Finishing up 2nd year as a neurosurgery attending, ask me anything

[tarsuc]

As a student, how does one aim to come up with independent researches related to neurosrugery (for 1st author publications in high IF journals)

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[mmmcdowe]

When you were a neurosurgery applicant vs. what you know now: what are the most important factors to consider when comparing neurosurgery residencies?

Resident compliment, the ability to give verbal orders, moonlighting privaleges, fit, cost of living

 

[tarsuc]

As a student, how does one aim to come up with independent researches related to neurosrugery (for 1st author publications in high IF journals)

Sorry i should have framed it better. Apologies if its lame to ask.

I meant to ask if getting published as the first author, has got more to do with asking around residents and faculty for topics/research ideas,

or independent reading and coming up with ideas on your own, and then meeting up faculty to discuss?

I feel the research ideas that I can come up with on my own would be pretty superficial to be published in a well reputed journal.

For an unpublished MS3, and looking into the charting outcomes, it seems very daunting, that the mean number of publications for the average matched applicant is 15 or so.

Could you give some advice?

 

[jowblow997]

Sorry i should have framed it better. Apologies if its lame to ask.

I meant to ask if getting published as the first author, has got more to do with asking around residents and faculty for topics/research ideas,

or independent reading and coming up with ideas on your own, and then meeting up faculty to discuss?

I feel the research ideas that I can come up with on my own would be pretty superficial to be published in a well reputed journal.

For an unpublished MS3, and looking into the charting outcomes, it seems very daunting, that the mean number of publications for the average matched applicant is 15 or so.

Could you give some advice?

A few important points about the charting outcomes:
1) They reflect abstracts+presentations+publications

2) It is important to remember that the 13.4 abstract/presentation/publication average is only an average. You have people with additional degrees, (masters or PhD) that inflate this average. When you look at the graph (NS-6, page 105 on the 2016 charting outcomes), the majority of those who matched fall into the "5 or more" category.

3) These numbers are further inflated by how far one can stretch a single research project. Say you start doing research with a PI and a few months in, your school or other local organization is having a poster symposium. You submit and present some preliminary data. A little while later, you have some new data and a national conference comes along. You submit to that and get accepted. Eventually, your work gets published. From one experience, you got a poster presentation, abstract accepted at a national conference, and a publication. This is why that 13.4 average is so high. You can stretch a single project to AT LEAST: school poster session, state/national conference, publication. And PDs know this.

4) I'll let mmmcdowe confirm this but I have heard that quality of your research experience is important. While publications show you can be productive, I wouldn't get bogged down in the numbers game.

 

[AcademicNeurosurgery]

Thank you for sticking around to answer questions.

How does your program handle re-applicants? I imagine it is especially tough for those who have a below-average Step 1 as they can't really improve that with a year off. Just curious as to how these applicants are discussed in rank meetings.

 

[Gordon Gekko]

Sorry i should have framed it better. Apologies if its lame to ask.

I meant to ask if getting published as the first author, has got more to do with asking around residents and faculty for topics/research ideas,

or independent reading and coming up with ideas on your own, and then meeting up faculty to discuss?

I feel the research ideas that I can come up with on my own would be pretty superficial to be published in a well reputed journal.

For an unpublished MS3, and looking into the charting outcomes, it seems very daunting, that the mean number of publications for the average matched applicant is 15 or so.

Could you give some advice?

ERAS 'Publications' Listing FAQ
How do some students have so many publications?

 

[failedatlife]

Step 1 cutoff for non-rotators used?

 

[AcademicNeurosurgery]

Step 1 cutoff for non-rotators used?

Are you applying to neurosurgery? If so, I wish you the best of luck. Hope things work out for you.

 

[mmmcdowe]

As a student, how does one aim to come up with independent researches related to neurosrugery (for 1st author publications in high IF journals)

Reading a lot of papers published that month and attending research conferences. You need to see the edge to look beyond.

 

[mmmcdowe]

Thank you for sticking around to answer questions.

How does your program handle re-applicants? I imagine it is especially tough for those who have a below-average Step 1 as they can't really improve that with a year off. Just curious as to how these applicants are discussed in rank meetings.

