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

[Skindoc83]

Define major markets for me please.

NYC, San Fran, Denver, LA, Philly, Seattle

---

Members don't see this ad.

 

[Lucca]

NYC, San Fran, Denver, LA, Philly, Seattle

When Denver makes the list but not Houston

 

[mmmcdowe]

NYC, San Fran, Denver, LA, Philly, Seattle

No but ultimately desirable locations means more competition so you will on average get paid less, have more second or third opinions to compete with, and a harder time advancing relative to places with less draw. You can definitely find a job but it may not be your dream job unless you're a heavy duty player in the game or very lucky/connected.

 

[nimbus]

FWIW, I used to work in Palm Springs. At the time we couldn’t get a single neurosurgeon to move there and the hospitals would get coverage by a rotating pool of out of town doctors. I’m currently at a community hospital with a level 1 trauma center in a large coastal Southern California city. Here we have at least 10 neurosurgeons on staff. And a couple years ago we had 2 separate neurosurgery groups competing pretty vigorously to provide trauma coverage. It’s definitely more saturated in large metro areas.

 

[LebronManning]

When Denver makes the list but not Houston

Because Denver is desirable unlike Houston

 

[Pseudostrategy]

Thanks for the thread, @mmmcdowe . Very informative.

Couple of questions re your research year in med school.

1.) You mention that this year out allowed you to feel competent in generating your own hypotheses/projects. Was this something that just happened naturally by going through the amount of projects and publishing the amount of papers that you did? Or was this the result of a lot of self study (i.e. learning which stats are appropriate to apply to a given data set, what questions still needed to be asked and answered on a given topic, etc.)?

2.) You said a lot of your work was done remotely. What did a typical day look like for you? How did you manage multiple projects at a single time? Were you still able to carve out time to build relationships with the residents at your institution by spending time observing/going to conference, or was this less important for you?

Thanks in advance!

 

[ChopinLiszt]

Hi @mmmcdowe thanks again for doing this!
Another research question - if you have a decent number of publications (maybe 7-8 manuscripts and 8-10 abstracts, some book chapters, case reports, etc) would you say a research year is still recommended? From applicants you’ve seen come through, is there a kind of minimum threshold of research/pubs that seems like enough without a research year?

Also, I’m wondering about burnout and your feelings about the field. When you get exhausted and you’re doing the same procedure for the 100+ time, does the nsg magic die? Do you feel like you like the specialty now as much as (or more or less than) when you were applying?

 

[LebronManning]

Do you think groundbreaking advances in treating neurological disease or enhancing human cognition will come from neurology or neurosurgery?

I guess the question could also be asked as: will drug therapy or electrical/mechanical manipulation of the CNS be the wave of the future?

 

[mmmcdowe]

Thanks for the thread, @mmmcdowe . Very informative.

Couple of questions re your research year in med school.

1.) You mention that this year out allowed you to feel competent in generating your own hypotheses/projects. Was this something that just happened naturally by going through the amount of projects and publishing the amount of papers that you did? Or was this the result of a lot of self study (i.e. learning which stats are appropriate to apply to a given data set, what questions still needed to be asked and answered on a given topic, etc.)?

2.) You said a lot of your work was done remotely. What did a typical day look like for you? How did you manage multiple projects at a single time? Were you still able to carve out time to build relationships with the residents at your institution by spending time observing/going to conference, or was this less important for you?

Thanks in advance!

1) Doing projects, learning skills, but especially just going to research conferences and actually attending.

2) I'd wake up when I felt like it and do data review, analysis, and paper writing.id break for a couple hours total throughout the day and go to bed when tired. The goal is to treat research like a game of not potato. You want to not be the one holding the potato meaning not the one delaying project completion. So whatever your role was you should try to complete it and get it on someone else's desk. I tended to try to bang out the short ones first I'm between longer periods. I was able to yeah by partially doing the things that you listed but most importantly I went out of my way to be a research tank for as many residents as possible and would ask residents to sponsor projects even if it was my idea.

