Why you should consider neurosurgery - ask me anything

[dr_kateb]

Was the "69" in your name a conscious decision?

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[Skullcutter69]

Was the "69" in your name a conscious decision?

No haha I literally just typed some random numbers that I thought wouldn't already be associated with an account that's taken.

 

[Cardinals1999]

Have you noticed any difference in pay between male and female residents/attendings?

 

[Skullcutter69]

Have you noticed any difference in pay between male and female residents/attendings?

No. All residents at a given institution make the exact same amount/year that is solely dependent on how many years they've been a resident. As such, if you're a third year resident, male/female, dermatologist or heart surgeon in training, you make the same PGY-3 amount.

As an attending, the majority of private practice jobs are "eat what you kill" in that your income is directly proportional to the RVUs that you generate. Medicare as well as private insurers have no idea and don't care if you're a man or woman. As such, any differences in income that I've seen are either due to subspecialty choice (spine/vascular vs. functional/peds) or generating fewer RVUs (ie filling your week with fewer cases). Academic jobs are typically a set salary that is the same for all entry assistant professors for any given specialty.

 

[woktheline]

Hi @Skullcutter69,

This has been an absolute pleasure to read, even as someone not yet into the medical school/residency decision matrix, because I am increasingly thinking that Neurosurgery is my ultimate goal.

On that, I have a few specific questions about your career and life as a student earlier on:
1) What "clicked" about the specialty with you? I am (perhaps naively and without direct experience) drawn to the level of mastery available - the idea that what you do requires deliberate practice and the kinds of intense deep training reserved for other really skillful disciplines like concert violin, programming, etc. I am drawn to the appearance of direct translation of research to clinical care - I have a significant research background I would like to carry forward into my MD and beyond.

2) What did you do prior to medical school, regarding research, clinical and non-clinically to volunteer and set yourself apart as an applicant? Beyond the obvious work of stellar grades and MCATs, my PhD advisor (who's also an MD) where I am on leave says finding the right/meaningful experience can be huge for Adcoms at more selective med schools, which follows the chain of reasoning that to match with better neurosurg programs I would need to matriculate a more selective program.... etc. Do I need to contribute to something directly related to Nsurg or even neurology?

Thanks!

 

[CanIBeAnonymous]

Have you met any NSGs who have had zero interest in surgery all together until some experience (presumably a rotation) made them pack everything up and change trajectories?

 

[Calizboosted76]

Hello @Skullcutter69

Thank you for this post! I have read and reread it about 5 times.
So currently I will beginning medical school in the fall at an osteopathic school. The hospital that is associated with the school that I am attending has over 2 DO neurosurgeons working there. I plan to reach out to them once I have my classes and rhythm down. I have a LOR from a neurosurgeon who is very well known and I also had surgery when I was under 7 years old for a malformation that has been the sole reason for my drive to pursue medicine.

I realize that once I do rotations I may find something that is more interesting to me than neurosurgery and if that happens then okay and I am remaining open minded.

My question is, would my back story of having neurosurgery play any part in making my application more interesting if I end up applying to NSGY? Or did that "wow" factor of my story end with entrance to medical school? Will I need to draw more from my experiences in medical school as opposed to my history with NSGY?

 

[deleted393595]

Out of curiosity, is your program more oriented towards MIS approaches to the spine or in doing big open whacks?

Are they strongly polarized either way? Some programs I've been told feel that anything besides MIS is malpractice, whereas my program (especially our deformity surgeons) strongly favor big open whacks and feel that MIS is malpractice (especially since we get a lot of MIS screwups from OSH surgeons that we end up revising)

No haha I literally just typed some random numbers that I thought wouldn't already be associated with an account that's taken.

 

[Skullcutter69]

Out of curiosity, is your program more oriented towards MIS approaches to the spine or in doing big open whacks?

Are they strongly polarized either way? Some programs I've been told feel that anything besides MIS is malpractice, whereas my program (especially our deformity surgeons) strongly favor big open whacks and feel that MIS is malpractice (especially since we get a lot of MIS screwups from OSH surgeons that we end up revising)


View attachment 323534

We do a lot of both. We have a huge name in MIS as well as numerous amazing open and deformity surgeons. I find it incredibly hard to believe that someone would say that anything other than MIS is malpractice - a very large proportion of spine surgeons feel that the indications for MIS are quite narrow and that it is highly overused, with questionable ability to achieve adequate decompression and fusion in many patients. I personally love MIS and am fortunate that we get such a significant exposure to it during our training. I think every budding spine surgeon should be able to do the basic MIS approaches to have it in their toolkit for the right patient.

 

[Skullcutter69]

Hello @Skullcutter69

Thank you for this post! I have read and reread it about 5 times.
So currently I will beginning medical school in the fall at an osteopathic school. The hospital that is associated with the school that I am attending has over 2 DO neurosurgeons working there. I plan to reach out to them once I have my classes and rhythm down. I have a LOR from a neurosurgeon who is very well known and I also had surgery when I was under 7 years old for a malformation that has been the sole reason for my drive to pursue medicine.

I realize that once I do rotations I may find something that is more interesting to me than neurosurgery and if that happens then okay and I am remaining open minded.

My question is, would my back story of having neurosurgery play any part in making my application more interesting if I end up applying to NSGY? Or did that "wow" factor of my story end with entrance to medical school? Will I need to draw more from my experiences in medical school as opposed to my history with NSGY?