Re-applicants are heavily weighted against. It's a huge red flag. We do not screen them out for it, but they get closely scrutinized to try to understand 1)Why every program they applied to did not want to match them/were there any extenuating circumstances (for example, couples matching) and 2) What have they done to make up for whatever was holding them back before.

 

[mmmcdowe]

Step 1 cutoff for non-rotators used?

We don't have one, each application is given to multiple reviewers. Each reviewer assigns a score/grade based on their impression of the applicants strength and fit for our program based on all available factors, of which score is one. All those scores are averaged and the people with the highest scores are invited. I can't speak for other reviewers, but a good/bad score tends to tilt my rating by 1-2 points on a ten point scale basically (So, for example, someone with stellar research and letters but a score of 210 I might give an 8 versus someone with a score of 272 and the same application I might give a 9 or 10).

 

[Wroke]

Firstly, are there any openly gay physicians/surgeons that you encountered and were there ever cases of blatant discrimination against them that you noticed? I am aware that physicians are traditionally conservative so I stayed in the closet to most people, but I question its necessity. Would most colleagues go ballistic if they found out, or would they shrug it off?
I am sorry if this question comes off rude or cynical, but as someone raised in the less liberal parts of the South, I have seen extremely bad outcomes as a consequence of people being themselves and have grown to assume the worst in people regarding this matter.

Secondly, my school has an unresponsive NS department. All members of the NS faculty have yet to respond to any emails regarding a possible appointment to discuss possible mentoring/shadowing/research. I have tried emailing each of them (all 3 of them) every few weeks over the course of months and I have left messages with their secretaries.
Are there any polite options I am overlooking to reach out to them?

Thirdly, there have been 0 matches to NS from my school for the past 5 years.
Does this put me at a disadvantage for NS residencies, or does it merely mean I would be an outlier to my school?
(I wonder if questions 2 and 3 are related).

Lastly, were you involved in any service activities/services abroad during medical school? Or is service generally overshadowed by research?

Thanks for your time!

 

[bannie22]

Are you applying to neurosurgery? If so, I wish you the best of luck. Hope things work out for you.

He is ENT

 

[bannie22]

when u dissect lumbar spine do u use bovie to dissect muscle off the bone or do u use blunt dissection like a key elevator to scrape muscle off the bone.
do u put screws in before u decompress or vice versa?

 

[mmmcdowe]

when u dissect lumbar spine do u use bovie to dissect muscle off the bone or do u use blunt dissection like a key elevator to scrape muscle off the bone.
do u put screws in before u decompress or vice versa?

I personally have been trained to use the bovie to perform a subperioesteal dissection but I have seen attendings who use the Cobb to detach muscle bluntly. Different people at my programs do it differently. Some decompress and the fixate, some fixate then decompress. If instability is a major issue but alignment is not, I think it makes sense to fixate at least once side, whereas if you're going to do a deformity correction then I think the opposite is important.

 

[mmmcdowe]

Firstly, are there any openly gay physicians/surgeons that you encountered and were there ever cases of blatant discrimination against them that you noticed? I am aware that physicians are traditionally conservative so I stayed in the closet to most people, but I question its necessity. Would most colleagues go ballistic if they found out, or would they shrug it off?
I am sorry if this question comes off rude or cynical, but as someone raised in the less liberal parts of the South, I have seen extremely bad outcomes as a consequence of people being themselves and have grown to assume the worst in people regarding this matter.

Secondly, my school has an unresponsive NS department. All members of the NS faculty have yet to respond to any emails regarding a possible appointment to discuss possible mentoring/shadowing/research. I have tried emailing each of them (all 3 of them) every few weeks over the course of months and I have left messages with their secretaries.
Are there any polite options I am overlooking to reach out to them?

Thirdly, there have been 0 matches to NS from my school for the past 5 years.
Does this put me at a disadvantage for NS residencies, or does it merely mean I would be an outlier to my school?
(I wonder if questions 2 and 3 are related).

Lastly, were you involved in any service activities/services abroad during medical school? Or is service generally overshadowed by research?

