their necks out for a DO student from another institution, no matter how much they like you (and tell you they like you and will go to bat for you). Taking a research year and really getting to work with multiple people in the department is your best shot IMO, and then you can do your sub-i's when/if things get back to normal next year.

I think 7-8 sub-i's is nuts—it's more time than interns spend on service in most programs, and you will be at huge risk of burning out and underperforming, which would tank your chances and make it worse than if you had never rotated there.

All that said, to tackle your questions:

1. You can definitely work with sick patients, deal with both brain and spine, and get involved in tech in INR. Be careful, though—I'm not sure how easy it would be to match in DR if you fail to match nsg 3 separate times.
2. I like backup plan 2 the best. The neurosurgeon who could be happy as a neurologist (option 3) is a rare, rare bird. In fact, I think one of the best things about neurosurgery is that there are neurologists to deal with all the non-surgical issues that fields like ENT still have to handle themselves. On the other hand, lots of neurosurgeons are into imaging and would have done DR as a backup, or even as a preferred alternative for lifestyle reasons. Planning not to match and doing a prelim year with no advanced position (option 1) is planning to fail. Your best chance of matching is your first attempt, and applying this year knowing you're not likely to match is a huge mistake. Don't compound it by expecting to do a prelim year and reapplying. If you're already resigned to doing a prelim year as a backup, apply to DR so you would have an advanced position lined up and not nuke your career prospects.

 

[trundlethegreat]

Your chance of matching is indeed low right now. Honestly I think your best option, if you really want to do nsg, is to do a research year in a neurosurgery department that might conceivably take you in the match the following year. A 260 Step 1 score alone is not going to cut it, especially as a DO. Unfortunately your research output is actually below the average for matched applicants, which I think is completely absurd, but the point is it's not going to be a big wow factor either, and as a DO you need multiple wow factors. A high Step 1 score is great but only gets you so far. Connections are great and indeed crucial, but sadly when push comes to shove people may not stick their necks out for a DO student from another institution, no matter how much they like you (and tell you they like you and will go to bat for you). Taking a research year and really getting to work with multiple people in the department is your best shot IMO, and then you can do your sub-i's when/if things get back to normal next year.

I think 7-8 sub-i's is nuts—it's more time than interns spend on service in most programs, and you will be at huge risk of burning out and underperforming, which would tank your chances and make it worse than if you had never rotated there.

All that said, to tackle your questions:

1. You can definitely work with sick patients, deal with both brain and spine, and get involved in tech in INR. Be careful, though—I'm not sure how easy it would be to match in DR if you fail to match nsg 3 separate times.
2. I like backup plan 2 the best. The neurosurgeon who could be happy as a neurologist (option 3) is a rare, rare bird. In fact, I think one of the best things about neurosurgery is that there are neurologists to deal with all the non-surgical issues that fields like ENT still have to handle themselves. On the other hand, lots of neurosurgeons are into imaging and would have done DR as a backup, or even as a preferred alternative for lifestyle reasons. Planning not to match and doing a prelim year with no advanced position (option 1) is planning to fail. Your best chance of matching is your first attempt, and applying this year knowing you're not likely to match is a huge mistake. Don't compound it by expecting to do a prelim year and reapplying. If you're already resigned to doing a prelim year as a backup, apply to DR so you would have an advanced position lined up and not nuke your career prospects.

Great points and I've basically settled on my plan 2 outlined above, but love hearing everyone's thoughts. I really appreciate the perspective and time you spent to give well-thought-out advice. And yeah I've always known that I couldn't be equal to my MD colleagues but needed to be better. So I also understand that as my application sits right now it does not send that message (although I am very proud of it and worked hard for it). The three matched DOs last year had an avg of 21 pubs/abstracts/etc.

Plan 2 or research year, if I find something in the next 3 months, is my move. I agree that a prelim year by itself doesn't seem to really add a whole lot to my application besides potentially getting an in with the onsite program (and as you say, that's not a guarantee). But who knows, maybe in my sleep one of these days I devise a new standard of care for GBM and ride that into the sunset.

Anyway, I really appreciate it. Stay safe and stay frosty out there.

I

As you outlined in your post, the main question is how bad do you want to be a neurosurgeon? You can't even really answer this until you've at least done an elective and ideally a couple sub internships. Your most viable options are probably:

1. Continue on your current path. Try to get rotations at the program you are doing research with and any other nearby programs. Secure as many letters as possible. If you can't do any subis, your app is probably tanked but who knows. This will be a weird year and it doesn't really cost you anything to apply even if you have a subpar app (other than the application fees). Given you likely won't match you have to have a solid contingency plan to continue research or move on to another field.

2. Try to land a 1-2 year research position. Once again most viable option will be with the program you are already working with. The main question is funding. They probably won't be able to pay you so you either need your own money (great if you or your family have it) or need to maintain student status to keep getting your loans. That might require doing MSCR, MPH, or MBA. Look and see if these are offered at your current research institution or other places you could move to. Your school may be able to help you with this or find other ways you can continue to get your federal loans.

