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

[LebronManning]

Do patients every code or die during brain surgery?

Also..this is kind've dumb but the image in my mind of a Neurosurgery resident and subsequent Neurosurgeon is that of utmost organization, work ethic, etc. all the time. I wonder..do you still find time to occasionally kick back and watch some Netflix or just be lazy sometimes? Were you always hyper organized and had your **** together or did this develop with your interest in NSGY in medical school?

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[mmmcdowe]

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 ?

No, other than treating these diseases medically I think the basics of surgery are relatively stable and efficient as is. As surgery becomes more efficient we typically just do more per day . That being said you can find family friendly practices it is just going to affect how much you make and or where you live.

 

[mmmcdowe]

You'd need to do 3 aways. The best option is to seek out a nearby program. Private practice isn't terrible but they likely won't have the same level of options available for research. Definitely want to find something for the summer and apply for a summer research grant.

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.

 

[mmmcdowe]

Very rarely. Ive had two code during induction of anesthesia and I jad one during a massive spine surgery with high blood loss that we had to close immediately. I imagine several people that I have done emergent craniotomies for stroke or hemorrhage may have been brain dead at the time of surgery or before the end but hard to say.

As far as relaxing yeah I'll binge watch some Netflix or play some video games on a day off or while on call when it's quiet. It is dangerous to be "on" all the time. Even with a full nights sleep the mental exertion of a busy day full of complex problems takes a toll and you'll pass out like you hadn't slept in a week when your head hits the bed.

Do patients every code or die during brain surgery?

Also..this is kind've dumb but the image in my mind of a Neurosurgery resident and subsequent Neurosurgeon is that of utmost organization, work ethic, etc. all the time. I wonder..do you still find time to occasionally kick back and watch some Netflix or just be lazy sometimes? Were you always hyper organized and had your **** together or did this develop with your interest in NSGY in medical school?

 

[LebronManning]

Would DBS research with a Neurologist or in a neuroscience department be good for NSGY apps even though it is not with neurosurgeons?

 

[mmmcdowe]

Would DBS research with a Neurologist or in a neuroscience department be good for NSGY apps even though it is not with neurosurgeons?

It's close but neurosurgery is a tight field and there is a preference for seeing letters of rec and papers by colleagues.

 

[newcastleb423]

I'm a pre-med who's been lurching on these forums for years and reading through this thread has been more helpful than talking IRL to some people about medicine. Thank you for doing this!

Anyways, I have refractory epilepsy (>15 seizures/month on average) and after years of urging by my epilepsy doctors, I am finally heading down the surgery path this summer. I just barely crawled across the finish line of undergrad (still did well), but wanting to head to medical school in a few years is a big part of my decision. As much as epilepsy has messed up my life, I'm kind of glad I waited and Stereo-EEG is now the standard of care versus subdural grid electrodes for pre-surgical "testing." Still blows my mind that people had to get a craniotomy to determine if they were a candidate for surgery. As if refractory epilepsy wasn't sh*** enough.

I know SDN isn't for medical advice and I'm not looking for comments on my case, but I'm wondering 1) how common it is for patients to not want surgery/be scared. I imagine this might be more common in a field like neurosurgery where the surgeries and potential complications are really scary. How do you convince patients like me that surgery is the best option? I know my doctors are almost certainly right and that epilepsy surgeries have great outcomes but it's still terrifying.

2) Do you ever advise patients to wait if you think there's a new, better technique right around the corner? Obviously some patients can't afford to wait, but for the one's that can, is that ever something that happens? Similarly, is it common for centers to advise that patients seeks out surgery at other centers where there is better/newer technology? I know Stereo-EEG, for example is still only available at certain centers, and many centers are still using subdural grids. Do these centers not inform patients of the option to seek out Stereo-EEG at other centers?

 

[Eye-eye]

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 ?

I don't think the tools are the problem with the ridiculous prep time, unfortunately. At least at my institution, it's politics and regulations on the ancillary staff that just make things move SO damn slow in between cases. But I've seen some private ASCs where things move very quickly (granted, smaller cases, but still) because they've hand picked and trained their staff to get one case out and the next one in as quick as possible. I imagine it just depends on where you are and how much control whoever's in charge has over picking and training staff (and how much that person cares about the efficiency of moving cases along).

 

[mmmcdowe]

I'm a pre-med who's been lurching on these forums for years and reading through this thread has been more helpful than talking IRL to some people about medicine. Thank you for doing this!

