Is the neurosurgical residency program harder than general surgery?

[drbruce]

General surgery is considered a really tough program to complete, a five year hard slog and at the end, if the stories are to be believed, most surgeons limp over the finish line, but I was just wondering how the residency compares to the mighty neurosurgery.

In terms of developing the necessary surgical skills, is neurosurgery really the hardest field in medicine? And in what way is neurosurgery much harder than the other surgical specialities?

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[Winged Scapula]

General surgery is considered a really tough program to complete, a five year hard slog and at the end, if the stories are to be believed, most surgeons limp over the finish line, but I was just wondering how the residency compares to the mighty neurosurgery.

In terms of developing the necessary surgical skills, is neurosurgery really the hardest field in medicine? And in what way is neurosurgery much harder than the other surgical specialities?

Having never tried to master necessary neurosurgical skills (save for the occasional trauma burr hole or ventric drain placement), I cannot comment on how hard that is.

However, IMHO, neurosurgery residency is particularly hard because of the work load. Most programs take no more than 1-2 residents per year, yet they often, especially at programs with a lot of trauma, have the same number of patients to see as the non-neurosurg residents do. While I would often complain about keeping neurosurg trauma patients on the trauma service, frankly I had a lot more help in the way of gen surg residents (as well as a few ED and Anesthesia) than they did.

 

[toxic-megacolon]

Agreed, neurosurgery residency is also more demanding b/c of the call schedule. Although rarely inhouse call, you are on home call anywhere between 15-25 nights per month, and often come in EVERY night for some sort of consultation. Cases are often LONNGGG and you rarely leave at a reasonable time. And you are always tied to your damn pager, which WILL go off a LOT more often than ENT or Uro. At most programs anyway. With general surgery, because call is so often in house, your call schedule is usually never more frequent than Q3, and you have many "protected" evenings where you can go home without a pager to worry about.

 

[Winged Scapula]

Agreed, neurosurgery residency is also more demanding b/c of the call schedule. Although rarely inhouse call, you are on home call anywhere between 15-25 nights per month, and often come in EVERY night for some sort of consultation. Cases are often LONNGGG and you rarely leave at a reasonable time. And you are always tied to your damn pager, which WILL go off a LOT more often than ENT or Uro. At most programs anyway. With general surgery, because call is so often in house, your call schedule is usually never more frequent than Q3, and you have many "protected" evenings where you can go home without a pager to worry about.

I think it depends on where you are - at my residency, a level 1 trauma center, the neurosurg residents were in house every night. Only the Chief resident took home call.

As for general surgery having "protected" evenings, only for junior residents. Once you become Chief of Service, that pager never gets turned off. Thank goodness for fellowship! 😉

 

[toxic-megacolon]

I think it depends on where you are - at my residency, a level 1 trauma center, the neurosurg residents were in house every night. Only the Chief resident took home call and as you noted, often has to come in when there was a Neurosurg consult, especially in the Trauma Bay for someone needing to go to the OR.

As for general surgery having "protected" evenings, only for junior residents. Once you become Chief of Service, that pager never gets turned off. Thank goodness for fellowship! 😉

Interesting... Its opposite at my program, the Neurosurg residents jr/sr/cheif only take home call, and the chiefs take in-house call Q7 only with no home call.

 

[Winged Scapula]

Interesting... Its opposite at my program, the Neurosurg residents jr/sr/cheif only take home call, and the chiefs take in-house call Q7 only with no home call.

RE: General Surgery Chiefs without home call.

Interesting. So who does the junior, in-house resident, call with problems on the patients? The Chief is/was responsible for taking all calls from the in house junior residents, about problems, questions, etc. Some services required the Chief to come in and see new admissions, regardless of the time (although that wasn't supposed to be the case, some faculty haven't changed their ways). Nurses would also call if they felt they weren't getting the right answer from the junior resident, or just would rather speak to the Chief (especially early in the intern year, or with residents they didn't like).

In the old days, our Chiefs never took in-house call, but once the 80 hr work week started, the 4th years (who took the most in house call, because they were responsible for running the traumas), needed some assistance in the trauma Bay. Thereafter, the Chiefs were in-house about twice a month, and back-up trauma call twice a month (which often meant coming in anyway) and took service back up call every night (unless there was a fellow, with whom you could alternate back up service call).

Neurosurg was too busy a service not to have someone in house to cover the patients, although often if it was a Neuro trauma in the SICU, the Trauma or SICU residents would be called first anyway. But in the summer time especially, given our rate of blunt trauma and pediatric stuff, the Nsgy residents would be coming in every hour - better just to stay in house, IMHO!

