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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?

That's a great question. The answer I think depends a little bit on what you want. School prestige carries some weight but much more than that it's your letters that really matter (probably about as much as Step I). School name just happens to correlate well to how well the faculty are known and the research opportunities that applicants have. There's no doubt that if you take a year off and do research at a well known place with some big name faculty and then Sub-I that you'll match at a great program. I also bet that if you could squeeze some Sub-Is in next year (and remember that as per the SNS rules, if you don't have a home neurosurgery program then you CAN rotate in person at another program, even during COVID) then you would likely match.

Long story short, if you just want to match and save yourself a year, then try and network as much as you can (fire off emails, try to set up Sub-Is for next year, etc.) and go for it. If your goal is to end up at a top tier place, take a research year at a big name program and work your tail off. Happy New Year!
 
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oopsaloo

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Which US programs have the reputation of being a bit more “lifestyle friendly” (within the relative spectrum of neurosurgical programs, which I understand are very intense in general)?

Thanks so much and Happy New Year!
 
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Have you had any infectious disease cases? Like herpes encephalitis or neurocystercercosis? Or even complications from HIV/AIDS?
 
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That's a great question. The answer I think depends a little bit on what you want. School prestige carries some weight but much more than that it's your letters that really matter (probably about as much as Step I). School name just happens to correlate well to how well the faculty are known and the research opportunities that applicants have. There's no doubt that if you take a year off and do research at a well known place with some big name faculty and then Sub-I that you'll match at a great program. I also bet that if you could squeeze some Sub-Is in next year (and remember that as per the SNS rules, if you don't have a home neurosurgery program then you CAN rotate in person at another program, even during COVID) then you would likely match.

Long story short, if you just want to match and save yourself a year, then try and network as much as you can (fire off emails, try to set up Sub-Is for next year, etc.) and go for it. If your goal is to end up at a top tier place, take a research year at a big name program and work your tail off. Happy New Year!
Thanks so much for the advice, happy new year!
 

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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.
Thanks for this answer! One thing I've noticed is that people generally tend to note that residency is brutal but fellowship is a bit better, so, say, a cardiologist may also do 6-7 years of training but the last 3-4 of those are at least a little less intense than IM residency. Does neurosurgery residency ebb and flow or is it exhausting for seven years straight?

On another note, is there a reason pediatric neurosurgery cannot be enfolded?
 
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Have you had any infectious disease cases? Like herpes encephalitis or neurocystercercosis? Or even complications from HIV/AIDS?
All the time. Brain abscesses, CNS lymphoma, etc. Last year we had a patient with severe hydro that ended up being due to a neurocysticercosis cyst blocking the foramen of Monro. Had to take it out endoscopically.
 
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Thanks for this answer! One thing I've noticed is that people generally tend to note that residency is brutal but fellowship is a bit better, so, say, a cardiologist may also do 6-7 years of training but the last 3-4 of those are at least a little less intense than IM residency. Does neurosurgery residency ebb and flow or is it exhausting for seven years straight?

On another note, is there a reason pediatric neurosurgery cannot be enfolded?
Ebbs and flows for sure. I'm sure it depends on the program but the first year cardiology fellows at our program would definitely take issue with that (depending on where they did their medicine residency) ;) In neurosurgery, your hardest years will be PGY-2 and PGY-6 or 7 (whenever you do your chief year). As a junior, you typically do the bulk of in-house call and the learning curve is very steep. As a chief, you're sharing the responsibility of the entire neurosurgical service with your co-chiefs. Although program-specific, usually every year after PGY-2 year gets significantly better until you hit your chief year. This is because a) you're doing little if any in house call, b) your morning routine gets easier and you're no longer getting in super early to make lists and c) you're much more comfortable operating. When I was a PGY-4 I rarely had to sit down and prep/read for every single case I had the next day, because I was so comfortable with bread & butter operations.

Pediatric neurosurgery fellowships are all ACGME-accredited, and they mandate that it's done after completion of your residency (and that you're board eligible). The vast majority of neurosurgery fellowships are outside the purview of ACGME.
 
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asa0009

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I appreciate this thread so much. Sorry to re-open it as it's been a few weeks. I just had a question on how do you establish mentorship?

I'm at a DO school with no home NSG program. I don't exactly know where to begin. DO match rates are literally garbage and having no home NSG program puts me at an even bigger disadvantage. Most hospitals with residencies don't just put the emails up of their physicians, how do you even get in contact with one? Do you just call?

Thank you so much for helping all of us!!
 
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I appreciate this thread so much. Sorry to re-open it as it's been a few weeks. I just had a question on how do you establish mentorship?

I'm at a DO school with no home NSG program. I don't exactly know where to begin. DO match rates are literally garbage and having no home NSG program puts me at an even bigger disadvantage. Most hospitals with residencies don't just put the emails up of their physicians, how do you even get in contact with one? Do you just call?

