Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
I saw that a lot of people were posting threads with information about their specialty for current/prospective medical students. I remember benefitting from these kinds of resources when I was a student. With the MS2s now starting their clinical year, I wanted to add another write-up for neurosurgery. I’m currently a PGY-6 resident in neurosurgery at a busy program and have really enjoyed the field as well as my time in residency. I think that this is a specialty about which people have a lot of preconceptions and I remember having a difficult time getting honest and accurate information. Several of these definitely discouraged me from exploring the specialty as a medical student but I’m very glad that I did. To that end, I wanted to start the writeup by debunking a couple of these:

1. “As a neurosurgeon you’re on call all the time and can’t have a life.” This was probably the most common (and now that I’m approaching the end, most inaccurate) of them all. In the vast majority of practices, attendings take call in 1 week intervals. While there is the occasional job out there where call is 1:4 or less, none of my friends or co-residents have accepted positions with more than 1:6 call (and most are 1:8+). This means that you’re free from the pager for over A MONTH at a time before your turn comes up again. You can take weekend trips with your family, spend your nights doing your hobbies, go out to restaurants, etc. Of course, if something happens to one of your patients, you’ll get a courtesy call/text to give you the heads up (as any good doctor would want to know), but you’re not up in the middle of the night driving to the hospital when you’re not on call.

Furthermore, the vast majority of hospitals in practice are not the level I trauma warzones that you cover in residency. If you choose to go into private practice (or academics outside of busy metro areas), the actual call burden can actually be fairly light (a few phone calls at night without OR cases). If you have a strong interest in trauma and want to be heavily involved in that you certainly can, but the vast majority of neurosurgeons are not doing this.

2. “The outcomes are awful and all the patients are always dying.” Having now gone through training, I can confidently say that this certainly isn’t true. Are there certain conditions that are particularly devastating? Sure, severe TBI/DAI, SAH, and ICH patients can be very sick and frequently don’t do well. However, I’ve had tons of subdural/epidural hematoma patients bounce back and leave the hospital, grateful that you saved their life. GBM patients have a poor prognosis. However, they’re very gratifying to work with and you’re hopefully buying them several more months of life. Furthermore, when you do neuro-oncology, you’ll have TONS of patients with pituitary tumors, meningiomas, and low grade gliomas who often do well and are incredibly grateful. On vascular you’ll place WEB devices into unruptured aneurysms and the patients will literally walk out the door the next day, completely intact. AVM patients who undergo gamma knife and fistula patients who you do an embolization for and are then cured. This isn’t even getting into functional/epilepsy where the outcomes are phenomenal and you’re curing people of seizures and disabling tremor. The majority of spine patients tend to do very well too.

Tl;dr as a neurosurgery attending, regardless of subspecialty, your practice will mostly consist of interesting pathology where most patients actually do very well after surgery.

3. “Residency is impossible to get through with all the call and malignancy.” The biggest thing I didn’t realize as a medical student is just how much heterogeneity there is among residency programs. If having a quality life outside the hospital as a resident and a good resident culture is important to you, there are numerous programs that you can target (Barrow, Mayo Clinic, Michigan, Miami, Yale, etc..) If you want a significant emphasis on research you can easily find that. Similarly, if you want to eschew research and operate all day every day there are programs for you as well. If you know what you are looking for ahead of time, you can target those programs via away rotations, phone calls from your mentors, etc. At some of the programs above, in house call is either condensed into a single year (with no in house call later) or spread out so much that you can have a very reasonable life as a resident that is comparable or even exceeds the schedules of other surgical specialties. Are there programs where you’re worked into the ground with insane schedules and bad personalities? Sure, but you can easily find out what they are and avoid them.

4. “Doing a SEVEN YEAR residency is just crazy and not worth it.” 7 years sounds like a very long time when you just say that number to someone. However, if you want to be a specialist in medicine in general, you’re looking at a minimum of 6 years of post-graduate training. The vast majority of orthopods do a fellowship (6 years total). Radiology? 6 years (5+1). If you want to be a cardiologist, you’re looking at 6 years minimum (7-8 if you want to do interventional with an additional structural fellowship), 6 for oncology, 6 for GI (+1 for advanced endoscopy), etc. Luckily in neurosurgery, the trend is now to “enfold” your fellowship into your residency. Many programs have 1-2 years of elective time, and you can often move this year to the 7th year while doing chief year as a PGY-6, so that you’re fellowship trained after 7.

5. "Neurosurgeons end up divorced, on their fourth spouse and paying tons of alimony/child support." This is a classic characterization that is fortunately only widespread on internet forums and not in real life. Just as an example, in my program ~90% of the residents are married. Among the attendings, only 1 isn't married. The rest have a rich home life with tons of hobbies, nice vacations, doing stuff with their kids. One of our tumor guys coaches his kids' baseball team (schedules practices on clinic days and his light OR one). Remember that as an attending you have 2 days of clinic/week that usually runs 8-4 unless you're on call that week and have an add on case.

I'm not sure where this stereotype came from, but I remember being worried about this as a med student. Probably from the 1970s/80s, when residents exclusively consisted of young men who married at an early age because that was the socially acceptable thing to do and then got worked in the surgical culture at that time. Are there some neurosurgeons who work themselves to death and end up divorced? Sure, but then again so can anyone. My dermatologist (N=1) is now twice divorced and paying child support. YOUR life is what YOU make of it.

Now for the actual subspecialties. The majority of neurosurgeons end up subspecializing in one of the following areas. Some like to combine different elements (eg. epilepsy + brain tumors) which is often done in academics.

Neuro-oncology: A wide variety of benign and malignant tumors. In academics, most people classifying themselves as this do a lot of glioma surgery (vs. skull base). Cases can range from simple cortical metastases to complex insular lobe gliomas. There are many cool toys, including fluorescence-guided surgery, laser interstitial thermal therapy, etc. as well as a variety of treatment options, including biologics and radiation. Most people subspecializing in this enjoy doing research and make it a part of their practice, as basic science tumor research is what often advances the field.

Skull-base: Also often involves tumors, as well as some vascular lesions deep within the brain. These are some of the most challenging/long cases, and involve lesions around key vascular and neural structures. Some substantial variety here as well, with lots of endoscopic, key-hole approaches, as well as traditional complex approaches (like far-laterals for foramen magnum meningioma and orbitozygomatic).

Open vascular: Although the case volumes are falling due to the advent of endovascular, this seems to remain a popular fellowship option among residents. Includes the classic aneurysm clipping, as well as open resection of AVMs, cavernous malformations, etc. A much more popular approach is to become “dual trained” where residents try and log many open cases during residency and pursue an endovascular fellowship enfolded in order to offer patients both options.

Endovascular: Has exploded in the last decade. Involves using wires and catheters to treat a lot of the lesions mentioned above. Tons of new devices coming out, seemingly every year. Mechanical thrombectomy for large vessel occlusion has revolutionized the treatment of stroke. Similarly, innovations like the WEB device have replaced even coiling for a lot of wide-necked aneurysms. A lot of variety in diseases/interventions, including carotid stenting, pipeline devices, stent-assisted coiling. In very high demand, as many hospitals prefer to have a dual trained neurosurgeon who can run an endovascular service but also perform open surgery when needed. Lots of opportunities to partner with device companies.

