A guide for navigating whether neurosurgery is right for you and getting involved early in medical school.
This article is intended to offer a transparent, accessible, and informative look into navigating a career in neurosurgery early in your medical school career. Remember that it is okay to not really know if neurosurgery is for you- that's what the early part of this guide is intended for. The latter part of the guide lays out specific steps to set yourself up for neurosurgery early in medical school.
You will figure out more about what you are interested in as you talk to clinicians in various specialties and see different kinds of cases. Keep an open mind because you may just not know enough to determine whether you really like something or just like the "idea" of it. You may also be pleasantly surprised by certain specialties that you may not have considered but really enjoy on clerkships.
Neurosurgery residencies are highly standardized by the ACGME across all programs. All neurosurgery programs last 7 years with 6-24 months of research/enfolded-fellowship and stringent case volume requirements.
All programs are supposed to adhere to 88 hours/week on average (80 hours at some programs and in New York). The average program accepts 2 residents per year (range 1-4), with the vast majority taking two or three. As of 2019/20, there were 112 programs with 232 positions.
In 2019, 273 M.D. Seniors applied and 203 (74%) matched. While the match rate fluctuates every year, the trend over the last few years shows a decreasing match rate -- 2016: 86.3%, 2017: 84.6%, 2018: 84.6%, 2019: 80.4, 2020: 74%. For more on trends in neurosurgery residency and training programs over the last decade, click here for the publication by Yaeger et al.
Neurosurgery is a diverse field comprising multiple subspecialties which may consist of additional fellowship training. Pediatrics is the only subspecialty that requires a 1-year post-residency fellowship for board certification. Other subspecialties include:
- Skull base
- Peripheral Nerve
- Neurocritical Care
What to do in Pre-Clinical Years (MS1)
Early in your medical school career it is important to establish a good foundation and study habits. You will need to do well in classes (especially if not pass/fail) and concurrently explore specialties of interest. One of the best ways to explore the field of neurosurgery is by taking time to shadow a neurosurgery resident for full days (5 am to sign out) to get a sense of the daily lifestyle. Occasionally, you should attend Grand Rounds, weekly case conferences/journal club, and shadow in the OR.
It is also important to get engaged in the neurosurgery community at your medical school. This can be done by joining the neurosurgery medical student interest group at your institution.
The next step is to get involved with student events and volunteer/research activities early on. Neurosurgeons are busy people—do NOT be discouraged if it takes multiple emails and reminders to get on somebody’s radar for research opportunities.
If you continue to remain interested, you should meet with your home department chair, program director, and other senior faculty early in medical school to get on their radar. Find out who their administrative assistant is and always be polite and flexible when setting up meetings.
Finding a mentor in neurosurgery (senior faculty is strongly preferred) can be very useful during this time. They can help set up research projects, offer advice (professional/personal), and provide network connections. Eventually, having someone that has known you for several years who can advocate for you during the match is an invaluable resource for which there is no substitution.
What to do in Summer (Between MS1/MS2)
The summer between MS1 and MS2 is traditionally a research block ranging for 8-10 weeks. You should start thinking about your summer research plans in the Fall since applications for many summer funding opportunities and research fellowships are due in January.
You should first decide between doing basic science versus clinical research and then decide who you would like to work with. If you decide on basic science, keep in mind that it would be beneficial and would maximize productivity if you joined the lab during the school year. Everything will then be set for you to start full time during summer.
Reach out early so that you can put together a summer fellowship proposal. More info on neurosurgery research fellowships will be posted on the blog in the future.
Submitting abstracts to annual AANS and CNS meetings is an excellent opportunity to show off basic science research interest and productivity without having to go through the arduous process of having a basic science paper published in peer-reviewed journals—repeats, submission, review process, etc. can take well over a year. Take advantage of conference funding at your institution.
USMLE Step 1
This was historically the number one objective criterion used in the match process, mostly in getting interviews. However, with Step 1 moving to pass/fail this will inevitably place more weight on Step 2 CK and clerkship grades. Therefore, a strong foundation from pre-clinical and Step 1 will still be critical in doing well on clerkships and Step 2 CK.
Consensus resources: UWorld question banks, First Aid, Pathoma, and Sketchy Micro.
