For students interested in pursuing a career in neurosurgery, clerkship or rotation performance in the field has been shown to be a very important factor in the residency selection process. In the 2021 NRMP Program Director Survey, 63.2% of neurosurgery program directors cited "grades in clerkship in desired specialty" as an important factor in making interview decisions. It was given a mean importance rating of 4.6 on a scale of 1 (not at all important) to 5 (very important).
Most aspiring neurosurgeons will perform away or audition electives. These electives are also very important in the residency selection process, with 26.3% of program directors using "audition elective/rotation within your department" to make interview decisions.
The importance of the neurosurgery rotation goes far beyond the rotation or clerkship grade. Neurosurgery applicants seek to strengthen their residency applications with strong letters of recommendation, and most letters are based on clinical performance of students during home and away rotations.
Given the importance of the neurosurgery rotation in the residency selection process, I am often asked for advice on how medical students can make a favorable impression on attending physicians and residents. Below are some very specific recommendations for success.
Demonstrate a Strong Work Ethic in your Neurosurgery Rotation
A strong work ethic is important in all fields and neurosurgery is no exception. "Neurosurgery can be a demanding field," writes the Department of Neurosurgery at LSU. "The hours can be long. We expect hard work from our students."
Part of your clinical evaluation and your suitability for a career in the field will be based on your work ethic. "It's physical hard work, and it's emotionally hard work," writes Dr. Kailish Narayan, program director of the neurosurgery residency at Doctors Hospital. "We have to get a sense that these students know what they're getting into."
A warning for medical students: don't ever complain about how hard you're working. While this sounds obvious, students have been known to drop their guard, especially later in the rotation when they have developed close working relationships with team members. Just because the residents are complaining about their work hours doesn't mean you should too.
Highlight Qualities that Would Make You an Excellent Neurosurgeon
Students aspiring to become neurosurgeons should highlight qualities that are important for success in the field. In a survey sent to members of the Canadian Neurosurgical Society, respondents were asked to rate the importance of 22 personal skills and attributes, and their ability as educators to teach students these characteristics during residency training. The five most important traits were:
Honesty
Motivation
Willingness to learn
Ability to problem solve
Ability to handle stress
Other qualities noted to be important included willingness to consult informed sources, critical thinking, ability to do realistic self-appraisal, empathetic/caring, inquiring mind, maturity, ability to control emotions, decisiveness, organized, team player, manual dexterity, and communication skills. Neurosurgeons believed that many of the 22 skills and attributes could be taught but felt that the traits listed above, with the exception of ability to problem solve, were difficult or impossible to teach.
"What we're really looking for is their ability to take direction, their integrity and their willingness to learn, " writes Dr. Jason Seibly, program director of the neurosurgery residency at Advocate BroMenn Medical Center. "Initiative, motivation, and interpersonal skills are the most important traits we seek."
Learn How to Perform the Neurosurgical History and Physical Exam
As you would expect, the neurosurgical history and physical exam shares a lot in common with the neurology history and physical exam. Before the rotation, I recommend that you reacquaint yourself with the particulars of this exam. I wrote extensively about it in the blog post "How to Succeed in Your Neurology Rotation: Tips for Medical Students."
Develop an Approach to the Patient with Neurosurgical Emergency
Medical students seldom encounter patients with neurosurgical emergencies on other rotations or services. As a result, many students enter the rotation unsure of how to evaluate and manage such patients. The following resources are highly recommended to bring you up to speed before the rotation:
Essential to the care of the neurosurgical patient will be your ability to recognize changes in your patients' clinical status. Proceed through your rotation with the mantra "Time is brain!" The phrase, referring to the importance of early diagnosis of stroke, is applicable to other patient situations in neurosurgery, and is a reminder that patients on the service are typically quite ill. As you evaluate neurosurgical patients, remain vigilant for any deterioration in their clinical status. Seek the expertise of your resident or attending physician as soon as possible should you encounter such situations.
Become Familiar with the Evaluation of Commonly Encountered Problems in Neurosurgery
Students often ask me what to read before the neurosurgery rotation. The Congress of Neurological Surgeons Committee on Education has created an excellent online curriculum of neurosurgery topics for medical students. Included in this resource are such high yield topics as intracranial hypertension, head trauma, brain tumors and abscess, headache, cerebrovascular disease, spinal cord injury, peripheral nerve disease and hydrocephalus. This Medical Student Curriculum in Neurosurgery is essential reading for all rotating students.
