Ask a neurosurgery resident anything

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First off, thank you for using the little leisure time you have to help aspiring neurosurgeons.

I have been striving towards nrsg since high school and next month, I start medical school at a mid-tier public institution in the South East. I could really benefit from knowing your thoughts on the following questions:

1. Did you, and/or do you recommend, applying to residency programs in specialties other than neuro as "fall backs", since neuro is so competitive? If so, what specialties do you think constitute good fall backs? (I thought maybe General Surgery?) If so, how should you distribute applications (example: 30 nrsg apps and 10 "fall back" apps?)?

2. Do you feel that physical fitness (being in very good shape) is very important as a neurosurgery resident? You mentioned in previous posts that you enjoyed running. I plan to be in good shape (healthy weight, balanced diet), but don't think I'll ever consider myself in "athletic" shape. Are most neuro residents fit or does this vary? During residency interviews, did you notice any kind of trend related to physical fitness?

3. As someone who wants to have children, do you notice a particular year/period of time when female residents choose to start a family? If not, in your opinion, during which year(s) do you think would be best (least difficult) to consider having a child?

4. You mentioned for external sub-internships to pick at least one place where many students rotate and one place you are actually interested in going. Can you give some examples of institutions for the former?

Thanks in advance!

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First off, thank you for using the little leisure time you have to help aspiring neurosurgeons.

I have been striving towards nrsg since high school and next month, I start medical school at a mid-tier public institution in the South East. I could really benefit from knowing your thoughts on the following questions:

1. Did you, and/or do you recommend, applying to residency programs in specialties other than neuro as "fall backs", since neuro is so competitive? If so, what specialties do you think constitute good fall backs? (I thought maybe General Surgery?) If so, how should you distribute applications (example: 30 nrsg apps and 10 "fall back" apps?)?

2. Do you feel that physical fitness (being in very good shape) is very important as a neurosurgery resident? You mentioned in previous posts that you enjoyed running. I plan to be in good shape (healthy weight, balanced diet), but don't think I'll ever consider myself in "athletic" shape. Are most neuro residents fit or does this vary? During residency interviews, did you notice any kind of trend related to physical fitness?

3. As someone who wants to have children, do you notice a particular year/period of time when female residents choose to start a family? If not, in your opinion, during which year(s) do you think would be best (least difficult) to consider having a child?

4. You mentioned for external sub-internships to pick at least one place where many students rotate and one place you are actually interested in going. Can you give some examples of institutions for the former?

Thanks in advance!


1) Talk to your advisors at your home program and see how they feel about your application. If you are strong, a backup may be unnecessary. Most everyone should have a contingency plan in mind, should they not match. Would you want to reapply? Is there another field that interests you? You mention Gen Surg, and this is a common one. Others I have heard are neurology and radiology. As for a specific ratio, I don't suspect there really is one. Most applicants, I believe, really only apply to one specialty.

2) I enjoy running both for physical fitness and just overall how it helps make me feel better. I would not say most residents are very fit, or athletic, but from what I gather, most do exercise on a somewhat routine basis. There are some programs who certainly value students who are more athletic, e.g. have competed at the NCAA or Olympic level, but that is the exception, not the rule. I would say the trend is neurosurgery residents tend to be normal with respect to fitness.

3) This can be a touchy subject. For the most part, the female residents that plan for having children during residency, do so during their elective or research time. The board is rather strict with respect to the training requirements, so time off for having a child outside of those specific periods may result in an extended training duration.

4) Popular places tend to vary from year to year, but there seem to be a number of students who rotate at Hopkins, UCSF, Mayo, Northwestern, MGH, Barrow, Pitt, and Miami.
 
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1) Talk to your advisors at your home program and see how they feel about your application. If you are strong, a backup may be unnecessary. Most everyone should have a contingency plan in mind, should they not match. Would you want to reapply? Is there another field that interests you? You mention Gen Surg, and this is a common one. Others I have heard are neurology and radiology. As for a specific ratio, I don't suspect there really is one. Most applicants, I believe, really only apply to one specialty.

2) I enjoy running both for physical fitness and just overall how it helps make me feel better. I would not say most residents are very fit, or athletic, but from what I gather, most do exercise on a somewhat routine basis. There are some programs who certainly value students who are more athletic, e.g. have competed at the NCAA or Olympic level, but that is the exception, not the rule. I would say the trend is neurosurgery residents tend to be normal with respect to fitness.

3) This can be a touchy subject. For the most part, the female residents that plan for having children during residency, do so during their elective or research time. The board is rather strict with respect to the training requirements, so time off for having a child outside of those specific periods may result in an extended training duration.

4) Popular places tend to vary from year to year, but there seem to be a number of students who rotate at Hopkins, UCSF, Mayo, Northwestern, MGH, Barrow, Pitt, and Miami.
Thank you! Very insightful =]
 
Another research question: If I know I want to do residency elsewhere (not at my home institution), would it be wiser to begin shadowing at my home institution early in M1, but conduct research during M1 summer at one of the institutions I'd actually be interested in completing residency at (so I get to know them, and they get to know me), or would it be wiser to begin shadowing at my home institution and conduct research with a physician here over M1 summer?

I know I will shadow during M1, but I don't think I will begin conducting research until M1 summer (so I am able to wait until I'm fully settled). However, I am worried if I go somewhere else over the summer to conduct basic science research (say, UCSF), then I won't be able to have continuity—I doubt two months is long enough to finish any project I'd be interested in. But if I conduct research at an institution I'd actually like to train at, I would be able to meet the people there (attendings, residents, etc) and it could help me with attaining a year-long fellowship at the institution (should I decide to do one), an away rotations, a residency interview, etc.