I think you should definitely have experiences in medical school (clinical, research) that you can draw on to support your decision to pursue neurosurgery. That being said, your personal story is important and can only help you in your personal statement and interviews.

 

[Skullcutter69]

Have you met any NSGs who have had zero interest in surgery all together until some experience (presumably a rotation) made them pack everything up and change trajectories?

I've definitely met people like that. Nowadays with SDN, early shadowing in undergrad, youtube videos, etc. a lot more people get exposed to at least the idea of being a surgeon before coming to medical school, and then have clinical and research experiences that further strengthen their desire to pursue this. That being said, I know several people in neurosurgery who simply loved their surgery experience during third year and then took an additional year off for research to strengthen their application prior to applying.

 

[Skullcutter69]

Hi @Skullcutter69,

This has been an absolute pleasure to read, even as someone not yet into the medical school/residency decision matrix, because I am increasingly thinking that Neurosurgery is my ultimate goal.

On that, I have a few specific questions about your career and life as a student earlier on:
1) What "clicked" about the specialty with you? I am (perhaps naively and without direct experience) drawn to the level of mastery available - the idea that what you do requires deliberate practice and the kinds of intense deep training reserved for other really skillful disciplines like concert violin, programming, etc. I am drawn to the appearance of direct translation of research to clinical care - I have a significant research background I would like to carry forward into my MD and beyond.

2) What did you do prior to medical school, regarding research, clinical and non-clinically to volunteer and set yourself apart as an applicant? Beyond the obvious work of stellar grades and MCATs, my PhD advisor (who's also an MD) where I am on leave says finding the right/meaningful experience can be huge for Adcoms at more selective med schools, which follows the chain of reasoning that to match with better neurosurg programs I would need to matriculate a more selective program.... etc. Do I need to contribute to something directly related to Nsurg or even neurology?

Thanks!

1) For me there wasn't a single romanticized "click" where I fell head over heels and knew in that exact moment that this is what I was going to do (like you see in so many personal statements). For me, neurosurgery just represented the perfect combination of the things I wanted to do. I loved surgery and wanted to work with my hands to make patients better. I really enjoyed neuroanatomy and the enormous breadth of neurosurgery, like cancer, cerebrovascular disease, bony spine work, trauma, functional (the actual content/pathology was the most interesting to me vs. something like ortho), and I really liked a lot of the other opportunities that you could pursue as a surgeon (involvement in everything from basic to clinical research, collaboration with device companies/clinical trials, the enormous future potential for innovation, etc.)

2) Unfortunately I'm too far away to give meaningful advice on medical school admissions. I will say that MD school admissions have very little overlap with residency applications (other than grades/scores). For med school, you want a stellar GPA, very high MCAT scores, and then boatloads of volunteering, clinical experiences, campus leadership positions, great letters, and research (for top schools). This doesn't need to be remotely related to anything neuro- you should do whatever research you're interested in that will allow you to be productive and get strong letters. For residency, absolutely no one cares about volunteering, leadership, or any of the checkboxes you have to hit in college. All that matters are your USMLE scores, clinical grades/AOA, *research output*, and letters from well known surgeons (which come from long-term relationships at your med school as well as performing well on away rotations). Good luck!

 

[longhaul3]

Out of curiosity, is your program more oriented towards MIS approaches to the spine or in doing big open whacks?

Are they strongly polarized either way? Some programs I've been told feel that anything besides MIS is malpractice, whereas my program (especially our deformity surgeons) strongly favor big open whacks and feel that MIS is malpractice (especially since we get a lot of MIS screwups from OSH surgeons that we end up revising)

MIS is cool for some stuff but I think it can get out of hand. If you're doing a 2-level TLIF I don't get why people get so excited about about doing it MIS. The open exposure is not huge and you can just do a nice fascial closure. Do it MIS and you end up with 7 incisions, one of which is almost as long as an open incision. I think it gets silly. For an XLIF, sure, because there's not a great open alternative. Then you can do your perc screws or whatever. I still like a classic open PSIF though.

 

[agiraffe999]

Hi Skullcutter69, thanks for taking the time out of your (very busy) day to do this! I have a few questions for you:
1) Whats your advice on maximizing academic output during medical school? Any specific research I should aim for, such as doing retrospective chart reviews, case report, bench research, etc?
2) Whats your "favorite" and "least favorite" surgery for you to do?

Hope everything else is going well for you. Thanks in advance!

 

[Skullcutter69]

Hi Skullcutter69, thanks for taking the time out of your (very busy) day to do this! I have a few questions for you:
1) Whats your advice on maximizing academic output during medical school? Any specific research I should aim for, such as doing retrospective chart reviews, case report, bench research, etc?
2) Whats your "favorite" and "least favorite" surgery for you to do?

Hope everything else is going well for you. Thanks in advance!

1) Great questions. I think it depends a little bit on your overall game plan for applying to residency. If you're starting early (and this means your academics are taken care of - you're doing well in school, studying consistently for the boards, etc.) I think it could be reasonable to go straight through without a research year. In that case you can focus your efforts on retrospective clinical studies (people love to hate on this but there are many phenomenal, clinically-impactful papers that come out in top journals every year from projects like this). Long-term hearing outcomes in acoustic neuromas after gamma knife? A med student/junior resident went back through a bunch of charts and got a great first-author paper in a top neurosurgery journal and guess what? Turns out that this is pretty important in patient counseling when they ask you what their options are to save their hearing. The key is having a great research question, and your mentor can help you with that.