Thank you so much for helping all of us!!
Your best bet is to see if there are any places nearby with a neurosurgery department where you can reach out to mentors. Most faculty have emails that you can find by searching the university or hospital employee database. Sometimes you can find the emails in publications if they're the PI on a paper.

In any case, you're going to need to take a year off between third and fourth year to do research at a well known place. This will serve the dual purpose of helping you ramp up the research portion of your CV (especially once Step 1 is gone) as well as build connections/mentorship to try and neutralize the advantages that other students have.
 
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asa0009

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Your best bet is to see if there are any places nearby with a neurosurgery department where you can reach out to mentors. Most faculty have emails that you can find by searching the university or hospital employee database. Sometimes you can find the emails in publications if they're the PI on a paper.

In any case, you're going to need to take a year off between third and fourth year to do research at a well known place. This will serve the dual purpose of helping you ramp up the research portion of your CV (especially once Step 1 is gone) as well as build connections/mentorship to try and neutralize the advantages that other students have.
Thank you for getting back to me.

Is the research year more for networking or the actual research? I'm *HOPING* by the end of my first year to have 2 first author lit reviews (possibly 3), working on 2 separate retrospective research projects on strokes with residents at the local hospital and second author on 2 other lit reviews. - So if I continue with this rate I'll probably have tons of research just not at a huge institution. The only way around this is if I happen to get my rotations at the one large hospital with a NSG program (only 1 available for me to rank so I'd have to get my first pick in a very sought after area - I'm a 4.0 student but GPA doesn't matter in our rotation ranking system). I'm hoping to not do lit reviews after this year and do only clinical research - so even if I had 20+ pubs would you still recommend a research year if I hadn't completed any of it in affiliation with a highly ranked hospital/program?
 

longhaul3

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Thank you for getting back to me.

Is the research year more for networking or the actual research? I'm *HOPING* by the end of my first year to have 2 first author lit reviews (possibly 3), working on 2 separate retrospective research projects on strokes with residents at the local hospital and second author on 2 other lit reviews. - So if I continue with this rate I'll probably have tons of research just not at a huge institution. The only way around this is if I happen to get my rotations at the one large hospital with a NSG program (only 1 available for me to rank so I'd have to get my first pick in a very sought after area - I'm a 4.0 student but GPA doesn't matter in our rotation ranking system). I'm hoping to not do lit reviews after this year and do only clinical research - so even if I had 20+ pubs would you still recommend a research year if I hadn't completed any of it in affiliation with a highly ranked hospital/program?
One could argue it's more for the networking, but if you're not extremely productive during your research year they won't be that interested in going to bat for you.

Are these neurosurgery residents? What about the PIs? In your position you will almost certainly need a letter from a neurosurgery PI (really almost everyone does these days), so you will need to find your way into an academic neurosurgery program at some point anyway.
 
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Thank you for getting back to me.

Is the research year more for networking or the actual research? I'm *HOPING* by the end of my first year to have 2 first author lit reviews (possibly 3), working on 2 separate retrospective research projects on strokes with residents at the local hospital and second author on 2 other lit reviews. - So if I continue with this rate I'll probably have tons of research just not at a huge institution. The only way around this is if I happen to get my rotations at the one large hospital with a NSG program (only 1 available for me to rank so I'd have to get my first pick in a very sought after area - I'm a 4.0 student but GPA doesn't matter in our rotation ranking system). I'm hoping to not do lit reviews after this year and do only clinical research - so even if I had 20+ pubs would you still recommend a research year if I hadn't completed any of it in affiliation with a highly ranked hospital/program?

I completely agree with the poster above. Your main problem is that you have very little firepower behind you in the match (in terms of reputable letters of rec as well as potential phone calls/advocacy). Now this in and of itself could potentially be fixed without a research year, but you're already coming from a school with no home program, and you're a DO which comes with its own set of problems. Given this (unless you get a spot at a formerly DO (pre-merger) program, which I admittedly know very little about), you're going to need a lot of help to even get your application read at a lot of places. If you were at a low tier MD school without a department, you could potentially try and be very productive in med school, schedule 3-4 away rotations and try to get great letters from superstar Sub-I performances (which even then would be risky). I honestly don't think that this is a pathway that you can confidently pursue. I'm usually quite equivocal about research years, but in this case I think that it would exponentially help you. Not only would you get more papers (assuming you're productive), but you'd have people who would a) help you get Sub-Is to get other letters, b) potentially consider you for their own residency, c) get you 1-2 great letters of rec right off the bat, and d) help you later on in the match process by advocating for you at other places.
 