Thanks for your time!

I have never met an openly gay neurosurgeon to my knowledge. I have met a few physicians who were gay but the reality is I knew most of them in medical school and thus knew they were gay prior to them becoming doctors. I haven't seen any discrimination but I also haven't seen it openly discussed. I think most physicians would accept it, but we work with a lot of non-physician staff and at least here in Pittsburgh things run conservative among them.

Go find them, worst comes to worst just put on scrubs and walk into the beginning of their case and ask to observe. You aren't hurting yourself by trying compared to not getting to meet them to begin with.

Depends, did people apply to neurosurgery? If not, then probably won't make a huge difference.

I was involved heavily in a student clinic weekly. It had little impact on my application strength but it was personally one of the most meaningful experiences that I had. I believe strongly that people should seek out things important to them, not just seek activities that they think will help their application.

 

[Aphiah]

What's your opinion on the Doximity residency navigator and the Neurosurgery Rankings list (sorted by reputation)?

Does someone who trains at UCSF (Ranked #1) have a much better chance of getting a job at a major (high ranked) teaching hospital than someone who trains at the University of Illinois at Chicago (Ranked #70)?

 

[chuelas1]

I realize you are a Neurosurgeon, but in the case of Just Neurology.. it it crazy for an IMG w average/maybe slightly below par scores to match?

Im very interested in Neurology and if not I would probably shoot for Internal

Step 1 = 215
Step 2 = 235


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[mmmcdowe]

What's your opinion on the Doximity residency navigator and the Neurosurgery Rankings list (sorted by reputation)?

Does someone who trains at UCSF (Ranked #1) have a much better chance of getting a job at a major (high ranked) teaching hospital than someone who trains at the University of Illinois at Chicago (Ranked #70)?

I think it is a poor measure at best but unfortunately all of the measures are poor measures at best -_-. I'm not a fan of how they determine reputation as I feel that it doesn't allow for much granulation when you just pick five programs off the top of your head to vote for without a lot of breakdown in terms of clinical vs research reputation. If anything the other options are more illuminating such as research output and subspecialities. One of the biggest issues that comes up in residency matching is the difference between a great program and a great training program. You can be both, neither or just one.

I do find some of the secondary functions interesting such as a quick way to look up gender balance and location of alumni. That being said yes a graduate from UCSF is much more likely to end up at an academic job than a less academic program. Part of that is self selection and part of it is connections and track record.

 

[mmmcdowe]

I realize you are a Neurosurgeon, but in the case of Just Neurology.. it it crazy for an IMG w average/maybe slightly below par scores to match?

Im very interested in Neurology and if not I would probably shoot for Internal

Step 1 = 215
Step 2 = 235


Sent from my iPhone using SDN mobile

Sorry I wouldn't be able to give you very good advice. My general impression would be that you might be able to match neurology but perhaps you should dual apply?

 

[aalamruad]

I think it is a poor measure at best but unfortunately all of the measures are poor measures at best -_-. I'm not a fan of how they determine reputation as I feel that it doesn't allow for much granulation when you just pick five programs off the top of your head to vote for. One of the biggest issues that comes up in residency matching is the difference between a great program and a great training program. You can be both, neither or just one.

I do find some of the secondary functions interesting such as a quick way to look up gender balance and location of alumni. That being said yes a graduate from UCSF is much more likely to end up at an academic job than a less academic program. Part of that is self selection and part of it is connections and track record.

Is there a ton of inbreeding from top academic residencies to academic jobs at the same programs? Does doing your nsg residency at UCSF give you a good shot at working there indefinitely, or is it super competitive to land a job at your home program at a place like that?

 

[mmmcdowe]

Is there a ton of inbreeding from top academic residencies to academic jobs at the same programs? Does doing your nsg residency at UCSF give you a good shot at working there indefinitely, or is it super competitive to land a job at your home program at a place like that?

At some programs yes, UCSF does have a fair number of its own alumni. As far as the second question, no. Factor in the fact that they are graduating 3 a year. It just wouldn't be sustainable to have spots for all of those graduates. My experience has been that while some do have interest in staying at their home program many are eager to go elsewhere for a fresh start and potentially a better beginning practice. I imagine that the transition from resident to colleague can be tough to do.

