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

[mmmcdowe]

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

yes

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[mmmcdowe]

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?

In terms of subspecialties that have the most growth potential Id say functional is at the top only because so few patients with movement disorders are being referred to neurosurgeons relative to other diseases. I don't think functional will ever have the same profit margin as spine unless spine takes a hit on their reimbursement rather than functional increasing its reimbursement.

 

[tarsuc]

If im taking a year off to do research, which among these (or anything else) should i look for in a PI.

His fame, no of publications he has already, no of pubs he lets students write up?, how well i get along with him?

 

[mmmcdowe]

If im taking a year off to do research, which among these (or anything else) should i look for in a PI.

His fame, no of publications he has already, no of pubs he lets students write up?, how well i get along with him?

I would suggest that working with a junior attending has advantages because they tend to be less encumvered and more hungry to publish. I would also say that a personal relationship with a reaearch mentor is very valuable and not an easy thing to find. Most PIs will shake your hand and send you on your way with a fist full of pubs and nothing more. Finding someone who will really invest in you beyond your utility to themselves is an incredible gift. Those are the people who will help you get your firat job, remember you when a good research opportunity pops up, etc.

 

[jd989898]

I'm a rising M2 MD/PhD student, and I'm interested in neurosurgery. I'm planning to do my PhD in the Dept of neuroscience, either with a PI who studies the neuronal basis of mental health, or one that studies neural stem cells in the potential treatment of motor/sensory disorders. I am equally interested in both options. Would picking one over the other make a difference in my eventual residency application? My intuition says no, but there still seems to be a stigma around psychiatry/mental health. Thanks.

 

[mmmcdowe]

I'm a rising M2 MD/PhD student, and I'm interested in neurosurgery. I'm planning to do my PhD in the Dept of neuroscience, either with a PI who studies the neuronal basis of mental health, or one that studies neural stem cells in the potential treatment of motor/sensory disorders. I am equally interested in both options. Would picking one over the other make a difference in my eventual residency application? My intuition says no, but there still seems to be a stigma around psychiatry/mental health. Thanks.

No I think both are fine. Psychiatric illness is becoming of increasing illness in functional neurosurgery

 

[bannie22]

I'm a rising M2 MD/PhD student, and I'm interested in neurosurgery. I'm planning to do my PhD in the Dept of neuroscience, either with a PI who studies the neuronal basis of mental health, or one that studies neural stem cells in the potential treatment of motor/sensory disorders. I am equally interested in both options. Would picking one over the other make a difference in my eventual residency application? My intuition says no, but there still seems to be a stigma around psychiatry/mental health. Thanks.

Not a Neurosurgery PGY3 but I would say that your PhD thesis matters little in the match process in compared to the other essentials like Step 1/research productivity.

I also feel that if you are going to spend 2-4 years on a PhD that you should pick something that you most love.

 

[Ms Procrastinator]

When did you really start getting involved in surgeries when you started residency and how involved in surgeries were you from pgy1 to now?

 

[ChopinLiszt]

Hopkins and the Barrow. I couldnt say regarding the later question but I do know that fit is a big factor in who they take.

How was your sub-i at Barrow? (culture, duties, etc) Did it make you want to go back there for residency, or was there something about it that turned you off/away and more towards your current program? Thank you!

 

[neusu]

How was your sub-i at Barrow? (culture, duties, etc) Did it make you want to go back there for residency, or was there something about it that turned you off/away and more towards your current program? Thank you!

I rotated there as well back in the day. I loved it. They have a truly unique set up and tend to see both a large volume and a wide diversity of interesting cases. The program I ended up at was smaller, as they all are, but I was very happy. Focusing on becoming exceptionally trained during residency helps, and my experience at the Barrow certainly set the bar high.

 

[WhittyPsyche]

I rotated there as well back in the day. I loved it. They have a truly unique set up and tend to see both a large volume and a wide diversity of interesting cases. The program I ended up at was smaller, as they all are, but I was very happy. Focusing on becoming exceptionally trained during residency helps, and my experience at the Barrow certainly set the bar high.

@neusu and @mmmcdowe

How many external rotations are necessary? Some suggestions I’ve received from Dean and faculty in the department is 3. And how important is geographical spread of rotation sites for showing non-bias?

Not saying I wouldn’t love to, but have school-aged children and no family nearby, so differentiating necessity from nicety is important.