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I completely agree with the poster above. Your main problem is that you have very little firepower behind you in the match (in terms of reputable letters of rec as well as potential phone calls/advocacy). Now this in and of itself could potentially be fixed without a research year, but you're already coming from a school with no home program, and you're a DO which comes with its own set of problems. Given this (unless you get a spot at a formerly DO (pre-merger) program, which I admittedly know very little about), you're going to need a lot of help to even get your application read at a lot of places. If you were at a low tier MD school without a department, you could potentially try and be very productive in med school, schedule 3-4 away rotations and try to get great letters from superstar Sub-I performances (which even then would be risky). I honestly don't think that this is a pathway that you can confidently pursue. I'm usually quite equivocal about research years, but in this case I think that it would exponentially help you. Not only would you get more papers (assuming you're productive), but you'd have people who would a) help you get Sub-Is to get other letters, b) potentially consider you for their own residency, c) get you 1-2 great letters of rec right off the bat, and d) help you later on in the match process by advocating for you at other places.
I appreciate your honesty! Sometimes hard to hear but it’s needed. Thanks for taking the time to explain the benefits to me, I’m going to start looking into this!
 
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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.
I’m wondering if you know much about Canadians transferring to the states post residency+fellowship, as there are barely any new jobs per year and many new neurosurgeons per year.
 
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I’m wondering if you know much about Canadians transferring to the states post residency+fellowship, as there are barely any new jobs per year and many new neurosurgeons per year.

It's more difficult now than ever before. Canadian graduates who finished training after 1997 are not board eligible and cannot sit for the American Board of Neurological Surgery series. While any individual hospital can technically grant you privileges as long as you have a license to practice medicine, almost every job requires that you're at least BE. Moreover, a lot of Canadians require an H1b visa, which a lot of community hospitals are unwilling to sponsor. As such, most Canadian neurosurgeons (and other specialists in competitive fields without reciprocity) you'll see in practice are at academic medical centers where they were hired and granted privileges because they're a big name and have a lot to offer academically.
 
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It's more difficult now than ever before. Canadian graduates who finished training after 1997 are not board eligible and cannot sit for the American Board of Neurological Surgery series. While any individual hospital can technically grant you privileges as long as you have a license to practice medicine, almost every job requires that you're at least BE. Moreover, a lot of Canadians require an H1b visa, which a lot of community hospitals are unwilling to sponsor. As such, most Canadian neurosurgeons (and other specialists in competitive fields without reciprocity) you'll see in practice are at academic medical centers where they were hired and granted privileges because they're a big name and have a lot to offer academically.
Interesting, yeah it’s unfortunate about Canadians not able to become board certified. For someone currently in Canadian medical school pursuing NSGY, do you think I should try and match into a US neurosurg residency then to have greater options? I’m assuming this would be extremely hard if even possible. I’m just worried as there have been a lot of studies about over saturation in neurosurgery job market in Canada. Just trying to figure out what’s best in my scenario.

thanks man!
 
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Interesting, yeah it’s unfortunate about Canadians not able to become board certified. For someone currently in Canadian medical school pursuing NSGY, do you think I should try and match into a US neurosurg residency then to have greater options? I’m assuming this would be extremely hard if even possible. I’m just worried as there have been a lot of studies about over saturation in neurosurgery job market in Canada. Just trying to figure out what’s best in my scenario.

thanks man!

It's a completely personal decision that depends on you and where you'd like to live. Only you know how much the different elements (career, training time, location) matter to you.

Just from talking to people from places like the U Toronto at meetings, what you're saying seems to be true. People are doing 2-3 fellowships for even a chance to get a job in the middle of nowhere for very little money. As a physician in Canada, you represent an expense to hospitals rather than value, because every procedure you perform or piece of technology you'd like to buy (even as simple as a Leica scope) loses the hospital money. But every system has its pros and cons, and that's the system they chose, so now they live with the consequences.
 
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It's a completely personal decision that depends on you and where you'd like to live. Only you know how much the different elements (career, training time, location) matter to you.

Just from talking to people from places like the U Toronto at meetings, what you're saying seems to be true. People are doing 2-3 fellowships for even a chance to get a job in the middle of nowhere for very little money. As a physician in Canada, you represent an expense to hospitals rather than value, because every procedure you perform or piece of technology you'd like to buy (even as simple as a Leica scope) loses the hospital money. But every system has its pros and cons, and that's the system they chose, so now they live with the consequences.
Thanks for the insight, do you know any Canadians or heard of any matching into US NSGY Residencies? Haven’t been able to find much data on it but I’m guessing the sample size is just really small.
 

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Hi!

Thank you so so much for doing this! I apologize if this has already been asked, but what are the chances getting a PGY2 spot in neurosurgery after SOAPing into a surgery prelim spot? I got my STEP 1 score back a few weeks ago and didn't do so well unfortunately (235). I'm still planning on applying NSG but will honestly probably end up SOAPing.

Thank you!