Would you have any advice? Thanks very much!
 
Another research question: If I know I want to do residency elsewhere (not at my home institution), would it be wiser to begin shadowing at my home institution early in M1, but conduct research during M1 summer at one of the institutions I'd actually be interested in completing residency at (so I get to know them, and they get to know me), or would it be wiser to begin shadowing at my home institution and conduct research with a physician here over M1 summer?

I know I will shadow during M1, but I don't think I will begin conducting research until M1 summer (so I am able to wait until I'm fully settled). However, I am worried if I go somewhere else over the summer to conduct basic science research (say, UCSF), then I won't be able to have continuity—I doubt two months is long enough to finish any project I'd be interested in. But if I conduct research at an institution I'd actually like to train at, I would be able to meet the people there (attendings, residents, etc) and it could help me with attaining a year-long fellowship at the institution (should I decide to do one), an away rotations, a residency interview, etc.

Would you have any advice? Thanks very much!

This is a tough question, and I will try my best to explain my rationale for my response. First, your home institution can be the best asset you have in your toolbox. You will likely have the most exposure to these individuals, and as such, the most access to them. While the summer between M1 and M2 is usually sufficient to build a project, and perhaps even something meaningful, it is a short period. Rather than seeing this time as a check box for your application, e.g. research project - check, published - check, see it as an opportunity to take on a project that will get published, and open the door so that you can continue with that group for the duration of your medical school. The latter is important because you may well not have enough time to design the project, enroll patients, and collect data during your summer (or simply collect the data for retrospective projects). That being said, spending the time at another institution may prove to be wasted time as you will have more difficulty continuing a project from afar. Not to mention, how do even know, yet, what sort of institution you would like to match to, having little to no experience in medical school, little to no clinical experience, and not having met the people in that department. Finally as you hinted, should things go splendidly, you go away for a summer, love it, get a project and publish your findings, you should plan on going back during 4th year for a subinternship. Research is entirely different than clinical practice. What you love about one place for their research infrastructure and prowess may not translate to clinical support or program culture for the residents on service. Spending an entire year doing research at an away institution would help ensure both sufficient time to finish a project, and exposure to the department. Regardless, spend time on the service as a subI.
 
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Favorite condiments on your burger? :p

Hey bro, are you an attending yet?
 
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Favorite condiments on a your burger? :p

Hey bro, are you an attending yet?

Do bacon and cheese count as condiments? Otherwise a good mustard or mayo or something.

I mentioned it elsewhere recently but I'd rather maintain somewhat of a veil of anonymity, but yes, I am somewhere in the range of attending/fellow/chief.
 
Not sure if it has been asked before, but did you have a back-up to NSG? Were you thinking of any other surgical specialties or did you always know that is what you were interested in?
 
Do bacon and cheese count as condiments? Otherwise a good mustard or mayo or something.

I mentioned it elsewhere recently but I'd rather maintain somewhat of a veil of anonymity, but yes, I am somewhere in the range of attending/fellow/chief.


Neurosurgery deals with arguably some of the sickest patients in the hospital. How do you not let the patient population get you down/depress you?
 
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Do bacon and cheese count as condiments? Otherwise a good mustard or mayo or something.

I mentioned it elsewhere recently but I'd rather maintain somewhat of a veil of anonymity, but yes, I am somewhere in the range of attending/fellow/chief.
Hell yeah they do!

Don't lie to me, you know you had to redo the residency. :p I have not been active on the forums these past few months.

Congratulations! I do remember you wanting to do an endovascular fellowship, though.
 
Not sure if it has been asked before, but did you have a back-up to NSG? Were you thinking of any other surgical specialties or did you always know that is what you were interested in?

I did not actually have a backup. I had briefly thought about CT surgery, but to get there at that point required general surgery, in which I was not terribly interested. Other fields I gave some thought to, but ultimately decided against were ENT, radiology, PMR, FM, and neurology.
 
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Neurosurgery deals with arguably some of the sickest patients in the hospital. How do you not let the patient population get you down/depress you?

This is a tough question. There are a number of coping mechanisms we all have. In acute, devastating situations, often the way we deal with our error, or failures, is to rationalize that the patient would have done poorly, anyway (e.g. ruptured aneurysm or severe traumatic brain injury that we drop a lung putting in a central line or cause a worse brain bleed trying to place an ICP monitor). This can be harder to swallow, however, if harm is done to someone younger and/or healthier (e.g. stroke after angiogram in a young healthy patient, spinal fluid leak in elective surgery).

We tend to have dark humor, or gallows humor. What we do is pretty morbid in itself. We tell ourselves we are the best at what we do, but ultimately we are human and make mistakes.

Many of our patients do have poor outcomes. Often, seeing me or my colleagues in the ER, or as a consultant on the floor, is one of the worst things in someone's life, up until that point. Telling someone they have an incurable brain cancer, or telling someone's family the injury suffered is irreparable and their loved one will be permanently paralyzed or never wake up is not something I enjoy. That being said, it is part of my job, and my job is to help both my patients get better, and failing that, help their families through their disease course. We may not be able to cure a disease or fix a problem, now, though with advances in our understanding of these pathologies, perhaps, in the future we can.
 
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I did not actually have a backup. I had briefly thought about CT surgery, but to get there at that point required general surgery, in which I was not terribly interested. Other fields I gave some thought to, but ultimately decided against were ENT, radiology, PMR, FM, and neurology.

