Finishing up 4th year as a neurosurgery attending, ask me anything

[mmmcdowe]

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For context to those reading this now, I started this thread near the end of a year of residency and update annually.

But for those who don't frequent pre-allo often, make sure to read from neusu's thread for the perspective of someone at the end of neurosurgery residency.

 

[halfwaycrooks]

Are the hours as tough as you thought they would be? What has been the hardest transition from medical school to internship? Thank you

 

[Shjanzey]

Do you regret it now?
Would you recommend it to others?
For someone who is interested in surgery, what drew you to neurosurgery as opposed to ortho, general, cardiothoracic, etc.

 

[mmmcdowe]

Are the hours as tough as you thought they would be? What has been the hardest transition from medical school to internship? Thank you

Depends on if you are referring to the ones that I log or the ones that I work 😉

That being said, no the hours are not nearly as hard to endure as feared, especially in comparison to neurosurgery sub-is. Being actively involved in patient care really makes a difference in terms of fatigue and enjoyment. There are definitely days where you're exhausted, but I wake up eager for another shot of it. The hardest transition for me has been in taking theory and putting it into practice. All the medicines and mechanisms are bouncing around in my head, sometimes even an alogrithm as to when to use which, but what's the dosing? How do I correct for renal failure? How many days? All of this stuff I had to learn on the fly.

 

[Kelevra]

Have/do you ever struggle(d) with imposter syndrome, or blows to what you consider your competence (feeling stupid, making same mistakes more than once, etc.)?

 

[mmmcdowe]

Do you regret it now?
Would you recommend it to others?
For someone who is interested in surgery, what drew you to neurosurgery as opposed to ortho, general, cardiothoracic, etc.

Nope
Yup, if you are doing it because you like neurosurgery and not for money/power/prestige.
Fit with the people is what did it for me. I liked a lot of specialties, but I resonated the most with neurosurgery residents/attendings.

 

[Southplains]

Are/were you in a serious relationship when the year started? If not, would you have reconsidered if you were?

 

[mmmcdowe]

Have/do you ever struggle(d) with imposter syndrome, or blows to what you consider your competence (feeling stupid, making same mistakes more than once, etc.)?

All the time, just always do the right thing. If you don't know, don't lie. If you messed up, tell someone immediately. It's a learning process.

 

[mmmcdowe]

Are/were you in a serious relationship when the year started? If not, would you have reconsidered if you were?

I was engaged to someone during my 4th year. That fell apart and was a very dark time in my life (especially during my sub-is), but I don't regret giving it a go. It wasn't meant to be, but it was worth seeing if it was.

 

[Southplains]

I was engaged to someone during my 4th year. That fell apart and was a very dark time in my life (especially during my sub-is), but I don't regret giving it a go. It wasn't meant to be, but it was worth seeing if it was.

I'm sorry to hear that. If you can get through that during sub Is and match well as you did, you can definitely survive the residency. Best of luck.

 

[deleted518368]

How do you see neuro-related fields changing in the near future as we learn more about the brain? Neurosurg, neuro, interventional rads, PM&R?

 

[Mjolner]

How many hours did you work vs how many hours you logged. And how do you see that comparing to other specialties in the hospital?

 

[mmmcdowe]

How do you see neuro-related fields changing in the near future as we learn more about the brain? Neurosurg, neuro, interventional rads, PM&R?

I think who is doing what will change. The composition of neurocritical care positions and neuro-IR positions, for example. I think you will also see a continue outflow of specialists to smaller and smaller hospital systems compounded potentially by a movement to attempt centralization of the same specialists. I think we will hit a few more low hanging targets successfully and do some good, but I think the future of neurological treatment is going to rely heavily on bio-informatics to determine appropriate individual treatment. As far as neurosurgery goes, I think we are going to continue to invest heavily in technology to improve our surgical performance.

 

[mmmcdowe]

How many hours did you work vs how many hours you logged. And how do you see that comparing to other specialties in the hospital?

I'm going to have to decline to answer that first part on the open forum due to the fact that I have never taken measures to overly protect my identity (though I do appreciate that people do not post direct links, etc even though there are 50+ ways to figure out who I am if you really wanted to know). Having rotated on a number of other fields (EM, Trauma Surgery, GI surgery, Neuro ICU, Stroke, etc) during my internship, neurosurgery residents absolutely do work longer hours than many other residents in the hospital on average. Every field has their "hardest month". Still less hours than a neurosurgery intern for the ones that I have participated in.