Pediatrics: A huge array of diseases (including tumors, hydrocephalus, congenital malformations, spine problems, etc.) This is a fellowship that you cannot enfold, and you would have to do an ACGME accredited PGY-8 year. A lot of these patients actually end up doing very well (even if they do require a shunt revision, ha!)

Spine: This includes the huge gamut of surgeries, ranging from huge osteotomies for deformity correction to MIS decompressions through a tube. Going through any neurosurgery residency, you will be extremely comfortable with the majority of spine at graduation. If you’re interested in this and you pick the right program, you could even graduate with an advanced skill set (complex deformity, lateral approaches, etc.)

A note on neurosurgery vs. ortho for spine. It is true that for a lot of bread and butter spine, experienced attendings in both specialties have similar cases and do a similarly great job. In addition, many big names in academic spine are traditionally orthopods, like Lenke (although he gives half of his fellowship spots to neurosurgeons), Vaccaro, etc. However, there are several advantages to being a neurosurgeon. First, in private practice, a lot of community hospitals couple head and spine trauma call, so the job market as a neurosurgeon tends to be significantly better, especially in desirable places to live that are more saturated (we only graduate ~200 neurosurgeons/year and your services are desperately needed). Second, if you’re interested in any type of intradural work (eg spine tumors), you would need to go the neurosurgery route. For me, the brain was a lot more interesting than general ortho, and I know that I would personally prefer to have a complex spine practice mixed in with an occasional subdural evacuation or brain tumor than doing general ortho call.

Neurocritical care: Can often become certified through neuro-ICU rotations during residency. Also in high demand as you can operate as well as manage the sickest of patients.

Functional: Can operate to treat an array of diseases (Parkinson’s, essential tremor, even pain). Fans of this field like to say that it has some of the best “future potential” (current trials of DBS for addiction, OCD, and even chronic pain are ongoing). A lot of people who go this route tend to incorporate a lot of research as well.

Income: This is a taboo topic and should be lower on your list of things to consider when picking a field. However, I’ve always believed in transparency as this is real life and most medical students have a substantial amount of debt. In addition, neurosurgery is often excluded from most salary surveys that med students look at (like Medscape, Merritt Hawkins) because we’re a small specialty and the sample size is too small.

If you know where to look, there are some neurosurgery specific surveys, and I’ve reported the results here:

Mean private practice/employed: $889,000; 25th percentile: $525,000 and 75th percentile: $1,021,000

Median academic: $647,000

On call pay: Level 1 daily rate: $2,466, level 2: $2,000, level 3: $1,385.

I’m hopeful that more medical students see how great of a specialty it is. Based on the match data last year (75% match rate among US senior MDs) it looks like it has become even more competitive. I really hope more of you look into this specialty (especially those considering other surgical subspecialties) without dismissing it just based on what someone’s perceptions may be regarding outcomes and lifestyle. Best of luck to you in your medical careers!

Feel free to ask any questions.
 
Last edited:
  • Like
Reactions: 41 users

JoaoMoutinho

2+ Year Member
Jun 10, 2016
359
586
Status
  1. MD/PhD Student
Thanks for posting. In your experience, how many successful surgeon-scientists have you seen? It's difficult to run a lab and see patients no matter what you do, but I've always been told it's exceptionally difficult in surgery. Since you seem to have had a different experience than the stereotype for your field, can you comment on how many people you have seen successfully do both research and surgery?
 
  • Like
Reactions: 1 user
About the Ads

odyssey2

7+ Year Member
Jul 30, 2013
339
424
Status
  1. Medical Student
“Skullcutter69”
Are there 68 other skullcutters here or did you just like that number for some reason?

jk this was great and super informative
 
  • Like
Reactions: 5 users

Tangerine123

2+ Year Member
Aug 18, 2017
140
139
Status
  1. Medical Student
Really good constructive post!

Sadly this meme is real. The MS1 Syndrome.

st,small,845x845-pad,1000x1000,f8f8f8.jpg
Looking back, I laugh every time I remember that half of my class wanted to go into Neurosurgery (including me). Many of them dropped out in MS1.

Honest and wholesome posts like this can give insight to people that have no idea what they are talking about.
 
  • Like
Reactions: 1 user
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
It’s really less than that after all the alimony and child support.

Thank you this is actually very helpful. I knew I forgot to include one. I originally had 5 misconceptions in mind.

5. "Neurosurgeons end up divorced, on their fourth spouse and paying tons of alimony/child support." This is a classic characterization that is fortunately only widespread on internet forums and not in real life. Just as an example, in my program ~90% of the residents are married. Among the attendings, only 1 isn't married. The rest have a rich home life with tons of hobbies, nice vacations, doing stuff with their kids. One of our tumor guys coaches his kids' baseball team (schedules practices on clinic days and his light OR one). Remember that as an attending you have 2 days of clinic/week that usually runs 8-4 unless you're on call that week and have an add on case.

I'm not sure where this stereotype came from, but I remember being worried about this as a med student. Probably from the 1970s/80s, when residents exclusively consisted of young men who married at an early age because that was the socially acceptable thing to do and then got worked in the surgical culture at that time. Are there some neurosurgeons who work themselves to death and end up divorced? Sure, but then again so can anyone. My dermatologist (N=1) is now twice divorced and paying child support. YOUR life is what YOU make of it.
 
  • Like
  • Care
Reactions: 6 users

FalconSlice

7+ Year Member
Feb 23, 2012
600
591
Intersection of CutCo, EdgeCom and InterSlice
Status
  1. MD/PhD Student
Thank you this is actually very helpful. I knew I forgot to include one. I originally had 5 misconceptions in mind.

5. "Neurosurgeons end up divorced, on their fourth spouse and paying tons of alimony/child support." This is a classic characterization that is fortunately only widespread on internet forums and not in real life. Just as an example, in my program ~90% of the residents are married. Among the attendings, only 1 isn't married. The rest have a rich home life with tons of hobbies, nice vacations, doing stuff with their kids. One of our tumor guys coaches his kids' baseball team (schedules practices on clinic days and his light OR one). Remember that as an attending you have 2 days of clinic/week that usually runs 8-4 unless you're on call that week and have an add on case.

I'm not sure where this stereotype came from, but I remember being worried about this as a med student. Probably from the 1970s/80s, when residents exclusively consisted of young men who married at an early age because that was the socially acceptable thing to do and then got worked in the surgical culture at that time. Are there some neurosurgeons who work themselves to death and end up divorced? Sure, but then again so can anyone. My dermatologist (N=1) is now twice divorced and paying child support. YOUR life is what YOU make of it.
This is true. However, I think everyone should be weary of "you can have it all!" type advice. Not saying that's what you're saying, but at the end of the day, it's about priorities, and some things have to give.
 
  • Like
Reactions: 2 users
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
Thanks for posting. In your experience, how many successful surgeon-scientists have you seen? It's difficult to run a lab and see patients no matter what you do, but I've always been told it's exceptionally difficult in surgery. Since you seem to have had a different experience than the stereotype for your field, can you comment on how many people you have seen successfully do both research and surgery?

