How to become a neurosurgeon
(Photo by iStockphoto)
The dismissive remark “It’s not brain surgery” for uncomplicated tasks reveals the common perception that neurosurgeons have preternatural intelligence and skills.
While they do need to be very bright and have great hands, neurosurgeons are not necessarily smarter or more dexterous than physicians in other demanding surgical specialties, those in the field insist. In fact, misconceptions about neurosurgery scare away some medical students who might excel in the specialty while enticing others to pursue it for the wrong reasons.
“If you think you might be interested in neurosurgery, you shouldn’t shy away from learning more about it because you feel your grades aren’t good enough,” says Oklahoma City neurosurgeon Dawn R. Tartaglione, DO, who serves on the governing board of the American College of Osteopathic Surgeons. “You’d be surprised at just whom this specialty suits.”
At the same time, those who are drawn to neurosurgery’s perceived prestige are in for a rude awakening, says Kailish Narayan, MD, the program director of the AOA-approved neurosurgical residency at Doctors Hospital in Columbus, Ohio.
“Some people say they want to do neurosurgery, but they don’t really know what it is,” Dr. Narayan says. “For example, they may see the glamour part and think it would be pretty cool to be a brain surgeon, not realizing that the majority of neurosurgeons do mostly spine surgeries.”
Neurosurgery requires physicians who have a special combination of traits, according to Dr. Narayan. Most surgeons are results-oriented individuals who like to fix patients’ problems. Neurosurgeons, though, must be able to take satisfaction from small improvements.
“It’s a peculiar field. What makes neurosurgeons happy would be considered poor outcomes in most other specialties,” Dr. Narayan notes. “That’s just the limitation of what we’re dealing with. The brain and the spine are unforgiving, and they have very little power to recuperate or heal.”
Although they frequently prolong patients’ lives, alleviate pain and enhance function, neurosurgeons rarely cure.
“A lot of our patients are very sick,” Dr. Narayan says. “A lot of them die or are paralyzed. This is the dark side, if you will, of neurosurgery that some students don’t really recognize or appreciate.”
Neurosurgeons, thus, often break bad news and need tremendous empathy and interpersonal skills as they manage the expectations of patients and their families through emotionally trying ordeals.
Specialists in neurosurgery also need extraordinary drive, residency directors say. The 10 AOA-approved neurological surgery residencies are now seven years in length, as are the 103 neurosurgical residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). On top of lengthy training, practicing neurosurgeons have long, unreliable hours and are frequently called in to do emergency procedures.
“It’s a very unpredictable job,” Dr. Tartaglione says. “I’ve cancelled more haircut appointments than I’ve shown up for. And in the past 10 days, there were only three in which I got home before 9:40 p.m. I try to be home by this time, so I can be in bed by 11 p.m.
“Neurosurgeons also take a lot of call. In my group, we’re short a person, so we’re on call 10 days a month.”
Osteopathic medical students who place a premium on balance between their professional and personal lives should steer clear of neurosurgery, advises Louis I. Jacobs, DO, who directs the AOA-approved neurosurgical residency program at Garden City (Mich.) Hospital.
“If you don’t want to work hard and long hours, you shouldn’t go into this specialty,” he says. “There is no work-life balance during residency. Nevertheless, when you’re an attending, you can and should make time for family and friends. In spite of my busy schedule, I never missed my seven children’s school and sports activities. If necessary, I would return to the hospital afterward.
Despite the challenges, neurosurgeons find much to love about their field.
“I like the diversity most of all. Every day is completely different,” says Jason Seibly, DO, who directs the AOA-approved neurosurgical residency at Advocate BroMenn Medical Center in Normal, Ill. “Just this week alone, I’ve taken out a brain tumor, I’ve done a carpal tunnel surgery, I’ve done a surgical spine reconstruction, and I’ve taken out lumbar disc herniations. It’s a vast specialty that is not monotonous by any measure.”
Intrigued by the brain and nervous system since childhood, Dr. Jacobs knew he wanted to become a neurosurgeon by the time he was 8. “My third-grade class went on a field trip to a medical center in Detroit. And it was just fortuituous that we went to the neurosurgery unit,” he remembers. “The residents were good with kids and explained in layman’s terms what they were doing. It was just fascinating. That experience captured me for the rest of my life.”
“I like the diversity most of all. Every day is completely different.”
“What propels us is that neurosurgery is technically very challenging and intellectually very challenging,” adds Dr. Narayan. “In spite of how far we’ve come, there is still so much more to know about the brain and how it functions.”
Rotation, rotation, rotation
Osteopathic medical students interested in a particular field should serve elective rotations at institutions with residency programs in that specialty. But this is especially crucial for students considering neurosurgery, residency directors say.
