It is no secret that neurosurgery residency is one of the longest and most difficult residency training pipelines to pursue.
All neurosurgery residency programs are 7 years long, and oftentimes, residents choose to complete an additional year or two of fellowship training in pediatrics, spine, skull base, functional/epilepsy, endovascular/cerebrovascular, neuro-oncology, peripheral nerve, radiosurgery, or trauma/critical care.
Despite this, approximately 19 MD/PhD students (95 MD/PhD applicants over a 5-year period from 2014-2018), who have already completed an additional 3-5 or more years of graduate school training in addition to medical school, apply to neurosurgery residency each year. Furthermore, 9.5% of matched neurosurgery applicants in 2016 had a PhD, compared to 4.1% of matched applicants in all other specialties. These students have either completed a PhD before or during medical school, or are part of the NIH-funded Medical Scientist Training Program (MSTP). In this past 2020 match, a total of 273 MD seniors (397 total applicants) applied to 112 programs offering 232 spots (58.4% total match rate).
To our knowledge, there is a paucity of MD/PhD specific guides for navigating the world of neurosurgery applications. As such, we aim to discuss the factors MD/PhD students may consider prior to and throughout the residency application process, and share our experiences from the neurosurgery residency trail.
We first describe the pathway from college to residency, followed by a discussion of specific challenges neurosurgery-bound MD/PhD students may face in graduate and medical school, and then discuss the residency application process as an MD/PhD student.
Getting into medical school is the first step towards becoming a neurosurgeon. There are a number of different pathways students may take to get into medical school. Although some students may go straight through college and directly into medical school, others may be career changers and have taken a significant amount of time off prior to starting medical school. Either way, once the decision is made to enter medical school, you must then decide on your specialty. Oftentimes, MD/PhD students choose to complete their graduate training because they want to pursue a career as a physician-scientist (Brass 2009, science).
Neurosurgery offers perhaps the greatest opportunities for aspiring surgeon-scientists, as the applicability of research to neurosurgical problems is not only extraordinarily diverse, but also greatly needed since some of the sickest patients with the poorest outcomes are neurosurgical patients. Although a successful neurosurgical research career can be achieved with or without a PhD, the dedicated research-intensive training a PhD confers facilitates the development of invaluable analytical and problem-solving skills that are relevant to many aspects of neurosurgical research. In addition to these skills, the work related to a PhD (e.g., manuscripts, patents, spin-off companies, etc.) undoubtedly strengthens your application. There are a number of ways a PhD can be integrated into your training, with some programs even offering the ability to complete a PhD during residency, although this requires additional training time.
We recognize that there are a number of pathways to obtain a PhD in addition to your MD. Some students enter medical school already having received a PhD. Others are part of the NIH-funded MSTP, while others choose to take time off during medical school to receive their PhD. Regardless of the specific pathway, we tried to make this guide as relevant as possible to all MD/PhD students, and any student interested in pursuing neurosurgery.
Challenges Faced (MD)
After getting into medical school, there are a number of options with how to best spend your time. In the months leading up to the start of your first year of medical school, you can choose to relax, travel, and spend time with friends and family. Alternatively, if you are a MSTP student, you can inquire to see if you are able to complete your first research rotation with a potential mentor the summer before starting classes.
In general, some useful advice would be to try to find a mentor early on in the process. With respect to mentors, they can come from a number of places. A clinical mentor, ideally within the neurosurgery department, is critical in developing a longitudinal relationship with that mentor, and eventually, the neurosurgery department itself. The first year of medical school is a great time to contact potential neurosurgeons and start to shadow them in the OR and build a relationship with them. Over time, this relationship may lend itself to research projects (both basic and/or clinical), and you can attempt to either work on these neurosurgery specific projects in tandem throughout your training, or even choose to complete your PhD with your neurosurgery mentor if possible. These are all things you can consider as you begin to plan out your time in medical school.