 

[W06]

Like most people have mentioned, hours and patient workload really depends on the program. And home-call can really suck when it's just a new invention to maintain a program's 80-hr complaince and not have to send you home "post-call" the next day.

In tems of "necessary surgical skills," there are definitely other surgical specialities that require very fine motor control. Microvascular anastamosis in plastic surgery and plenty of ENT procedures require delicate surgeries, however neurosurgery is definitely doing much of its work consistently under the scope. And rarely are other surgeons dealing consistenly in real-estate where minimal error (or just unavoidable adverse events) leads to paralysis, death, etc. Clipping an aneurysm exemplifies this - you get an intra-op rupture and the patient is devestated.
I am biased, but I also think that neuroanatomy (be it in the head or peripherally) is some of the most complex anatomy to master, and that's part of why it takes 7 years to become a neurosurgeon.

But the bottom line is, surgical residencies are hard, regardless (though uro, ent are often a bit less strenuous). You need to pick a specialty that you love, otherwise it won't be tolerable. NSGY and gen-surg are very different sets of pathologies, patients, procedures, and residency styles. Go for what you love, it's gonna be a long hard road in any residency.

My PGY1 NSG 2 cents.

 

[daisyduke]

Apologies to others for getting a little off topic, but for Dr. Cox:

At our program, there is a PGY4 who is always in house and acts as the "chief." PGY4s are always the "chief" on the trauma srvice. I haven't seen any situations where they've needed backup, but our attendings are closeby and will come in very quickly to backup the 4 if need be. (In theory). Our hospital is small, which probalby helps makes this possible. Overnight there is a 4, 2/3, and intern, the 2/3 covering the ICUs, intern covering the floor, and the 4 who runs the traumas and assists the intern or junior resident on call. All that said, I'm sure that a PGY5 will come in for an emergency lap if there is a particular patient they are worried about, but its more a choice and not call.
I have no idea what would happen if someone herniates in the ER at 2am, becuase there is no neurosurg in house. Come to think of it, is that even allowed at a level one trauma center???

 

[mpp]

The criteria for Level 1 Trauma center designation from the American College of Surgeons is an attending general surgeon and anesthesiologist in house at all times plus the specialty surgeons and other support such as ortho, neurosurg and radiology "readily available", whatever that might mean.

 

[Celiac Plexus]

The neurosurgery residents at my institution seem to be the most stressed of the surgical residents. That may be because there is only one resident per year.

As for the length of the residency: 6-7 years... that's about the same amount of training as, or less than, most general surgery based specialties, e.g. surg onc, vascular, prs, cts, laparoscopy, trauma.

I think how hard a residency is, depends mainly on the resident's perspective. If a surgical resident is truly interested in his/her chosen field, than it's not too bad. I know satisfied residents in all the surgical fields, including neurosurgery.

If the brain, and surgery, are your things, then don't get hung up on the hype.

Best of luck.

 

[Winged Scapula]

Apologies to others for getting a little off topic, but for Dr. Cox:

At our program, there is a PGY4 who is always in house and acts as the "chief." PGY4s are always the "chief" on the trauma srvice. I haven't seen any situations where they've needed backup, but our attendings are closeby and will come in very quickly to backup the 4 if need be. (In theory). Our hospital is small, which probalby helps makes this possible. Overnight there is a 4, 2/3, and intern, the 2/3 covering the ICUs, intern covering the floor, and the 4 who runs the traumas and assists the intern or junior resident on call. All that said, I'm sure that a PGY5 will come in for an emergency lap if there is a particular patient they are worried about, but its more a choice and not call.
I have no idea what would happen if someone herniates in the ER at 2am, becuase there is no neurosurg in house. Come to think of it, is that even allowed at a level one trauma center???

Thanks. Its very different depending on volume and need. While we always have a 4th year in house as well, it is not uncommon for the 5th year who serves as backup to have to come in - eg, if the 4th year has to go to the OR and someone needs to be in-house to cover trauma, multiple bad traumas, etc. And there are of course some services which want THEIR Chief to come in and see new patients, admissions, patients with problems rather than having the in-house 4th year see the patient.

Our 4th year in house is not supposed to act as Chief for all services, just for Trauma that night and for whatever service he/she normally covers. The "true" Chief of each service is expected to keep his/her pager on for calls, etc. from the juniors in-house - hence my comment that it is not true that as a senior or Chief resident you get to turn your pager off. At least not in my experience!

RE: herniating in the middle of night - it happens and when it does, I'm glad there is neurosurg in house!