This is a really great question. It truly comes down to a few things: a) what kind of a research setup you want and b) what subspecialty you go into. Just like within medicine in general, there are some subspecialties that are particularly amenable to being a busy physician-scientist. Hematology-oncology, for example, is really popular among IM residents because a lot of tenure-track faculty jobs facilitate a huge portion of protected research time that revolves around clinic. In neurosurgery, the 2 fields where this is very common is neuro-oncology (in particular, focusing on intra-axial gliomas) and functional. For people who want to do tumor, it really becomes a nice synergy of always having access to tissues and direct correlations to intraoperative findings and pathology. A lot of research around tumor markers, fluorescence-guided surgery, liquid biopsy, etc. can be translated directly within your practice. These folks are always involved in tumor boards, interdisciplinary trials with med-onc/rad onc, and collaboration with PhDs. There are many successful brain tumor neurosurgeons around the country who have independent R01s and their own basic science lab. Usually they have 1-2 days of protected research time, and then a mix of clinic/OR days. They usually go back to the lab after their clinic days to check in with their post-docs and experiments that day. In functional, there is a good mix of researchers who study basic neuroscience (eg dopamine pathways) and more translational things like new neurostimulators, clinical trials, etc. They're heavily involved with the neurology department that works with movement disorder patients. There are numerous functional neurosurgeons around the country with independent R01s as well and have been very successful in building up DBS practices. It is true that there are fewer true neurosurgeon-researchers in spine surgery as well as vascular. Some of this can be attributed to the types of cases (a lot of these cases are longer, patients need more frequent follow-up) but there's also a cultural component as well. A lot of these individuals tend to self select and prefer to operate a lot and minimize basic science research but you can certainly find well-funded investigators in both.
 
  • Like
Reactions: 2 users
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
This is true. However, I think everyone should be weary of "you can have it all!" type advice. Not saying that's what you're saying, but at the end of the day, it's about priorities, and some things have to give.

Completely agree with you. You definitely *can't* have it all. If you want to have a busy basic science lab with multiple R01s, the busiest clinical practice with the most RVUs in your group, AND be the department chair with multiple national leadership positions, you're not going to have free time. The same goes for many other fields in medicine. If you want to be the chair of GI with multiple grants and president of the AGA, you won't have a lot of time for your family. What I'm saying is that *clinical neurosurgery* as an attending and even at a good number of residency programs is not in any way, shape, or form the kiss of death to your social or home life, and is quite similar to that of our colleagues in ENT, ortho, urology, some IM subspecialties, etc.
 
Last edited:
  • Like
Reactions: 1 user

dr_kateb

Membership Revoked
Removed
2+ Year Member
Mar 23, 2017
1,034
2,377
Status
  1. Pre-Medical
It’s really less than that after all the alimony and child support.

This implies that neurosurgery is the cause my hypothetical wife and children hating me as opposed to internal factors that made me choose neurosurgery and caused the divorce and etc. ;)

Also even though we're joking here, I'd rather keep half of 800K than keep half of say.... 300K.
 
  • Like
Reactions: 1 users

giguerex35

2+ Year Member
Apr 7, 2017
652
332
Status
  1. Medical Student
This is a really great question. It truly comes down to a few things: a) what kind of a research setup you want and b) what subspecialty you go into. Just like within medicine in general, there are some subspecialties that are particularly amenable to being a busy physician-scientist. Hematology-oncology, for example, is really popular among IM residents because a lot of tenure-track faculty jobs facilitate a huge portion of protected research time that revolves around clinic. In neurosurgery, the 2 fields where this is very common is neuro-oncology (in particular, focusing on intra-axial gliomas) and functional. For people who want to do tumor, it really becomes a nice synergy of always having access to tissues and direct correlations to intraoperative findings and pathology. A lot of research around tumor markers, fluorescence-guided surgery, liquid biopsy, etc. can be translated directly within your practice. These folks are always involved in tumor boards, interdisciplinary trials with med-onc/rad onc, and collaboration with PhDs. There are many successful brain tumor neurosurgeons around the country who have independent R01s and their own basic science lab. Usually they have 1-2 days of protected research time, and then a mix of clinic/OR days. They usually go back to the lab after their clinic days to check in with their post-docs and experiments that day. In functional, there is a good mix of researchers who study basic neuroscience (eg dopamine pathways) and more translational things like new neurostimulators, clinical trials, etc. They're heavily involved with the neurology department that works with movement disorder patients. There are numerous functional neurosurgeons around the country with independent R01s as well and have been very successful in building up DBS practices. It is true that there are fewer true neurosurgeon-researchers in spine surgery as well as vascular. Some of this can be attributed to the types of cases (a lot of these cases are longer, patients need more frequent follow-up) but there's also a cultural component as well. A lot of these individuals tend to self select and prefer to operate a lot and minimize basic science research but you can certainly find well-funded investigators in both.
can you talk about what you did to actually match NSurg. I am extremely interested in the field but find that it is just stupid competitive. I mean i remember reading that the average matched applicant had like 6+ publications (not exact number) and if you do not have a home NSurg program it is rather difficult to find related research and even harder to find a neurosurgeon who will write a letter for you.
 
About the Ads
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
can you talk about what you did to actually match NSurg. I am extremely interested in the field but find that it is just stupid competitive. I mean i remember reading that the average matched applicant had like 6+ publications (not exact number) and if you do not have a home NSurg program it is rather difficult to find related research and even harder to find a neurosurgeon who will write a letter for you.

This is a little bit of a tough question for me to answer from a medical student perspective, just because it's been so long since I was applying. I took Step I in something like 2011. I am involved in reviewing applications though and helped pick our new class last year. The number one piece of advice I always give is to first and foremost excel in your academics before adding anything extra. You're a medical *student* and your job is to be the best possible student you can be. This is reflected in your USMLE scores and clinical grades. I was lucky in that I got a 260 something and AOA at my med school. You should try and honor as many rotations as you can. Once that piece is taken care of, you're right in that letters of recommendation are the next most important component of your application (honestly probably equal to your academics). In order to get strong letters you need to either a) rotate at a program and do very well, or in a more surefire way b) identify a mentor in neurosurgery and work with them on research over a long period of time. In my case I took a year off. Back in the day we had Howard Hughes and Doris Duke where you could work with a big name academic neurosurgeon for a year and hopefully publish research. This was important in not only generating academic output (I think I applied with 10 papers maybe?) but developing meaningful relationships with faculty that resulted in strong letters and a phone call to programs you wanted to go to. If your medical school doesn't have a neurosurgery department, I would implore you to take a year off at a well known academic program and work with a productive mentor. If you go to a strong medical school with a great department, it is possible to go straight through with proper planning by starting research early (M1 year, slow down for Step 1 dedicated, and then pick back up again M3 year). I know that Step I is becoming pass/fail for you, but I know we're requiring CK the year that this happens so you'll still have a test you'll need to take a few months off to study for. Best of luck!
 