Regardless of whether or not you choose to relax or get some research and shadowing done the summer before starting medical school, it is critical to focus on doing well in your M1 courses once classes start. Some medical schools offer accelerated primer courses over the summer before the start of classes. These accelerated primer courses may be useful for students who have taken time off after college or pre-med coursework, and in general may be useful, but certainly are not necessary in order to excel in your M1 courses.
There are a number of resources that will be available to you throughout your first year in medical school, but ultimately, focus on doing as well as you can in your courses, and try to learn the material as it will all be relevant when you eventually study for step 1.
Besides focusing on coursework, it is important to develop friendships and relationships with your fellow classmates, and take advantage of the extracurricular opportunities at your school. The M1 year is usually the “easiest” and most flexible year, despite having to learn to adapt to the rapid pace of medical school courses. You will quickly find that you will have the most flexibility and spare time as an M1, since you will not have the added stress of studying for step 1 as an M2, nor the time commitments that clinical rotations require as an M3.
In summary, focus on coursework, transition and adapt to the rapid pace of medical school, and meet new friends and take part in extracurricular activities. In tandem, you should try and reach out to your neurosurgery department, and begin interacting with potential mentors and shadowing them in the OR and clinic. These early relationships are essential to eventually building a long-lasting relationship with your neurosurgery department, and may lead to unique research opportunities that you can capitalize on throughout the remainder of your training. Towards the latter half of your M1 year, you should start thinking about how you will spend the summer between your M1 and M2 years. Most MSTP students complete 1 or more research rotations during this time, while other students may spend time doing research at a different institution, traveling abroad, or a number of other options.
Regardless of what you choose to do, make sure that it makes sense for your overall medical school plan. For example, if you want to focus on global neurosurgery, it may make sense to spend some time doing neurosurgery mission trips and building your experience in that realm. On the other hand, if you want to conduct basic science research, it makes sense to find a PI who you can work with on basic science projects. Although your research doesn’t have to be neurosurgery-specific, it makes sense to try to find a project that lines up with your clinical interests.
Many students also are unsure what specialty they want to pursue. The advice above is for students who have not yet decided on neurosurgery. If you are still unsure, you can also spend your M1 year shadowing different specialties and ultimately deciding on your specialty of choice. Although it may be difficult to decide on a specialty as an M1, in general, the earlier you pick your specialty, the more time you have to develop a relationship with that department and tailor your CV towards that specialty. It is also advisable to attend neurosurgery conferences whenever possible throughout the entirety of your MD/PhD training. Presenting posters and oral presentations at these conferences allows you to familiarize yourself with the format of neurosurgical conferences, and facilitates networking and relationship building with your neurosurgery mentor and your department.
It is also advisable to try to get a head start in a lab, either by starting to work in that lab the summer before M1 year and try to continue a project throughout your first year of medical school, or by finding a PI/mentor and starting to work on projects in conjunction with your M1 coursework. This can give you a nice headstart when you finally begin your PhD work, and can save you a significant amount of time. This advice is particularly applicable if your courses are pass/fail and now that Step 1 will become pass/fail. But keep in mind that your research should never come at the expense of your coursework and medical training. As far as resources to study for M1 courses, a combination of First Aid, UWorld, Online MedEd, Pathoma, and Sketchy will cover all your bases.
The M2 year traditionally was all about doing well in your courses, wrapping up research projects in the first half of the year, and then studying for step 1 in the second half of the year. Now that step 1 is transitioning to a pass/fail grading system, the emphasis neurosurgery residency programs place on step 1 may change. As such, the large amount of preparation and step 1 studying that usually takes place during the M2 year may be less critical, since a numerical score is no longer relevant. You should continue to develop a relationship with a neurosurgery mentor throughout the remainder of the M2 year, and attend grand rounds when possible. Try to learn as much about neurosurgery as early as possible so that you can confidently make the decision to pursue neurosurgery, and you can even explore other specialties to further reinforce your desire to become a neurosurgeon.