Wow, some of the specialties you decided against are arguably almost completely opposite of neurosurgery. Very interesting. Thanks!
 
Strength training, when done with proper form, is good for strengthening muscle and bones, including the spine. The issue with things like squats and deadlifts, is people use bad form, or try to do too much weight, and end up with injuries. Therapy can help with recovery, but two things to consider: 1) as we grow older recovery takes longer and longer and is less likely to return to prior baseline 2) injured tissue is never as "good" as the pre-injured tissue.

I do have a battle battle station, both at my home office and my work office. At work I have a 8-core processor with 32 gb RAM and a Titan XP running two displays. At home I have another 8-core i7 with 64 gb RAM and 2x 980 Ti running two 4k displays and two 1080p displays. I typically run Windows 10, but have them set up to dual boot Linux and MacOS if I need those for any reason. I never really find the organizational software to actually help much, so I tend to have a routine for where I keep things and how I track changes. Moreover, a lot of the software that is purportedly supposed to organize/manage is buggy and bloated in my assessment (e.g. Endnote, Word, etc.).
You ever have time to use your home PC for gaming? I can only imagine playing overwatch on your behemoth of a home computer lol
 
Obviously there are quite a big differences in the surgeries you perform, but what would you say is the average length for a case?

What is the longest "kind" of surgery that you perform often, and what is the shortest?
 
Hell yeah they do!

Don't lie to me, you know you had to redo the residency. :p I have not been active on the forums these past few months.

Congratulations! I do remember you wanting to do an endovascular fellowship, though.

Thanks! I've been asked if I would redo residency if I had to, or if I could go back knowing now what I do would I do it again. That's a tough call. Residency is one of those necessary evils that trains us to think and act in a non intuitive way. I have doubts that an alternative method would be as effective. There is a lot of chatter from those in charge about how to make it more bearable, given the focus on burnout and suicide. I wish I had the answer. That being said, we need to be more open and honest with those applicants to the medical field in the first place that it is not a lifestyle friendly lifestyle. I find myself comparing residency to military boot camp. While entirely different, it is very emotionally and physically challenging. To my knowledge, there has not been much discussion on how to make the lifestyle of an enlisted infantryman better. They go in to it knowing what it is, and suffer through.
 
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Wow, some of the specialties you decided against are arguably almost completely opposite of neurosurgery. Very interesting. Thanks!

I think I would have been happy in those fields for different reasons. That being said I knew I made the right decision.
 
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Kind of a broad question but I wanted to see what your thoughts are: how is clinical vs bench research in med school seen by residency adcoms? If someone enjoys both, would you recommend one over the other?
 
You ever have time to use your home PC for gaming? I can only imagine playing overwatch on your behemoth of a home computer lol

I used to game a lot when I was younger. Anymore, I get bored with the games though so I haven't really played much of anything lately.
 
Obviously there are quite a big differences in the surgeries you perform, but what would you say is the average length for a case?

What is the longest "kind" of surgery that you perform often, and what is the shortest?

It is very variable. The shorter cases tend to be anywhere from half hour to an hour (shunt, burr holes or crani for hematoma, anterior cervical discectomy and fusion, lumbar discectomy). Longer cases, it really varies on the extent of dissection required, the anatomy involved, and the complexity of the case. A single level spine fusion (XLIF/ALIF/TLIF/PLIF) can be an hour or two. A thoracic or lumbar corpectomy with a long construct +/- pelvic fixation can be 6 or 8 or 10+ hours. A skull base tumor can be 12+. Aneurysm clipping again varies, a quick one may be an hour and a half whereas a slow one may be 4 to 6 or 8 or more. This is the skin to skin surgical time. Add in anesthesia time, lines/monitoring, etc. and each case can add up.
 
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I do have a battle battle station, both at my home office and my work office. At work I have a 8-core processor with 32 gb RAM and a Titan XP running two displays. At home I have another 8-core i7 with 64 gb RAM and 2x 980 Ti running two 4k displays and two 1080p displays.

I think that's more RAM than all the computers that were in my high school combined.
 
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It is very variable. The shorter cases tend to be anywhere from half hour to an hour (shunt, burr holes or crani for hematoma, anterior cervical discectomy and fusion, lumbar discectomy). Longer cases, it really varies on the extent of dissection required, the anatomy involved, and the complexity of the case. A single level spine fusion (XLIF/ALIF/TLIF/PLIF) can be an hour or two. A thoracic or lumbar corpectomy with a long construct +/- pelvic fixation can be 6 or 8 or 10+ hours. A skull base tumor can be 12+. Aneurysm clipping again varies, a quick one may be an hour and a half whereas a slow one may be 4 to 6 or 8 or more. This is the skin to skin surgical time. Add in anesthesia time, lines/monitoring, etc. and each case can add up.

Wow. For cases like this, how do you schedule your OR days, and how do you handle it if a case goes over time? Would you have an OR day where your only case for the whole day would be the lubmar corpectomy with long construct? Do you budget the time needed for a procedure in advance based on imaging and past experience?
 