 

[mmmcdowe]

Hi @mmmcdowe thanks again for doing this!
Another research question - if you have a decent number of publications (maybe 7-8 manuscripts and 8-10 abstracts, some book chapters, case reports, etc) would you say a research year is still recommended? From applicants you’ve seen come through, is there a kind of minimum threshold of research/pubs that seems like enough without a research year?

Also, I’m wondering about burnout and your feelings about the field. When you get exhausted and you’re doing the same procedure for the 100+ time, does the nsg magic die? Do you feel like you like the specialty now as much as (or more or less than) when you were applying?

It's all relative. Doing a research year is a personal choice. That's a fairly strong research application but the reality is someone with that portfolio would probably crush a research year and end up with a ton more papers. There is no threshold.

I have been lucky that I haven't had burnout in the traditional work sense or at least am delusionally unaware of it. I enjoy doing cases for the hundredth time because I do them better than before. You can always be better and faster. Once you've decided that you've perfected a procedure you stop improving.

 

[mmmcdowe]

Do you think groundbreaking advances in treating neurological disease or enhancing human cognition will come from neurology or neurosurgery?

I guess the question could also be asked as: will drug therapy or electrical/mechanical manipulation of the CNS be the wave of the future?

It will come mostly from phds but neurosurgeons will be involved for implementation. I am personally pessimistic about how much of that is truly possible. I don't think we have the computers get to process the magnitude of the problem. There are so many connections.

 

[agiraffe999]

Hey @mmmcdowe , thanks for doing this it's really informative. I've got a few questions for you:

1) How big of a benefit is doing a sub-I at an institution? Im curious to know how big of a boost it is compared to applying without them.

2) How far down a match-list would you say the average NSG applicant falls -- like top 3ish?

3) I know the guy you're talking about with 80+ pubs (a private practice neurosurgeon I work for graduated from Pitt a few years ago and mentioned him). How is that even possible? I understand with a productive research year it would add publications, but that seems like an impossibly large number.

Thanks for all the information!

 

[longhaul3]

Hey @mmmcdowe , thanks for doing this it's really informative. I've got a few questions for you:

1) How big of a benefit is doing a sub-I at an institution? Im curious to know how big of a boost it is compared to applying without them.

2) How far down a match-list would you say the average NSG applicant falls -- like top 3ish?

3) I know the guy you're talking about with 80+ pubs (a private practice neurosurgeon I work for graduated from Pitt a few years ago and mentioned him). How is that even possible? I understand with a productive research year it would add publications, but that seems like an impossibly large number.

Thanks for all the information!

Here's a link to the application cycle spreadsheet from last year. Obviously it's self-reported, but It'll help you answer your first two questions.

 

[agiraffe999]

@longhaul3 You are amazing, thanks a ton for the information!

 

[sovereign0]

@mmmcdowe

Just wanted to drop in and say that I followed this thread throughout my decision making process during the first three years of medical school and it was a big help. I chose to dive in and matched neurosurgery this year and will be starting this month.

 

[sovereign0]

Hey @mmmcdowe , thanks for doing this it's really informative. I've got a few questions for you:

1) How big of a benefit is doing a sub-I at an institution? Im curious to know how big of a boost it is compared to applying without them.

2) How far down a match-list would you say the average NSG applicant falls -- like top 3ish?

3) I know the guy you're talking about with 80+ pubs (a private practice neurosurgeon I work for graduated from Pitt a few years ago and mentioned him). How is that even possible? I understand with a productive research year it would add publications, but that seems like an impossibly large number.

Thanks for all the information!

I'm not the OP but I matched this cycle so I can try and contribute a bit.