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[MedicineZ0Z]

Not going into NSG or a surgical field - but what does it take for a DO to match into NSG (acgme)? I do know of one applicant this year but don't know the details besides having 2 years of research & a 270+ step 1. Is there something specific that a DO must do to overcome the "no DO rule" that most places seem to virtually have.

 

[mmmcdowe]

@neusu and @mmmcdowe

How many external rotations are necessary? Some suggestions I’ve received from Dean and faculty in the department is 3. And how important is geographical spread of rotation sites for showing non-bias?

Not saying I wouldn’t love to, but have school-aged children and no family nearby, so differentiating necessity from nicety is important.


Sent from my iPhone using SDN mobile

3 sub-is total, 1 at your home and 2 aways. The reason being that it is hard to fit LORs beyond 3 programs and hard to schedule before interview season/application submission. Your application is your story, doing subis in the same region implies a need/desire to stay there. It isn't necessarily an impossible obstacle to overcome, but it will need to be addressed on interviews.

 

[mmmcdowe]

Not going into NSG or a surgical field - but what does it take for a DO to match into NSG (acgme)? I do know of one applicant this year but don't know the details besides having 2 years of research & a 270+ step 1. Is there something specific that a DO must do to overcome the "no DO rule" that most places seem to virtually have.

It is very difficult. Developing a personal relationship with a specific program is the best option.

 

[mmmcdowe]

When did you really start getting involved in surgeries when you started residency and how involved in surgeries were you from pgy1 to now?

My program gets you heavily involved rapidly. I think that the biggest differences between PGY1 and now (PGY4) is that the oversight has diminished significantly and the complexity of the cases has gone up. For example, I was doing basic spine cases as a PGY1, but back then the attending was there step by step whereas now when I do basic spine the attending comes in to poke around after I have done everything but the critical portion of the case (i.e. I'll do the laminectomy/decompression alone and they will come in for the screws/graft, etc and/or to check the adequacy of my decompression). I also get assigned to more complex rooms such as tumors, CEAs, etc and again the level of attending participation is tailored to the skills that I have obtained over the last few years. I've done 70 or so tumors so those attendings tend to show up for the actual removal vs I have only done 4 CEAs so the attendings tend to be present for essentially the whole case. There is also significant variability among attendings and even days (i.e. does the attending have 2 rooms vs 1).

 

[mmmcdowe]

How was your sub-i at Barrow? (culture, duties, etc) Did it make you want to go back there for residency, or was there something about it that turned you off/away and more towards your current program? Thank you!

I enjoyed my sub-i at BNI a lot. Great group of people, great training. There are pros and cons to every program so I would say looking back BNI's greatest strength was the positive culture, the operative training, and the ease/efficiency of clinical practice for all those involved. The downsides were the lack of a major medical center attached, essentially no research collaboration options outside of the neuroscience departments (last time I checked all NIH funding at St Joes was BNI funding), and only a token medical school affiliation. At the time there was a lot of concern about who was going to replace Spetzler though that is obviously not an issue. Losing Nicholas Theodore was a shame, he was an awesome guy and probably would have turned me into a spine surgeon by the magnetism of his personality alone. I went to ASU so obviously was familiar and comfortable with Phoenix.

 

[Spectre of Ockham]

Did you ever got the feeling ... this is easy ? Have you been proven wrong in a horrible afterwards ?

 

[mmmcdowe]

Did you ever got the feeling ... this is easy ? Have you been proven wrong in a horrible afterwards ?

I watched nsg residents get crushed for five years. I never thought it was going to be easy. Theres a nsg saying "If its easy you arent doing it right" That being said it wasnt quite as hard as I thought. It is endurable. On one rotation there is a private practice and academic group of equal volume. the PP group employs 4 PAs to round, see consults, work in clinic and assist in case. The academic group has you. Nothing easy about itm

 

[Aphiah]

@neusu and @mmmcdowe

Do you suggest rotating at the place you want to do residency?

 

[mmmcdowe]

@neusu and @mmmcdowe

Do you suggest rotating at the place you want to do residency?

Yes but I also suggest rotating at a variable set of places. Try a heavily clinical one and a heavily academic one at the very minimum.

 

[Eye-eye]

Yes but I also suggest rotating at a variable set of places. Try a heavily clinical one and a heavily academic one at the very minimum.