 

[NontradCA]

I'm going to have to decline to answer that first part on the open forum due to the fact that I have never taken measures to overly protect my identity (though I do appreciate that people do not post direct links, etc even though there are 50+ ways to figure out who I am if you really wanted to know). Having rotated on a number of other fields (EM, Trauma Surgery, GI surgery, Neuro ICU, Stroke, etc) during my internship, neurosurgery residents absolutely do work longer hours than many other residents in the hospital on average. Every field has their "hardest month". Still less hours than a neurosurgery intern for the ones that I have participated in.

What motivates you to work longer and for lack of a better word, harder than everyone else?

 

[mmmcdowe]

What motivates you to work longer and for lack of a better word, harder than everyone else?

Because I love what Im doing more than what I could be doing otherwise. Find the job you would do for free (but dont tell your boss).

 

[tiedyeddog]

How many EVDs have you done solo? How many did it take to feel confident in doing them alone?

 

[mmmcdowe]

How many EVDs have you done solo? How many did it take to feel confident in doing them alone?

I did about 75 lumbar punctures/drains this year, but only 5 EVDs. At my institution pretty much all evds are placed by the consult resident (a second year), because they are responsible for admitting traumas and do it in the trauma bay during the initial admission. It will have been 6 months since my last evd placement (as I am off service) so I will ask my senior to supervise me at least once. It took me about 3 supervision during lps before I felt comfortable trying on my own unsupervised.

 

[NontradCA]

What annoys you the most about students doing a rotation on your service?

 

[mmmcdowe]

What annoys you the most about students doing a rotation on your service?

Infighting/gunning other people down. For example, I don't like it when students bring in gifts for the residents without making it a group thing. If all the sub-is want to bring in coffee or something on the last day that's fine, appreciated, and reciprocated. However, it isn't cool when one shows up and the others are left in the dark that someone was bring in stuff. When I was a student, I'd label things from "the students", even if no one else contributed. Working cohesively makes everyone look better because we are looking for team players, not alphas.

 

[Make Or Break]

Would you say that a lot of neurosurgeons are cocky and have a God complex?

 

[mmmcdowe]

Would you say that a lot of neurosurgeons are cocky and have a God complex?

Not really. I think this may have been more prevalent in the older generation before imaging was routine, back when you were flying by the seat of your pants and had to make educated guesses as to where the lesion was and then open up the patient's head looking for it. That requires tremendous self-assurance.

 

[tiedyeddog]

Would you say that a lot of neurosurgeons are cocky and have a God complex?

That's something that surprised me about the field when I was doing sub-Is. Maybe it was just the places I rotated, but most of the attendings at my home program and the two places I did always at are genuinely nice, decent people. There are attendings that are egomaniacal tools but they are far and in between.

Most neurosurgeons aren't going to have the personality of a pediatrician, they understandably have to be confident people to do what they do. But I would say the personalities aren't too different from CT surg, vascular, or other intense surgical specialities.

 

[Kelevra]

1) What do you wish you knew about neurosurgery (or the field of surgery in general) prior to applying for residency?
2) How has your view of the fields changed?
3) What scares you most about the future of neurosurgery (or surgery in general)? This could be regarding anything, including insurance, autonomy, technology, job security, etc.

 

[deleted518368]

I think who is doing what will change. The composition of neurocritical care positions and neuro-IR positions, for example.

Do you mean that neurosurgeons will be doing more of those jobs, or that the other specialties will be doing more interventions?

 

[mmmcdowe]

1) What do you wish you knew about neurosurgery (or the field of surgery in general) prior to applying for residency?
2) How has your view of the fields changed?
3) What scares you most about the future of neurosurgery (or surgery in general)? This could be regarding anything, including insurance, autonomy, technology, job security, etc.

1) That no matter how confident you are about where you want to be, it is likely to change and to no feel guilty if it does.
2) Hard to say, your preconceptions get washed away so quickly that I struggle to remember thinking different.
3) I don't have any overwhelming fears, maybe that the career I want will be saturated (i.e no good academic jobs to be had).

 

[Kahreek]

....

 

[mmmcdowe]

what are the bread and butter cases at your institution?
do you feel the midlevels are creeping in?