  • Like
Reactions: 4 users
Feb 20, 2019
98
105
This is a little bit of a tough question for me to answer from a medical student perspective, just because it's been so long since I was applying. I took Step I in something like 2011. I am involved in reviewing applications though and helped pick our new class last year. The number one piece of advice I always give is to first and foremost excel in your academics before adding anything extra. You're a medical *student* and your job is to be the best possible student you can be. This is reflected in your USMLE scores and clinical grades. I was lucky in that I got a 260 something and AOA at my med school. You should try and honor as many rotations as you can. Once that piece is taken care of, you're right in that letters of recommendation are the next most important component of your application (honestly probably equal to your academics). In order to get strong letters you need to either a) rotate at a program and do very well, or in a more surefire way b) identify a mentor in neurosurgery and work with them on research over a long period of time. In my case I took a year off. Back in the day we had Howard Hughes and Doris Duke where you could work with a big name academic neurosurgeon for a year and hopefully publish research. This was important in not only generating academic output (I think I applied with 10 papers maybe?) but developing meaningful relationships with faculty that resulted in strong letters and a phone call to programs you wanted to go to. If your medical school doesn't have a neurosurgery department, I would implore you to take a year off at a well known academic program and work with a productive mentor. If you go to a strong medical school with a great department, it is possible to go straight through with proper planning by starting research early (M1 year, slow down for Step 1 dedicated, and then pick back up again M3 year). I know that Step I is becoming pass/fail for you, but I know we're requiring CK the year that this happens so you'll still have a test you'll need to take a few months off to study for. Best of luck!

Sort of piggybacking off of your response. I'm an M1 at a t5/t10 med school interested in a competitive specialty (not gonna name it for anonymity). My school's home department in this specialty is pretty good, but another med school in the same city has the number one ranked program for this specialty, and I would very much like to do residency at this other program. I've already started doing research at this outside program in hopes of developing some solid connections there. Meanwhile, how important do you think it is for me to also develop connections at my home institution's department? I don't want to "burn any bridges" so to speak, so should I also reach out to faculty in my home program and work with two mentors? My school is all p/f and there's no AOA until after the match, so I'm trying to focus a lot of my time on things like research and crushing step 2.
 
  • Like
Reactions: 1 user

libertyyne

5+ Year Member
Mar 5, 2015
10,949
21,793
Status
  1. Medical Student
What are your thoughts on overutilization of spinal fusions in private practice?

How about the culture of neurosurgery?
 
  • Like
Reactions: 2 users
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
Sort of piggybacking off of your response. I'm an M1 at a t5/t10 med school interested in a competitive specialty (not gonna name it for anonymity). My school's home department in this specialty is pretty good, but another med school in the same city has the number one ranked program for this specialty, and I would very much like to do residency at this other program. I've already started doing research at this outside program in hopes of developing some solid connections there. Meanwhile, how important do you think it is for me to also develop connections at my home institution's department? I don't want to "burn any bridges" so to speak, so should I also reach out to faculty in my home program and work with two mentors? My school is all p/f and there's no AOA until after the match, so I'm trying to focus a lot of my time on things like research and crushing step 2.

This is the perennial predicament among NYC medical students interested in ortho. There are so many great med schools in New York: Columbia, NYU, Mount Sinai, etc. but everyone seems to want to do research at HSS. My big piece of advice is that you can do that IF, and only if, this doesn't take away from building a meaningful relationship with a faculty member at your home program. At the end of the day, you're going to need a letter from your department chair that's going be mostly based on the work you've done with an attending at your program (they'll write about this and then include nice quotes about you). On the interview trail, people will be calling *your* home program to get information about you (admittedly some places, including us, will call all your letter writers) but the focus will be on your med school's faculty since you'll be "the NYU kid" or "the Columbia guy." This isn't even getting into the hypothetical political pitfalls, where when you sit down with your chair pre-ERAS and explain to them that you've only been pumping out papers for a rival institution. Of course, it's possible to do both: have most of your projects going at your home med school and have a few with an outside mentor, but if something has to give due to time constraints, I'd prioritize your home program unless you have very unique circumstances (really significant personal relationships/connections to the other place).
 
  • Like
Reactions: 4 users
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
What are your thoughts on overutilization of spinal fusions in private practice?

How about the culture of neurosurgery?

I actually think that the shady PP spine stuff is a little bit outdated. Of course, there are always going to be unscrupulous people in every specialty (there was recently a huge Medicare ophthalmology fraud case). A lot of what people have traditionally criticized about spine surgery (surgery for low back pain/no clear imaging correlate, surgery for black disc disease, etc.) is already banned by insurers (eg they simply won't reimburse for what they see as non-indicated surgery). Payers have really tightened the screws in regard to that kind of stuff. In addition, there's actually more and increasingly better evidence for a lot of spine surgeries (vs. 10 years ago when there was barely any). There was a recent NEJM RCT showing the benefits of microdiscectomy vs. medical management for chronic sciatica in disc herniation.

In terms of culture, this is what I was getting at in my previous post. I genuinely don't think that there's a specific "culture" in this specialty. The residents in my program are all SO different. In addition, there are SO many different residency programs. I didn't and couldn't imagine this as a student and I also thought that different fields had different personalities (neurologists are nerds, neurosurgeons are mean workaholics, etc.) but that's complete BS. Are there some residencies that are work-hard programs with strict hierarchy and meaner attendings? Definitely. But there are also a lot of programs that value lifestyle and where you're unlikely to be yelled at all of residency. This is the case in all surgical subspecialties. One of my best friends is in ENT and there are some ENT programs where you're worked into the ground with really mean residents in every class. This is something you should consider when you're deciding on where to apply and rank, NOT when picking a specialty. This is even more obvious now that I've signed my first job offer. After residency, you can truly pick your partners and the exact individuals you're going to be working with. You will absolutely be able to find your people. It's deciding *what* you do for the rest of your life that matters at your stage.
 
  • Like
Reactions: 2 users

7331poas

5+ Year Member
Jun 16, 2015
2,819
3,431
Status
  1. Medical Student
What are some other specialties you considered other than neurosurg?

Any tips for matching neurosurgery?
 

IMG69

2+ Year Member
May 11, 2017
295
253
Status
  1. Medical Student
Where do you see the biggest growth in the field over the next 10 years and what area do you predict to have the most significant advances happening? Functional?