Would you recommend this even if you know you don't like research?

 

[neusu]

@neusu and @mmmcdowe

Do you suggest rotating at the place you want to do residency?

I'd have to agree with @mmmcdowe

To add to his statement spreading away rotations geographically also helps from getting pegged as only wanting to be in a certain area.

 

[ChopinLiszt]

I'd have to agree with @mmmcdowe

To add to his statement spreading away rotations geographically also helps from getting pegged as only wanting to be in a certain area.

What if you do want to be in a certain area? Would it be ok to focus rotations in that area to build relationships at those programs, or is that too risky in terms of limiting match options?
Also, I know there is age bias in terms of wanting to train people with the longest possible career potential, but what would you say is the oldest age most programs would consider in an applicant? Thank you for this thread, @mmmcdowe and @neusu - it has been very helpful!

 

[neusu]

What if you do want to be in a certain area? Would it be ok to focus rotations in that area to build relationships at those programs, or is that too risky in terms of limiting match options?
Also, I know there is age bias in terms of wanting to train people with the longest possible career potential, but what would you say is the oldest age most programs would consider in an applicant? Thank you for this thread, @mmmcdowe and @neusu - it has been very helpful!

You certainly could limit your aways to a certainfgeographic area, and it may increase odds of matching at a particular program at which you rotate. Nonetheless, other programs in different areas may decline to interview you or rank you lower due to the perception of being tied to an area and unlikely to seriously consider outside that area.

Age is a tough one. Many MD/PhD applicants are in their 30s when they match. I don't suspect that there is an upper limit, but realistically someone in their 40s or 50s may not be able to handle the grueling requirements

 

[bioboy23]

When do neurosurg residents get significant time in the OR? Just wondering if it is similar to general surgery when basically the whole intern year is spent in the wards.

 

[Anti-PD1]

Thanks neusu, mmcdowe

I just matched into neurosurgery.

Is there anything you recommend, any resources to review, prior to intern year? I've just been relaxing/traveling before it all starts.

What would you do differently as a fresh intern?

 

[mmmcdowe]

When do neurosurg residents get significant time in the OR? Just wondering if it is similar to general surgery when basically the whole intern year is spent in the wards.

Highly variable by program. Clinically heavy programs get you in day 1 with progressively more and or better cases as you advance.

 

[mmmcdowe]

Thanks neusu, mmcdowe

I just matched into neurosurgery.

Is there anything you recommend, any resources to review, prior to intern year? I've just been relaxing/traveling before it all starts.

What would you do differently as a fresh intern?

If you have research interests now is a good time to start making connections and writing IRBsor proposals. Otherwise I'd focus on lifestyle improvements like cooking and gym routines. Flipping through the intro courses on learningradiology is a quick read

 

[Eye-eye]

Highly variable by program. Clinically heavy programs get you in day 1 with progressively more and or better cases as you advance.

Would you happen to know of programs that are clinically heavy like that, and aren't known for being malignant? Thanks!

 

[mmmcdowe]

Would you happen to know of programs that are clinically heavy like that, and aren't known for being malignant? Thanks!

Mayo, BNI, Indiana come to mind. I attend Pitt and I haven't had a malignant experience but it is definitely harder.

 

[Eye-eye]

Mayo, BNI, Indiana come to mind. I attend Pitt and I haven't had a malignant experience but it is definitely harder.

Thanks! By harder, do you just mean more hours or more responsibilities (e.g., extra academic ones on top of clinical expectations)?

Also, if anyone has had good or bad experiences with any of the following, I'd love to know - it's hard to get a sense of what places are malignant and which are supportive, having not been involved with any outside my home program yet:
Yale, UVA, Vanderbilt, Cleveland Clinic, Stanford, Case Western, U Cincinnati, Ohio State, U Buffalo, UCSD, U Chicago, Mass General, Northwestern, Johns Hopkins, U Maryland, Penn State, U South Florida... or any others you want to mention one way or the other

Thank you, everyone who takes the time to contribute to forums like this! It's a big help for people earlier on in the process.

 

[NYCdude]

How do you maintain your health? When I was on neurosurg, the residents worked like factory animals. One second year dude would come in at 4 and leave at like 8, while snacking on random things here and there as opposed to eating actual meals lol.