3. Switch to rads or neurology. Rads is probably a more natural fit for people interested in neurosurgery. Many people who leave surgical subspecialties wind up in radiology. Most radiology programs are also fine with this and won't be turned off by your prior interest in neurosurgery. As far as transitioning from these into neuro IR, my impression is that it is not super competitive. It's not that it's easy - you are still going to have to work really hard, do research, network etc. - there just isn't the same kind of bottle neck as you will face applying neurosurgery as a DO. With your app, you should be able to get into a strong academic program for either radiology or neurology. At that point, there just aren't that many people interested in doing neuro IR. The lifestyle is awful compared to the average radiologist or neurologist, so if you're dedicated to it you should be able to get a fellowship spot.

Ultimately is a personal decision based on how bad you want neurosurgery and what your risk tolerance is. There are a ton of unknowns and the scheduling issues with coronavirus make it even worse. Trying to find a mentor would be a good idea if you can.

Also check out neurosurgery hub if you haven't yet. It looks like some people are putting together meetings and providing info on how to plan for this years app given the extenuating circumstances:
Nsg applicant town hall

Thanks for the clear message and it certainly validates my concerns as well as the potential solutions I've been thinking through. I'll definitely be looking into that NSG town hall resource!

 

[longhaul3]

Great points and I've basically settled on my plan 2 outlined above, but love hearing everyone's thoughts. I really appreciate the perspective and time you spent to give well-thought-out advice. And yeah I've always known that I couldn't be equal to my MD colleagues but needed to be better. So I also understand that as my application sits right now it does not send that message (although I am very proud of it and worked hard for it). The three matched DOs last year had an avg of 21 pubs/abstracts/etc.

Plan 2 or research year, if I find something in the next 3 months, is my move. I agree that a prelim year by itself doesn't seem to really add a whole lot to my application besides potentially getting an in with the onsite program (and as you say, that's not a guarantee). But who knows, maybe in my sleep one of these days I devise a new standard of care for GBM and ride that into the sunset.

Anyway, I really appreciate it. Stay safe and stay frosty out there.

I


Thanks for the clear message and it certainly validates my concerns as well as the potential solutions I've been thinking through. I'll definitely be looking into that NSG town hall resource!

Here's an important update about the application cycle:

Recruitment Guidelines & Letters of Recommendation - societyns.org

www.societyns.org

Things are obviously still up in the air, but it's going to be hard for DOs this year. If the department you're doing research with is the closest institution to your school, you may be in luck in that you could rotate there and have a chance to stand out more because there won't be any other visiting sub-is.

This situation has quickly turned political, with some departments coming out and saying they weren't consulted or didn't agree to this policy, they are not bound by SNS policy, etc. I'm getting my popcorn ready from a safe distance but sadly this is all playing out at the expense of the rising 4th year class. Make sure you stay tuned and do your own due diligence, because you can't count on others (especially with no home department) to know what's going on this year.

 

[The wise one]

It's over. If you don't have a home NSG, you are not matching this year. If I remember it correctly, one of the presenters said:" letters from outside institutions would be looked upon unfavorably".

Here's an important update about the application cycle:

Recruitment Guidelines & Letters of Recommendation - societyns.org

www.societyns.org

Things are obviously still up in the air, but it's going to be hard for DOs this year. If the department you're doing research with is the closest institution to your school, you may be in luck in that you could rotate there and have a chance to stand out more because there won't be any other visiting sub-is.

This situation has quickly turned political, with some departments coming out and saying they weren't consulted or didn't agree to this policy, they are not bound by SNS policy, etc. I'm getting my popcorn ready from a safe distance but sadly this is all playing out at the expense of the rising 4th year class. Make sure you stay tuned and do your own due diligence, because you can't count on others (especially with no home department) to know what's going on this year.

 

[bobjonesbob]

It's over. If you don't have a home NSG, you are not matching this year. If I remember it correctly, one of the presenters said:" letters from outside institutions would be looked upon unfavorably".

If you're going to post, at least attempt to say something useful. They made a clear suggestion for what people without home programs should do.

"For students without a home program, they should have 8 weeks (2 rotations) of neurological surgery experience at the closest ACGME accredited program, in order to minimize travel and keep within regional disease demographics."

 

[The wise one]

How though? From the article you posted:

If you're going to post, at least attempt to say something useful. They made a clear suggestion for what people without home programs should do.

"For students without a home program, they should have 8 weeks (2 rotations) of neurological surgery experience at the closest ACGME accredited program, in order to minimize travel and keep within regional disease demographics."

 

[trundlethegreat]

How though? From the article you posted:

View attachment 304967

It seems to me like a lip-service suggestion, but has no real pragmatic value when it comes to mandating nearby ACGME programs whether they would take a student or not. Often its up to the hospital system itself anyway, so who knows. I've already reached out to the powers that be to see if they could coordinate with nearby schools, but I'm not optimistic.

I'll be honest, this **** just sucks lol.