With only 15 or so openings a year in AOA-approved neurological surgery residencies, the field is highly competitive. And it is even tougher for DOs to get into ACGME-accredited neurosurgical residencies. As a result, potential neurosurgeons need to impress directors of the targeted programs, other attendings and neurosurgical residents before the residency application process begins.
Neurosurgical residencies vary significantly, particularly in the final years, depending on the number of trauma surgeries versus office-based surgeries trainees perform and the subspecialty expertise of a program’s faculty. Consequently, students need to rotate through a number of different sites to gauge which programs hold the most appeal and where they best fit in.
Student doctors should start shadowing neurosurgeons as early as their first or second year, suggests Dr. Seibly. “Students can come here to Advocate BroMenn during their breaks or summer vacation to spend some time with us and check out our program and learn more about neurosurgery before their fourth year, when they have to make more of a commitment,” he says. “What we don’t like to see is a fourth-year student who hasn’t spent much time in neurosurgery get into a program and discover it’s not for them.”
Interested students should try to serve their core rotations and other elective rotations at institutions that have neurosurgical residencies. That way, students may be able to spend some of their free time shadowing neurosurgeons and observing neurological surgeries.
“During a pathology rotation, for example, you won’t be expected to stay until 9 every night,” Dr. Tartaglione says. “So if you have time, ask a neurosurgeon if you can watch a surgery or shadow him or her in the office.”
To increase their shadowing opportunities, premeds who are contemplating a career in this specialty should apply to medical schools affiliated with hospitals that have neurological surgery residency programs.
At Doctors Hospital, Dr. Narayan receives roughly 20 applications a year for two openings. He will consider only candidates who have rotated in his program—for two weeks or four weeks during their third or fourth year.
“During the rotations, students participate in rounds, they scrub in, and some may be interested in lecturing on a topic,” Dr. Narayan says. “They get to see what we have to offer, and we get to see who would be the best fit for our program.”
Dr. Jacobs, who has been training residents for three decades, always requires candidates to have rotated in his program. “This is the only way you can judge somebody’s potential to become a neurosurgeon,” he insists. “You have to see how they react to people and how they look in the operating room.” Over the years, he has developed a knack for discerning who has the hands for neurosurgery, he says.
Neurosurgeons have to be much more than “book smart,” says Dr. Jacobs, who looked at more than 30 applications last year for one opening.
“What propels us is that neurosurgery is technically very challenging and intellectually very challenging.”
Prospective neurosurgery candidates should do well on the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA), but they don’t need stratospheric scores. In 2011, for example, those who matched into neurosurgery as their first-choice specialty had scores ranging from 491 to 686 on Level 1, according to a report by the American Association of Colleges of Osteopathic Medicine (AACOM). However, the average score of 581 was the second highest among all the specialties.
“Those with the highest scores don’t always make the best neurosurgeons,” Dr. Jacobs contends. “It’s better to have someone who is more well-rounded and can relate to people.
“Neurosurgeons also have to be creative. Each operation you do is like creating a painting. If I weren’t a neurosurgeon, I’d probably be a graphic arts designer. So when students are on rotation, I look for signs of their creativity.”
Dr. Seibly, who receives approximately 30 applications a year for one or two positions, prefers candidates who’ve scored above the 85th percentile on COMLEX-USA. But he rates rotation performance very highly.
“We let students first-assist on nearly every surgery so they’re in there seeing things close up,” he says. “They also help residents evaluate emergencies in the emergency room. We let the students do as much as they are capable of doing. They round on the inpatients. And a couple of days a week, they come to the clinic and see patients independently in the office.”
During these intense rotations, Dr. Seibly doesn’t judge students’ manual dexterity. “We don’t really look at their skills per se because that’s what they will develop during their training years,” he explains. “What we’re really looking for is their ability to take direction, their integrity and their willingness to learn. Initiative, motivation and interpersonal skills are the most important traits we seek.”
Students need to show that they have a bedside manner, Dr. Seibly notes. “Patience and compassion are so important because we probably have the most difficult patients to take care of compared with all other specialties,” he says. “It’s very common for a patient to have a malignant brain tumor and a very short life expectancy, so you’re dealing with end-of-life issues on a daily basis. On the flip side, neurosurgeons do a lot of spine surgery on patients who have chronic pain ailments. These patients can also be demanding and need compassion and understanding.”
Rotations, moreover, allow programs to assess the intelligence of students far better than tests do, according to Dr. Tartaglione. “On a rotation you can see the people who get it,” she says. “If we tell a student to review a complex topic and he or she can converse about it the next day, we can see that this person is intelligent. It doesn’t just have to do with excelling on exams.”