~ Katniss
 

longhaul3

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Hi!

Thank you so so much for doing this! I apologize if this has already been asked, but what are the chances getting a PGY2 spot in neurosurgery after SOAPing into a surgery prelim spot? I got my STEP 1 score back a few weeks ago and didn't do so well unfortunately (235). I'm still planning on applying NSG but will honestly probably end up SOAPing.

Thank you!

~ Katniss
Probably quite low. Your best chance will be through the match. While your score is low for neurosurgery, it works out for some people. I would not count on or even really hope for a PGY-2 spot. I think you would have a better chance of reapplying through the match if you don't match the first time, though unfortunately your Step 1 score sticks with you for life.
 
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Thanks for the insight, do you know any Canadians or heard of any matching into US NSGY Residencies? Haven’t been able to find much data on it but I’m guessing the sample size is just really small.
The sample size is probably just small. You honestly likely have a better chance than most IMGs, simply because you're in a system/curriculum that's more similar, and can do research with people who are relatively known to American letter readers.

Best of luck with everything!
 
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Hi!

Thank you so so much for doing this! I apologize if this has already been asked, but what are the chances getting a PGY2 spot in neurosurgery after SOAPing into a surgery prelim spot? I got my STEP 1 score back a few weeks ago and didn't do so well unfortunately (235). I'm still planning on applying NSG but will honestly probably end up SOAPing.

Thank you!

~ Katniss
No problem at all. I hate to be the bearer of bad news, but quite honestly your chances of being successful through that pathway are close to zero. If you end up not matching, I would do everything in your power to delay graduation and take a research year to reapply again.
 
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The sample size is probably just small. You honestly likely have a better chance than most IMGs, simply because you're in a system/curriculum that's more similar, and can do research with people who are relatively known to American letter readers.

Best of luck with everything!
Appreciate it! Thanks for taking to time to answer these questions.
 
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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.
Hi,

I just have a few questions to follow up on Neurosurgeon Family Life.

1) Do you get any free time?

2) Do neurosurgeons still get long hours and overnight shifts after residency?

3) Can you raise kids as a neurosurgeon?

4) Do you get home in time for dinner?

5) Do you have to sacrifice on relationships and family in order to become a neurosurgeon?

Thanks,
Sarah
 
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Maimonides1

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Hi,

I just have a few questions to follow up on Neurosurgeon Family Life.

1) Do you get any free time?

2) Do neurosurgeons still get long hours and overnight shifts after residency?

3) Can you raise kids as a neurosurgeon?

4) Do you get home in time for dinner?

5) Do you have to sacrifice on relationships and family in order to become a neurosurgeon?

Thanks,
Sarah
I thought to jump and help you Sarah while @Skullcutter69 finish operating..

1- Yes and Yes .., and it depends on your PGY year and program type and city.., but definitely YES!

2- NO, but if you like to continue to be busy in Trauma and calls then might be yes..!

3- Absolutely! Up to 20% of residents are females and get their normal maternity leaves by law

4- Most of the time.., and it depends on what’s for Dinner..?

5- NO, part of being successful physician beside being a busy neurosurgeon you should practice the art of balancing between what is important personally and career.., you should always enjoy your life and significant others while you are dedicated to successful career in medicine and not to drift away from this ultimate equilibrium!!
 
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I thought to jump and help you Sarah while @Skullcutter69 finish operating..

1- Yes and Yes .., and it depends on your PGY year and program type and city.., but definitely YES!

2- NO, but if you like to continue to be busy in Trauma and calls then might be yes..!

3- Absolutely! Up to 20% of residents are females and get their normal maternity leaves by law

4- Most of the time.., and it depends on what’s for Dinner..?

5- NO, part of being successful physician beside being a busy neurosurgeon you should practice the art of balancing between what is important personally and career.., you should always enjoy your life and significant others while you are dedicated to successful career in medicine and not to drift away from this ultimate equilibrium!!

Sorry, I wasn't sure if that was a troll post. Thanks for responding.
 

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Thanks for taking the time to answer our questions!

How does research in another surgical field look upon? Will they help boost your application or not really?
 
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Thanks for taking the time to answer our questions!

How does research in another surgical field look upon? Will they help boost your application or not really?

I think it does. I was really involved in the match last year and saw quite a few people with research in other surgical subspecialties (ENT, ortho (non spine), etc.) I remember those applicants matching quite well. I think that it is important to make a pivot at some point and to make sure that you have a few neurosurgery papers at the top of your CV, but a strong track record of research productivity (even in another specialty), can only help you. When you're making the switch, be mindful of the importance of letters of recommendation, and try to take some research electives to work with a neurosurgery mentor. Depending on the rest of your application, you could potentially transition nicely without a research year. If you don't have a lot of research or mentorship, then consider taking a year to do research.
 
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