For #1, I assume you're asking how much doing a sub-I helps your odds at a place you're interested in. Every applicant is expected to do at least 3 total sub-internships, a growing number are doing 4. You won't match without doing any. If my previous assumption is correct, it's very institution dependent. Some programs are notorious for only taking their sub-interns or home students. Most places will consider their Sub-I's very closely for their rank list. For middling or weaker applicants it's easier to land a sub-internship at a place where you're swinging above your weight, it's a chance to look good and match at a place you otherwise wouldn't have interviewed at. Neurosurgery is a pretty risk-adverse field because of the reputational and logistical ramifications of losing residents, and the best way to evaluate an applicant is have them work with you for a month. If you didn't rotate somewhere, the letters from places you did rotate serve that purpose.

Regarding #2, it's a really hard question to answer because a program has 4 spots at most, but is ranking anywhere from 40-100 people, and each applicant is interviewing at 10-30 programs. There's people who rank 25+ programs and don't match, there's people who rank <5 and do match - I know people in both camps.

For #3, I don't know the person or have the experience of the OP, but I can say there's a lot of unethical BS behind publishing papers, and it gets easier the more senior you get. There are traded favors and backtables deals to get people on papers who contributed very little to the actual research. It's all a game, and some people and institutions play it better than others.

 

[mmmcdowe]

Hey @mmmcdowe , thanks for doing this it's really informative. I've got a few questions for you:

1) How big of a benefit is doing a sub-I at an institution? Im curious to know how big of a boost it is compared to applying without them.

2) How far down a match-list would you say the average NSG applicant falls -- like top 3ish?

3) I know the guy you're talking about with 80+ pubs (a private practice neurosurgeon I work for graduated from Pitt a few years ago and mentioned him). How is that even possible? I understand with a productive research year it would add publications, but that seems like an impossibly large number.

Thanks for all the information!

Well since this got revived at the right time I've adjusted the title to finishing up PGY6. Starting chief residency, applying for pediatric neurosurgery fellowships and starting to look for jobs. Life continues along. My dog died of lymphoma. I am about to get engaged (pending coronavirus), wondering when case volume will normalize, etc etc.

To answer your questions.

1) It depends on the institution and they can both help and hurt but at most institutions it can be a major factor I would say. Obviously, things are disrupted this year.

2) On their own list, I would say many rank in the top 3 but it is not uncommon for people to plunge. That being said, rank lists are tricky because they are heavily affected by interpersonal interactions. You got a great vibe about some program and they also meshed with you and so you have a self-fulfilling prophecy scenario when you both rank each other highly.

3) Closing in on 200 now I believe, but frankly he casts a very wide net in terms of publications, seeks out pre-existing data sources that can be collected/analyzed by medical students or other people with basic knowledge, and he employs people full time to do research. That employment is often funded by research grants and then those people write up more grants. Its very sophisticated and Pitt is a great environment for that sort of thing, but you really have to love research. I like research in my nitch and myself just published my 66th paper, but I tend to work with a few students at a time and focus on career development and education. He's going to end up as a chairman with a big data-mining lab I'm sure, but I want to be a program director and have focused my interests accordingly. We all have finite time, make sure you're proud of what you make of it. I'm the course director for a medical school neurosurgery course that I personally have developed with the help of students. Most of those students are or will be neurosurgeons and all of them are surgeons. That is what I am proud of, not my 66th paper or even 666th paper.

 

[mmmcdowe]

@mmmcdowe

Just wanted to drop in and say that I followed this thread throughout my decision making process during the first three years of medical school and it was a big help. I chose to dive in and matched neurosurgery this year and will be starting this month.

Glad I could have a positive influence on your success. As stated in the above post, that's what motivates me as a physician.

 

[BlueRocket]

@mmmcdowe how are tattoos viewed in neurosurgery (ex. A tasteful non-vulgar half sleeve on one arm)

 

[mmmcdowe]

@mmmcdowe how are tattoos viewed in neurosurgery (ex. A tasteful non-vulgar half sleeve on one arm)

They won't see it until you've already matched except perhaps at your subis. Overall I think most people don't care. Some may have personal opinions about professionalism but it probably isn't a deal breaker anywhere.