This is a tough question, and I will try my best to explain my rationale for my response. First, your home institution can be the best asset you have in your toolbox. You will likely have the most exposure to these individuals, and as such, the most access to them. While the summer between M1 and M2 is usually sufficient to build a project, and perhaps even something meaningful, it is a short period. Rather than seeing this time as a check box for your application, e.g. research project - check, published - check, see it as an opportunity to take on a project that will get published, and open the door so that you can continue with that group for the duration of your medical school. The latter is important because you may well not have enough time to design the project, enroll patients, and collect data during your summer (or simply collect the data for retrospective projects). That being said, spending the time at another institution may prove to be wasted time as you will have more difficulty continuing a project from afar. Not to mention, how do even know, yet, what sort of institution you would like to match to, having little to no experience in medical school, little to no clinical experience, and not having met the people in that department. Finally as you hinted, should things go splendidly, you go away for a summer, love it, get a project and publish your findings, you should plan on going back during 4th year for a subinternship. Research is entirely different than clinical practice. What you love about one place for their research infrastructure and prowess may not translate to clinical support or program culture for the residents on service. Spending an entire year doing research at an away institution would help ensure both sufficient time to finish a project, and exposure to the department. Regardless, spend time on the service as a subI.

Thanks for the detailed response, it was very helpful.
 
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Kind of a broad question but I wanted to see what your thoughts are: how is clinical vs bench research in med school seen by residency adcoms? If someone enjoys both, would you recommend one over the other?

Residency doesn't really have adcoms in the way that medical school does. There may well be a committee, but for the most part, the department attendings meet and discuss the applicants at a final rank list meeting. For the initial evaluation, each program does it differently, however the applications are given to attendings to look over and select those who get an interview.

Bench research tends to have a higher value, overall, because of the rigor involved. So far as I can tell, however, there is not a clear-cut formula for the relative weight. Moreover, the topics for bench research tend to be so specific, and not terribly relevant to general neurosurgery, or other sub-specialties within, that it is hard to compare. Add to this the impact factor and name recognition of journals and the waters are quite muddy. Finally, clinical research is far easier to conduct, and get published, so an equal amount of time spent may result in multiple publications. Thus, a comparison of an applicant with one good basic science paper vs another applicant with multiple good/average clinical studies is difficult.

My best advice would be to do both. If you are spending time in the lab, at the bench, surely you can appreciate there is significant down time waiting for assays to run, reagents to thaw, and so forth. During this time you could be working on a clinical project, and have the best of both worlds.
 
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Wow. For cases like this, how do you schedule your OR days, and how do you handle it if a case goes over time? Would you have an OR day where your only case for the whole day would be the lubmar corpectomy with long construct? Do you budget the time needed for a procedure in advance based on imaging and past experience?

Scheduling can be tricky. We have a feel for, on average, how long a case will take. The OR also has data on this and schedules the case start times based on the individual surgeon's record, turn over, and so forth. Each attending is different, some try to put more on the schedule than they will foreseeably finish, and will work late in to the night. Others want to be home by 5 so they book cases to accomplish that. For the most part, when a big case is on the schedule, the rest of the day is compensated, e.g. putting 3 12-hour cases on is not reasonable, but a 30 minute case followed by a 12-hour case is. When a case is booked, all of the necessary components are included (navigation, intra-operative imaging, microscope, co-surgeons).
 
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I understand that in several aneurysm cases, you split the Sylvian Fissure to reach certain arteries like PICA and such. Does this splitting result in any morbidities, or are you merely "spacing" out the halves of the brain?
 
You mentioned a typical day in the life when you were a PGY-4. Could you perhaps update that in your most senior (6-7) years? Did you still have to come in as early and stay as late?

Also, how did the more junior (1-3) compare to the 4th year?

Thank you for this thread by the way.
 
It is very variable. The shorter cases tend to be anywhere from half hour to an hour (shunt, burr holes or crani for hematoma, anterior cervical discectomy and fusion, lumbar discectomy). Longer cases, it really varies on the extent of dissection required, the anatomy involved, and the complexity of the case. A single level spine fusion (XLIF/ALIF/TLIF/PLIF) can be an hour or two. A thoracic or lumbar corpectomy with a long construct +/- pelvic fixation can be 6 or 8 or 10+ hours. A skull base tumor can be 12+. Aneurysm clipping again varies, a quick one may be an hour and a half whereas a slow one may be 4 to 6 or 8 or more. This is the skin to skin surgical time. Add in anesthesia time, lines/monitoring, etc. and each case can add up.

During your medical school years, were you nervous watching surgeries? For example, I've seen some brain tumor resections, and I think they're incredibly cool–except I'm nervous, thinking "How could I do that?". How did you reconcile with that fact when applying to neurosurgery? What was, and what currently is, your mental state upon seeing, and now performing surgeries? Do you still get nervous performing a craniotomy, etc. or does that go away with time?
 
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I understand that in several aneurysm cases, you split the Sylvian Fissure to reach certain arteries like PICA and such. Does this splitting result in any morbidities, or are you merely "spacing" out the halves of the brain?

We do split the natural fissures to access vessels without any cortical transgression. The PICA is in the posterior fossa, and tends to be easily accessible, so the Sylvian would not be split. The Sylvian is more for anterior (carotid) circulation aneurysms, such as AComm, PComm, Ophthalmic, Choroidal, MCA, and carotid terminus.

The split in itself, in theory, should not result in any cortical or subcortical injury. Injury can result, however, from if the fissure is stuck and we end up going subpial, or have to take a traversing vein and it results in a venous hemorrhage, or from a retractor that is placed. Further, clipping the aneurysm itself can result in inclusion of perforating vessels and subsequent stroke. We do our best to prevent all of this, but there are risks of surgery, and these things happen regardless of how careful and skilled the surgeon is.
 
You mentioned a typical day in the life when you were a PGY-4. Could you perhaps update that in your most senior (6-7) years? Did you still have to come in as early and stay as late?

Also, how did the more junior (1-3) compare to the 4th year?

Thank you for this thread by the way.

This can vary dramatically by program. Each institution structures rotations differently, and accordingly, the day looks vastly different.