Bread and butter is pretty variable by attending. Some attendings due uncomplicated meningiomas, acoustics, and GBMs as their "bread and butter" Others its microdiscs, ACDFs, and at least for one TLIFs. We have over 30 attendings, so things vary a lot. Midlevels here do a great job of freeing residents to do actual clinical and surgical work. They never take precedence in the OR but on days where we have more cases than we can handle they will do the minor spine stuff that we can't staff.

 

[mmmcdowe]

Do you mean that neurosurgeons will be doing more of those jobs, or that the other specialties will be doing more interventions?

It's up in the air, but neurosurgery is attempting to gain dominance based on the argument of operative versatility.

 

[Psai]

duke of minimal vowels?
half of the letters in that title are vowels

 

[Kelevra]

never take precedence in the OR but on days where we have more cases than we can handle they will do the minor spine stuff that we can't staff.

How "invasive" are the procedures in which they can be most autonomous? I'm not quite sure what is considered minor spine procedures. Would this be procedures such as LPs?

 

[mmmcdowe]

How "invasive" are the procedures in which they can be most autonomous? I'm not quite sure what is considered minor spine procedures. Would this be procedures such as LPs?

They dont do floor procedures like that, but they will open and close spine cases by themselves or with the attending and assist the attending with the rest. Im not sure what the letter of the law is in terms of their ability to do lps and stuff by themselves, but at the very least it is not the custom here. They do pull drains, take out stitches, etc though.

 

[Shipping News]

What has been your experience interacting with the radiology department at your institution? Do you guys have a good working relationship with the neurorads folks?

 

[mmmcdowe]

What has been your experience interacting with the radiology department at your institution? Do you guys have a good working relationship with the neurorads folks?

By neurorads you mean diagnostic and not interventional, right? We have a good relationship, but we don't interact all that much with them because they tend to do a good job and do it fast. Every now and then I'll call for a read or something, but rarely. Our departments interventionalists are half neurosurgery and half neurology. The fellows are autonomous from both departments.

 

[Make Or Break]

Does each NS have a recorded percentage of how many people survive vs how many die from them operating? Or are there any other 'stats' that follow you around in the hospital? As in those are the numbers they look at to determine how good you are?

 

[mmmcdowe]

Does each NS have a recorded percentage of how many people survive vs how many die from them operating? Or are there any other 'stats' that follow you around in the hospital? As in those are the numbers they look at to determine how good you are?

Attendings keep a record as do hospitals, but these sort of things arent routinely distibuted for residents or attendings. So no one is whispering behind your back "thats xyz, the only pgy to change a dbs battery in under 12 parsecs!"

What really determines your reputation Is your behavior. If you arent nice to staff, yell, dont answer pages, are rude to families, etc then it doesnt matter if you are a hotshot surgeon or not.

And yes, I know parsecs are a measure of distance not time.

 

[jw3600]

Have you made the "Come on, it's not brain surgery," joke yet?

 

[addy]

MS2, going into MS3 here.

I love neurosurgery, especially functional/DBS stuff. However, the thought of doing spine work sounds like hell, with the exception of spinal oncology stuff. What would you say to a person like me who has a relatively narrow interest given that spine work makes up such a big part of a neurosurgeon's work.

My problem is is that I have small areas of interest in a lot of fields, most notably CT surg, peds CT surg and neurosurgery. I don't know if I'm kidding myself if I think I can make a career out of those niches given that my step was only 0.5 st dev over mean and my path in academic Xsurgery will likely be an uphill battle coming from a 'low tier' school...

 

[mmmcdowe]

MS2, going into MS3 here.

I love neurosurgery, especially functional/DBS stuff. However, the thought of doing spine work sounds like hell, with the exception of spinal oncology stuff. What would you say to a person like me who has a relatively narrow interest given that spine work makes up such a big part of a neurosurgeon's work.

My problem is is that I have small areas of interest in a lot of fields, most notably CT surg, peds CT surg and neurosurgery. I don't know if I'm kidding myself if I think I can make a career out of those niches given that my step was only 0.5 st dev over mean and my path in academic Xsurgery will likely be an uphill battle coming from a 'low tier' school...

You certainly can strive towards a functional only practice, but the bottom lines is you are going to do hundreds of spine cases in residency and there is nothing you can do to avoid it. So ask yourself why you dislike spine so much. Many medical students start out disliking spine becausse the cases are long, you don't get to do much, and you can't see anything from your angle. It may not be your favorite thing in the world to do, but I have found spine cases to be much more enjoyable than when I was a medical student.