If you are taking step 1 for a score, you should focus on studying as much as possible and obtaining as high a score as possible. In general, it is difficult to state a specific cutoff you should aim for, but a higher score will generally help you. Cutoffs range, with some programs not having cutoffs, while others having cutoffs in the 240s, and everything in between. It is certainly possible to match with a score below a 240, but obtaining a higher score will generally help you. For example, a 250 will most likely not exclude you from any programs cutoff, and a 240 may exclude you from a handful of programs. A phone call, letter of recommendation, or other notable accomplishment in your application may offset a low score that may fall below cutoffs at certain programs, but the general advice is to obtain as high of a score as you can. Practice tests help you gauge how well you are doing, and developing a solid study plan for your dedicated time is critical.
If taking step 1 for pass/fail, make sure to study the material well enough to easily pass, and remember that the material will still be relevant during clinical rotations and for step 2 CK/CS. Once step 1 is complete, you will traditionally be preparing to transition to the PhD phase of your training if you are a MSTP student, or will prepare to start M3 year if you completed a PhD prior to starting medical school. Most students pick a mentor or advisor after completing an additional research rotation or two after step 1 is complete. If you already know who you will be working with, you can hit the ground running right after step 1. It is advisable to make efforts to continue working with a neurosurgery mentor throughout the entirety of your PhD training, as this will allow you to stay in touch with your department, and helps you develop a strong relationship with your neurosurgery mentor. When possible, working on neurosurgery specific clinical research projects also helps diversify your research skills and further develop a working relationship with your neurosurgery mentor.
The M3 year is dedicated to completing your clinical rotations. If you are a MSTP student, it is an important transition period, in which you will have just completed or are wrapping up your dissertation and all related PhD work. If you are an MSTP student coming back to your M3 year, you may find that many of your fellow classmates are new and you may not know many of them. This may be challenging since the close relationships you developed with your initial medical school class will not be there to help you during your M3 year. On the other hand, you may find that your classmates from your initial M1 year are now residents at your hospital, and this relationship may actually be very beneficial during your clerkships. Do your best to make new friends, work with your new classmates, and focus on studying and trying to honor as many clerkships as possible.
At this point, hopefully you have made the decision to pursue neurosurgery. If the decision has not yet been made, it is an excellent opportunity to explore other specialties, and if able to, complete a neurosurgery rotation to get some direct clinical exposure to the field. Depending on your school's grading system, you should try to honor as many clerkships as possible.
Particularly focus on honoring your surgery rotation, and if applicable, the neurology/neuroscience rotation. With respect to the timing of clinical rotations, some argue that it's best to push your surgery rotation to the end of the M3 year so that you have a few rotations under your belt before starting your surgery rotation. The theoretical downside of completing the surgery rotation at the end of the year is that the residents/attendings evaluating you will expect you to perform at a higher level compared to a student completing surgery as their first M3 clerkship. On the other hand, some argue that taking the surgery rotation early on means that the residents and attendings will be more lenient since it would be your first rotation and an early surgery rotation would help confirm your desire to be a neurosurgeon.
The other rotations are equally important, and honoring as many rotations as possible is generally advised. It is also important to study since you will have to take Step 2 CK and CS towards the end of M3 or beginning of M4 year. Especially as Step 1 is becoming a pass/fail test, the Step 2 CK score may be used as a new screening tool for students.
Although it is unclear how Step 2 CK will be used in the application process once Step 1 becomes pass/fail, it would be advisable to study appropriately for this exam and do as well as possible.
In the latter half of M3 year, you should start preparing and planning for your neurosurgery application. This application is called ERAS, but before worrying about ERAS, you first have to apply for and secure away rotations. Most programs use VSAS to have students apply to their programs for an away rotation, though some programs bypass VSAS and have the relevant application information on their website. VSAS requires a standardized AAMC immunization form, which should be completed prior to the opening of VSAS applications which can range from February to April (give or take a month or two before and after this time frame).
VSAS requires you to upload your immunizations, CV, some programs require a letter of rec as well. It is advisable to prepare all of these documents beforehand, as away rotations can quickly fill up. In picking away rotations, it is important to discuss possible choices with your mentor. Picking away rotations is an important part of the application process, as you will likely spend a month on 1-3 away rotations and spend a significant amount of time with each neurosurgery department.