 

[mmmcdowe]

Was asked about publications for applicants. The median applicant that I see had about 3 papers. Those who were interviewed had a median of about five at my program. Top research resumes had at least ten and the real outliers had 20 plus. Quality counts too obviously though most of the folks with a heavy hitting journal on their resumes tended to have a larger number of publications regardless.

 

[7331poas]

Was asked about publications for applicants. The median applicant that I see had about 3 papers. Those who were interviewed had a median of about five at my program. Top research resumes had at least ten and the real outliers had 20 plus. Quality counts too obviously though most of the folks with a heavy hitting journal on their resumes tended to have a larger number of publications regardless.

How much does reputation/rank of the applicants medical school play into your program's evaluation (and others)?

Could an average/below average application be mitigated by doing 4+ sub-Is with good clinical performance?

If an applicant does not have a home program, what steps should they take to improve their application?

 

[mmmcdowe]

How much does reputation/rank of the applicants medical school play into your program's evaluation (and others)?

Could an average/below average application be mitigated by doing 4+ sub-Is with good clinical performance?

If an applicant does not have a home program, what steps should they take to improve their application?

It makes a difference but how much is program dependent. Top 20 gets you one additional point out of 30 compared to top 40 at one program for example but may be almost mandatory at a very few

Number of rotations is secondary to performance. Doing more than three is more to try to press that specific program.

Reach out to other nearby programs for mentorship and research opportunities particularly grants for summer research or years off.

 

[ineedhelpplse]

Was asked about publications for applicants. The median applicant that I see had about 3 papers. Those who were interviewed had a median of about five at my program. Top research resumes had at least ten and the real outliers had 20 plus. Quality counts too obviously though most of the folks with a heavy hitting journal on their resumes tended to have a larger number of publications regardless.

So when the charting outcomes say 18.3 pubs, abstracts, posters that means ~5 pubs at 10+ posters/abstracts?

 

[freezingsneezing]

Outside of class, during medical school how much time a week do aspiring neurosurgeons spend on extracurriculars( research, etc.). Additionally, is clinical volunteering, non clinical volunteering, shadowing and such also necessary as it was during undergrad?

 

[mmmcdowe]

So when the charting outcomes say 18.3 pubs, abstracts, posters that means ~5 pubs at 10+ posters/abstracts?

Correct

 

[cybermed2424]

Do you have any thoughts as to why this past cycle was so competitive and what it might mean for the next few cycles? My understanding is that there were 70 US seniors who went unmatched this year (203/273).

 

[mmmcdowe]

Outside of class, during medical school how much time a week do aspiring neurosurgeons spend on extracurriculars( research, etc.). Additionally, is clinical volunteering, non clinical volunteering, shadowing and such also necessary as it was during undergrad?

There is no specific number or algorithm to competitiveness. I spent maybe 20 hours doing research, did free clinic one or two Saturdays a month, and did esoteric Hong's like 9 plays during medical school. ECs other than research can define you and make you more interesting and better an applicant but they are not a general requirement the way that it may have been for medical school applications.

 

[mmmcdowe]

Do you have any thoughts as to why this past cycle was so competitive and what it might mean for the next few cycles? My understanding is that there were 70 US seniors who went unmatched this year (203/273).

I don't have any specific insight. Perhaps it is the rising number of us md applicants. Perhaps it's the perception that due to work hours restrictions that neurosurgery residency is more manageable. Hard to track a trend based on a single data point. Neurosurgery is a small field. The number of spots goes up very slowly.

 

[ineedhelpplse]

Do you have any thoughts as to why this past cycle was so competitive and what it might mean for the next few cycles? My understanding is that there were 70 US seniors who went unmatched this year (203/273).

I am guessing that this is because students saw the relatively high 2018 match rate (i think it was 85% off the top of my head) and thought it was safe enough to apply. Or just the increase in US seniors

 

[deleted849476]

So for two years now 18 DOs applied and only 3 each year were accepted... Since low sample size, do you have any insight on what might influence those 3? I'm guessing its mostly because there are just fewer DO-accepting programs relative to the number that applied, because I mean, what are the odds the DO applicants are that much worse lol. I might venture that they also have less mentorship for NS and apply a bit more haphazardly?