Anyways, I have refractory epilepsy (>15 seizures/month on average) and after years of urging by my epilepsy doctors, I am finally heading down the surgery path this summer. I just barely crawled across the finish line of undergrad (still did well), but wanting to head to medical school in a few years is a big part of my decision. As much as epilepsy has messed up my life, I'm kind of glad I waited and Stereo-EEG is now the standard of care versus subdural grid electrodes for pre-surgical "testing." Still blows my mind that people had to get a craniotomy to determine if they were a candidate for surgery. As if refractory epilepsy wasn't sh*** enough.

I know SDN isn't for medical advice and I'm not looking for comments on my case, but I'm wondering 1) how common it is for patients to not want surgery/be scared. I imagine this might be more common in a field like neurosurgery where the surgeries and potential complications are really scary. How do you convince patients like me that surgery is the best option? I know my doctors are almost certainly right and that epilepsy surgeries have great outcomes but it's still terrifying.

2) Do you ever advise patients to wait if you think there's a new, better technique right around the corner? Obviously some patients can't afford to wait, but for the one's that can, is that ever something that happens? Similarly, is it common for centers to advise that patients seeks out surgery at other centers where there is better/newer technology? I know Stereo-EEG, for example is still only available at certain centers, and many centers are still using subdural grids. Do these centers not inform patients of the option to seek out Stereo-EEG at other centers?

It is very common for patients not to want surgery. There are often several different options for the management of disease and patient preference can tip the balance. I don't try to convince anyone of anything. Surgery is dangerous, it isn't a golden ticket like how people treat it. You could die, you could never be the same. The benefits can be huge, but the risks are unquestionable.

No I don't advise that. You never know how long a better technique is going to take, how much trail and error will be involved as surgeons learn to use it proficiently, and what the long term consequences will be. Often it is a matter of individual outcomes rather than average outcomes. X procedure may be 10% better than y on average, but I have 20 years of experience doing X and so my Y patients do 20 percent worse than my X patients due to the learning curve. On occasion a surgeon will refer out if they think that they don't have a reasonable option to provide.

 

[mmmcdowe]

Is it reasonable to get 10 case reports during The preclinical years of med school? Also is the only authorship you can get from case reports, first author?

Possible but very unlikely to find that many to do. you can be listed in any order authorship. First and last authorship are most desirable. Last authorships go to the senior mentor.

 

[mmmcdowe]

Would an applicant with 10 clinical pubs be considered more competitive than one with 1 basic science; assuming that the pubs aren’t groundbreakingly amazing.

Probably. 10 case reports vs a good basic science pub maybe not but 10 real clinical papers would win the day at most institutions except perhaps amongst physicians who do similar research.

 

[LebronManning]

So obviously NSGY residency allows very little free time, but are you still able to go on dates or go out for a drink with friends once or twice a week?
My question is to assess the viability of starting a life during residency as these tend to be very precious and the last "young" years of one's life. For example, this would be the time many would meet their wives (would need to be able to date) and have kids. Do you think these things are still possible?

 

[FistLength]

How do you carve out time for research? Do you build it in your schedule and do chunks of it at a time on a daily basis, or do you just get to it when you can?

 

[mmmcdowe]

How do you carve out time for research? Do you build it in your schedule and do chunks of it at a time on a daily basis, or do you just get to it when you can?

I do both. In my free time I will designate tasks and then while at work I will do bits here and there.

 

[mmmcdowe]

So obviously NSGY residency allows very little free time, but are you still able to go on dates or go out for a drink with friends once or twice a week?
My question is to assess the viability of starting a life during residency as these tend to be very precious and the last "young" years of one's life. For example, this would be the time many would meet their wives (would need to be able to date) and have kids. Do you think these things are still possible?

It is variable depending on the rotation but yes overall there is time to go out. It depends on what's most important to you at a given time. My highest priority is often maximising my sleep but certainly there are times where I would give some of it up in order to go do something fun. When I am in a relationship typically I have done 2 date nights a week.

 

[sovereign0]

Sorry if this has been answered before, but how much sleep do you get per night?

 

[mmmcdowe]

Sorry if this has been answered before, but how much sleep do you get per night?

I am an exception to the general trend in that sleep is my utmost priority outside of work. I typically sleep 7 to 7 and a half hours a night. Sometimes more and sometimes less. At my most strenuous point of residency I was sleeping 6.5 to 7. I think the majority of most grievous of resident errors are due to chronic sleep deprivation.

 

[sovereign0]

I am an exception to the general trend in that sleep is my utmost priority outside of work. I typically sleep 7 to 7 and a half hours a night. Sometimes more and sometimes less. At my most strenuous point of residency I was sleeping 6.5 to 7. I think the majority of most grievous of resident errors are due to chronic sleep deprivation.