Globally, a program is based at one institution. Rotations can be divided any number of ways. The easiest is a hypothetical program with one institution and one service for everything. All residents are "on service" when they are, or off service on research or electives when they are not. To add complexity, a single institution with multiple services (e.g. spine, vascular, tumor, pediatrics). Residents may be assigned to different services, run by a senior or chief resident. Adding further complexity, add additional sites (either within one institution, or across institutions). You catch my drift, it can become very complicated very easily when different residents are at different places.

Taking that in mind, the simplest 1 service for everything model is pretty easy, everyone on service has a similar schedule. For programs with rotations or multiple services, this varies. Each year may be carved up on to different pieces e.g. 3 months spine, 3 months pediatrics, 3 months vascular, 3 months tumor. This can be based on calendar months or arbitrary blocks of a number of weeks. Each rotation has intrinsic variation as well, say you have 3 months of pediatrics over the summer, and the attendings each take 1-2 weeks of vacation over the summer. Well, your experience may be a little diluted.

With that in mind, an arbitrary schedule based on years:
PGY - 1 - interns generally spend some time on neurosurgery, and function similar to the PGY-2. See the PGY-2 post to get an idea for these rotations. Off service rotations vary, but often are neurology, neuroradiology, trauma/icu, etc.

PGY - 2 - neurosurgery junior. This is one of the hardest years. Again, every program is different with respect to the work flow responsibilities, but assume you are responsible for seeing all of the floor patients, writing all the notes, doing the pre-op paperwork, H&P/consults, discharge summaries, and in charge of the ICU. There may be help from more senior residents (PGY-3/4) and/or midlevel providers. Hours and roles again vary by institution but assume rounds start at anywhere from 5 to 7 AM (often 6 or 630 from what I hear), meaning if you have to pre-round etc you need to plan to arrive in an appropriate time frame to see the patients on the list (ranging from services with 2-5 patients up to 70). Maybe nightfloat or the on-call resident is responsible for all or some of this, so you arrive later in the morning, but it is robbing Peter to pay Paul. Someone has to do this work, and it will be you at some point. Once rounds are done either the juniors or chiefs (again, program dependent) update attendings and the plans change. Cases start anywhere from 7 to 8 AM for first start. The PGY-2 may have a room, may be assigned to double scrub, or may just be out doing floor work. Afternoon rounds vary by institution whether or not they happen, the formality, and/or timing of it. Some chiefs require the entire team to stay until the last case, others let people peel of as their work is done. For the most part, a night-float or on call resident arrives between 4:30 and 7 PM to take over the pager. Again, depending on the program, this varies. Some expect the day junior to get all work done before going home, others have a true "sign-out" where anything needing to get done after that time is handed off to the night resident. The former is more surgeon's mindset, the latter a shift-work mentality. The junior can expect to be out of the hospital at 5 on light days where everything aligns (rarely) more commonly 7 or 8, but on horrible days later than that even.

PGY - 3 to 6 - neurosurgery junior/midlevel/senior. This is widely varied based on the particular rotation and institution involved. Expect some rotation to be essential the PGY-2. Others are extra light e.g. research - show up when you want, do what you want. For surgical services though, even though they are light, they still tend to be rather demanding e.g. rounds at 6 or 7, cases/clinic, done late in the day.

PGY - 7 - The chief resident in general runs the service. Historically, many programs had the chief in a transition to practice role, and running an independent service. This no longer is the case, but as a field, neurosurgery tends to grant the chief a very large role. The specific responsibilities varies by institution, again, but generally administrative tasks such as making schedules (call coverage, rotations, and operative) as well as educational tasks such as coordinating conferences is required. The chief may be a service chief e.g. vascular/tumor/spine/etc, hospital e.g. University/Trauma/VAMC or some mix therein. Having multiple chiefs also is handled differently either by carving out chiefdoms, or sharing roles and responsibilities. The chief is responsible for the daily plan on each patient, and for every new admission and consultation. They work closely with the junior resident, acting as a buffer between the attendings and the juniors. The chief also handles resident issues e.g. personality conflicts, educational or academic issues, and carries out directives from the department and GME. The hours vary, again by service and institution, but rounds start as described anywhere from 5 to 7. The chief generally covers the cases and may have to stay late for late cases. Likewise, call varies by institution. Chief call is generally at home, and they handle the issues over the phone. Some places have the chief coming covering all cases, while others have a senior resident fill this role. Personally, I love to operate, so coming in for a case in the middle of the night was rarely an issue. That being said, after many many craniotomies for subdural hematoma evacuation or washing out infections I am a little less enthusiastic.

Hope this helps
 
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During your medical school years, were you nervous watching surgeries? For example, I've seen some brain tumor resections, and I think they're incredibly cool–except I'm nervous, thinking "How could I do that?". How did you reconcile with that fact when applying to neurosurgery? What was, and what currently is, your mental state upon seeing, and now performing surgeries? Do you still get nervous performing a craniotomy, etc. or does that go away with time?

I can't really say I was ever nervous watching surgery. I'm not sure if it is intentional, but part of the process of performing surgery, draping out the wound for creating a sterile field, dehumanizes the process. Instead of being a patient, with a family and personality, who happens to have a brain tumor, it becomes a small strip of skin and a series of steps to reach a tumor. There is a lot of arrogance in surgery, and the question "how could I do that?" is a valid one.