What to do in Clinical Year (MS2/MS3)
Keep an open mind in all clerkships and do well. No need to lie to residents/attendings who ask what you are interested in, but if you are labelled early on in a clerkship as a student interested only in neurosurgery, you will invariably suffer in terms of attention, and subsequently clerkship evaluation grades.
Show interest and passion in every clerkship, even if you know that will not be the field you’ll end up in. Honors in neurology and general surgery are most important. AOA is often based on clerkship grades, but check with your school.
If your institution has the option of rotating on the neurosurgery service during neurology or general surgery, take advantage of working directly with neurosurgery residents and attendings. If not, advocate for this option. Similarly, if your institution has the option of rotating in the neuro ICU, take advantage.
USMLE Step 2 CK
With Step 1 becoming pass/fail, we anticipate Step 2 CK will become more important. Take it as close to your clinical year as possible. Save high-yield material and your favorite books from clerkship year to create a study resource.
Consensus resources: UWorld question bank, NBME exams.
USMLE Step 2 CS
This is the practical, in-personal exam of the USMLE series. Take this exam as close to your clinical year as possible. Failing is possible, seemingly random, and can have devastating consequences. Take it seriously.
The logistics of this exam can be unnecessarily stressful. It is often difficult to get dates less than 6 months out. You often have to travel to another city to take this test. There are only 5 testing centers where this is offered. This is also a costly exam. Plan your Step 2 CS strategy early in your third year.
Consensus resources: First Aid for Step 2 CS (Do all the cases).
Board Scores and Med School Grades
The median USMLE Step 1 for matched students was 249 ± 11 in 2018 and 28% of students were AOA.
As mentioned above, honors in general surgery and neurology are most important. It is great to get honors on rotations, but plenty of people match with high pass and even pass on their transcripts. Perhaps more importantly, avoid red flags, i.e. failing a clerkship or a board exam.
Neurosurgery is predicated on research and unique in the sense that the residency is structured to include 1-2 years of research. Therefore, getting involved in research is not only an important part of your application, but important for you to gauge if neurosurgery is a good fit for you.
Even though many neurosurgeons go into private practice, most programs like to produce academic surgeon-scientists. Although your main focus is publication quality, you should aim to have at least 1-2 first-author papers (i.e. clinical case series, case report, review paper, etc.).
To get set up with a research project, you should contact the most active researchers at your institution. Alternatively, it might be a good idea to work with a resident on your first research project or two.
Keep in mind that neurosurgeons are particularly fond of clinical neurosurgery journals (mainly Neurosurgery, JNS, and World Neurosurgery). Articles in these journals weigh more heavily than articles in higher-impact journals of other specialties/fields.
Basic/translational science research can be very helpful in applications, as they make for good sub-I presentations and interview discussion. If the basic science work isn’t published yet, they will understand as long as you can explain it clearly.
Additional Research Year
There is slight variation year-to-year but neurosurgery applicants are 15% MD/PhD, 50% additional research year, 35% no time off.
Dedicated research definitely helps with matching at more research-oriented programs. It gives you work to talk about at interviews, and publications will always help your resume.
Plan early in 3rd year, if possible, so that you can apply for grant funding (Many have a January 1 deadline). Give yourself at least 1.5 months to prepare a grant proposal.
If aiming for an academically oriented program: Basic science/translational research makes the most sense as the focus of a research year. However you should also get some easier clinical papers submitted to help build your CV.
It is very easy to start clinical projects during your research year as time requirements for basic science work vary greatly. Also take advantage of this opportunity to really get to know the people in your department.
If you are more interested in clinical programs: Don’t feel obliged to do a basic science research year. You can either apply without a year off (people do match to very good clinical programs) or do a year focused on clinical research projects and be productive in publishing.
Click here for more information about planning a research year.
Last, but certainly not least, keep enjoying your life outside of medical school. This should not stop at any step of the process along the way.
The Editorial Board, Brain & Spine Report
Brain & Spine Report is a product of the Brain and Spine Group, Inc. and the statements made in this publication are the authors’ and do not imply endorsement by any other group. The material on this site is for informational purposes only and is not medical advice. Unauthorized reproduction is prohibited.