(Sorry if you already answered, haven't had time to read through everything)

Thanks a lot for this post - i'm looking at going into Neuro trama/crit care myself
 

JoaoMoutinho

2+ Year Member
Jun 10, 2016
359
586
Status
  1. MD/PhD Student
This is a really great question. It truly comes down to a few things: a) what kind of a research setup you want and b) what subspecialty you go into. Just like within medicine in general, there are some subspecialties that are particularly amenable to being a busy physician-scientist. Hematology-oncology, for example, is really popular among IM residents because a lot of tenure-track faculty jobs facilitate a huge portion of protected research time that revolves around clinic. In neurosurgery, the 2 fields where this is very common is neuro-oncology (in particular, focusing on intra-axial gliomas) and functional. For people who want to do tumor, it really becomes a nice synergy of always having access to tissues and direct correlations to intraoperative findings and pathology. A lot of research around tumor markers, fluorescence-guided surgery, liquid biopsy, etc. can be translated directly within your practice. These folks are always involved in tumor boards, interdisciplinary trials with med-onc/rad onc, and collaboration with PhDs. There are many successful brain tumor neurosurgeons around the country who have independent R01s and their own basic science lab. Usually they have 1-2 days of protected research time, and then a mix of clinic/OR days. They usually go back to the lab after their clinic days to check in with their post-docs and experiments that day. In functional, there is a good mix of researchers who study basic neuroscience (eg dopamine pathways) and more translational things like new neurostimulators, clinical trials, etc. They're heavily involved with the neurology department that works with movement disorder patients. There are numerous functional neurosurgeons around the country with independent R01s as well and have been very successful in building up DBS practices. It is true that there are fewer true neurosurgeon-researchers in spine surgery as well as vascular. Some of this can be attributed to the types of cases (a lot of these cases are longer, patients need more frequent follow-up) but there's also a cultural component as well. A lot of these individuals tend to self select and prefer to operate a lot and minimize basic science research but you can certainly find well-funded investigators in both.
What a baller response. Thank you! My research interests definitely lean toward the basic science side–the setup you mentioned of a few protected days for research and then checking in on the lab after clinic is pretty close to the balance I want, and I didn't think that was possible in surgery, especially not neurosurgery. Glad to know there are more ways to get to where I want to go than I had previously thought.
 
  • Like
Reactions: 1 users
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
What are some other specialties you considered other than neurosurg?

Any tips for matching neurosurgery?

I considered most of the surgical subspecialties honestly. I did electives in both ortho and ENT. I enjoyed ortho (especially spine and joints) but didn't really like the content of the other subspecialties. As far as the non-spine fellowships, I realized that brain tumors and head trauma were much more interesting to me than foot & ankle, ligament tears in sports medicine, hand, etc. Also (at least at the home program at my med school at the time), the ortho residency was actually more brutal in a lot of ways than the neurosurgery one. Just goes to show you how programs are very different, even within the same specialty. I knew that it would take me 1 extra year in neurosurgery (7 vs. 6 in ortho or ENT) but that I'd graduate with a unique skill set and had a genuine interest in the majority of the field. Hopefully I answered how to be competitive in my post above.

A note to those interested in spine. When I was applying it was very common to receive advice along the lines of: "if you're interested in spine, go the ortho route because it's 1 fewer year and an easier residency." Having now almost finished the program here I emphatically disagree. Not only can you equalize the lifestyle component by picking the right program, but you'll have a much more enjoyable time in residency. Almost 70% of neurosurgery is spine, and at my program (admittedly among the better ones in terms of OR exposure) we were doing basic 2 level lamis C-L by PGY-2 and were helping with hardware. By the end of PGY-4, I was doing ACDFs, C2-T2, OC fusions alone skin to skin. As a PGY-6, you're doing VCRs, 3 column osteotomies, and ALIFs/XLIFs/OLIFs. If that's what you're interested in, you can graduate with over 1,000 spine cases and be extremely well prepared for whatever you want to do (including tumor and deformity). While spine surgeon distribution varies tremendously by region, you'll find that the job market tends to be better for neurosurgery-trained spine folks since you can offer both head and spine call services, even in bigger metro areas.
 
  • Like
Reactions: 2 users
About the Ads
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
Where do you see the biggest growth in the field over the next 10 years and what area do you predict to have the most significant advances happening? Functional?

(Sorry if you already answered, haven't had time to read through everything)

Thanks a lot for this post - i'm looking at going into Neuro trama/crit care myself

Good question. I think that expanded indications for functional to more common conditions like mood disorders, metabolic disorders, etc. is definitely up there. I think that regenerative medicine as well as operations to restore function (combination of peripheral nerve and spine) will continue to advance. MIS will get better, with superior cages and better fusion techniques through smaller incisions. Endovascular will continue to make huge advances as devices and delivery systems continue to get better to treat more complex aneurysms and carotid disease.

Best of luck to you!
 
  • Like
Reactions: 1 user
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
What steps should an M1 take to make themselves competitive enough to match?

Be the best medical student that you can possibly be. Make sure that studying is your priority #1, 2, and 3. Even with Step I becoming pass/fail, you should learn the material as well as you can since this absolutely comes back during third year clerkships and shelf exams (which will now be worth a lot more). Students who study well from the beginning excel throughout the rest of their med school careers since pathophys builds on itself and you won't have as much time to study when you're on the wards. Since we and a lot of other programs will be requiring CK, it may make sense to start studying for that a lot earlier (maybe even before clerkship year but I'm honestly not the best person to give advice on logistics). AFTER you feel comfortable with doing well in your classes, then choose a mentor in neurosurgery who does the work that you're interested in and try to develop a meaningful, long-term working relationship with them (research during the summer after M1, go to conferences, etc.)

Good luck to you.
 
  • Like
Reactions: 2 users
May 19, 2019
147
316
Status
  1. Pre-Medical
To whom would you recommend Neurosurgery and for whom would you say it is a mistake? I came into med school this year thinking I want to do ortho or psych. Ortho mostly because of loving the attitude I saw amongst folks working in the field when I shadowed some and because I think its the coolest thing ever to see someone come in broken and leave whole or on the way to whole. Psych because I think mental health is fascinating and because I have had many personal reasons for it. Just a month in I had a clinical experience where a third year performed a ventriculostomy and it blew my mind no pun intended. Now I am sitting here studying a bunch of viruses while thinking about that procedure and thinking how epic it was and wondering whether I should seriously consider your field however also knowing that the lifestyle I often hear attributed to Nsgx doesn't really align with the one I want.

Thoughts?
 
  • Like
Reactions: 1 user

longhaul3

2+ Year Member
Feb 29, 2016
987
1,875
To whom would you recommend Neurosurgery and for whom would you say it is a mistake? I came into med school this year thinking I want to do ortho or psych. Ortho mostly because of loving the attitude I saw amongst folks working in the field when I shadowed some and because I think its the coolest thing ever to see someone come in broken and leave whole or on the way to whole. Psych because I think mental health is fascinating and because I have had many personal reasons for it. Just a month in I had a clinical experience where a third year performed a ventriculostomy and it blew my mind no pun intended. Now I am sitting here studying a bunch of viruses while thinking about that procedure and thinking how epic it was and wondering whether I should seriously consider your field however also knowing that the lifestyle I often hear attributed to Nsgx doesn't really align with the one I want.

Thoughts?
It is a mistake for people who don't really like neuroanatomy, don't like critical care, and/or care about or expect to follow duty hours.

The EVD is the undisputed king of bedside procedures and is a lot of fun, but you get tired when you do 4 back to back overnight and then have to manage the patients' other problems—they're septic, they have 5 large scalp lacs that need to be repaired, they need to be intubated, they need a central line, they need another scan, they have a c-spine injury and you have to book them for the OR. The biggest lifestyle issue in neurosurgery is not necessarily that the procedures are long and complicated, but rather that the patients are so sick. Most of the time we can't just drop an EVD and peace out, because with an EVD it is by definition an ICU patient and we often provide the ICU care. This is grueling in a way that ortho is not. If all we saw were elective spine, functional, and tumor cases, our lives would be much easier.