 

[mmmcdowe]

How do you maintain your health? When I was on neurosurg, the residents worked like factory animals. One second year dude would come in at 4 and leave at like 8, while snacking on random things here and there as opposed to eating actual meals lol.

It's hard if you are single in the early years but it is a matter of priorities. During the hardest part. I used all available off time to sleep. others exercised or went out. As you become efficient you learn to squeeze more in. Whatever keeps you sane and safe. Later on you have more free time. For example I'm walking my dog currently and then cooking breakfast and heading in at 630.

 

[mmmcdowe]

Thanks! By harder, do you just mean more hours or more responsibilities (e.g., extra academic ones on top of clinical expectations)?

Also, if anyone has had good or bad experiences with any of the following, I'd love to know - it's hard to get a sense of what places are malignant and which are supportive, having not been involved with any outside my home program yet:
Yale, UVA, Vanderbilt, Cleveland Clinic, Stanford, Case Western, U Cincinnati, Ohio State, U Buffalo, UCSD, U Chicago, Mass General, Northwestern, Johns Hopkins, U Maryland, Penn State, U South Florida... or any others you want to mention one way or the other

Thank you, everyone who takes the time to contribute to forums like this! It's a big help for people earlier on in the process.

That's part of it but the other part is we have a very high rate of nonelective cases due to the large catchment area our main hospital serves in.. On a given day we may add 6 to 10 new cases on for the next day not counting emergent cases. It creates a lot of work and means we often have a lot of sick people that need attention. We also cover 5 hospitals.

 

[Blackdogue]

i think that neurosurgeons have and will maintain a strong presence in the field by virtue of versatility. A neurologist who has a endovascular procedure that needs to convert to open cannot do it. They cant do any surgeries on the side nor can they take operative call that might be needed at places with endovascular abilities but not the volume for full time neuro ir guys.

On the other hand, mechanical thrombectomy is bound to become the bulk of neuro ir procedures over the next few years and neurologists are ideally placed to do these procedures, since they admit the patients, don't you think? Thanks for doing this, btw, very helpful thread.

 

[mmmcdowe]

On the other hand, mechanical thrombectomy is bound to become the bulk of neuro ir procedures over the next few years and neurologists are ideally placed to do these procedures, since they admit the patients, don't you think? Thanks for doing this, btw, very helpful thread.

But they can't place the evd when they perf. Stroke centers tend to have specialized stroke services which are neurologists but not necessarily IR trained ones. All clmprehensive stroke centers have neurosurgeons I believe. Thrombectomies go to whoever is on call here regardless of specialty and those physicians are essentially detached from other aspects of stroke care

 

[mmmcdowe]

Wasnt going to bump quite yet but since it's been revived I'll update the threat title, finishing up pgy4 year AMA. Doing a skull base infolded fellowship during my elective time with emphasis on peds.

 

[Blackdogue]

But they can't place the evd when they perf. Stroke centers tend to have specialized stroke services which are neurologists but not necessarily IR trained ones. All clmprehensive stroke centers have neurosurgeons I believe. Thrombectomies go to whoever is on call here regardless of specialty.

I see. And what about neurology trained neurointensivists, do they place evds where you work, or do they call you for all of them? Don't see why that makes such a difference, although I would like as a potential neurologist to not have to call surgery for every little thing. Maybe I'm just thinking like a naive med student. Appreciate your answer.

 

[mmmcdowe]

They do not ever place them here. It isnt some ultra complex process but it is a separate skill set unrelated to IR and there is an aspect of decision making beyond just the manual task. If they aren't taught by a neurosurgeon they won't have a way to learn and they will be potentially a legal risk if something goes wrong. The bottom line is if you can't manage the consequences you shouldn't be meddling with it.

QUOTE="Blackdogue, post: 19953514, member: 865661"]I see. And what about neurology trained neurointensivists, do they place evds where you work, or do they call you for all of them? Don't see why that makes such a difference, although I would like as a potential neurologist to not have to call surgery for every little thing. Maybe I'm just thinking like a naive med student. Appreciate your answer.[/QUOTE]

 

[pbrocks15]

skull base infolded fellowship during my elective time with emphasis on peds.

What is a skull base infolded fellowship? And do you still manage time for research (if you're interested)?

Thanks for this!

 

[jdh71]

When you are done are you currently planning to accept catastrophic heads bleeds that you plan not to intervene on at 3am on behalf of your colleague medical intensivist without telling him and then also planning to not talk to the family or put a note in the chart?