Follow up question:

How?

 

[mmmcdowe]

Follow up question:

How?

by prioritizing it over socialization, exercise, food, research, studying, recreation, etc. That isn't to say that I didn't do those other things only that if i had to choose I chose sleep.

 

[sovereign0]

by prioritizing it over socialization, exercise, food, research, studying, recreation, etc. That isn't to say that I didn't do those other things only that if i had to choose I chose sleep.

That's reassuring. My impression was always that residency (particularly surgical specialties) are a package deal with 5-7 years of chronic sleep deprivation because work hours make it mathematically impossible to get a reasonable amount of sleep.

 

[mmmcdowe]

That's reassuring. My impression was always that residency (particularly surgical specialties) are a package deal with 5-7 years of chronic sleep deprivation because work hours make it mathematically impossible to get a reasonable amount of sleep.

There are high points and there are low points. I certainly wouldn't lie and say I always get a full night sleep but FWIW I'm going to bed now and waking up in 7 hours and 50 mins from now.

 

[lagbydesign]

What are the most annoying consults that you get?

What other specialties do you enjoy working with or really admire?

 

[mmmcdowe]

What are the most annoying consults that you get?

What other specialties do you enjoy working with or really admire?

I hate just so you're aware consults. These most commonly are related to shunts. Frequently the patient is there for something unrelated like a leg injury or, once, a testicular hydrocele with a ct head and shunt series that are unconcerning. I hate "I don't know what this means" consults. Getting called to interpret radiology interpretations isn't my job, call radiology. The worst, however, are "I don't know why" consults. I frequently get consulted for a neurological exam finding with no workup and no attempt by the consulting team to comprehend or investigate the problem.

I don't admire any individual specialty, each one has solid and weaksauce players

 

[neusu]

I hate just so you're aware consults. These most commonly are related to shunts. Frequently the patient is there for something unrelated like a leg injury or, once, a testicular hydrocele with a ct head and shunt series that are unconcerning. I hate "I don't know what this means" consults. Getting called to interpret radiology interpretations isn't my job, call radiology. The worst, however, are "I don't know why" consults. I frequently get consulted for a neurological exam finding with no workup and no attempt by the consulting team to comprehend or investigate the problem.

I don't admire any individual specialty, each one has solid and weaksauce players

Maybe I missed this during orientation, but what does having someone on board even mean?

 

[ValentinNarcisse]

Would an applicant with 10 clinical pubs be considered more competitive than one with 1 basic science; assuming that the pubs aren’t groundbreakingly amazing.

No. Basic Science will always trump clinical papers. That being said you need to have track record of being productive, and there is no reason you cannot do both.


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[ValentinNarcisse]

Maybe I missed this during orientation, but what does having someone on board even mean?

It means that the requesting service has no actual question, but would like to wash their hands of all responsibility for neurological management of the patient, whether or not they have an active issue.


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[mmmcdowe]

It means that the requesting service has no actual question, but would like to wash their hands of all responsibility for neurological management of the patient, whether or not they have an active issue.


Sent from my iPhone using SDN mobile

neusu is an attending neurosurgeon. He is joking.

 

[mmmcdowe]

As more and more neurosurgeons finish up residency and become attendings, will the salary of a neurosurgeon decrease because others are taking their patients or will it remain about the same?

The rate of neurosurgery residency expansion is very slow and the board has been careful to not allow supply to exceed demand. I don't think this is going to be a significant t driver of finances compared to other causes of reimbursement reduction.

 

[mmmcdowe]

What other causes of reduction are there

lower ability to get reimbursement from insurers. increasing costs of practice.

 

[Eye-eye]

Ok. Also what would be the best general region of the country to open a practice(in terms of making the most $)?
Also how can you tell whether a hospital is private practice or academic? Are the hours in a hospital more than private practice? How about academic?

From my understanding, avoiding big cities and the coasts is financially wise, but you're not going to be doing too shabby in neurosurg either way. Most docs are going to hospital employment over private practice, though, and solo practice is especially hard - there's a lot of overhead you don't have to deal with as an employee, and they can often negotiate better reimbursement rates. As a general rule, hospitals associated with a school are academic; others are public (county hospitals, VA, IHS, etc.), and others are private (Billybob McRichpants' Hospital, a bunch of other non-academic, non-government hospitals). Hours vary a lot within type of hospital or practice by your particular job description and what you negotiate in your contract, but I'll let others with more knowledge explain any trends they may have seen with regards to this.