If you're planning on taking a year off to do research, you can get involved in translational/basic science work. This can range from traditional bench research to AI/software or imaging that can be applied to neurosurgery. Under these circumstances, you'll usually be affiliated with a specific PI/lab (if you're devoting an extra year, try and make sure it's a well-known, connected neurosurgeon so you can maximize your advantages from the match on top of the research itself).

2) Tough question. I love a lot of different surgeries. I really enjoy challenging spine deformity cases but I also get a kick out of the traditional trauma crani/SDH evacuation. One of the nicest things about neurosurgery is that even mundane, bread and butter cases are very cool. Scooping a huge clot off of the brain is our equivalent to tubes/tonsils and appendectomy.

Best of luck!

 

[numbersloth]

Can you comment on training length - did this ever make you think twice about pursuing this specialty vs. shorter surgical subspecialties?

 

[Skullcutter69]

Can you comment on training length - did this ever make you think twice about pursuing this specialty vs. shorter surgical subspecialties?

No not at all. I touched on this a little bit in my original post:

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), 9 for peds surgery (7 gen surg at an academic program + 2 years fellowship) 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. When you look at this in relation to comparable specialties, it really isn't significantly longer.

 

[agiraffe999]

1) Great questions. I think it depends a little bit on your overall game plan for applying to residency. If you're starting early (and this means your academics are taken care of - you're doing well in school, studying consistently for the boards, etc.) I think it could be reasonable to go straight through without a research year. In that case you can focus your efforts on retrospective clinical studies (people love to hate on this but there are many phenomenal, clinically-impactful papers that come out in top journals every year from projects like this). Long-term hearing outcomes in acoustic neuromas after gamma knife? A med student/junior resident went back through a bunch of charts and got a great first-author paper in a top neurosurgery journal and guess what? Turns out that this is pretty important in patient counseling when they ask you what their options are to save their hearing. The key is having a great research question, and your mentor can help you with that.

If you're planning on taking a year off to do research, you can get involved in translational/basic science work. This can range from traditional bench research to AI/software or imaging that can be applied to neurosurgery. Under these circumstances, you'll usually be affiliated with a specific PI/lab (if you're devoting an extra year, try and make sure it's a well-known, connected neurosurgeon so you can maximize your advantages from the match on top of the research itself).

2) Tough question. I love a lot of different surgeries. I really enjoy challenging spine deformity cases but I also get a kick out of the traditional trauma crani/SDH evacuation. One of the nicest things about neurosurgery is that even mundane, bread and butter cases are very cool. Scooping a huge clot off of the brain is our equivalent to tubes/tonsils and appendectomy.

Best of luck!

Thanks for the lengthy reply! I'm currently doing some retrospective chart reviews, but there are hundreds (if not thousands) more patients to be sorted through. What advice would you have for someone who would like to become more productive/efficient in research?

Also, as an attending, what percent of the nights on call for cranial/spine would you have to go into the hospital for emergency surgery? Thanks again Skullcutter, this has been a great read.

 

[Lawpy]

No not at all. I touched on this a little bit in my original post:

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), 9 for peds surgery (7 gen surg at an academic program + 2 years fellowship) 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. When you look at this in relation to comparable specialties, it really isn't significantly longer.

What are your thoughts on the scope and future of interventional neurology?

 

[Skullcutter69]

What are your thoughts on the scope and future of interventional neurology?

Decreasing more and more with every passing year. Dual trained neurosurgeons have functionally taken over endovascular, partly because they're able to fix complications and offer surgical options for vascular problems. From a hospital's perspective, it makes much more sense to hire a neurosurgeon who can do it all. Of the non-neurosurgery trained folks, there are significantly more interventional radiologists than neurology-trained interventionalists (mostly for historical reasons, since they pioneered a lot of the techniques that are being used today).

 

[Skullcutter69]

Thanks for the lengthy reply! I'm currently doing some retrospective chart reviews, but there are hundreds (if not thousands) more patients to be sorted through. What advice would you have for someone who would like to become more productive/efficient in research?

Also, as an attending, what percent of the nights on call for cranial/spine would you have to go into the hospital for emergency surgery? Thanks again Skullcutter, this has been a great read.

Try and pick and choose your projects wisely. A retrospective chart review of thousands of patients (depending on how novel the question is) may not be the best use of a medical student's time. Alternatively, you could get some help from other students/research coordinators and all be on the paper.

For the second question, it *completely* depends on what kind of job you take after training. If you're at a busy metropolitan level I trauma center, you could be operating every night. If you're in a suburban community hospital/level III center, you might be fielding just a few phone calls at night.

 

[Lawpy]

Decreasing more and more with every passing year. Dual trained neurosurgeons have functionally taken over endovascular, partly because they're able to fix complications and offer surgical options for vascular problems. From a hospital's perspective, it makes much more sense to hire a neurosurgeon who can do it all. Of the non-neurosurgery trained folks, there are significantly more interventional radiologists than neurology-trained interventionalists (mostly for historical reasons, since they pioneered a lot of the techniques that are being used today).