Sometimes, watching fantastic surgeons operating, a procedure does seem simple, and as if anyone could do it. Compare a top surgeon to a top athlete, however, as often they are more visible and somehow we relate better to them. Watching LeBron James or Kobe Bryant in the NBA make those around them look like they are standing still can be awe inspiring. They are competing against other professional athletes and absolutely dominating. Imagine playing against anyone else on that court in a game of pick-up, and you would still lose handily.

How do I reconcile my personal limitations and discrepancies? Well, I realize it is a long training process for a reason, and trust that the system in place is meant to train me to the best of my abilities. I personally put as much effort as I can in to learning, and in surgery there are many levels of learning. There is surgical anatomy, procedural steps and techniques, and technical skills. Much of what we do is fine motor control so simply practicing is necessary be it scrubbing in to cases or going to the lab and trying it there.

My mental state when I operate now is generally relaxed. I enjoy what I do and find it to be soothing. Sometimes the OR is the only place I can be where I am uninterrupted and almost impossible to yank away for something else. I can't really say I have ever been nervous. Surgical training, at least in my experience is both rigorous, so you feel comfortable and confident in what you know, and subtle. We watch cases for a period, then maybe get to make an incision, or a burr hole, or close. Soon enough we're stringing them all together and doing the case and the senior resident or attending is assisting. Eventually, they're not even scrubbed for the whole thing, etc. For me, anyhow, I always trusted that the person instructing me wouldn't let me get in to trouble or harm anyone.
 
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This can vary dramatically by program. Each institution structures rotations differently, and accordingly, the day looks vastly different...Hope this helps

This is a literally incredible response.
 
Hi Neusu! Thank you so much for doing this Q/A. Would you say that conducting neurosurgical procedures on animals as part of research (neuroscience) is beneficial/relevant at all as a skill to have when applying for residencies? Or is it not worth the time?
 
I can't really say I was ever nervous watching surgery. I'm not sure if it is intentional, but part of the process of performing surgery, draping out the wound for creating a sterile field, dehumanizes the process. Instead of being a patient, with a family and personality, who happens to have a brain tumor, it becomes a small strip of skin and a series of steps to reach a tumor. There is a lot of arrogance in surgery, and the question "how could I do that?" is a valid one.

Sometimes, watching fantastic surgeons operating, a procedure does seem simple, and as if anyone could do it. Compare a top surgeon to a top athlete, however, as often they are more visible and somehow we relate better to them. Watching LeBron James or Kobe Bryant in the NBA make those around them look like they are standing still can be awe inspiring. They are competing against other professional athletes and absolutely dominating. Imagine playing against anyone else on that court in a game of pick-up, and you would still lose handily.

How do I reconcile my personal limitations and discrepancies? Well, I realize it is a long training process for a reason, and trust that the system in place is meant to train me to the best of my abilities. I personally put as much effort as I can in to learning, and in surgery there are many levels of learning. There is surgical anatomy, procedural steps and techniques, and technical skills. Much of what we do is fine motor control so simply practicing is necessary be it scrubbing in to cases or going to the lab and trying it there.

My mental state when I operate now is generally relaxed. I enjoy what I do and find it to be soothing. Sometimes the OR is the only place I can be where I am uninterrupted and almost impossible to yank away for something else. I can't really say I have ever been nervous. Surgical training, at least in my experience is both rigorous, so you feel comfortable and confident in what you know, and subtle. We watch cases for a period, then maybe get to make an incision, or a burr hole, or close. Soon enough we're stringing them all together and doing the case and the senior resident or attending is assisting. Eventually, they're not even scrubbed for the whole thing, etc. For me, anyhow, I always trusted that the person instructing me wouldn't let me get in to trouble or harm anyone.



Thanks for the response.

Is there a threat of mid-level encroachment in neurosurgery? One of my friends is in PA school and she mentioned that an older PA she shadowed had said that he gets to do some unsupervised nsg cases after the nsg opens.. seems a bit hard to believe.
 
Hi Neusu! Thank you so much for doing this Q/A. Would you say that conducting neurosurgical procedures on animals as part of research (neuroscience) is beneficial/relevant at all as a skill to have when applying for residencies? Or is it not worth the time?

Hi there. Thank you for the reply, I glad you enjoyed this thread.

Research certainly is worth the time in preparing for applications for medical school or residency. Get published. Animal surgery really has no relevance, though, to human surgery. The protocols and procedures are vastly different, and in my experience, attempts by applicants who try to play that as a strength are dismissed outright. In any case, we as surgeons, in preparing for human surgery, do procedures on animals to practice specific techniques. If, somehow, your lab is involved in this, that may be somewhat useful.
 
Im super interested in doing near (probably more rehab type stuff than surgery)
How do you ensure that you get a neuro residency and research opportunities during Medical School. Im doing a Masters in Clinical Neuroscience now. Will that help me or is it just kinda for fun
 
Thanks for the response.

Is there a threat of mid-level encroachment in neurosurgery? One of my friends is in PA school and she mentioned that an older PA she shadowed had said that he gets to do some unsupervised nsg cases after the nsg opens.. seems a bit hard to believe.

Happy to help.

So far as I can tell there is no threat of encroachment of midlevel providers in neurosurgery. Certainly, individual surgeons may train their midlevels to assist during surgery. In my experience, this involves opening and closing routine cases. More commonly, though, they are involved in provider extension e.g. running clinic, rounding, and taking call. Only the future will tell, though, to what degree midlevels will function autonomously.
 
