Ask a neurosurgery resident anything

[deleted1095841]

I really appreciate your detailed answer! This is advice I will take to heart.

I'm fascinated by the brain, and am of the opinion that significant advances can be made through interventions in the brain which cannot be accomplished through medication or noninvasive therapy alone, but I am starting to wonder whether I should instead opt for a field like neurology, where I can finish training faster and have better work-life balance (please correct me if I'm wrong), but lose the privilege to operate.

As a neurosurgeon, what has been your experience working with neurologists? Do they have the opportunity to contribute meaningfully to the development of novel direct brain therapies or devices?

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[software-geek-]

Thanks for doing this AMA and for continuing to respond so many years later @neusu . Do you think it is worth spending a dedicated summer research block of 2-2.5 months conducting research at a program I am interested in matching at, and sacrificing productivity that I would have if I stayed and did research at my home school (because I could run many projects side by side at my home school over the summer while only likely working on 1-2 projects at a different place)? Would the connections I build be worth the decrease in productivity? I attend a mid-tier school and would like to match at a program near my hometown which is why I am interested in doing this if it can increase my chances at all.

 

[voxveritatisetlucis]

What is the living standards/conditions of a typical neurosurgery resident? Do most borrow heavily under the assumption that they will be able to pay it all back once they become an attending? I’m surprised banks aren’t jumping off of their chairs to lend relatively high sums to neurosurgery and other specialty residents since the risk of default is probably so low

 

[neusu]

I really appreciate your detailed answer! This is advice I will take to heart.

I'm fascinated by the brain, and am of the opinion that significant advances can be made through interventions in the brain which cannot be accomplished through medication or noninvasive therapy alone, but I am starting to wonder whether I should instead opt for a field like neurology, where I can finish training faster and have better work-life balance (please correct me if I'm wrong), but lose the privilege to operate.

As a neurosurgeon, what has been your experience working with neurologists? Do they have the opportunity to contribute meaningfully to the development of novel direct brain therapies or devices?

We work closely with neurologists in various fields and capacities. As a generality, neurologists and other clinical (e.g. non-surgical) doctors lend a more longitudinal approach to care. If I put in a deep brain stimulator, take out a tumor, place a spinal cord stimulator etc, it is commonly managed on a routine basis by the movement disorder neurologist, neuro-oncologist, or pain medicine doctor. Really, any physician involved in care, or anyone with an idea that can be tested, could play a meaningful role in development of therapeutics or devices.

 

[neusu]

Thanks for doing this AMA and for continuing to respond so many years later @neusu . Do you think it is worth spending a dedicated summer research block of 2-2.5 months conducting research at a program I am interested in matching at, and sacrificing productivity that I would have if I stayed and did research at my home school (because I could run many projects side by side at my home school over the summer while only likely working on 1-2 projects at a different place)? Would the connections I build be worth the decrease in productivity? I attend a mid-tier school and would like to match at a program near my hometown which is why I am interested in doing this if it can increase my chances at all.

This can be a mixed bag. Certainly making connections can prove fruitful, and going away for the summer could benefit from that. My advice for any student pursuing an interest, even more so in research, is what do you gain from it? Experience and connections, may benefit at that single institution, but if it's not published, it didn't happen. What I mean is, the yard-stick with which we measure medical students to match in to residency is # and impact of publications. Having nothing to show for that time, except memories, may prove to have better spent it elsewhere.

As an aside, it can also backfire. Becoming too comfortable, too early, with a program often changes the expectations on both parts, resulting in negative impressions. I can recall several students who came for summer research, and then later in the year rotated with us. They did stellar on the research, but crashed and burned on the clinical side. That isn't to say that is always how it happens, there have been plenty that did both and succeeded. Only fair warning that you have to work even harder once you set the bar high, as opposed to your co-applicants who are coming in de novo.

 

[neusu]

What is the living standards/conditions of a typical neurosurgery resident? Do most borrow heavily under the assumption that they will be able to pay it all back once they become an attending? I’m surprised banks aren’t jumping off of their chairs to lend relatively high sums to neurosurgery and other specialty residents since the risk of default is probably so low

Most neurosurgery residents live like residents. They make $40-80 k/year, working ~80 hrs/week. If they have student loans, that eats in to the amount of spending money available. Banks tend to want a guarantee and/or collateral, so unless you have a job lined up post-graduation they treat you the same as any other person off the street. In practice, this does tend to change. Even so, keeping track of your debt and credit score is important.