That's interesting and a huge plus for nsgy. I was reading about CT vs interventional cards and how for some reason CT was dying for years from losing the turf wars to interventional guys until recently. But nsgy seems to be really versatile and knows how to be useful and effectively make interventional neuro an increasingly declining field

 

[Skullcutter69]

That's interesting and a huge plus for nsgy. I was reading about CT vs interventional cards and how for some reason CT was dying for years from losing the turf wars to interventional guys until recently. But nsgy seems to be really versatile and knows how to be useful and effectively make interventional neuro an increasingly declining field

Yep. That was a catastrophic mistake by the cardiac surgeons. Neurosurgery training is a lot more versatile, and with elective time at most programs, residents can meet their first year angio numbers quite easily. The open vascular skill set (carotid endarterectomy, microsurgical clip ligation, AVM resection) also complements endo quite nicely, in addition to the standard general neurosurgery things like hemicrani/suboccipital crani for stroke, ICH evacuation, etc.

 

[longhaul3]

What are your thoughts on the scope and future of interventional neurology?

Decreasing more and more with every passing year. Dual trained neurosurgeons have functionally taken over endovascular, partly because they're able to fix complications and offer surgical options for vascular problems. From a hospital's perspective, it makes much more sense to hire a neurosurgeon who can do it all. Of the non-neurosurgery trained folks, there are significantly more interventional radiologists than neurology-trained interventionalists (mostly for historical reasons, since they pioneered a lot of the techniques that are being used today).

Agree. Also don't mean to sound like a prick but I would never let a neurology-trained interventionist operate on my friends or family. We are by no means perfect and have complications all the time that we have to live with, but the others, especially neurologists, are just not proceduralists by training. Two months into intern year I had done more lines than the PGY-5 or 6 neuro fellows I knew, even the ones going into IR. I really think that makes a difference. I doubt there are any data to substantiate this, but I've seen horrific complications from relatively routine endovascular procedures in neurology and IR. Furthermore we are the ones who take care of these patients postoperatively and do the stat crani when there's a catastrophic complication.

I know that some of this is just pure parochialism, the same way I'd never send a family member needing spine surgery to an orthopedic surgeon despite acknowledging that there are many excellent orthopedic spine surgeons.

 

[Lawpy]

Agree. Also don't mean to sound like a prick but I would never let a neurology-trained interventionist operate on my friends or family. We are by no means perfect and have complications all the time that we have to live with, but the others, especially neurologists, are just not proceduralists by training. Two months into intern year I had done more lines than the PGY-5 or 6 neuro fellows I knew, even the ones going into IR. I really think that makes a difference. I doubt there are any data to substantiate this, but I've seen horrific complications from relatively routine endovascular procedures in neurology and IR. Furthermore we are the ones who take care of these patients postoperatively and do the stat crani when there's a catastrophic complication.

I know that some of this is just pure parochialism, the same way I'd never send a family member needing spine surgery to an orthopedic surgeon despite acknowledging that there are many excellent orthopedic spine surgeons.

Wait why does the neuro IR pathway continue to be popular?

 

[Neopolymath]

Wait why does the neuro IR pathway continue to be popular?

I think to call it popular is probably a stretch but maybe I'm wrong.

 

[longhaul3]

Wait why does the neuro IR pathway continue to be popular?

I dunno. Maybe because they get paid a lot compared to regular neurology? Prestige? Cool technology? It's definitely not a lifestyle specialty. I'd say 1/3-1/2 of the neuro residents I know are planning on doing it, or at least say they are.

Or do you mean radiologists doing it? No idea.

Everyone calls it something different. Neurology calls it interventional neurology. Radiology calls it neurointerventional radiology. We call it endovascular neurosurgery (or just "angio").

 

[Lawpy]

I dunno. Maybe because they get paid a lot compared to regular neurology? Prestige? Cool technology? It's definitely not a lifestyle specialty. I'd say 1/3-1/2 of the neuro residents I know are planning on doing it, or at least say they are.

Or do you mean radiologists doing it? No idea.

Everyone calls it something different. Neurology calls it interventional neurology. Radiology calls it neurointerventional radiology. We call it endovascular neurosurgery (or just "angio").

Idk i don't want to sound mean but it's really feeling that the neuro and rads intervention pathways are just alternatives that popped up for MS4s who couldn't match nsgy. Because the neuro IR pathway seems to be too clinically high risk of a career (with worse patient outcomes) compared to safer and longer term nsgy care.

 

[Skullcutter69]

From my understanding (mostly from my angio rotations and coresidents going into vascular), regardless of how popular interventional may be among neurology residents, there simply aren't the spots for the vast majority who want to do it since fellowships often fill internally (or externally via connections) with neurosurgeons >>>>> IR >>>>>>> neurology. Of course it depends on the program but this is generally the landscape nationally. In any case, endovascular is just one part of neurosurgery among the many things you can do.

 

[banan123]

@Skullcutter69 1st off, thank you so much for doing this. Your answers have been extremely helpful.

Im a MS2 and I love the brain. I’m trying to figure out if I like neurology or neurosurgery more. I was a neuro major in undergrad, spent two gap years working in a lab. Did stereotactic brain surgeries on mice and rats and liked that aspect. What I loved the most is modulating neuroanatomy to improve brain faculties (memory and sleep in my research). As a result I’m interested in neurology/functional neurosurgery. The thought of doing DBS is fascinating. I specifically like how functional nsx goes beyond motor disorders (vs neurologists who use neuromodulation mostly for movement.)

I understand that neurology is focused more on academically understanding the brain which I love. But I also want a career in which I can make a clear difference to my patients. Do you have any tips for figuring this out?

 

[Skullcutter69]

@Skullcutter69 1st off, thank you so much for doing this. Your answers have been extremely helpful.