Thank you for the thread!!

 

[mmmcdowe]

So for two years now 18 DOs applied and only 3 each year were accepted... Since low sample size, do you have any insight on what might influence those 3? I'm guessing its mostly because there are just fewer DO-accepting programs relative to the number that applied, because I mean, what are the odds the DO applicants are that much worse lol. I might venture that they also have less mentorship for NS and apply a bit more haphazardly?

Thank you for the thread!!

Mentorship, research resources, possibly lower boards scores over all, general bias that their schools may not provide the same education standard (osteopathic manipulation particularly) , lack of familiarity with applicants from that institution, no one to advocate for you when match lists are due. I would imagine that the three who matched did a lot of sub internships and did a bangup job.

 

[hebrewBAMmer]

Currently finishing up a neurosurgery rotation. Just want to say, there is no way in hell I could ever do this field, but I will admit that the stuff I saw in neurosurgery ended up being waaaaay more awesome than I was expecting it to be.

 

[Rachapkis]

Are you better at dealing with failure now than when you started in neurosurgery? I can imagine enjoying the procedures and helping patients, but fear that I would be devastated when a procedure was unsuccessful or when nothing could be done to help.

 

[mmmcdowe]

Currently finishing up a neurosurgery rotation. Just want to say, there is no way in hell I could ever do this field, but I will admit that the stuff I saw in neurosurgery ended up being waaaaay more awesome than I was expecting it to be.

It's important to be able to be honest with yourself about what you want. Many a person has ignored their gut feeling until too late .

 

[mmmcdowe]

Are you better at dealing with failure now than when you started in neurosurgery? I can imagine enjoying the procedures and helping patients, but fear that I would be devastated when a procedure was unsuccessful or when nothing could be done to help.

Yes I would say to an extent I am but the degree of severity from my mistakes is much greater which balances it out. Sure I used to ruminate as an intern about my wound closure breaking down, but now when I mess up as a chief it can potentially cost a patient their lives. You learn to brace for your failures by celebrating the wins, bit as my signature says every surgeon has a graveyard where they go to pray.

 

[MilesDavisTheDoctor]

I don't have any specific insight. Perhaps it is the rising number of us md applicants. Perhaps it's the perception that due to work hours restrictions that neurosurgery residency is more manageable. Hard to track a trend based on a single data point. Neurosurgery is a small field. The number of spots goes up very slowly.

Do you think work hour restrictions have made a big impact and for the most part are actually followed?

 

[mmmcdowe]

Do you think work hour restrictions have made a big impact and for the most part are actually followed?

I think it has made an impact on perception of the field and encouraged people with unrealistic expectations to consider the field. It has been my experience that people who are hyperfocused on work hours by the week or month rather than taking a more general approach to it being averaged over seven years tend to not be happy in neurosurgery. Programs will absolutely respond to any reported work hours violation to address it. It's a big deal for all specialties, speaking as someone on the GME accredidation subcommittee. However addressing it usually means assigning the work to other more senior people who have finally reached the payoff point where they're getting the time back to pursue nonclinical work like research and tends to not generate good will among your cohort who are asked to shoulder a burden they've already shouldered without complaint. Alternatively you miss out on valuable training in order to ensure no irregularities in your hour logging. I have literally done a skull base surgery so long that it was by it's very definition a violation of work hours and then did another one the next day that was also in itself a violation. No one forced me to do it. I signed up for them. I could have asked to be relieved, but I also would have lost the learning opportunity in my subspecialty interest. Reporting my program in that context would have technically been appropriate, but it would have resulted in changes that I don't want for my education.