 

[ner0]

I noticed you started this thread 10 years ago, and that is perfect for my question: how has neurosurgery changed in the past 10 years, and how do you see it changing over the next 10 years? I'm a career changer, so I'm only starting my freshman year in undergrad, and I'm betting the neurosurgery that I have minimal knowledge about today will be vastly different 10 years from now, especially with how fast technology is pushing the mold on everything. Hope to hear back from you!

 

[allseasons]

I noticed you started this thread 10 years ago, and that is perfect for my question: how has neurosurgery changed in the past 10 years, and how do you see it changing over the next 10 years? I'm a career changer, so I'm only starting my freshman year in undergrad, and I'm betting the neurosurgery that I have minimal knowledge about today will be vastly different 10 years from now, especially with how fast technology is pushing the mold on everything. Hope to hear back from you!

it's incredible that this thread spans 39 pages and a decade and is still active. Thank you for starting this discussion @neusu

 

[neusu]

I noticed you started this thread 10 years ago, and that is perfect for my question: how has neurosurgery changed in the past 10 years, and how do you see it changing over the next 10 years? I'm a career changer, so I'm only starting my freshman year in undergrad, and I'm betting the neurosurgery that I have minimal knowledge about today will be vastly different 10 years from now, especially with how fast technology is pushing the mold on everything. Hope to hear back from you!

We'll have to have a birthday party for it in October lol

The last 10-years have been rather transformative for neurosurgery. Two areas stick out in my mind as being dramatically different: instrumented spine and stroke.

For spine, when I was in med school and early on in training, the majority of instrumented surgery was open and inpatient. That is to say, we would make a midline incision and expose to the transverse process, bilaterally, place pedicle screws, possibly PLIF or TLIF cages, then close. Patients would stay in the hospital 2-10 days, often needing rehab discharge. As time went on, MIS changed approaches, dissection, and length of stay. Some of this truly is technology responding to surgeons pushing envelopes, and some of it is payments from reimbursers changing and requiring us to adapt.

For stroke, when I started, if it was a large vessel occlusion (LVO) patients were on "hemi-crani watch." In essence, wait for the patient to decompensate/herniate and rush them to the OR to remove half the skull. Hemorrhagic stroke was not much better. Often large craniotomies/craniectomies and big tracts through the brain. Now we have endovascular thrombectomies that can reperfuse acutely blocked arteries. This truly was game-changing where a patient typically doomed to hemiparesis, possibly aphasia, and SNF could go home intact. Further, for ICH, we have stereotactic guidance and portal retractors that can push in to the clot and evacuate it from the inside. Less tract and cortical disruption.

Moreover, with changes, advances, and implementation of technology, the bar continues to raise. A city that may only have had one MRI scanner or no dedicated teams for things like stroke care would benefit from the standard of care advancing.

So yes, I truly believe the next 10-years are going to change the world of neurosurgery in a good way. I am happy to be a part of that, and excited to see where we go.

 

[neusu]

it's incredible that this thread spans 39 pages and a decade and is still active. Thank you for starting this discussion @neusu

You are most welcome. It has been quite the adventure!

 

[The Knife & Gun Club]

I remember reading this an a premed! Can’t believe it’s still going. I’m an EM PGY2 now.

What is one common knowledge misunderstanding you see from your ED Docs? Not necessarily annoying things we do (I know those are plentiful) but concepts in neurosurgery you’ve noticed EM docs fails to grasp.

 

[Round786]

We'll have to have a birthday party for it in October lol

The last 10-years have been rather transformative for neurosurgery. Two areas stick out in my mind as being dramatically different: instrumented spine and stroke.

For spine, when I was in med school and early on in training, the majority of instrumented surgery was open and inpatient. That is to say, we would make a midline incision and expose to the transverse process, bilaterally, place pedicle screws, possibly PLIF or TLIF cages, then close. Patients would stay in the hospital 2-10 days, often needing rehab discharge. As time went on, MIS changed approaches, dissection, and length of stay. Some of this truly is technology responding to surgeons pushing envelopes, and some of it is payments from reimbursers changing and requiring us to adapt.