Im a MS2 and I love the brain. I’m trying to figure out if I like neurology or neurosurgery more. I was a neuro major in undergrad, spent two gap years working in a lab. Did stereotactic brain surgeries on mice and rats and liked that aspect. What I loved the most is modulating neuroanatomy to improve brain faculties (memory and sleep in my research). As a result I’m interested in neurology/functional neurosurgery. The thought of doing DBS is fascinating. I specifically like how functional nsx goes beyond motor disorders (vs neurologists who use neuromodulation mostly for movement.)

I understand that neurology is focused more on academically understanding the brain which I love. But I also want a career in which I can make a clear difference to my patients. Do you have any tips for figuring this out?

Congratulations! It sounds like you've been doing some great work. I think that the specialties are so fundamentally different that it really comes down to what you want to do day to day. Neurology is very similar in workflow to internal medicine, where you have inpatient blocks on different services that are filled with long rounding, doing admissions, managing medications, etc. This is interspersed with outpatient blocks where you're seeing patients in clinic. Neurosurgery is all about quick rounds in the morning and then doing operative cases during the day.

What do you see yourself doing more? Deciding whether to start perampanel because of an EEG change overnight, or turning a bone flap to operate on the brain? That being said, if you're interested in doing research, there's extraordinary potential in functional. A lot of neurosurgery residents shy away from it because the actual technical component of the surgery is relatively easy (usually involves a burr hole or 2, all the hard part is in the planning) but for those who want to do real basic science research it's pretty amazing. The outcomes are also awesome. You can often times literally see patients' tremors go away once you place the electrodes (just from the lesion created by inserting them). The neurologists usually stop by to do a neuro exam since the patient is woken up in the OR and to fine tune the settings. Best of luck with your decision!

 

[oopsaloo]

Thanks so much for this thread and for taking the time to answer our questions!

I have a few:

1) For the long skull base tumor/vascular surgeries, how do you handle not drinking water/using the bathroom/no food for 10+ hours straight? I’ve hardly seen residents scrub out in the middle of a long procedure for these things before.

2) Have you ever worried about surgical plume (the smoke that comes out when you use the Bovie - there have been several studies about how it might be toxic/carcinogenic)? If so how do you mitigate risks?

3) How do you go about mastering the operative neuro anatomy? What resources do you use? Finally, from intern year to third/fourth year, what are the expectations in terms of your mastery of neuro anatomy/Neuroradiology? How do you keep up with it?

Thanks again!

 

[doctormans]

Does doing research in another field have a negative impact on matching into neurosurgery?

 

[Lebron's hairline]

How much sleep do you get every night? When during medical school is a good time to get involved in research (I'm an M1 and just finished up my first semester)?

 

[deleted849476]

I heard from a private practice spine (neuro) surgeon that anyone can do neuro, you just have to be a people person. Do you think that's true?

Also, are letters of rec from private practice neurosurgeons enough to get into neurosurgery programs, or do you have to have academic letters?

Thanks for the thread!

 

[Skullcutter69]

Thanks so much for this thread and for taking the time to answer our questions!

I have a few:

1) For the long skull base tumor/vascular surgeries, how do you handle not drinking water/using the bathroom/no food for 10+ hours straight? I’ve hardly seen residents scrub out in the middle of a long procedure for these things before.

2) Have you ever worried about surgical plume (the smoke that comes out when you use the Bovie - there have been several studies about how it might be toxic/carcinogenic)? If so how do you mitigate risks?

3) How do you go about mastering the operative neuro anatomy? What resources do you use? Finally, from intern year to third/fourth year, what are the expectations in terms of your mastery of neuro anatomy/Neuroradiology? How do you keep up with it?

Thanks again!

1. I've gotten this question a lot from students. Interestingly, this hasn't really been an issue in residency. Usually when you're doing those huge whacks, there's a whole team involved - you, the attending, an ENT chief resident/fellow and the ENT attending. A lot of times during their portion of the case you can break scrub and go get some food/use the bathroom. If it's a super long spine case, I usually bring a bar and some coffee that I can eat during the spin, etc. Overall, it hasn't been a problem.

2. No, usually the person you're operating with will suction the smoke for you. You're rarely breathing in huge plumes of smoke.

3. I could probably write a whole thread on this. I ended up using Rhoton right from the start. Now the junior residents have this anatomy exam that they take between their first 2 years of residency. There are popular flashcards (The Rhoton Top 100) that people use. Some people like the "Neuroanatomy Text and Atlas." The neurosurgical atlas is incredible for live, operative anatomy. If you want a quick reference, there are numerous books like "Neurosurgery Tricks of the Trade" that have the relevant landmarks for common operations.

Happy to help!

 

[Skullcutter69]

Does doing research in another field have a negative impact on matching into neurosurgery?

No. A lot of things are actually quite relevant. Surgical outcomes, psych pathways for functional, spine in ortho, a lot of ENT stuff, etc. I know people who have done a lot of work in other areas and then applied into neurosurgery. Once you decide that you want to go into it, you should try and get involved in some projects that you can list at the top of your CV to show interest.

 

[Skullcutter69]

How much sleep do you get every night? When during medical school is a good time to get involved in research (I'm an M1 and just finished up my first semester)?

