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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.
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.
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