For stroke, when I started, if it was a large vessel occlusion (LVO) patients were on "hemi-crani watch." In essence, wait for the patient to decompensate/herniate and rush them to the OR to remove half the skull. Hemorrhagic stroke was not much better. Often large craniotomies/craniectomies and big tracts through the brain. Now we have endovascular thrombectomies that can reperfuse acutely blocked arteries. This truly was game-changing where a patient typically doomed to hemiparesis, possibly aphasia, and SNF could go home intact. Further, for ICH, we have stereotactic guidance and portal retractors that can push in to the clot and evacuate it from the inside. Less tract and cortical disruption.

Moreover, with changes, advances, and implementation of technology, the bar continues to raise. A city that may only have had one MRI scanner or no dedicated teams for things like stroke care would benefit from the standard of care advancing.

So yes, I truly believe the next 10-years are going to change the world of neurosurgery in a good way. I am happy to be a part of that, and excited to see where we go.

Sorta a broad question, but do you think robotic surgery, like DaVinci replacing traditional hand surgery, is something we are going to see in our lifetime?

 

[longhaul3]

I remember reading this an a premed! Can’t believe it’s still going. I’m an EM PGY2 now.

What is one common knowledge misunderstanding you see from your ED Docs? Not necessarily annoying things we do (I know those are plentiful) but concepts in neurosurgery you’ve noticed EM docs fails to grasp.

If a patient in the shock room with head trauma is hypertensive and may have an acute subdural you should NOT reflexively try to lower the BP. The Cushing reflex is adaptive - let the BP ride to protect the CPP until either a large hematoma is ruled out or dura is open in the OR. A common rote move is if ICH then SBP < 140, but in acute trauma that can kill the patient

A transverse process fracture is not an indication for neurosurgery consult; there are peer-reviewed studies in the trauma literature supporting this

Please send coags immediately for any patient with intracranial hemorrhage or who may need to go to the OR

 

[neusu]

I remember reading this an a premed! Can’t believe it’s still going. I’m an EM PGY2 now.

What is one common knowledge misunderstanding you see from your ED Docs? Not necessarily annoying things we do (I know those are plentiful) but concepts in neurosurgery you’ve noticed EM docs fails to grasp.

In private practice, most ER docs seem to do a good job setting the expectation that back pain is not an emergency (after emergent needs are ruled out). I am sure it is reimbursement related, or utilization review etc, but x-ray/CT is far less useful than MRI to evaluate radicular symptoms.

For stroke/TBI the general concept of GCS and paresis (e.g. 0-4/5 strength) gets a little loose.

 

[Mian97]

Mad respect. How do u even have time to be on SDN I’ve heard NSG residents work 100 hours a week. Sounds brutal

 

[neusu]

Sorta a broad question, but do you think robotic surgery, like DaVinci replacing traditional hand surgery, is something we are going to see in our lifetime?

I presume you mean hand surgery as in surgery by hand. Surgical aids such as navigation and robotics will become more prevalent. Moreover, as these become standard of care, we risk our trainees losing the ability to do it the "old fashioned way." When it works, these technologies can be amazing. That being said, in real life, often, things do not work as intended.

 

[Round786]

I presume you mean hand surgery as in surgery by hand. Surgical aids such as navigation and robotics will become more prevalent. Moreover, as these become standard of care, we risk our trainees losing the ability to do it the "old fashioned way." When it works, these technologies can be amazing. That being said, in real life, often, things do not work as intended.

Ah ok. And yes, if you couldn’t sense my blatant inexperience from my question, I am but a mere freshman in undergrad. I was just curious if by the time I can even apply to surgical residencies, would surgeons even touch the patient?

 

[ner0]

We'll have to have a birthday party for it in October lol

The last 10-years have been rather transformative for neurosurgery. Two areas stick out in my mind as being dramatically different: instrumented spine and stroke.

For spine, when I was in med school and early on in training, the majority of instrumented surgery was open and inpatient. That is to say, we would make a midline incision and expose to the transverse process, bilaterally, place pedicle screws, possibly PLIF or TLIF cages, then close. Patients would stay in the hospital 2-10 days, often needing rehab discharge. As time went on, MIS changed approaches, dissection, and length of stay. Some of this truly is technology responding to surgeons pushing envelopes, and some of it is payments from reimbursers changing and requiring us to adapt.