 

[SpikesnSpookes]

Do you guys ever do surgeries with Vascular? What is your opinion of that field?

 

[mmmcdowe]

Do you guys ever do surgeries with Vascular? What is your opinion of that field?

Not really no unless something goes terribly wrong (i.e. a vascular injury during spine instrumentation). There is some overlap in the fact that both do carotid endarterectomies and I've seen endovascular neurosurgeons do a below the neck endovascular case and vice versa in a pinch.

 

[neusu]

Who do you think ends up better trained, residents who complete enfolded fellowships or post graduate fellowships?

 

[tiedyeddog]

Who do you think ends up better trained, residents who complete enfolded fellowships or post graduate fellowships?

I would think this depends highly on the quality of the fellowship, enfolded or post-graduate. Also depends on the year in residency the enfolded fellowship was done I would guess. I don't think there is a definite correct answer to this question. What do you think?

 

[HereWeGo21]

Columbia neurosurgery seems like it has a pretty strong preference for graduates of its medical school. Is that an admitted bias or does it just just end up that way? Would you outright pick a good Columbia applicant over a great applicant from another school? Does that change for rotators?

 

[anbuitachi]

Why does Neurosurgery take 7 years? That seems EXCESSIVELY long. We have a very busy neurosurgery department and a LARGE portion of the cases are craniotomies/tumor resections, spines, and smaller procedures like VP shunt, DBS. Plus with all the amazing equipments you guys have that tells you where you are in the brain, is it really necc to be 7 years? A lot of cases the attending surgeon pops in for like 20 minutes and let the residents do the rest of the entire procedure

 

[CrazyboyMD]

Could you go over the steps of a neurological exam?

 

[mmmcdowe]

I agree that there is a lot of variability. One factor is the structure of the training system. At Pitt chiefs and infolded fellows choose before fellows. Great for residents not as great for fellows.

That being said I think doing predominantly in folded fellowships should be the direction we take our training system.

I would think this depends highly on the quality of the fellowship, enfolded or post-graduate. Also depends on the year in residency the enfolded fellowship was done I would guess. I don't think there is a definite correct answer to this question. What do you think?

 

[mmmcdowe]

It is more a bias of familiarity. A great cv does not make a great fit. Doing a subi or a year of research is a big leg up because they have a more reliable sense of your mettle. Most programs have some degree of preference towards that.

Columbia neurosurgery seems like it has a pretty strong preference for graduates of its medical school. Is that an admitted bias or does it just just end up that way? Would you outright pick a good Columbia applicant over a great applicant from another school? Does that change for rotators?

 

[HereWeGo21]

It is more a bias of familiarity. A great cv does not make a great fit. Doing a subi or a year of research is a big leg up because they have a more reliable sense of your mettle. Most programs have some degree of preference towards that.

Thanks. Do you mean a year of research in general or at that particular institution?

How are HHMI and MRSP looked upon?

 

[mmmcdowe]

Why does Neurosurgery take 7 years? That seems EXCESSIVELY long. We have a very busy neurosurgery department and a LARGE portion of the cases are craniotomies/tumor resections, spines, and smaller procedures like VP shunt, DBS. Plus with all the amazing equipments you guys have that tells you where you are in the brain, is it really necc to be 7 years? A lot of cases the attending surgeon pops in for like 20 minutes and let the residents do the rest of the entire procedure

It's a tough question to answer. One of the biggest arguments against the now standardized education is that programs have different levels of exposure based on volume and other responsibilities. The reality is that as a PGY3 resident with a couple more months to go before hitting PGY4 I have completed almost all of the minimum course requirements designated by ACGME with the exception of vascular cases and being deficient for 14 cervical spine cases still. I have logged 309 minor procedures and 685 major cases. I'm still far from competent at complex surgery and the critical portions of cases to be an attending but certainly early exposure to numerous cases does provide some benefit to my education compared to a program where operative experience is more limited in the early years. There is also the fact that some residents may progress more quickly in their skills than other residents even in the same program. The best answer that I can give is that 7 years provides the greatest likelihood of generating skilled and safe neurosurgeons across 100+ programs and my advice is to find the program or programs that are going to give you the most out of those 7 years by whatever criteria are important to you.