Now? Probably 7-8 hours/night. Your life as a senior resident gets substantially better (- your chief year). By the time you get in, all the lists have been made and someone would have already seen all of your patients. You just go lay eyes on them and then head to the OR for your cases. As a junior resident it was very variable, I probably got around 5.5-6, but we took in house call much more frequently as well (where you very rarely get sleep). As a chief it totally depends on how much you get called, but you have a ton of responsibilities (you're responsible for every single thing that happens clinically as well as a ton of admin stuff with making call schedules/vacations, etc.)

 

[Skullcutter69]

I heard from a private practice spine (neuro) surgeon that anyone can do neuro, you just have to be a people person. Do you think that's true?

Also, are letters of rec from private practice neurosurgeons enough to get into neurosurgery programs, or do you have to have academic letters?

Thanks for the thread!

Tough question. You should definitely try and get some academic letters, both to at least show that you're open to academics in residency and because most academic neurosurgeons are more well known/connected. If your med school doesn't have a home program, you should go and rotate at a nearby academic center to get a letter. I've seen letters from private practice neurosurgeons (and they don't usually hurt, especially if they're strong), but most people reading them have no idea who they are. It would be nice to mix that in with some well known academic chairs.

 

[IMG69]

How did you get use to breaking bad news/get comfortable with it? I've only broken it a few times and i'm really hit or miss at it. It's very difficult in the patients who can't accept it (obviously rightly so), so how are you navigating the talk with these patients? (I get the general idea and i've asked all my attendings on the appropriate technique/format to do it).

In general I just be as honest as possible but yeah I have palliative care coming up so i'd really like to get solid at it. Tips are much appreciated.

 

[Lebron's hairline]

How does lifestyle in residency compare to other surgical specialties? (Ortho, ent, gsurg, etc.)

 

[agiraffe999]

How does lifestyle in residency compare to other surgical specialties? (Ortho, ent, gsurg, etc.)

Not a neurosurgeon but am friends with about a dozen. They've all said it can be some of the worst but they also manage all the medical management of their patients (unlike cardiac surgery where once the surgeon leaves, the ICU staff manages the patient) and many of their cases are urgent and cant be pushed off till the morning. I've heard they try to limit it <88 whenever possible, but some cases like skull base tumor removals are so long that by definition, that single procedure is a violation of ACGME rules. They also all are workaholics and don't mind pushing 100 hours a week either if needed.

Theres a reason the joke goes How do you hide a $100 from a neurosurgeon? Tape it to their kids forehead. Its cause they've got some of the worst hours but due to ACGME rules, its more doable than before. (also sorry idk why this is in italics but I cant undo it)

 

[Skullcutter69]

How did you get use to breaking bad news/get comfortable with it? I've only broken it a few times and i'm really hit or miss at it. It's very difficult in the patients who can't accept it (obviously rightly so), so how are you navigating the talk with these patients? (I get the general idea and i've asked all my attendings on the appropriate technique/format to do it).

In general I just be as honest as possible but yeah I have palliative care coming up so i'd really like to get solid at it. Tips are much appreciated.

It's always challenging, and there's no easy formula. I honestly try and follow 2 key principles: 1. Be honest and forthright and 2. Empower the family (eg "The reason it is so important for us to talk to you about this is because YOU know them best and understand what they would have wanted in a situation like this"). By emphasizing their relationship with the patient it really helps guide the rest of the conversation in terms of goals of care, etc.

 

[Skullcutter69]

How does lifestyle in residency compare to other surgical specialties? (Ortho, ent, gsurg, etc.)

As you'll soon see, lifestyle is incredibly program specific. If you train in ortho at Vanderbilt or Penn, (although amazing programs), your lifestyle will be worse than at most neurosurgery programs (I know because my brother in law graduated from one of these). There are also several neurosurgery programs (particularly with large county hospitals that you're covering as a junior resident) where your lifestyle is awful. Conversely, there are neurosurgery programs with incredible APP support, neurocritical care doctors helping manage the ICU, and large resident complements where the lifestyle is phenomenal and better than at the vast majority of ortho and gen surg programs. When you decide on a specialty, all of these factors will come into play as you begin to look at programs and become readily apparent as you talk to more and more people (during your Sub-Is, interviews, etc.)

In general, the main difference between the specialties is the size of the resident complement. At most neurosurgery programs, the junior in house call pool is smaller and thus you take in house call more frequently (Q4-Q5). If you go to a 3/year or 4/year neurosurgery program, it honestly isn't that bad and you get the pain over with after PGY-2 year. At most ortho programs, you have more bodies and thus decreased in house call during the PGY-2 year (although still very busy and tough). The second main difference comes during the chief resident year. Because the chief is responsible for all the cases that get done on service, when you're on *you* are the one who gets all the tough phone calls in the middle of the night with all the emergencies that need to be taken care of. At most places, you have to come in the middle of the night (if only just to take a peek at what the junior is doing). The attending is usually protected and if they even happen to roll in 2 hours later they usually just nod and say "looks good" and go back to bed. This makes for a tough year because your call nights are split among all the chiefs (again, fewer than in ortho and with more emergencies to take care of in the middle of the night). Once again, this makes the *residency* chief year pretty tough, but among the *attendings*, where they have 25 people on faculty, it isn't anything remotely close to that. That's the point that I was making, while your chief resident year in neurosurgery may be plentiful in hemicranis, suboccipital cranis, bleeding intracranial masses, etc. that is not even remotely close to what your practice looks like just a year later when you take your first job.