For stroke, when I started, if it was a large vessel occlusion (LVO) patients were on "hemi-crani watch." In essence, wait for the patient to decompensate/herniate and rush them to the OR to remove half the skull. Hemorrhagic stroke was not much better. Often large craniotomies/craniectomies and big tracts through the brain. Now we have endovascular thrombectomies that can reperfuse acutely blocked arteries. This truly was game-changing where a patient typically doomed to hemiparesis, possibly aphasia, and SNF could go home intact. Further, for ICH, we have stereotactic guidance and portal retractors that can push in to the clot and evacuate it from the inside. Less tract and cortical disruption.

Moreover, with changes, advances, and implementation of technology, the bar continues to raise. A city that may only have had one MRI scanner or no dedicated teams for things like stroke care would benefit from the standard of care advancing.

So yes, I truly believe the next 10-years are going to change the world of neurosurgery in a good way. I am happy to be a part of that, and excited to see where we go.

Thanks for the information! As far as the training, do you see any new fellowships being created apart from cerebrovascular, endovascular, functional, pediatric, spine, and neuro-oncology? I've seen posts of more programs offering enfolded fellowships, but just curious if you believe as time time progresses the field will be further hyper-specialized?

 

[neusu]

If a patient in the shock room with head trauma is hypertensive and may have an acute subdural you should NOT reflexively try to lower the BP. The Cushing reflex is adaptive - let the BP ride to protect the CPP until either a large hematoma is ruled out or dura is open in the OR. A common rote move is if ICH then SBP < 140, but in acute trauma that can kill the patient

A transverse process fracture is not an indication for neurosurgery consult; there are peer-reviewed studies in the trauma literature supporting this

Please send coags immediately for any patient with intracranial hemorrhage or who may need to go to the OR

Cushing reflex is there for a reason! Same idea, but giving hypertonics can actually expand the hematoma.

Cervical TP fractures are a different story.

Agreed. Also history of NOACs etc

 

[neusu]

Mad respect. How do u even have time to be on SDN I’ve heard NSG residents work 100 hours a week. Sounds brutal

During residency would check on my days off or downtime on call. It is a lot of work!

Now, as an attending, life is better, though I am further and further away from relating to what its like to be a pre-med, med student, resident, or fellow.

 

[neusu]

Ah ok. And yes, if you couldn’t sense my blatant inexperience from my question, I am but a mere freshman in undergrad. I was just curious if by the time I can even apply to surgical residencies, would surgeons even touch the patient?

There will always be need for surgeons, at least until some Star Trek IV type device is created. Even with robots, the ports need to get in etc. The future holds a lot of neat advancements for medicine. It is an exciting time.

 

[neusu]

Thanks for the information! As far as the training, do you see any new fellowships being created apart from cerebrovascular, endovascular, functional, pediatric, spine, and neuro-oncology? I've seen posts of more programs offering enfolded fellowships, but just curious if you believe as time time progresses the field will be further hyper-specialized?

I suspect spine will break off in to its own program straight out of med school (similar to plastics or cards). Hyper-specialization is rampant in medicine. IMHO it is driven by admin/insurance etc to encourage gate-keeping and creating silos within medicine to have us fight one another instead of them. The more generalists we can be, the better. Certainly, for those interested in a particular field, or academic practice, fellowship is a benefit. Again, IMHO, enfolded fellowships are not the same experience as post-graduate fellowships. To put it in perspective, my operative abilities, clinical acumen, and decision making as a PGY-4, 5, or 6 (the years these fellowships are typically conducted) were rudimentary compared to following my chief year. The expectation that these residents spending a year or two focusing on a particular facet of neurosurgery, and learning the same amount without the foundational basis, seems flawed. My take, is that the writing on the wall is that super-sub-specialization is not going anywhere, and allowing residents to do these enfolded fellowships is a way to offset further extending the already long training period. That being said, if some day they require a fellowship to take out a brain tumor, or put in a pedicle screw, that would be problematic. There simply are not enough neurosurgeons around, nor enough of these pathologies, to support this model without a dramatic change in the landscape.