Im super interested in doing near (probably more rehab type stuff than surgery)
How do you ensure that you get a neuro residency and research opportunities during Medical School. Im doing a Masters in Clinical Neuroscience now. Will that help me or is it just kinda for fun

I presume you meant that you are interested in doing neuro. I am less familiar with neurology or PMR and what factors they consider highly for their applicants, but I suspect there is little difference from other fields: Step scores, grades, research, letters, etc. To get involved in research as a medical student it is pretty simple, get in touch with the doctors in the department doing research and get involved in a project. A masters in clinical science will unlikely translate in to any tangible benefit, but if you enjoy it, then go for it.
 
Hello, @neusu !
First off, thank you for creating this thread.

A bit about myself, I'm a medical student who's currently exploring various surgical specialties. Specifically, I'm interested in doing open vascular surgeries and perhaps big-whack oncologic resections too.
I haven't had any exposure to neurosurgery until recently. A couple days ago, however, I had the chance to scrub into a neurosurgery case. It was only a "simple" convexity meningioma resection, as one resident put it, but nevertheless, it left a huge impression on me. Even though they said the case was straightforward, it really blew my mind. I was astonished, really!
Since I'm just beginning to learn more about the field, I have a few questions for you regarding the practice of neurosurgery.
1.) From what I've gathered, most neurosurgeons in the community have 80:20 spine:crani practice. Realistically, is it possible for one to have a practice mainly consisted of brain tumour and neuro-oncology cases? Is such practice common, given that primary brain tumours are fairly rare and most metastatic brain tumours are treated with radiation therapy? What about in academic settings?
2.) How's the volume for open procedures in neurosurgery, specifically in tumour and neuro-oncology? I know open surgeries are common for trauma and spine. Is microsurgical resection still the gold standard for treating brain tumour? There seem to be a lot of minimally-invasive technologies in neurosurgery, like Gamma-Knife and Cyberknife radiosurgery, endovascular and catheter-based procedures, stereotactic system...
Sorry if that's a stupid question, but "open surgery" is a big factor for me in considering surgical specialty.

Big thanks, neusu!
 
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Hello, @neusu !
First off, thank you for creating this thread.

A bit about myself, I'm a medical student who's currently exploring various surgical specialties. Specifically, I'm interested in doing open vascular surgeries and perhaps big-whack oncologic resections too.
I haven't had any exposure to neurosurgery until recently. A couple days ago, however, I had the chance to scrub into a neurosurgery case. It was only a "simple" convexity meningioma resection, as one resident put it, but nevertheless, it left a huge impression on me. Even though they said the case was straightforward, it really blew my mind. I was astonished, really!
Since I'm just beginning to learn more about the field, I have a few questions for you regarding the practice of neurosurgery.
1.) From what I've gathered, most neurosurgeons in the community have 80:20 spine:crani practice. Realistically, is it possible for one to have a practice mainly consisted of brain tumour and neuro-oncology cases? Is such practice common, given that primary brain tumours are fairly rare and most metastatic brain tumours are treated with radiation therapy? What about in academic settings?
2.) How's the volume for open procedures in neurosurgery, specifically in tumour and neuro-oncology? I know open surgeries are common for trauma and spine. Is microsurgical resection still the gold standard for treating brain tumour? There seem to be a lot of minimally-invasive technologies in neurosurgery, like Gamma-Knife and Cyberknife radiosurgery, endovascular and catheter-based procedures, stereotactic system...
Sorry if that's a stupid question, but "open surgery" is a big factor for me in considering surgical specialty.

Big thanks, neusu!

Thanks for the reply, I am happy to hear you are interested.

To address your opening statement regarding interest in open vascular and big whacks: yes, these do tend to be interesting surgeries. They do, however, tend to derive from separate school's of thought, and thus, are not often overlapping with respect to training (e.g. fellowship).

1) You are correct, many community neurosurgeons do mostly spine. Building a practice is a complicated thing, and there are many factors that influence the ultimate make-up of a surgeons patient population. First, in private practice, the majority of patients are from referrals of other physicians. Thus, building a referral base takes both time, experience, and the ability to out compete other surgeons who may want the same cases. I have yet to meet a neurosurgeon who does not like brain tumors, so even if you hang up your shingle, after a fellowship specifically for brain tumors, and announce you want all of the tumors in your area, the likelihood of that happening is zero. More likely, as your practice grows, and your reputation builds, you will be referred more of these cases. In the interim, to stay busy and have an income, you do other cases. Academic centers tend to be better aligned to having a surgeon who's practice is within a single sub-specialty. Most of these centers are tertiary or quaternary referral centers and get sent cases from numerous community hospitals that do not have neurosurgery coverage. Depending on the department, a brain tumor may be funneled to the on call person or to the tumor specialist. Again, though, tumors are desired cases and within the scope of practice for a general neurosurgeon. Politics being as they are, it is not uncommon for the new guy tumor specialist to officially have all tumors that are transferred to the academic center go to them, except if the on call physician has been in the department for a long time and does not want to give up tumors. So, you can see, having that be your practice can be difficult.

2) The volume for open tumor surgery is still robust. As you suggested, metastasis are more common the primary brain neoplasms. Even so, in a large center, there is no disparity of newly diagnosed tumors that need evaluation. The gold standard truly depends on the type, location, and associated symptoms of the tumor. In fact, for most, there really is no hard and fast gold standard. The management really is dictated by the attending's experiential knowledge, skill set, and implementation of the clinical guidelines. Yes, gamma knife and radiosurgery have taken some of the volume away from open surgery, especially for skull base lesions. That being said, it is not always the best solution, nor the first choice.