Students on rotation also demonstrate whether they have the stamina for neurosurgery. “It’s physically hard work, and it’s emotionally hard work,” Dr. Narayan says. “We have to get a sense that these students know what they’re getting into.”
Many neurosurgical procedures are only an hour or two in length, but complex operations, such as removing invasive brain tumors, can last 15 hours, notes Dr. Tartaglione. Students with hip problems, bad backs and other physical limitations probably should not select this specialty, she says.
Besides standing out during their rotations and having good board scores and grades, neurosurgery applicants need to show that they are well-rounded to land interviews.
“Extracurricular activities show that a student has outside interests and, hopefully, can relate to a wider variety of people,” Dr. Tartaglione says.
Participating in research during medical school, not necessarily related to the nervous system, is helpful, she suggests. “It’s good to have your name on some publications to show that you have some interest in didactic work and manuscript writing,” she says. “In residency, you are going to be required to write papers, and you are going to have to do a good job.”
According to AACOM’s report on the 2011 match, 85% of those who matched into neurosurgery as their first-choice specialty had research experience—a higher percentage than any other specialty.
Volunteer work is also beneficial for neurosurgical residency applicants. “The volunteer work doesn’t necessarily have to be medical,” Dr. Tartaglione says. “It’s good for students to get out and see the world, to see how other people live.”
Dr. Jacobs says he values volunteer experience over research. “I’d rather see someone who has done something with people that shows they are a caring person,” he says.
Students should also try to attend the annual clinical assembly of the American College of Osteopathic Surgeons and sit in on some of the neurosurgical discipline’s continuing medical education classes. This is a great networking opportunity and exposes students to the latest developments in the field, Dr. Tartaglione says.
After winnowing down the residency applicants to those who are known and have desirable credentials, Dr. Jacobs invites a limited number of candidates for formal interviews. “They’re interviewed not only by me and two other neurosurgeons, but also by at least two of the residents,” he says. “Then we sit down and make a decision. And it’s a hard decision.
Read more about specialties
This is the 19th article in a series profiling medical specialties. The others focused on the following:
- Emergency medicine
- General surgery
- Internal medicine
- Occupational and preventive medicine
- Osteopathic manipulative medicine
- Proctology, urology
- Physical medicine and rehabilitation
“Last year, frankly, I didn’t want to train anybody who applied, so I didn’t take a resident. If I don’t find a candidate whom I think is going to succeed, it’s too much of an investment in time for myself, my colleagues and my residents to take someone on. We don’t want to commit ourselves in that way.”
Sometimes neurosurgery candidates act pretentious rather than genuine and try to second-guess what they think their interviewers want to hear, he says.
“The biggest thing people should do when they go into an interview is be themselves and not try to put on airs with the interviewer because arrogance shines through,” Dr. Jacobs says. “We want people who are down to earth, well-rounded and hard workers.”
Some neurosurgical residencies expect candidates to answer questions about neurosurgery to show that they already have basic knowledge of the field. But Dr. Narayan takes a different stance. “I don’t really need to know what they know,” he says. “What I want to know is whether a candidate has the intelligence, integrity and drive to be taught to be a neurosurgeon.”
Osteopathic neurosurgical programs prepare residents to be skilled general neurosurgeons, residency directors say. Program graduates can pursue additional subspecialty training but face restrictions from entering formal accredited fellowships and obtaining subspecialty board certification.
The only accredited subspecialty fellowships are ACGME programs in pediatric neurosurgery, Dr. Tartaglione points out. Because of changes to the ACGME’s common program requirements effective July 2016, these programs will not be able to accept DOs who’ve completed AOA-approved neurosurgery residencies unless the candidates are considered exceptional and meet certain additional criteria.
Career prospects for AOA-trained neurosurgeons are excellent, Dr. Tartaglione says. Although many neurosurgeons today are employed by hospitals or large groups, neurosurgery is a specialty in which it is still possible to thrive in an independent small-group, or even a solo, practice.
“I’ve always been by myself, though I’ve associated loosely with two other neurosurgeons,” Dr. Jacobs says. “We cover each other’s practice. That way, we can take as much time off as we want to.”
Experienced neurosurgeons can make more than $500,000 a year, but the salary range is very wide. Because of the length of training and the personal sacrifices required, earnings potential should not be the main reason for pursuing this specialty, residency directors agree.
Neurosurgeons must have passion for their field and the motivation to keep learning.
“The nervous system is still an open frontier,” Dr. Narayan says. “There is so much about it that we don’t really understand. And we are continuing to learn.
“And every time we get some new insights, old concepts that have held for decades are thrown out and something new starts to be done. We realize that what we thought was the best thing to do 10 years ago is now the worst thing to do.
“I find this aspect of neurosurgery exciting. But the field is not for everyone. It takes a peculiar mindset. It is very, very different from anything else.”