These away rotations are month long auditions/interviews and culminate with a letter of recommendation from the chair or program director at that department. It is best to discuss which rotations you should do with your mentor, and get advice from upperclassmen. In general, you should choose away rotations at programs that you think fit what you are looking for. Some programs are very heavy clinically, while others have more of a research focus.
Given that you have a PhD, it makes sense to focus on research heavy programs, though it may also make sense to expand your horizons and look at a clinically heavy program since you already have extensive research training. Ultimately the choice of where to do an away is subjective and comes down to what you are looking for in a program, and where you see yourself after you are done with your training.
If you decide to pursue a career as a neurosurgeon-scientist, a research heavy program with significant research infrastructure and resources makes sense. You may also want to factor in geographic location, family, program size, and a multitude of other factors when deciding which programs to rotate at.
The M4 year is all about completing sub-internships/away rotations and applying. The first few months can be spent either studying for and taking Step 2 CK/CS, or completing a sub-internship at your home program and 1-3 away rotations. Step 2 CK is a multiple choice exam similar to Step 1, but focuses more on the clinical treatment/management of patients, rather than the basic science of the M1/2 years.
Most students find it helpful to study from a Qbank like UWorld, and supplement that Qbank with Online MedEd or another resource that you can study from. Some find the notes that Online MedEd provides along with the videos a good starting point for understanding the material, and UWorld allows you to really crystalize and put into practice that knowledge.
The emphasis on the Step 2 CK score may change once Step 1 becomes pass/fail, and the general score minimums are similar for both Step 1 and Step 2CK (i.e., aim for a 240 minimum, 250 would be safer). It is always possible to match with lower scores, but again, make it as easy for yourself as possible and target the highest score you can achieve. Take multiple practice tests prior to taking the actual exam, and make sure to sign up for both Step 2CK and CS early as test dates rapidly fill up.
Step 2 CS is a clinical exam that involves seeing standardized patients, taking a H&P, and writing a note that includes possible diagnoses and tests you want to order. Most people use the practice cases in the Step 2CS First Aid book to study for this exam.
By the start of the M4 year, hopefully you have already figured out and locked in the away rotations you will be completing. It will be important to find an apartment/housing for each away rotation, and make sure you complete all required paperwork for that specific rotation so that there are no issues when you show up to complete the rotation.
The Congress of Neurological Surgeons (CNS) published a useful guide for medical students titled “Essential Neurosurgery for Medical Students.” This guide can be used to study for your rotations, and watching the Rhoton videos can also help familiarize yourself with the anatomy. Other resources include the Handbook of Neurosurgery by Dr. Greenberg and Neurosurgery Fundamentals by Dr. Agarwal.
Away rotations give you the chance to be a part of the neurosurgery team. You wake up early to help get numbers and round on patients, and then attend cases in the OR for the remainder of the day. Be useful, amiable, kind, and hard-working. This is a month long interview, so you want to impress the team without being overbearing, annoying, or getting in the way.
At the end of the away rotation, most programs oftentimes have you give a short 10-15 minute presentation either on a research topic you have studied, or on a case they will assign you during the rotation. Preparing this presentation beforehand is advised, so that you do not have to frantically put together a compelling research presentation while you are working long hours on your away rotation.
Towards the end of the away rotation season, you will have to prepare and submit your ERAS application. This application is effectively your CV, a section for hobbies, extracurriculars, and your personal statement along with a maximum of 4 letters of recommendation.
Keeping an updated CV with all poster/oral presentations, publications, extracurricular activities, etc. will facilitate filling out the ERAS application. It is also useful to begin brainstorming what you will write in your personal statement either at the end of your M3 year or beginning of the M4 year. The personal statement allows programs to understand your story and why it is you decided on neurosurgery.
Once you have submitted your ERAS application, you will spend the next few months completing interviews, and once those are over, you will complete the remainder of your required M4 courses. Oftentimes, there is plenty of elective time built into your M4 year, and you can try to allocate time to vacation. The choice of electives should reflect your interests, though you should try to balance more time-consuming electives with spending quality time with friends and family and/or vacationing prior to starting residency.