 

[mmmcdowe]

Thanks. Do you mean a year of research in general or at that particular institution?

How are HHMI and MRSP looked upon?

At that institution, doing research elsewhere isn't going to increase your familiarity with a specific program though it certainly increases the strength of your resume and can get you some good advocates. Those are looked upon positively by academic/basic science focused programs.

 

[mmmcdowe]

Could you go over the steps of a neurological exam?

Well in terms of a basic neurosurgical examination, which is by no means a complete neurological examination that can take up to a couple of hours if you get really crazy:

Awareness: Eyes open spontaneously/to voice/to stimulation/remained closed
Orientation: Person/place/time
Following Commands?
Extraocular motions intact, pupils reactive to light and accomodation, face symmetric, facial sensation intact in all trigeminal distributions, hearing grossly intact and symmetric, palate elevates in midline, tounge extends in midline, speech/swallow normal
Motor strength in deltoids, biceps, tricieps, wrist flexors, wrist extensors, hand grip, hand intrinsic muscles
Motor strength in iliopsoas, quads, hamstrings, extensor hallucis, foot dorsiflexors, foot plantar flexors
reflexes in biceps, triceps, brachioradialisis, patella, and ankle
Presence of hoffmans/clonus/babinski
sensation to light touch and pinprick
gait examination
presence of tremor, dysmetria, dysdiadokinesia

That would be a fairly basic full examination.

 

[bannie22]

It's a tough question to answer. One of the biggest arguments against the now standardized education is that programs have different levels of exposure based on volume and other responsibilities. The reality is that as a PGY3 resident with a couple more months to go before hitting PGY4 I have completed almost all of the minimum course requirements designated by ACGME with the exception of vascular cases and being deficient for 14 cervical spine cases still. I have logged 309 minor procedures and 685 major cases. I'm still far from competent at complex surgery and the critical portions of cases to be an attending but certainly early exposure to numerous cases does provide some benefit to my education compared to a program where operative experience is more limited in the early years. There is also the fact that some residents may progress more quickly in their skills than other residents even in the same program. The best answer that I can give is that 7 years provides the greatest likelihood of generating skilled and safe neurosurgeons across 100+ programs and my advice is to find the program or programs that are going to give you the most out of those 7 years by whatever criteria are important to you.

Are you the average neurosurgery PGY3?
309 assistant procedures and 685 lead/senior cases is a significant volume.
That suggests to me that you will be hitting at least 2k cases as a PGY7.

i think your program is a redonculous stupendous training program to have had the opportunity to lead/senior so many cases available to you even when as a lower resident! i was expecting someone below halfway to be mostly involved with assisting the senior resident/chief/attending. for cranis perhaps pin the patient and open till dura and close dura etc. and for spines to start putting in screws at pgy2....

 

[Lexicon0]

Do you have any advice for off-service interns rotating with neurosurgery for a month? Aside from generally being a good surgical intern, is there anything one can do in preparation?

 

[mmmcdowe]

Are you the average neurosurgery PGY3?
309 assistant procedures and 685 lead/senior cases is a significant volume.
That suggests to me that you will be hitting at least 2k cases as a PGY7.

i think your program is a redonculous stupendous training program to have had the opportunity to lead/senior so many cases available to you even when as a lower resident! i was expecting someone below halfway to be mostly involved with assisting the senior resident/chief/attending. for cranis perhaps pin the patient and open till dura and close dura etc. and for spines to start putting in screws at pgy2....

Im actually below average slighty by probably about 30 to 50 cases compared to my co residents due to how my rotation schedule lined up. Every program has pros and cons but Pitts source of greatest strength is our operative volume. We cover about 8500 cases a year out of the 10k or so in our system. The spine experience as a two is fairly robust but the cranial experience definitely picks up as a pgy. I did the vast majority of the crani for tumor cases in the last three months during my neuronc rotatiom at shadyside hospital. I even got to do a few spine tumors which was a pleasant surprise. Theres a price for everything though. That rotation I logged 133 cases but I also saw 202 consults and ran the service by myself. Exceptional clinical volume only exists with exceptional patient turnover.