 

[Dunkthetall]

I suspect spine will break off in to its own program straight out of med school (similar to plastics or cards). Hyper-specialization is rampant in medicine. IMHO it is driven by admin/insurance etc to encourage gate-keeping and creating silos within medicine to have us fight one another instead of them. The more generalists we can be, the better. Certainly, for those interested in a particular field, or academic practice, fellowship is a benefit. Again, IMHO, enfolded fellowships are not the same experience as post-graduate fellowships. To put it in perspective, my operative abilities, clinical acumen, and decision making as a PGY-4, 5, or 6 (the years these fellowships are typically conducted) were rudimentary compared to following my chief year. The expectation that these residents spending a year or two focusing on a particular facet of neurosurgery, and learning the same amount without the foundational basis, seems flawed. My take, is that the writing on the wall is that super-sub-specialization is not going anywhere, and allowing residents to do these enfolded fellowships is a way to offset further extending the already long training period. That being said, if some day they require a fellowship to take out a brain tumor, or put in a pedicle screw, that would be problematic. There simply are not enough neurosurgeons around, nor enough of these pathologies, to support this model without a dramatic change in the landscape.

I’ve been wondering about this. During residency, aren’t you spending two years either in an enfolded fellowship or doing research? And if doing research, do clinical and surgical skills improve much if most of your time is spent in the lab? Or am I underestimating the amount of time in the clinic and OR during that period?

Which leads to another question: why isn’t neurosurgery five years, with fellowship afterwards?

 

[ner0]

I’ve been wondering about this. During residency, aren’t you spending two years either in an enfolded fellowship or doing research? And if doing research, do clinical and surgical skills improve much if most of your time is spent in the lab? Or am I underestimating the amount of time in the clinic and OR during that period?

Which leads to another question: why isn’t neurosurgery five years, with fellowship afterwards?

I read in an earlier post that if research, elective, and on service clinical time was shortened it could potentially be 5 years, but almost certainly require a fellowship beyond the most common cases. Then you'd have a bunch of residency trained neurosurgeons doing 2-year fellowships, and ultimately spending 7 years in training anyway lol. I have heard of more programs going into a 6-year residency and PGY7 serving as a fellowship, but I may be wrong on that end as well.

 

[ner0]

I suspect spine will break off in to its own program straight out of med school (similar to plastics or cards). Hyper-specialization is rampant in medicine. IMHO it is driven by admin/insurance etc to encourage gate-keeping and creating silos within medicine to have us fight one another instead of them. The more generalists we can be, the better. Certainly, for those interested in a particular field, or academic practice, fellowship is a benefit. Again, IMHO, enfolded fellowships are not the same experience as post-graduate fellowships. To put it in perspective, my operative abilities, clinical acumen, and decision making as a PGY-4, 5, or 6 (the years these fellowships are typically conducted) were rudimentary compared to following my chief year. The expectation that these residents spending a year or two focusing on a particular facet of neurosurgery, and learning the same amount without the foundational basis, seems flawed. My take, is that the writing on the wall is that super-sub-specialization is not going anywhere, and allowing residents to do these enfolded fellowships is a way to offset further extending the already long training period. That being said, if some day they require a fellowship to take out a brain tumor, or put in a pedicle screw, that would be problematic. There simply are not enough neurosurgeons around, nor enough of these pathologies, to support this model without a dramatic change in the landscape.

Thanks for what you do!

 

[Davidfromcali]

Woah neusu, still active on this thread

I remember reading this thread back in 2014 when I was thinking about doing premed…crazy stuff. I was even seriously thinking neurosurgery in college because of this thread. Fast foreword to med school now and I can confidently say neurosurgery isn't for me but your explanations of the field really did peak interest.

 

[neusu]

I’ve been wondering about this. During residency, aren’t you spending two years either in an enfolded fellowship or doing research? And if doing research, do clinical and surgical skills improve much if most of your time is spent in the lab? Or am I underestimating the amount of time in the clinic and OR during that period?

Which leads to another question: why isn’t neurosurgery five years, with fellowship afterwards?

There are arguments that can be made either way. We have the ABNS and the Senior Society whose object is to determine training metrics and certification. I can not pretend to understand the nuance that goes in to these decisions, but they seem to know what they are doing.