 

[addy]

You certainly can strive towards a functional only practice, but the bottom lines is you are going to do hundreds of spine cases in residency and there is nothing you can do to avoid it. So ask yourself why you dislike spine so much. Many medical students start out disliking spine becausse the cases are long, you don't get to do much, and you can't see anything from your angle. It may not be your favorite thing in the world to do, but I have found spine cases to be much more enjoyable than when I was a medical student.

Thanks for the response.

I suppose my reservation is with regards to the outcomes and indications...I don't want to work with the "cheeseburger" population where most of their pathologies are due to their diets. Plus, an attending at our institution was telling me how there isn't a lot of concrete data on how much some of the spine procedures actually help.

Thoughts?

 

[mmmcdowe]

Thanks for the response.

I suppose my reservation is with regards to the outcomes and indications...I don't want to

Thanks for the response.

I suppose my reservation is with regards to the outcomes and indications...I don't want to work with the "cheeseburger" population where most of their pathologies are due to their diets. Plus, an attending at our institution was telling me how there isn't a lot of concrete data on how much some of the spine procedures actually help.

Thoughts?

work with the "cheeseburger" population where most of their pathologies are due to their diets. Plus, an attending at our institution was telling me how there isn't a lot of concrete data on how much some of the spine procedures actually help.

Thoughts?

The purpose of a surgical residency is to learn the thinking and technique of a bunch of surgeons and then walk out on the other end with your own combination of those based on your preferences. Until then you operate on what they sayd and do it how they say. If operating on people you may not believe need it is a deal breaker, then it is what it is. However, in all subspecialties including functional there will be controversial cases.

 

[PL198]

By neurorads you mean diagnostic and not interventional, right? We have a good relationship, but we don't interact all that much with them because they tend to do a good job and do it fast. Every now and then I'll call for a read or something, but rarely. Our departments interventionalists are half neurosurgery and half neurology. The fellows are autonomous from both departments.

so there's no neuro IR at your hospital? is that something you guys lobbied for or is that how its always been?

 

[mmmcdowe]

so there's no neuro IR at your hospital? is that something you guys lobbied for or is that how its always been?

There is a neuro ir group but they are a joint section that is part of neurology and neurosurgery departtments.

 

[PL198]

There is a neuro ir group but they are a joint section that is part of neurology and neurosurgery departtments.

Any bad blood or what is your viewpoint on the neurology/ neuro IR / Neurosurg intersection

 

[mmmcdowe]

Any bad blood or what is your viewpoint on the neurology/ neuro IR / Neurosurg intersection

Not to my knowledge.

 

[Zedor]

In addition to clinical work, were you involved in any research during your intern year? How early does one begin setting the groundwork for their research years?

 

[mmmcdowe]

In addition to clinical work, were you involved in any research during your intern year? How early does one begin setting the groundwork for their research years?

It depends a lot on you and your program. At Columbia you do a research year as a pgy2 and then another as a pgy5 to build on it. At Pitt, many people pursue fellowships instead of reseach years, though both options are routinely chosen. I have a lot of research interests so I wrote a few irbs, grants, and minor papers this year, mostly during my off service time,

 

[Make Or Break]

Do you have any recommendations or advice for incoming M1's who might possibly want to go into NS? (Or some other competitive surgery field for that matter)

 

[mmmcdowe]

Do you have any recommendations or advice for incoming M1's who might possibly want to go into NS? (Or some other competitive surgery field for that matter)

Explore as many fields as you can early. If you've never met a urologist or seen a urologic case then how can you definitively know that it might be an interest of yours? Tons of people at my school would fall in love with surgical subspecialties during third year and then scramble to become competitive. If you have 3 interests and one of the three is much more competitive, focus the majority of your time on that speciality because it is much easier to transition out than transition in later on.

 

[nyc1990]

@mmmcdowe, first off, thanks for doing this. I'm a soon-to-be MS2, interested in NS or ENT (leaning towards the latter, assuming all scores are in place later on). What advice would you have for someone trying to decide between these two? Also, I've a bit nervous about my fine motor skills since I have a slight tremor and am not the most useful with tools, so to speak. Is this something to worry about? I guess we practice so much 3rd year and beyond that it will all become a lot easier?