 

[Skullcutter69]

Not a neurosurgeon but am friends with about a dozen. They've all said it can be some of the worst but they also manage all the medical management of their patients (unlike cardiac surgery where once the surgeon leaves, the ICU staff manages the patient) and many of their cases are urgent and cant be pushed off till the morning. I've heard they try to limit it <88 whenever possible, but some cases like skull base tumor removals are so long that by definition, that single procedure is a violation of ACGME rules. They also all are workaholics and don't mind pushing 100 hours a week either if needed.

Theres a reason the joke goes How do you hide a $100 from a neurosurgeon? Tape it to their kids forehead. Its cause they've got some of the worst hours but due to ACGME rules, its more doable than before. (also sorry idk why this is in italics but I cant undo it)

The whole situation regarding ICUs is very interesting. That may have been true 15 years ago, but is certainly not the case at the majority of programs today. Just like anesthesiologists/crit care doctors took away the CICU from the cardiac surgeons, there is a huge push to increase the role of neurologists/critical care doctors in the neuro-ICU. Neurosurgery is still certainly pivotal to decision making, but the days of "open ICUs" with neurosurgery residents making all the calls are coming to an end. "Closed" and "semi-closed" ICUs are becoming the norm.

Regarding skull base, I can assure you that this will not be a large part of your residency (unless you specifically seek it out). Having ENT partners drill the IAC is irritating but conducive to taking a break and grabbing some food 🙂

 

[woktheline]

Great to see that this is still active and I think we all really appreciate @Skullcutter69 's immense help.

However, I wanted to return to the "lifestyle" questions for a bit, since recently my calculus and relationship situation changed significantly. You touched on it some in your original post, but I want to dive a bit deeper:

1) I have creeping doubts that I will run people away who want to be close/love me. Part of me thinks this was in the back of the mind of my SO, who left me last month, given that I am so driven to the field. Do you mind if I ask your marital situation? Do you find that you or those you work with have enough time and attention left to cultivate a family life? I find both excellence in work and family to be my main two goals, but get an endless barrage of warning from family members, colleagues at my lab with medical backgrounds etc. that these are incompatible in neurosurgery. I am sure there's institutional heterogeneity here, so how would I find out about these intangibles about programs beforehand?

2) Do you believe there's an optimal time to have kids during training?

3) Knowing what you do about residency matching (specifically Nsurg), would you advise attending the much cheaper state school (~30 k tuition, potentially living at home but much slimmer dating opportunities-important) or a private school in a bigger setting (~60k tuition, obviously more opportunities to meet someone)? I get it, money ain't everything, and dating isn't everything, but both combined are pretty damn important. Note: I have no undergrad or debt from my master's.

In spite of the concerns I am pretty convinced I couldn't see myself doing anything else, these are just things I have too much time to mull over during holidays etc.

(sorry the first question is really multiple- THANKS)
TL;DR: older non-trad who's worried that a future in Nsurg would mean infinite loneliness and debt

 

[Detailsmatter]

Great to see that this is still active and I think we all really appreciate @Skullcutter69 's immense help.

However, I wanted to return to the "lifestyle" questions for a bit, since recently my calculus and relationship situation changed significantly. You touched on it some in your original post, but I want to dive a bit deeper:

1) I have creeping doubts that I will run people away who want to be close/love me. Part of me thinks this was in the back of the mind of my SO, who left me last month, given that I am so driven to the field. Do you mind if I ask your marital situation? Do you find that you or those you work with have enough time and attention left to cultivate a family life? I find both excellence in work and family to be my main two goals, but get an endless barrage of warning from family members, colleagues at my lab with medical backgrounds etc. that these are incompatible in neurosurgery. I am sure there's institutional heterogeneity here, so how would I find out about these intangibles about programs beforehand?

2) Do you believe there's an optimal time to have kids during training?

3) Knowing what you do about residency matching (specifically Nsurg), would you advise attending the much cheaper state school (~30 k tuition, potentially living at home but much slimmer dating opportunities-important) or a private school in a bigger setting (~60k tuition, obviously more opportunities to meet someone)? I get it, money ain't everything, and dating isn't everything, but both combined are pretty damn important. Note: I have no undergrad or debt from my master's.

In spite of the concerns I am pretty convinced I couldn't see myself doing anything else, these are just things I have too much time to mull over during holidays etc.

(sorry the first question is really multiple- THANKS)
TL;DR: older non-trad who's worried that a future in Nsurg would mean infinite loneliness and debt

just an MS2 so obviously skull cutter will have a better answer but I'm a firm believer in that something has to give. I could be misinformed or just incorrect but I don't think you can be both a truly great surgeon and an amazing/always there/incredible parent. You could be good at both of those but I dont think you can be world class at both. To be a spectacular surgeon I would imagine you have to consistently and constantly be putting in the work and same goes for being a parent if you always want to be around your family. I just dont see how its possible given the 24 hrs in a day we have. you can be good at one and absolutely phenomenal at the other but not both. What do you think @Skullcutter69 ?

 

[Skullcutter69]

just an MS2 so obviously skull cutter will have a better answer but I'm a firm believer in that something has to give. I could be misinformed or just incorrect but I don't think you can be both a truly great surgeon and an amazing/always there/incredible parent. You could be good at both of those but I dont think you can be world class at both. To be a spectacular surgeon I would imagine you have to consistently and constantly be putting in the work and same goes for being a parent if you always want to be around your family. I just dont see how its possible given the 24 hrs in a day we have. you can be good at one and absolutely phenomenal at the other but not both. What do you think @Skullcutter69 ?