I agree, for most people who go in to surgery, open surgery is a big consideration. We still do a lot of it. Even so, in every area of neurosurgery, things are trending towards less invasive, minimally invasive, or alternative treatment modalities. You mentioned radiosurgery for tumors and endovascular for vascular. Spine and functional are also becoming less invasive. For the former, we already do MIS, percutaneous, work through ports, or endoscopes. For the latter, we are using smaller corridors for open surgeries or more advanced navigation systems, robotics for placement of electrodes, or lasers for ablation as opposed to open resections.

The sum of it is we still train to do the big whacks, but in the future they will be less and less common. I am not a general surgeon, but from what I recall of my M3 rotation, appendectomy/cholecystectomy transitioned from open only, to many using laparoscopes, to laparoscopic being the preferred route. I would defer to my surgical resident colleagues, but I suspect the number of open appys or choles is dismally low.
 
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@neusu this is an excellent thread! I appreciate the time and effort you have put into this.

Quick question that I couldn't seem to find previously in the thread-- as far as extra endovascular/neurointerventional training goes, do these subspecialists, as a whole, receive a generally higher compensation than regular nsg? I have had so many other questions answered by this thread, but I couldn't seem to find that one. Not that at that point it even matters-- I was just curious. Thank you again for your time and best of luck.
 
@neusu this is an excellent thread! I appreciate the time and effort you have put into this.

Quick question that I couldn't seem to find previously in the thread-- as far as extra endovascular/neurointerventional training goes, do these subspecialists, as a whole, receive a generally higher compensation than regular nsg? I have had so many other questions answered by this thread, but I couldn't seem to find that one. Not that at that point it even matters-- I was just curious. Thank you again for your time and best of luck.

Thank you, I am glad you appreciate the thread!

With respect to compensation, it all depends. As an attending, there are multiple models for compensation, but it ultimately comes down to what the individual arranges for in their contract. Interventional attendings tend to take more call, for vascular emergencies, and have to come do procedures in the middle of the night. Also, diagnostic angiograms tend to be rather quick procedures. Thus, adding together an increase in call frequency with a higher volume of cases, they have potential for increased compensation.
 
Hi @neusu,

Thanks for answering all these questions over the years. I'm wondering about how you manage so many early mornings. I'm someone who is very much a night owl and hates waking up early, and it takes me 30 mins to an hour to go to sleep at night even when I'm tired. I also don't take caffeine because of the headaches it gives me. However I'm very interested in surgery and it seems to be a morning person job. Any advice for being able to handle the early hours?
 
Hi @neusu,

Thanks for answering all these questions over the years. I'm wondering about how you manage so many early mornings. I'm someone who is very much a night owl and hates waking up early, and it takes me 30 mins to an hour to go to sleep at night even when I'm tired. I also don't take caffeine because of the headaches it gives me. However I'm very interested in surgery and it seems to be a morning person job. Any advice for being able to handle the early hours?

I was a night owl growing up. Now I am an early bird. For the most part, we become acclimated to our schedule with time. I find being more regimented and strict about it helps maintain. That is, rather than hitting snooze and sleeping in until the absolute last second, set an alarm and force yourself out of bed at that time every day. Some people sit and drink a cup of coffee and read while others take a longer shower or exercise. Whatever it may be, have something to do when you get out of bed so that you wake up. Likewise, on days off, sleep in a little bit, but don't sleeping until noon etc. After a couple of weeks your body will adjust to this. Be prepared to be exceptionally tired/fatigued throughout the days at first. This is normal both because you got less sleep than you planned for, and your body is making a physiological adjustment. It really should not be an issue, though, because in surgery we often take 28-hour call. A 18-20 hour day, by comparison, is far more tolerable. Finally, falling asleep is not as intuitive as it may seem. We as a society are glued to our screens. Practicing sleep hygiene helps immensely. Set a bed time, and perhaps even a routine, so you mentally know you are getting ready for sleep. Try not to look at screens for at least a half hour before you go to sleep. Do not use your bed for activities other than sleep (or sex). If you are unable to fall asleep after 20 minutes, get out of bed and sit quietly and read a book or do another soothing, quiet activity. If you absolutely must look at a screen after dusk, I recommend apps like red-shift or f.lux to take the blue light out of the screen. I've found these to help immensely in both reducing insomnia and increase quality of sleep.
 
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I was a night owl growing up. Now I am an early bird. For the most part, we become acclimated to our schedule with time. I find being more regimented and strict about it helps maintain. That is, rather than hitting snooze and sleeping in until the absolute last second, set an alarm and force yourself out of bed at that time every day. Some people sit and drink a cup of coffee and read while others take a longer shower or exercise. Whatever it may be, have something to do when you get out of bed so that you wake up. Likewise, on days off, sleep in a little bit, but don't sleeping until noon etc. After a couple of weeks your body will adjust to this. Be prepared to be exceptionally tired/fatigued throughout the days at first. This is normal both because you got less sleep than you planned for, and your body is making a physiological adjustment. It really should not be an issue, though, because in surgery we often take 28-hour call. A 18-20 hour day, by comparison, is far more tolerable. Finally, falling asleep is not as intuitive as it may seem. We as a society are glued to our screens. Practicing sleep hygiene helps immensely. Set a bed time, and perhaps even a routine, so you mentally know you are getting ready for sleep. Try not to look at screens for at least a half hour before you go to sleep. Do not use your bed for activities other than sleep (or sex). If you are unable to fall asleep after 20 minutes, get out of bed and sit quietly and read a book or do another soothing, quiet activity. If you absolutely must look at a screen after dusk, I recommend apps like red-shift or f.lux to take the blue light out of the screen. I've found these to help immensely in both reducing insomnia and increase quality of sleep.

Excellent advice, thanks so much!
 
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