 

[Winged Scapula]

The criteria for Level 1 Trauma center designation from the American College of Surgeons is an attending general surgeon and anesthesiologist in house at all times plus the specialty surgeons and other support such as ortho, neurosurg and radiology "readily available", whatever that might mean.

There is some lee-way with the term "readily available". In our case, a Level 1 Trauma Center, we had an attending anesthesiologist in house but the attending surgeons (neuro, general, ortho, etc.) and interventional radiologists had to be within 5 minute drive from the medical center. Otherwise, it was in-house radiology, ortho, neuro, and gen surg residents. The diagnostic radiology attendings were "available" by tele-radiology - guess that suffices when there were questions.

 

[drbruce]

If neurosurg services is in such high demand, why do programs limit the number of training places to 1 or 2.

We have the same problem in England. There is not enough neurosurgeons to go around.

 

[Chronic Student]

I've always heard it termed "Birth Control". Keep the number of positions low and it keeps the demand high.

High demand = More money, prestige, power, exclusivity, etc. Maybe thats a bit cynical, but I really don't think so.

-Mike

 

[Celiac Plexus]

I've always heard it termed "Birth Control". Keep the number of positions low and it keeps the demand high.

High demand = More money, prestige, power, exclusivity, etc. Maybe thats a bit cynical, but I really don't think so.

-Mike

More likely, residency positions are set based on the minimum operative volume that can sustain a residency. There are a lot more appendectomies, and gallbladders to do than berry aneurysms to clip, which is illustrated by the fact that there are 5-6 times more general surgery residents than there are neurosurgery residents.

The thought that academic surgeons are so coordinated, and unified, so as to all agree to subjugate the interests of their training programs to hopefully limit the supply of fully-trained surgeons (which would benefit private not academic surgeons more anyway) is specious at best. Remember, a chairman of a surgery department is more likely to desire a bigger program, with more cases, and more residents, and more research, etc... I doubt that chairmen spend time trying to devise a way to reduce operative volume, and number of residents available to do work/research.

 

[W06]

Actually, the other post was correct about the desire to limit the number of neurosurgeons to maintain income and demand. It has nothing to do with what a chairman wants, it has to do with what the governing body of a specialty wants. The AANS or CNS desides how many positions for residents there are nation wide, and then applies the decisions to programs. Every chairman wants a bigger program, but not at the expense of enlarging the overall field and diluting demand, he wants to pick up spots that other programs are getting rid of.

Simple supply and demand.

 

[Chronic Student]

CP, I was not referring to 'birth control' as some codified idea and organizing force behind the scenes. I meant it in a much more general way than that.

-Mike

 

[dry dre]

Actually, the other post was correct about the desire to limit the number of neurosurgeons to maintain income and demand. It has nothing to do with what a chairman wants, it has to do with what the governing body of a specialty wants. The AANS or CNS desides how many positions for residents there are nation wide, and then applies the decisions to programs. Every chairman wants a bigger program, but not at the expense of enlarging the overall field and diluting demand, he wants to pick up spots that other programs are getting rid of.

Simple supply and demand.

Ditto. Ortho is guilty of this. There is a huge surplus of ortho cases limping around outside the hospital. Of the programs I am familiar with, if there is a relative lack of cases, it is because of a lack of interest or staffing in taking on the extra cases (e.g. joints needing replacement, tons of sports-type injuries, the endless supply of degenerative spines).

It's not the chairmen individually...it's the ethos of the field to include the lack of interest at the local level of operating more, even though the cases are out there to do.

 

[Celiac Plexus]

Perhaps I am wrong on this point. But I'm not really convinced that the number of training positions is based on the desire to maintain income based on a vague notion of supply vs. demand.

There is a very well-done study out of UPenn that looked at many factors that drive health care costs. It was completed around 1998 or 1999 I believe, and I don't remember the title of the resultant paper. One noted conclusion was that more physicians meant more health care costs. They found that the belief that income was related to the relative supply of physicians was false. They found that the more physicians there are, the more billing is generated, thus higher costs.

The confusing maze of American healthcare expenditures is dynamic though. And I admit I'm not an expert in this field. However it seems simplistic to attribute the number of training positions to a desire to limit doctor supply.

One other thought is that it is a lot easier to cut a position from a problematic program than it is to add a position. One of the subspecialty programs at my institution spent about a decade battling to add just one training position per year to their program.

There are probably many other reasons why the number of training positions for a given field doesn't change much year to year. I'm sure there are more informed sdners out there on this topic than I am.