But residency is not the rest of your career, and you can leave the critical care to others as an attending. There are not many attendings who will come in at 3am to drop an EVD, so in that regard the lifestyle isn't as bad as people make it out to be. They will just round on the patient in the morning and then go to the OR for their normally scheduled cases.
 
  • Like
Reactions: 3 users
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
To whom would you recommend Neurosurgery and for whom would you say it is a mistake? I came into med school this year thinking I want to do ortho or psych. Ortho mostly because of loving the attitude I saw amongst folks working in the field when I shadowed some and because I think its the coolest thing ever to see someone come in broken and leave whole or on the way to whole. Psych because I think mental health is fascinating and because I have had many personal reasons for it. Just a month in I had a clinical experience where a third year performed a ventriculostomy and it blew my mind no pun intended. Now I am sitting here studying a bunch of viruses while thinking about that procedure and thinking how epic it was and wondering whether I should seriously consider your field however also knowing that the lifestyle I often hear attributed to Nsgx doesn't really align with the one I want.

Thoughts?

Interesting question. I think it would be a mistake for anyone not interested in working with their hands, the overall flow of surgery (waking up early to round and write notes, operating most of the day, and then checking on your patients again in the afternoon), and having a combination of OR/clinic as an attending. I think an interest in the brain, neuroscience, and some degree of research to advance the specialty (even if it's surgical outcomes) helps because there's always so much new that's going on, but it isn't an absolute requirement. Like the previous poster said, neurosurgery (like CT surgery, trauma, peds surgery, etc.) has some degree of medical thinking and management, including critical care. Once again, however, there's definitely a very broad spectrum of residency programs, ranging from places with open ICUs (where neurosurgery manages all the patients there) to programs where neuro-intensivists co-manage with you and do the majority of the work. One or two places even has hospitalist teams that do all the medical management for you (rare).

If you love surgery, brain anatomy/neuroscience, and like a wide array of interesting pathology, you should definitely consider neurosurgery. I think ortho is a great specialty but to me was a lot more boring and the problems much more rote. Keep in mind too that there are some ortho programs where you get crushed with frequent in house call and weekend rounding too. A ton will depend on which program you decide to train at. You should pick the field that has the diseases you want to treat and the types of surgeries that you want to do. The difference between ortho and neurosurgery is not *that* different to justify doing it just for the perceived better lifestyle. If you really don't want to wake up or have any late nights ever, then that's a different story and you should pick a (like non-surgical) specialty that will facilitate that.
 
  • Like
Reactions: 1 users
Jan 11, 2020
54
35
Status
  1. Medical Student
How bad does not honoring surgery look assuming you do well on other rotations?

Haven't finished surgery yet, just curious tbh.
 
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
What advice to you have for an MS1 interested in the field? Is there anything they can do now to start building a good app for Neurosurg programs?

I think that the best advice I ever got applies to all medical students interested in a competitive specialty. You should work as hard as you can to be the best medical *student* that you can be. You're not there to be a research assistant or volunteer. You're here to be a *student*. You should work on establishing a study routine (covering up powerpoints, making flashcards, previewing lectures, or any other myriad of techniques that exist) so that you're retaining the material and doing well on exams. IF and only IF you've identified a routine that allows you to stay on top of the material and do well do you add on all the extras: identifying a good mentor in your specialty of interest based on mentorship style and research focus (ideally you'd know a resident or older student who can tell you how available they are), working on a research project or 2 on the side, submitting things to conferences (AANS, CNS, subspecialty meetings), shadowing/spending extra time with the residents, etc.

I cannot emphasize enough how important it is to have your academics tucked away before devoting a lot of time to other things. You cannot redo medical school (classes, USMLEs, clerkships, AOA) but you absolutely can do an extra year of research if you need more papers or letters from well-known faculty.
 
  • Like
  • Love
Reactions: 8 users
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
How bad does not honoring surgery look assuming you do well on other rotations?

Haven't finished surgery yet, just curious tbh.

It depends a little bit on the program. I think not honoring surgery would definitely not do you any favors and you could get asked about it. I'd really try and save yourself the trouble and study in advance. I remember people made their schedules in a way so that they had surgery last after they had already learned all the extra material that's on the shelf.

Good luck!
 
  • Like
Reactions: 1 user
About the Ads

MilesDavisTheDoctor

2+ Year Member
Jul 26, 2017
104
46
Status
  1. Medical Student
Lol every time I think I've decided I want to do ortho instead of neurosurgery I find a post from a nice neurosurgeon on sdn who dispels all of my negative preconceived notions about the field and makes me want to do it all over again. What would you say are the negative things about neurosurgery?

PS. I heard that enfolded fellowships were going away and were a thing of the past? Your post seems to strongly contradict this.
 
Last edited:
  • Like
Reactions: 1 user
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
Lol every time I think I've decided I want to do ortho instead of neurosurgery I find a post from a nice neurosurgeon on sdn who dispels all of my negative preconceived notions about the field and makes me want to do it all over again. What would you say are the negative things about neurosurgery?

PS. I heard that enfolded fellowships were going away and were a thing of the past? Your post seems to strongly contradict this.

Ha, happy to help. You'll find that once you become a resident that most of those stereotypes are silly, and that it would be ludicrous to allow them to influence your career. No, most orthopods aren't dumb jocks. They're actually really smart, and for the most part normal people. Most plastic surgeons aren't money hungry, cosmetic-focused people despite what you might have heard or seen on TV. You'll find a wide array of personalities and it depends a whole lot more on the specific program than the field.

In terms of negatives, there are several that I think are inherent to a serious surgical specialty. OR days can be physically taxing on your body, especially over time and using loupes (fatigue, neck pain, etc.) You have to get used to waking up very early to round in the morning (a lot earlier than non-surgical specialties). The pressure is high, as well as the stakes, especially early on in residency when you aren't very familiar with all the approaches and techniques. You still have to study a lot, and small class sizes/extremely talented people can make you feel like you're treading water in residency. As a surgeon, you're responsible for your patients and how they do, which is an awesome responsibility but can definitely sting if you don't have a great outcome (fortunately, this isn't very common but happens to even the very best surgeons).
 
  • Like
Reactions: 1 users

yungspleen

5+ Year Member
Oct 12, 2014
506
331
North Carolina
Status
  1. Medical Student (Accepted)
Endovascular: Has exploded in the last decade. Involves using wires and catheters to treat a lot of the lesions mentioned above. Tons of new devices coming out, seemingly every year. Mechanical thrombectomy for large vessel occlusion has revolutionized the treatment of stroke. Similarly, innovations like the WEB device have replaced even coiling for a lot of wide-necked aneurysms. A lot of variety in diseases/interventions, including carotid stenting, pipeline devices, stent-assisted coiling. In very high demand, as many hospitals prefer to have a dual trained neurosurgeon who can run an endovascular service but also perform open surgery when needed. Lots of opportunities to partner with device companies.

I know you're on the neurosurgery side but as a future radiology resident interested in NIR, what's the job market look like for me? Would I be able to land a job doing endovascular in a big city as a rads-trained fellow or do they prefer mostly NSGY. Also, what's call schedule like for this? is it in weekly blocks like you described or is it Q3?
 