Challenges Faced (PhD)
Selecting a Graduate Mentor
Mentor-mentee relationships are essential for professional development, but developing these interpersonal skills is not often highlighted as a priority in scientific endeavors. It is critically important to consider one’s preferred style of mentorship in considering their PhD advisor and home laboratory.
Generally speaking, scientific mentors may prefer to micromanage the research and increase work efficiency, or they can be more Socratic, allowing the mentee to solve problems on their own, make hypotheses on their own, and be first to analyze their own data and come up with their own conclusions or new hypotheses. If a given mentor has been a faculty PI for more than a decade, it may be advisable to look back at the first authors on the mentors’ early papers and evaluate what they are doing now. If former mentees are doing what you aspire to do, it’s a good lab for you – even better if they achieved more than you had considered for yourself. While not always the case, the style of micromanaging is more commonly seen in junior faculty scientists. This often ensures continued publications, but doesn’t necessarily result in mentees becoming problem-solvers.
A graduate mentor should be thoroughly evaluated through careful introspection, discussions with laboratory staff, and open dialogue between the potential mentor and mentee. Consideration should be given to a mentor’s funding situation, their preferred timeline for your PhD completion, and existing project opportunities within their laboratory. The timeline can be especially important, since neurosurgery is already a long training program, and factoring in fellowship, it may be advantageous to try to complete the PhD in a reasonable timeframe without extending it for too long. In general, the best mentors are careful listeners who actively promote and appreciate diversity. They consistently demonstrate high ethical standards, recognize the contributions of students - in publications and intellectual property - and have a record of research accomplishments and financial support.
Although it is not necessary to choose a neurosurgeon as a PI, it can help to have them as part of your thesis committee or involved longitudinally with your research as they can provide invaluable advice and clinical relevance for your projects. You can always apply the skills you learn completing a non-neurosurgery PhD to your work as a neurosurgeon, but some people find it easier to complete their PhD within a neurosurgical lab, as the relevance of this approach to a neurosurgical career is more clear. If you haven’t yet decided on pursuing neurosurgery and completed a PhD in an unrelated field, that is also completely reasonable and can be conveyed in your application and during your interviews. Regardless of the lab, choosing the right mentor is critical to having a successful research career.
Graduate Research Productivity
Upon selection of your graduate laboratory, it is critically important to become highly proficient in thinking as an experimental scientist. This requires a significant amount of reading scientific literature. We advise leaning on the practice of reading titles of papers, considering what the authors are getting at, thinking about what experiments you would do to test that hypothesis, then look at the figures to see if they chose your experiments. This way, every title you correctly solve will help train you as an experimental scientist.
In parallel, it is in your best interest to reach critical mass early by aiming to work with your laboratory members and potential collaborators across three to five basic science or translational projects by the end of your first graduate year. This is realistic in terms of the number of publications many individuals with PhDs have when applying to neurosurgery residency programs. It is also self-protective; if you are dependent on one or two projects, when they are failing, then you are failing. With five projects, multiple projects will be working to varying degrees with different levels of effort required to publication, staggering the publications themselves and enabling continued management of the work.
Protecting your own energy, enthusiasm, and self-confidence is very important to be successful at this stage.
Many students find it useful to try and work on some clinical projects in addition to their basic or translational science PhD project. This allows you to not only learn a new skill set and collaborate with your neurosurgery mentor, but bolsters the multitasking skill set that is critical to being a successful neurosurgery resident.
Students successfully match each year with a limited number of papers, some of which may be high quality papers in a high impact journal, but other students match without any high impact papers and a number of relevant clinical papers. When choosing between quantity of papers versus quality, it is best to err on the side of quality, and focus on developing and truly fleshing out a meaningful research question. It never hurts to bolster your CV with relevant clinical papers, and aiming for both a large volume of high quality clinical papers coupled with high impact basic and/or translational work is a good strategy.