 

[Dox4lyfe]

How likely am I to make useful connections at away programs by doing research there over the summer? Is the process for securing research at away programs the same as it is at home programs (I.e. cold emailing about any research opportunities with the PI)?

 

[Dox4lyfe]

Did you have strong geographic ties to where you're currently training? If not, then how did you sell yourself?

 

[mmmcdowe]

Do you foresee any turf wars occurring in the future? Or do you think neurosurgery is and will continue to be a stable field in terms of turf?

There is always overlapping areas such as spine, endovasculsr, acoustics, etc but I don't anticipate any substantial shift where neurosurgeons lose their stake.

 

[mmmcdowe]

How likely am I to make useful connections at away programs by doing research there over the summer? Is the process for securing research at away programs the same as it is at home programs (I.e. cold emailing about any research opportunities with the PI)?

Depends on how great a job you do. You can look for grants and such like the aans fellowship but otherwise it's a matter of reaching out directly or via your advisory dean or neurosurgeons at your local program . If you have a program that is at your institution that is doing research it is probably best to work with them longitudinally for years unless you have a very strong need to go elsewhere for residency .

 

[mmmcdowe]

Did you have strong geographic ties to where you're currently training? If not, then how did you sell yourself?

Not really. I did sub is at different places in the country and I was honest about having no ties geographically and that my interest was purely based of the fact that I thought the program was aligned with my career interests and my resume reflected that. Bottom line is don't tell a program you want to run a basic science lab if your resume has no research experience.

 

[Eye-eye]

Not really. I did sub is at different places in the country and I was honest about having no ties geographically and that my interest was purely based of the fact that I thought the program was aligned with my career interests and my resume reflected that. Bottom line is don't tell a program you want to run a basic science lab if your resume has no research experience.

Do you think there are any programs that really don't care if you want to be an academician/researcher or not? Most programs seem to require research in residency, and even if not, other elective rotations seem highly geared toward the resident doing research. Do you know of any programs that are more open to people with other career interests? How honest should you really be about this in interviews? I've always heard to play the game and do research / pretend you're dead set on being an academician regardless of your interests. But surely there are a lot of applicants who aren't sure what they want in the long run...

 

[mmmcdowe]

I do think many programs are less interested in publications and grooming academics. I would look at graduates on alumni pages and see what they are doing to get a sense of it. I would be honest. Finding a program that is going to encourage other interests such as secondary degrees or unfolded fellowships is worth the fact that some programs are going to dislike your message. Who cares? Why would you want to be at a program with a 3 pub a year requirement. Faking an interest will just set everyone up for disappointment, assuming your resume and interview don't out you also being dishonest.

Do you think there are any programs that really don't care if you want to be an academician/researcher or not? Most programs seem to require research in residency, and even if not, other elective rotations seem highly geared toward the resident doing research. Do you know of any programs that are more open to people with other career interests? How honest should you really be about this in interviews? I've always heard to play the game and do research / pretend you're dead set on being an academician regardless of your interests. But surely there are a lot of applicants who aren't sure what they want in the long run...

 

[LebronManning]

Curious about the practice variety of a private practice or community hospital employed neurosurgeon.

I heard it’s about 80/20 spine to cranial. Is that accurate? I’m curious about what types of cranial cases make up the majority of your cranial practice? Is it mostly tumors and trauma?

Does doing a cerebrovascular, neuro IR, or tumor fellowship help weigh that ratio more toward cranial?

 

[nimbus]

I don't think the tools are the problem with the ridiculous prep time, unfortunately. At least at my institution, it's politics and regulations on the ancillary staff that just make things move SO damn slow in between cases. But I've seen some private ASCs where things move very quickly (granted, smaller cases, but still) because they've hand picked and trained their staff to get one case out and the next one in as quick as possible. I imagine it just depends on where you are and how much control whoever's in charge has over picking and training staff (and how much that person cares about the efficiency of moving cases along).

It’s not just politics or being hand picked and trained. Most ASC’s don’t have a relief shift coming in at 3pm. In an ASC, the staff don’t go home until the cases are done, often after most of the doctors are gone. In a hospital, the staff go home at the end of their shift, regardless of how many cases are left. At my hospital it’s almost impossible to get certain staff members to bring a patient into the OR between 2:15-3:00pm. They have completely different incentives.

 

[mmmcdowe]

Curious about the practice variety of a private practice or community hospital employed neurosurgeon.

I heard it’s about 80/20 spine to cranial. Is that accurate? I’m curious about what types of cranial cases make up the majority of your cranial practice? Is it mostly tumors and trauma?