Jan 11, 2020
54
35
Status
  1. Medical Student
What are intern hours typically? In at 4 out at 6? Also what are the junior and senior call schedules normally? q3-4 for in house typically? Thanks!!
 
  • Like
Reactions: 1 user
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
I know you're on the neurosurgery side but as a future radiology resident interested in NIR, what's the job market look like for me? Would I be able to land a job doing endovascular in a big city as a rads-trained fellow or do they prefer mostly NSGY. Also, what's call schedule like for this? is it in weekly blocks like you described or is it Q3?

Endovascular is a completely different world, with its own separate thrombectomy call pool and techniques. At least at the institutions I know about, those guys are on 1 week at a time but they really do Q3/Q4 weeks. How bad it is depends on where you're located. If you have few strokes and predominantly an elective practice (a bunch of diagnostics, unruptured aneurysms, carotids, fistulas, etc.) it can be OK. The alternative is pretty tough since you're waking up a lot.

My co-resident is doing vascular and by the sounds of it the job market on the NSG side is amazing, but definitely does favor neurosurgeons by a long shot. It makes a lot more sense for the hospital to hire a dual trained NSG person, since they can fix any complication and offer open treatments. A lot of times places will hire radiology-trained folks since they need more bodies in the call pool but most of the procedures get referred to neurosurgery. I'm not sure how the job market is for purely rads trained interventionalists, especially in more saturated markets.
 
Last edited:
  • Like
Reactions: 1 user
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
What are intern hours typically? In at 4 out at 6? Also what are the junior and senior call schedules normally? q3-4 for in house typically? Thanks!!

This completely depends on the program. Some places frontload in house call, where you're working 4:30/5AM-6 PM and taking Q4 call for a year, but then don't take any in house call after that and just bounce once your cases are over. Some places spread it out over 3-4 years, but you take in house call something like Q10. Most programs are something in between. Chief call is more frequent (Q3/4 depending on the class size), but it's only for 1 year and at that point you're only coming in if it's an operative case since you have someone in house to take care of most things. Overall, every year of residency gets significantly better than the previous one.
 
  • Like
Reactions: 1 user

MilesDavisTheDoctor

2+ Year Member
Jul 26, 2017
104
46
Status
  1. Medical Student
Aren't enfolded fellowships not being done anymore or being discontinued soon? If this really was an option it would be great but i've heard its going away
 

yungspleen

5+ Year Member
Oct 12, 2014
506
331
North Carolina
Status
  1. Medical Student (Accepted)
Endovascular is a completely different world, with its own separate thrombectomy call pool and techniques. At least at the institutions I know about, those guys are on 1 week at a time but they really do Q3/Q4 weeks. How bad it is depends on where you're located. If you have few strokes and predominantly an elective practice (a bunch of diagnostics, unruptured aneurysms, carotids, fistulas, etc.) it can be OK. The alternative is pretty tough since you're waking up a lot.

My co-resident is doing vascular and by the sounds of it the job market on the NSG side is amazing, but definitely does favor neurosurgeons by a long shot. It makes a lot more sense for the hospital to hire a dual trained NSG person, since they can fix any complication and offer open treatments. A lot of times places will hire radiology-trained folks since they need more bodies in the call pool but most of the procedures get referred to neurosurgery. I'm not sure how the job market is for purely rads trained interventionalists, especially in more saturated markets.

What's typical salary like for endovascular? Idk if you can speak to whether a rads-trained endovascular would make a similar amount?
 
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
Aren't enfolded fellowships not being done anymore or being discontinued soon? If this really was an option it would be great but i've heard its going away

Sorry I missed that last part where you asked this. No, in fact it's actually the exact opposite. It's now becoming increasingly common to do your chief year as a PGY-6 and then an enfolded fellowship as a PGY-7. Numerous programs are making their formal curriculum so that you *have to* do an enfolded fellowship (or research if you want) (eg. Miami, Duke, etc.) and a lot of places, while not official, will allow interested residents to make that switch. It makes a lot of sense because unlike 5-10 years ago, where people did "enfolded fellowships" as a PGY-4/5, you have the exact same operative skills after PGY-6 chief year as you would had you taken an elective research year and done chief as a 7. From that standpoint it makes a lot of sense that this is where neurosurgery is heading, since many places will still give you elective/research time, and now you can be fully subspecialty trained after 7 years. What you may have heard is that CAST, the current accrediting body for enfolded fellowships, may be going away. This is true, but it's simply a technically, since it's going to be absorbed by the ABNS and the Society of Neurological Surgeons, which will then accredit them. Most neurosurgery fellowships (with the exception of peds, which is through ACGME) are internally accredited anyway. All that matters (for academic positions and some select private groups) is that you're fellowship trained, which you'll easily be able to do at a number of great places.
 
  • Like
Reactions: 1 user
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
So do most people not do fellowships post residency now?

Depends on their career goals. Most residents who go into private practice don't do any fellowships post-residency. You will easily get a job in any area of the country without one. Everyone who wants to do pediatric neurosurgery has to do a post-graduate year. Some people who want a high-powered academic job in a specific subspecialty may opt to do a post-graduate fellowship in their area (eg the Lawton open vascular fellowship, the USF van Loveren skull base one, etc.) In recent years, like I mentioned, a lot of people are doing enfolded fellowships at their own program and going into academics or private practice. If you want to do endovascular and be CAST accredited, you'll need to look at programs with 2 elective years and enfold both years within your residency. There are so many options and varieties, a lot just depends on what you want to do.
 
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
What's typical salary like for endovascular? Idk if you can speak to whether a rads-trained endovascular would make a similar amount?

Very high. Based on the looks of it, even higher than spine in some cases (150-300K above the neurosurgery mean). I know that neuro IR folks make somewhat more than their DR/IR counterparts, but I can't imagine it approaching neurosurgery money, since you're offering a fundamentally different skill set. A dual trained neurosurgeon can bring any hospital a very lucrative elective practice and revenue stream, on top of taking endovascular and cranial call. Neuro IR folks can take thrombectomy call, read scans on the side, and maybe try and get their hands on some elective endovascular cases. The latter is hard to do in any metro area since referrals usually go through neurosurgery and patients are evaluated and followed up in clinic where the decision for endo vs. open vs. radiation is made.
 

MilesDavisTheDoctor

2+ Year Member
Jul 26, 2017
104
46
Status
  1. Medical Student
You mentioned a big misconception in the field is that the patient outcomes aren't really that bad. Can you go into a little more detail on what types of conditions have good outcomes and what percent of your cases those make up for the avg neurosurgeon? Neurosurgeons often talk about spine having good outcomes but I've always found that weird because outside of the neurosurgeon community everyone seems to think spine outcomes are really bad(ie. even some orthopods with spine training, so they should kinda know what they are talking about, all say spine has the worst outcomes in ortho and in general isn't very good).
 