Effective Time Management
Depending on your laboratory, project(s), and mentor, you will face constant demand and substantial strain on your time. Keep in mind that it may be difficult to make meaningful progress in your project unless you commit at least 40 hours a week toward generating and analyzing data. You and/or your lab members/collaborators will also likely need to commit at least the same amount of time toward other ongoing projects. This is often the minimum workload, and can easily be surpassed during critical periods for a given project. We often had to invest more than 100 hours per week to prepare grant funding applications, academic presentations, manuscript publications, or other major documents for institutional research approval. This is demanding, and it will likely impact your graduate research and personal life.
Make sure you discuss your project status and its development plans with your PhD advisor, so you can protect both your academic and personal interests. Open dialog helps avoid lapses in communication, whereas poor communication leads to all sorts of negative interactions. In situations where you find your priorities conflicting with your advisor’s demands, focus on empathizing with their specific concerns and discussing actions you can take to alleviate them. This is another instance in which negotiation skills are highly valuable. These demands can be intimidating. To mitigate this, we maintained a detailed schedule to ensure that we made progress on each item daily. By keeping on schedule, we avoided rushing items as they got close to their due date. Time management in this manner is absolutely critical; your ability to execute tasks in a timely manner reflects on your credibility aptitude as a surgeon-scientist in-training.
Experience in Neurosurgery
As you progress in your graduate research, it is advisable to make an effort to remain involved with your home institution’s department of neurosurgery by conducting clinical research and attending grand rounds. While these added commitments may seemingly dilute your graduate research efforts, you will keep better connected to your department and become familiar with fundamental neurosurgical knowledge and techniques that will serve you well in your training. In addition, these activities will enhance your professional skills if you choose to seek out additional enrichment opportunities, such as participation in professional organizations and annual meetings.
Applying to Residency
Applications to residency involve several discrete documents that you have been preparing for some time, most notably letters of recommendation, personal statement, and resume. Having a personal statement and resume prepared are prerequisites for collecting letters of recommendation.
The Personal Statement
The thinking that goes into the personal statement will prepare you for interviews as well as which programs would be an appropriate ‘fit.’
You should now put together a personal narrative. There are several components of your narrative which can be conceptualized into the past preparation, immediate next steps, and future goals. Your past preparation, what you have accomplished in the PhD and medical school, is captured in the resume in its raw components, but the personal statement is how you take these components and form them into a coherent story. Ideally, this coherent narrative will point toward the choice of residency.\
Also important is identification of your long-term career goals. Beyond being integrated into the personal statement, it will make what type of residency experience you seek clear. In other words, what sort of training experiences will you require to achieve your goals? Do you ultimately seek an academic position? Do you intend to sub-specialize? Will you do research in your future career? What will the focus of your research program be? How do your academic or research goals interact with your clinical goals? The answers to these questions can be integrated into the personal statement, will be raised in interviews, and also are important in determining to what degree different programs will fulfill your goals.
Letters of Recommendation
There are a total of four letters that can be submitted with the application. You can collect additional letters and send different letters to different programs. With only rare exceptions, a letter from your PhD mentor should be included even if she or he is not a neurosurgeon or in the department of neurosurgery. Similarly, there should be a letter from the chair of your home institution or another individual who can speak to the quality of your work with the context of your performance of the home sub-internship. There is at least one away-rotation letter, usually from the chair of the institution you rotated at. The final letter can either come from another away rotation or neurosurgical clinical mentor. The specific mechanics of letter selection are subject to some flexibility.
If you are in the fortunate position of having more than four possible letters, you should include your thesis advisor’s letter, and then for the remaining three aim to select the strongest possible letters from neurosurgeons that you can provide. The strength of the letters are generally more important than the details, such as having at least one letter per away rotation
In all cases, it is sensible to ask in-person if possible and to be able to provide CV, personal statement, and research works if relevant.