Does doing a cerebrovascular, neuro IR, or tumor fellowship help weigh that ratio more toward cranial?

there's more to complex brain surgery than the surgery. it's the hospitals ability to provide neurocritical care and your partners willingness to manage your cases and referral patterns and the patient population. extraxial tumors and hematoma make up a fair bit of pp cranial. its quite common to be 100 percent spine but you ultimately can choose what you keep. if you only see one aneurysm a year in your clinic at some point you'll probably start giving then away.

 

[LebronManning]

In my very limited experience in the ED, most people that come in with catastrophic bleeds don’t really recover post craniotomy. The craniotomies continue to occur so I’m sure there must be plenty of good outcomes to survive it.

Do patients ever come in with catastrophic bleeds but fully or functionally recover?

 

[ValentinNarcisse]

In my very limited experience in the ED, most people that come in with catastrophic bleeds don’t really recover post craniotomy. The craniotomies continue to occur so I’m sure there must be plenty of good outcomes to survive it.

Do patients ever come in with catastrophic bleeds but fully or functionally recover?

Yes. Quite often for trauma or SAH caught in timely manner.


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[mmmcdowe]

In my very limited experience in the ED, most people that come in with catastrophic bleeds don’t really recover post craniotomy. The craniotomies continue to occur so I’m sure there must be plenty of good outcomes to survive it.

Do patients ever come in with catastrophic bleeds but fully or functionally recover?

Catastrophic is relative. Plenty of people coming in with operative bleeds recover well especially those under 65. in patients who have germination into the brainstem a small subset do well cognitively but with motor deficits.

 

[mmmcdowe]

I was wondering how much impact your undergrad has on getting into a top med school ? regardless of whether or not i have good stats from a number 60-ish university wouldnt the top med schools only take the kids from the top schools like theirs. Also what about the role that med school plays on NS residency? does it play a big role? thank you

I went to Arizona State and went to Columbia and also got into a number of other top schools. Ultimately personal excellence is the primary factor, but yes school name does have some effect, especially the high volume feeder schools because top programs will very very familiar with the standards and performance of those students. Medical school also plays a role in residency. Again, merit ultimately supercedes all things but it does give a boost.

 

[Lawpy]

Thanks for doing this. How often do you get to do endovascular procedures?

And from your expertise, how would you distinguish between endovascular neurosurgery and interventional neuroradiology based on scope, procedures, cases etc.?

Thanks and sorry if this was mentioned earlier. Just interested and would like to know more.

 

[mmmcdowe]

Thanks for doing this. How often do you get to do endovascular procedures?

And from your expertise, how would you distinguish between endovascular neurosurgery and interventional neuroradiology based on scope, procedures, cases etc.?

Thanks and sorry if this was mentioned earlier. Just interested and would like to know more.

We have an infolded fellowship tract that you can do and rack up a few thousand of them. I pursued other interests so I only did a few dozen. There is no hardline difference between the two except the inability to cover to open and place evds. Individual differences from the educational background may exist but are not concrete

 

[afib123]

How much research would you recommend to have a good chance of getting in? I scored in 250s on step 1. I have 6 presentations that are not neurosurgery research from the first 2 years.
I am working on 1 neurosurgery project which I should be done with data collection next week and hopefully publish. If not publish, for sure will get a poster presentation out of it.
I can probably work on 1-2 more neurosurgery projects by interview season. Will this be enough? Do I need more research? Would you recommend case reports as a easy way to get more research?
Would really appreciate your input.

 

[afib123]

Also, sorry for the double post but how do third years strengthen their application before applying to neurosurgery. My step 1 is in the 250s and have been trying to get honors/near honors for 3rd year grades. what else can I be doing/should I be doing come fourth year or even this year?

 

[mmmcdowe]

At least 3 papers to be average. Yes a case report isn't a bad thing to help bolster the numbers.

How much research would you recommend to have a good chance of getting in? I scored in 250s on step 1. I have 6 presentations that are not neurosurgery research from the first 2 years.
I am working on 1 neurosurgery project which I should be done with data collection next week and hopefully publish. If not publish, for sure will get a poster presentation out of it.
I can probably work on 1-2 more neurosurgery projects by interview season. Will this be enough? Do I need more research? Would you recommend case reports as a easy way to get more research?
Would really appreciate your input.

 

[mmmcdowe]

AOA and research. Building relationships with residents and attendings.

Also, sorry for the double post but how do third years strengthen their application before applying to neurosurgery. My step 1 is in the 250s and have been trying to get honors/near honors for 3rd year grades. what else can I be doing/should I be doing come fourth year or even this year?