 

[freezingsneezing]

How would a system such as Medicare for all affect salaries of neurosurgeons

 

[MilesDavisTheDoctor]

I think it has made an impact on perception of the field and encouraged people with unrealistic expectations to consider the field. It has been my experience that people who are hyperfocused on work hours by the week or month rather than taking a more general approach to it being averaged over seven years tend to not be happy in neurosurgery. Programs will absolutely respond to any reported work hours violation to address it. It's a big deal for all specialties, speaking as someone on the GME accredidation subcommittee. However addressing it usually means assigning the work to other more senior people who have finally reached the payoff point where they're getting the time back to pursue nonclinical work like research and tends to not generate good will among your cohort who are asked to shoulder a burden they've already shouldered without complaint. Alternatively you miss out on valuable training in order to ensure no irregularities in your hour logging. I have literally done a skull base surgery so long that it was by it's very definition a violation of work hours and then did another one the next day that was also in itself a violation. No one forced me to do it. I signed up for them. I could have asked to be relieved, but I also would have lost the learning opportunity in my subspecialty interest. Reporting my program in that context would have technically been appropriate, but it would have resulted in changes that I don't want for my education.

How do you know if you can handle the hours during residency as a medical student?

 

[NeuResurgens]

How do you know if you can handle the hours during residency as a medical student?

A subI has similar hours.

 

[mmmcdowe]

How would a system such as Medicare for all affect salaries of neurosurgeons

Probably reduced some and bring everyone's closer to some median number

 

[mmmcdowe]

How do you know if you can handle the hours during residency as a medical student?

Sub is may be similar hours but it's actually harder than as a resident because it's all watching. If you survive medical school you probably CAN survive the hours, the question is do you enjoy neurosurgery enough to tolerate it for seven years. That answers from spending as much time with the speciality as you can

 

[MilesDavisTheDoctor]

Sub is may be similar hours but it's actually harder than as a resident because it's all watching. If you survive medical school you probably CAN survive the hours, the question is do you enjoy neurosurgery enough to tolerate it for seven years. That answers from spending as much time with the speciality as you can

By spending as much time with the specialty as I can do you mean shadowing lots of people? Is there anything else I should be doing?

 

[medstudent20222022]

I just got my STEP1 score, and I only made a 222. I am really bummed because this is lower than I was expecting and I don't know if I can still do nsgy (?).

I have 3 pending publications, 8 poster presentations from 3 abstracts (public health and gyn onc projects), and I am planning to start helping a resident with a nsgy-specific project this year. I was the director of our school's free community clinic last year and I have a lot of service hours. mostly high-pass in pre-clinicals but some honors and a few passes.

1. is nsgy still feasible for me?
2. what are some lower/middle-tier programs that I should look at? and/or programs without specific cut-offs or >220 cutoff?

 

[mmmcdowe]

By spending as much time with the specialty as I can do you mean shadowing lots of people? Is there anything else I should be doing?

Shadowing and research

 

[mmmcdowe]

I just got my STEP1 score, and I only made a 222. I am really bummed because this is lower than I was expecting and I don't know if I can still do nsgy (?).

I have 3 pending publications, 8 poster presentations from 3 abstracts (public health and gyn onc projects), and I am planning to start helping a resident with a nsgy-specific project this year. I was the director of our school's free community clinic last year and I have a lot of service hours. mostly high-pass in pre-clinicals but some honors and a few passes.

1. is nsgy still feasible for me?
2. what are some lower/middle-tier programs that I should look at? and/or programs without specific cut-offs or >220 cutoff?

It's not impossible but you would really need to consider a year off to bolster your research and involvement in neurosurgery. Your research needs to be predominantly neurosurgical. The other stuff doesn't count without a track record in neurosurgery. Most programs don't have absolute cut offs in my experience except for the top tier where it's fairly common.

 

[MilesDavisTheDoctor]

What are the bread and butter surgeries that you should be excited about if you're thinking about neurosurgery?

 

[aaronrodgers]

Does neurosurgery feel saturated in any particular region or subspecialty?

 

[mmmcdowe]

Does neurosurgery feel saturated in any particular region or subspecialty?

Well Peds is simply because of the few truly pediatric jobs plus stable birth rate. It can be hard to find an open vascular or skull base practice right out of residency but they can be built.