 

[mmmcdowe]

The best thing you can do is get in touch with an intern or resident and get the run down on your responsibilities because it can be pretty variable. Otherwise I would say just follow orders and dont complain. Be prepared for long hours.

Do you have any advice for off-service interns rotating with neurosurgery for a month? Aside from generally being a good surgical intern, is there anything one can do in preparation?

 

[bannie22]

Im actually below average slighty by probably about 30 to 50 cases compared to my co residents due to how my rotation schedule lined up. Every program has pros and cons but Pitts source of greatest strength is our operative volume. We cover about 8500 cases a year out of the 10k or so in our system. The spine experience as a two is fairly robust but the cranial experience definitely picks up as a pgy. I did the vast majority of the crani for tumor cases in the last three months during my neuronc rotatiom at shadyside hospital. I even got to do a few spine tumors which was a pleasant surprise. Theres a price for everything though. That rotation I logged 133 cases but I also saw 202 consults and ran the service by myself. Exceptional clinical volume only exists with exceptional patient turnover.

Thats amazing.

From heresay, Ive seen programs with 40-50 patients on the list. But the 1 or 2 doesnt come to 10% of what you have yet obviously they are responsible for the care of the service.

 

[mmmcdowe]

Pitts list at presby alone hits 100 routinely. Add in 20 from shadyside 20 to 30 from mercy 20 from childrens and a few from the VA and thats how you generate 8500 cases.

Thats amazing.

From heresay, Ive seen programs with 40-50 patients on the list. But the 1 or 2 doesnt come to 10% of what you have yet obviously they are responsible for the care of the service.

 

[bannie22]

From Transcriptional Heterogeneity Underlying Neurovascular Differences in the Aneurysm Dome to deformity spine research.

and that case volume! kudos. be back to ask more questions in future. we appreciate your honest thoughtful responses!

 

[jd989898]

Which surgical field do you predict will see the biggest growth in the next 10-20 yrs?

 

[mmmcdowe]

Which surgical field do you predict will see the biggest growth in the next 10-20 yrs?

in general or in neurosurgery?

 

[jd989898]

in general or in neurosurgery?

In general (i.e among fields which have distinct residencies)

 

[KinasePro]

Ortho bruh here

Out of sheer curiosity, about how many spines have you scrubbed at this point?

Also, what do they let you guys do in the OR as residents? When do they let you go skin-to-skin on spines, or is that something you only get to do as a chief/fellow?

 

[mmmcdowe]

In general (i.e among fields which have distinct residencies)

Well I think all fields that derive a lot of business from the elderly will. I would wager that gen surg grows the most but just because it is already the largest. Ortho and neuro will get a boost from arthritis and old people trauma as well as neurodegenerative diseases like parkinsons.

 

[mmmcdowe]

Ortho bruh here

Out of sheer curiosity, about how many spines have you scrubbed at this point?

Also, what do they let you guys do in the OR as residents? When do they let you go skin-to-skin on spines, or is that something you only get to do as a chief/fellow?

Ive logged 110 spine cases not counting wound I and Ds. Skin to skin is very attending and resident specific. I have had a couple attending who for a given case let me go to town and drop the screws on both sides while he or she watches but at this point the reality is I usually do my side and they do their side. More minor cases like chronic subdurals, vagal nerve stimulators, shunts, etc I routinely do skin to skin though, again, there is wide variation based on attending preference. Some attendings scrub the whole case no matter who they operate with.

 

[tarsuc]

thanks for the ama again.

Which field in Neurosurgery do you predict to see the biggest growth in the next 10-15 years?

Whats the scope of Functional neurosurgery? Will there ever be a situation where a functional surgeon might earn as much as spinal?

 

[CrazyboyMD]

Can I Private Message you so we can discuss medicine? (High School student here)