Order the Correct Imaging Study and Learn How to Interpret It
Neurosurgeons have a wide array of imaging options to evaluate and manage patients with neurologic disease. In recent years, there has been increased attention on the importance of selecting the most appropriate test. In 2014, a joint effort of the American Association of Neurological Surgeons and Congress of Neurological Surgeons led to the release of a group of tests and procedures which were commonly ordered but often not necessary in neurosurgery. This release was part of Choosing Wisely®, an initiative of the ABIM Foundation.
Of course, after the appropriate test has been ordered, the challenge is to interpret it accurately. The interpretation of imaging tests in neurosurgery can be difficult for many medical students. The following resources will help you acquire the knowledge you need to be more effective in this important area:
Learn How to Lighten your Team's Workload by Understanding a Day in the Life of a Neurosurgical Resident
In an hour-by-hour snapshot, Dr. Colin Son provided an eye-opening and enlightening look at the life of a neurosurgery resident during a typical weekend call day. At the end of this 30-hour shift, he had "written more than 60 notes, rounded on 80 patients, done 2 EVDs, scrubbed 2 operations, seen 5 consults..."
I encourage you to read his account so that you can develop a stronger understanding of the roles and responsibilities of neurosurgical residents. With this understanding, you'll be able to see where you, as a medical student, can lighten the team's workload and increase efficiency. Some examples based on Dr. Son's account:
Pulling up new images on the computer for review in the morning before rounds
Obtaining vital signs and lab data for patients on the service
Writing notes
Assisting with the discharge process, including paperwork
Volunteering to begin the evaluation of "stable" consults or new admissions while the team is in the ICU or operating room
Of course, you'll have to adapt this approach to the structure and needs of your rotation and team. As you become more familiar with how work is performed on your team, ask yourself what you can do to keep the team on track to complete tasks in a timely manner.
Collaborate Effectively with Others During your Neurosurgery Rotation
Although your team will consist of an attending physician, residents, and medical students, you're also part of a larger team which includes a variety of healthcare professionals, including, but not limited to, pharmacists, nurse practitioners, social workers, occupational and physical therapists, nutritionists, and speech pathologists. You'll quickly see that cooperation among these diverse team members is essential to the practice of high quality neurosurgical patient care.
As a medical student, you'll have numerous opportunities to collaborate with these team members. You'll also be working closely with other medical students. These students may be competing with you for the few positions available at the residency program. Rather than adopting a competitive mindset, find ways to collaborate with one another. Friction between students is easily noticed by residents and attendings, and will prevent you from leaving the team with a favorable impression. In one study of resident attrition from neurosurgery residency programs, resident dismissal was more often due to issues related to professionalism such as ethics and interpersonal skills and behaviors rather than cognitive or psychomotor deficits.
Take Care of Yourself
The neurosurgery rotation will be one of the most demanding rotations you take as a medical student. To be at your best, it's very important that you take care of yourself during this rotation. This has obvious benefits to you well after the rotation ends. "When someone else's brain health is in your hands, you have to take exceptionally good care of yourself," writes Dr. Uzma Samadani, Associate Professor in the Department of Neurosurgery at the University of Minnesota. "If I'm operating, I make sure to go to bed early the night before, eat a hearty breakfast, and drink tons of water. I'm vigilant about that stuff, because you never want to be in a situation when you're not at your best...You absolutely cannot be sloppy about your own health, because doing so could affect your patient's health."
Finally, I would like to leave you with an informative video from Dr. Andrea Tooley. In this clip. Dr. Tooley interviews Dr. Maya Babu, a neurosurgery resident at the Mayo clinic. Dr. Babu shares her thoughts about becoming a neurosurgeon.
For more information on how to succeed in rotations, please check out our other posts in this series:
Dr. Samir Desai is the co-creator of the online course The Residency Interview 101 and the author of The Successful Match: Rules to Succeed in the Residency Match. He has been a faculty member in the Department of Internal Medicine at the Baylor College of Medicine for over 20 years, and has been the recipient of numerous teaching awards
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