 

[neusu]

I read in an earlier post that if research, elective, and on service clinical time was shortened it could potentially be 5 years, but almost certainly require a fellowship beyond the most common cases. Then you'd have a bunch of residency trained neurosurgeons doing 2-year fellowships, and ultimately spending 7 years in training anyway lol. I have heard of more programs going into a 6-year residency and PGY7 serving as a fellowship, but I may be wrong on that end as well.

I am no longer in academic neurosurgery, but I do know that, historically, neurosurgery was 5 or 6 years after a general surgery intern year. This was integrated in to a 7-year model, such that there weren't programs that were 6 years total or 7 years total; all were now 7 years in duration. Most recently, there may be some programs that do the "chief year" the PGY-6 year, and then an enfolded fellowship year the PGY-7, though I am uncertain on whether this is possible, or prevalent.

Several considerations are at play including staffing, finances, and training. For a 1 or 2 a year program, taking 2-years off the duration would removed 2-4 residents. Neurosurgery is a very intense call specialty, requiring in-house call for most any large volume, acuity, trauma, or stroke center. Having 24-7 resident coverage, while pretending to stick to the ACGME 80-hour limit, and cover educational requirements, can be quite the game of Tetris. While the enfolded fellowship model increases, the post-graduate fellowship model wanes. The latter allowed a fully-trained, board eligible neurosurgeon, to be beholden for 1-2 years for their sub-specialty training. While doing so, often, they could "supplement" their income taking general trauma call etc. and lighten the load for the other attendings.

 

[neusu]

Thanks for what you do!

You're welcome!

 

[neusu]

Woah neusu, still active on this thread

I remember reading this thread back in 2014 when I was thinking about doing premed…crazy stuff. I was even seriously thinking neurosurgery in college because of this thread. Fast foreword to med school now and I can confidently say neurosurgery isn't for me but your explanations of the field really did peak interest.

Glad you found it informative! I should go back and re-read it all to get an idea of how things were for me way back when! I hope you found what you love.

 

[VaultArmitage]

First off: Absolutely amazing that this thread has gone on for so long. I wonder how many people you've personally inspired to go into neurosurgery.

I'm a MD/PhD student who's very interested in neurosurgery. Glancing through the thread I noticed that you started in academics and then switched out so I'm interesting in your take on MD/PhDs and neurosurgery. I've heard that some people are able to negotiate 1-2 OR/Clinic days and 3-4 days of lab work. Have you ever seen that model work? I assume the surgeon would have to be fairly specialized and only do a limited range of cases. Any thoughts would be appreciated!

 

[neusu]

First off: Absolutely amazing that this thread has gone on for so long. I wonder how many people you've personally inspired to go into neurosurgery.

I'm a MD/PhD student who's very interested in neurosurgery. Glancing through the thread I noticed that you started in academics and then switched out so I'm interesting in your take on MD/PhDs and neurosurgery. I've heard that some people are able to negotiate 1-2 OR/Clinic days and 3-4 days of lab work. Have you ever seen that model work? I assume the surgeon would have to be fairly specialized and only do a limited range of cases. Any thoughts would be appreciated!

Thank you! I do hope some insight to the field I love gave some perspective.

For the MD/PhD I have seen several takes. First, those that enter as MD/PhD, I have seen get burnt out more quickly and want a "real life," because they spent the extra time in the lab. Moreover, the opportunity cost of a year in fellowship, as a post-doc, etc vs being a practicing neurosurgeon starts to weigh significantly as the order of magnitude of income is more proximal. That being said, I have seen some who do balance a lab and practice. For the most part, anything and everything is negotiable. If you only want clinical responsibilities 1-2-days a week and lab 3-4, that can often be accommodated. There may be expectations and/or strings attached (e.g. have funding, take a significant pay cut). Again, depending on the practice model, a limited subset of cases is possible, but the bills have to be paid, and there is no such thing as a free lunch. Academic programs are more likely to subsidize loss-leading fields like research and/or peds because they are needed for the program reputation/prestige or viability. Even so, there are limits. When you are closer to the job search you will see more the lay of the land as to what is available, where, and whether it is something you would consider doing or not. We all have our dream job, and expect it handed to us on a silver platter. In reality, there is a bit of a back and forth, where to get things we want, we give up things we don't want (e.g. more pay for extra call, more research time for less pay and so forth). Hope this helps.

 

[ohiosveryown]

Hi @neusu! Any advice for those without a home program, especially in the age of pass/fail step 1?