To me this argument never made a whole lot of sense. I completely agree that you can't be "world class" at everything. But why is this the standard that people hold themselves to when deciding on a specialty? Sure, it is very unlikely that you can have a busy vascular neurosurgery practice, an R01 funded research lab, leadership roles in multiple national organizations, always traveling to give talks, and have boat loads of time to spend with your family. Fortunately (or unfortunately depending on your goals) the reality is that the vast majority of surgeons (and doctors in general) aren't going to be doing this in their careers. Yes, something definitely has to give. However, you can absolutely be a fantastic clinical neurosurgeon AND have a rich and fulfilling family life. Will you also be running a productive basic science lab on the side and traveling 4x/month for subcommittee meetings? No, but that's a choice that you're making. Most residency graduates of surgical subspecialties (including neurosurgery) go directly into private practice or a privademic setup and never get involved in any of these other things. Yes, some days your OR cases may run long but you have at least 2-3 days of clinic/week where you're out at 4:30-5 and every single neurosurgeon I know in PP is married with tons of hobbies and time for their kids. 99% of ortho, ENT, urology, graduates end up choosing to be excellent clinicians and going out to practice in the community and no one really bats an eye. They never mention that the bigwigs in academia who are full professors at Rothman/Rush/HSS are also working 24/7. For whatever reason, in neurosurgery it's academic department chair or bust, even though 90% of neurosurgery graduates don't even pursue an academic career.

Long story short, YOU decide what matters to you most. You can absolutely have an amazing clinical career and have ample opportunities to pursue your personal life. Yes, if you choose to pursue an academic career, the research and political component will take up significant amounts of time and will cut into your personal life. There are many different practice opportunities available in neurosurgery after graduation.

 

[Skullcutter69]

Great to see that this is still active and I think we all really appreciate @Skullcutter69 's immense help.

However, I wanted to return to the "lifestyle" questions for a bit, since recently my calculus and relationship situation changed significantly. You touched on it some in your original post, but I want to dive a bit deeper:

1) I have creeping doubts that I will run people away who want to be close/love me. Part of me thinks this was in the back of the mind of my SO, who left me last month, given that I am so driven to the field. Do you mind if I ask your marital situation? Do you find that you or those you work with have enough time and attention left to cultivate a family life? I find both excellence in work and family to be my main two goals, but get an endless barrage of warning from family members, colleagues at my lab with medical backgrounds etc. that these are incompatible in neurosurgery. I am sure there's institutional heterogeneity here, so how would I find out about these intangibles about programs beforehand?

2) Do you believe there's an optimal time to have kids during training?

3) Knowing what you do about residency matching (specifically Nsurg), would you advise attending the much cheaper state school (~30 k tuition, potentially living at home but much slimmer dating opportunities-important) or a private school in a bigger setting (~60k tuition, obviously more opportunities to meet someone)? I get it, money ain't everything, and dating isn't everything, but both combined are pretty damn important. Note: I have no undergrad or debt from my master's.

In spite of the concerns I am pretty convinced I couldn't see myself doing anything else, these are just things I have too much time to mull over during holidays etc.

(sorry the first question is really multiple- THANKS)
TL;DR: older non-trad who's worried that a future in Nsurg would mean infinite loneliness and debt

1. Very sorry to hear that. I think that by far and away the most important thing is having a supportive partner who understands the commitment of becoming a doctor and is willing to support you. I'm very happily married, and now with 2 kids as well. That being said, my wife is the most amazing and supportive person I've ever met and has done everything in her power to make our family succeed. When I was a PGY-2 and was so tired I could barely move, she made sure everything was taken care of and even drove me in to work/picked me up post-call. Later on once I wasn't taking in house call as frequently and she was busy at work/pregnant I either made or got dinner most nights/week. Apart from chief year and PGY-2, we probably had date nights/activities 3-4 times/week (even if at home with our kiddos). I'm the luckiest person in the world and I'm not going to pretend that having an understanding partner who's committed to my success isn't a huge part of why I've been able to enjoy myself (even in neurosurgery residency). If your spouse has certain expectations about what time you have to be home or sets restrictions on you, you're going to be in for a long road and if they strongarm you into pursuing a different career that you're less passionate about then you should draw your own conclusions about what that means for your future happiness with that person. You can gain information about certain programs by talking to older students applying into neurosurgery. It's fairly well known which programs are more lifestyle friendly.

2. Any time after PGY-2 year is totally reasonable (worked well for us and I was at least able to somewhat help). Some programs have research years PGY-4/5 years, which would also be great options.

3. I would advise you to go to the best medical school you get into (within the same tier). The connections and research opportunities you can develop there will serve you well in your career.

"TL;DR: older non-trad who's worried that a future in Nsurg would mean infinite loneliness and debt" You should go out and meet some real neurosurgeons at your program or at national meetings. 95% of the ones I know are happily married with kids and extremely rich.

 

[tectum via rectum]

Realistically to what degree does school rank/prestige/connections play in matching?

Current M3 from a no-name MD school without a NSG residency, otherwise my app is built for nsg(26X/12+ nsg journal pubs/15+ conference presentations/all honors), but my school has absolutely no neurosurgical faculty and with sub-I's still being up in the air for the upcoming year i'm wondering if it would be necessary to take a research year just to make connections with another program even though I don't actually need more research?