  • Like
Reactions: 1 user
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
You mentioned a big misconception in the field is that the patient outcomes aren't really that bad. Can you go into a little more detail on what types of conditions have good outcomes and what percent of your cases those make up for the avg neurosurgeon? Neurosurgeons often talk about spine having good outcomes but I've always found that weird because outside of the neurosurgeon community everyone seems to think spine outcomes are really bad(ie. even some orthopods with spine training, so they should kinda know what they are talking about, all say spine has the worst outcomes in ortho and in general isn't very good).

You ask a very profound and interesting question. It really comes down to what "good outcomes" mean to you. To me, a good outcome is the delta between what a patient presents with and what your intervention is able to do for them after. For example, if you're removing people's moles (- melanoma), treating simple acne that goes away with benzoyl peroxide, or giving someone allergy shots that take care of their seasonal allergies, are you achieving good outcomes? From one perspective, sure, they were relatively healthy at baseline and remained that way but I'm sure you would agree that the context of an intervention and outcome is important. Depending on your view, ortho subspecialties like sports and hand have "the best outcomes", because you're bringing someone's shoulder function from 70 to 90%, or cutting the flexor retinaculum and their carpal tunnel goes away. To me, complex spine or total joints provide a feeling of doing much more for patients, because even though you have higher rates of infection and other complications, you're taking people who can't walk, breathe, or have devastating pain on narcotics to a functional quality of life. The reason many ortho residents shy away from spine is multifactorial, and a big component is that sports and hand allow you to have a solely outpatient practice (since you're doing such minor surgery that you don't need a hospital) on top of not liking the cases themselves (personal preference). As an aside, spine surgery is changing dramatically and patient selection is absolutely critical. If you're operating on people with chronic back pain and no imaging correlate, you have nobody but yourself to blame when they come back with more chronic back pain (ie a bad outcome). In addition, a lot of spine procedures like simple laminectomies are moving into ambulatory surgery centers, and quite a few surgeons I know (including in neurosurgery) spend the majority of their time at these, akin to their ortho colleagues.

With that being said, it isn't all sunshine and roses in neurosurgery. We have a number of surgeries that have poor outcomes. Surgery for glioblastoma can result in significant deficits, with an almost certain mortality over the next 2 years. You're buying them 6-8 months with their loved ones, but no one will deny that the outcome remains poor. Some people love tumor surgery but I know that this won't be a large part of my practice. Some head trauma patients you get on call can have bad outcomes, with significant problems with seizures and disability even if you save their life. Nevertheless, I submit that the majority of patients have a great outcome. I just went back several months to look at the cases we did during a 1 week span:

-Microvascular decompression (x6): trigeminal neuralgia patients were taking mega doses of AEDs and gabapentin with crippling pain. All had a large vessel pressing on the trigeminal. 4/6 completely off of medications and pain free. The rest significantly reduced meds and doses.
-Carotid endarterectomy (x2): High-grade stenosis, now resolved. No complications. Discharged home.
-Meningioma (x3): All large tumors pressing on the brain. 1 still had a slight foot drop, the rest have no deficits and are grateful to be tumor-free.
-Temporal lobectomy (x2): Crippling seizures pre-op. 1 now seizure free, 1 with only visual auras that are much less frequent.
-ETV (x3): Kids with hydrocephalus. 3/3 now resolved (although to be fair, this can recur in the future and still require a shunt).
-Pilocytic astrocytoma in a child presenting with hydro: complete resection, zero deficits postop.
-Laser interstitial thermal therapy (LiTT) for epilepsy (x4): 2/4 seizure resolution, 2/4 significantly decreased.
-Large pituitary adenoma (x4): 4/4 complete resection, no deficits or CSF leak.
-DBS for essential tremor (x2): Significantly improved (could see this in the OR after placing leads).
-GBM (x2): Unilateral weakness postop in 1. Poor outcomes as I wrote above.
-Crani for SDH (x5): 2/5 have no deficits. Another 2 have persistent neuro deficit and/or seizures. 1 was a polytrauma and didn't make it for other reasons.
-Wound washouts (x3): infection now resolved.
-ASIA B jumped facets: Still plegic in lowers. Poor outcome following major trauma (not much you can do in this case).
-Infratentorial supracerebellar approach to pineal tumor: Gross total, great outcome.

Spine: Too many to even list here. 2-3 level ACDFs, cervical disc arthroplasty, posterior cervical decompressions, tons of lumbar laminectomies, 2 deformity cases that were high cervical-pelvis with great correction, etc. All had a great outcome (- the major trauma on call).

In short, yes you can get some cases on call (traumas) that are outside of your control and have a poor outcome regardless of what you do. However, I'd still say that >50% of the on call cases I do have a good outcome. Spine can be whatever you want it to be. You can have an extremely fulfilling, diverse practice of MIS, deformity, and complex degenerative spine, including disc arthroplasty with predominantly good outcomes. If you're interested in more challenging, high-risk surgery, you can do spine tumors (yes, some of these will have worse outcomes due to the disease itself). You can also do basic spine decompressions, and practice in a predominantly outpatient setting with good outcomes.
 
  • Like
Reactions: 8 users

MilesDavisTheDoctor

2+ Year Member
Jul 26, 2017
104
46
Status
  1. Medical Student
@Skullcutter69 That was a fantastic answer, I really can't thank you enough for taking the time to write such a great response. You said that the residents in your class mostly got contracts with 1:6 and 1:8 call which sounds like a pretty solid deal. About how many hrs/wk do you think your cohort was working post residency?
 
Sep 21, 2020
51
182
Status
  1. Resident [Any Field]
@Skullcutter69 That was a fantastic answer, I really can't thank you enough for taking the time to write such a great response. You said that the residents in your class mostly got contracts with 1:6 and 1:8 call which sounds like a pretty solid deal. About how many hrs/wk do you think your cohort was working post residency?

It's my pleasure. I wanted to spend some time making this thread because I remember what it was like to be in your shoes. I grew up without much of anything. No one in my family was in medicine. All the information I got about applying to college, med school, studying for Step 1, picking a specialty, etc. was all from online resources. There were some amazing people on here, even back in the day, who shared an incredible wealth of knowledge on how to succeed. I remember going through these threads, which not only shed light on what to do, but gave me even more motivation to keep grinding.

In terms of hours, it depends a little bit on your subspecialty. My good friends are a few years out of residency, and mostly in private practice. They have 3 OR days/week, and 2 clinic days. They conveniently make Thursday, Friday their clinic days so that most of the patients they operate on M-W are discharged from the hospital before Saturday, thereby minimizing weekend calls. OR days are usually 7:30 until whenever they're done with cases (turnover is much faster in the community, so they're usually done by 6). Clinic days are 9-4:30. Call is unpredictable as expected, with some weeks having 0 OR cases, and sometimes adding on 3-5/week.
 
  • Like
  • Love
Reactions: 9 users

Your message may be considered spam for the following reasons:

  1. Your new thread title is very short, and likely is unhelpful.
  2. Your reply is very short and likely does not add anything to the thread.
  3. Your reply is very long and likely does not add anything to the thread.
  4. It is very likely that it does not need any further discussion and thus bumping it serves no purpose.
  5. Your message is mostly quotes or spoilers.
  6. Your reply has occurred very quickly after a previous reply and likely does not add anything to the thread.
  7. This thread is locked.
About the Ads