Hmmm??

 

[Blackdogue]

They do not ever place them here. It isnt some ultra complex process but it is a separate skill set unrelated to IR and there is an aspect of decision making beyond just the manual task. If they aren't taught by a neurosurgeon they won't have a way to learn and they will be potentially a legal risk if something goes wrong. The bottom line is if you can't manage the consequences you shouldn't be meddling with it.

QUOTE="Blackdogue, post: 19953514, member: 865661"]I see. And what about neurology trained neurointensivists, do they place evds where you work, or do they call you for all of them? Don't see why that makes such a difference, although I would like as a potential neurologist to not have to call surgery for every little thing. Maybe I'm just thinking like a naive med student. Appreciate your answer.

[/QUOTE]I was referring to neurointensivists, not neuro ir, when asking about evds, but I guess your opinion is the same, since they also can't deal with the complications alone. I was just asking because in many other threads I read neurointensivists saying they do evds and bolts regularly. Depending on their particular department of course.

 

[NeuResurgens]

Wasnt going to bump quite yet but since it's been revived I'll update the threat title, finishing up pgy4 year AMA. Doing a skull base infolded fellowship during my elective time with emphasis on peds.

Are most subspecialties of neurosurgery available as enfolded fellowships nowadays? Which ones outside of peds likely require (or at least benefit from) a separate post-residency fellowship experience if you're interested in academic positions?

 

[mmmcdowe]

What is a skull base infolded fellowship? And do you still manage time for research (if you're interested)?

Thanks for this!

It's a period where you focus on surgical approaches to the skull base and endonasal approaches. I do I am fairly active

 

[mmmcdowe]

What is a skull base infolded fellowship? And do you still manage time for research (if you're interested)?

Thanks for this!

It's a period where you focus on surgical approaches to the skull base and endonasal approaches. I do I am fairly active

When you are done are you currently planning to accept catastrophic heads bleeds that you plan not to intervene on at 3am on behalf of your colleague medical intensivist without telling him and then also planning to not talk to the family or put a note in the chart?

Hmmm??

with fervor.

 

[jdh71]

It's a period where you focus on surgical approaches to the skull base and endonasal approaches. I do I am fairly active


with fervor.

I KNEW IT!!!!

bastard

 

[mmmcdowe]

I was referring to neurointensivists, not neuro ir, when asking about evds, but I guess your opinion is the same, since they also can't deal with the complications alone. I was just asking because in many other threads I read neurointensivists saying they do evds and bolts regularly. Depending on their particular department of course.[/QUOTE]

Probably at outlying centers. Heavy duty academic centers with neurosurgery residencies probably not so much. Similar to ED critical care conforms to the resources and staff availability of their hospital. I personally have let ccm fellows drop evds with me but again it becomes problematic if you get a complication.

 

[mmmcdowe]

Are most subspecialties of neurosurgery available as enfolded fellowships nowadays? Which ones outside of peds likely require (or at least benefit from) a separate post-residency fellowship experience if you're interested in academic positions?

Yes they exist for everything besides peds and maybe open vascular. As far as which did most important to do after residency its tough to say because a lot of it is situational and program specific. Spine would be the least important but again it is situational. If you did 2000 endovasculsr cases and have 30 papers on it then you are probably going to get more credibility than someone who did half the cases.

 

[Spectre of Ockham]

A lot of the time spent in surgery is wasted on things like prepping the patient , entering the skull and suturing the skin .

Do you believe that as our tools get more advanced we will be able to waste less time and maybe get some time with our families ? I mean seriously 2-3 hours for a simple benign meningioma or a small subdural hematoma (at least at the places where I get to scrub in) ? It seems like there is a lot of improvement to make in the field in both the surgical times and the time we get to recover and not loose our drive.

What's your take on this ?

 

[7331poas]

3 sub-is total, 1 at your home and 2 aways.

Does this still apply if you don't have a home nsg program?

Could you comment a little on the ideal route to residency applications for someone applying from a mid tier medical school without a home neurosurgery program? What is the best method to get research in neurosurgery in that context? Will neurosurgeons on faculty at the attached hospital be sufficient for my long term goals if they aren't necessarily training residents? Should I attempt to do research elsewhere when given the opportunity?

Thanks.