There are three primary types of mentorship that you should utilize at this stage. First is the faculty neurosurgical mentor, oftentimes one who you have overlapping clinical and/or research interests with. Second, it is also very beneficial to have at least one resident mentor who has been through the application process within the last few years who can help to guide you through the process. Third, your PhD mentor will be important if you intend on working in a related area in residency. These mentors will be able to guide you at this point toward programs which would be able to fulfill your goals. You may have already done this when deciding upon away rotations, which should help to further refine the list of programs that you will apply to. You should aim to identify programs that would be ideal and you can then ask your mentors for more directed feedback on these locations and possible future mentors at these locations.
Number of Program to Apply to
A goal of at least 20 in order to interview/rank somewhere in the mid-teens according to data in the most recent Charting Outcomes. It can be difficult to assess your own competitiveness at this stage, and always err on the side of applying to more programs and then declining interviews. If you are in the fortunate position to decline/cancel interviews, do so as with courtesy and as early as possible.
After Submitting ERAS
At this stage, your immediate goal is to get an interview at the institution of interest, and reaching out either directly or via a mentor is done with the goal of maximizing the chances at an interview. Different programs have different timelines for interview decisions, so early action is required.
Most important of your mentors are those who have knowledge and contacts within the neurosurgical programs and departments. This is oftentimes best fulfilled by your faculty neurosurgical mentor, but resident mentors should not be underutilized. With a refined list of programs, a list of reasons why any of these specific programs would be a good ‘fit’ should be compiled. With these reasons available, you can ask your mentors if it is appropriate for you, or for them if willing, to establish contact at one or more of those programs of interest.
Keep your mentors updated as to how interview invitations are coming in. If you are not getting the interview invitations that you were hoping for/that you thought you were competitive for, seeking timely guidance is critical.
Contact with programs
Establishing contact with particular programs should be done if and only if you have sufficient interest in that program. Oftentimes, these are programs which you or your mentor has some tie to, such as a location of an away rotation. Do not waste anyone’s time with direct contact if you would not strongly consider training there.
The interview really is the time for your MD/PhD training to shine. This is what you learned how to do for your entire PhD-communicate precisely and efficiently not only your accomplishments and goals, but also your value. This will help you only when you are asked what research you plan on doing, but even when you need to say “why neurosurgery” for the 100th time.
Of course, before you get to that stage you need to land the interview. Having a leg up on the competition with a PhD helps, but it’s no guarantee. If there are a few places that you are especially interested in visiting it doesn’t hurt to reach out. Sooner rather than later is better, the latest you should be reaching out is immediately after interview invites are offered (if you did not get it).
Unfortunately, an email from you to the PD is generally useless and will likely be ignored except for by a few extra special PDs. A note from your PD or chair will definitely stand out far more, but if that is not an option a mentor with a connection might help as well. However, be careful what you wish for! Not only are favors limited, it would be poor form if you cancelled a requested interview to attend the interview of a different program that you prefer.
With their stellar portfolio, MD/PhDs are likely to get more interview offers than they can reasonably accept. You should be strategic on how you schedule them. Too many interviews and you will burn out; too few and you miss out on opportunities. The general rule of thumb is that after 15 or so interviews your chances of matching do not increase anymore according to data in the most recent Charting Outcomes.
In terms of timing, the interview date should not affect much from the perspective of the program, but it is generally recommended to avoid scheduling high priority programs for your first interview. If possible try to schedule geographical areas together, you can find forums where you can swap dates or request to be added to waitlists. Though spots fill up fast (it is not uncommon for dates to fill up in the first 5 minutes)! For times in which you are unavailable make sure to have someone else monitoring your inbox.
On interview day, the most important part is your mindset. This is not an opportunity for you to do a victory lap on your research. Of course, you should be prepared to discuss it as you never know who might be an expert in your field. More than your past accomplishments, your interviews will likely focus on where you want to go next. With your training level you are expected to be able to articulate a full research plan. However, the focus of your interviews will likely be far more broad. Listen carefully to the questions that they ask and always be prepared to ask your own. There is nothing more off putting than an applicant who only wants to talk about their accomplishments and narrow research focus. At the end of the day, the interview is an opportunity to chat to see if they like you. Anyone they are interviewing is already qualified to be a resident there, the interview is a chance to see what isn’t on your CV.
Most Commonly Asked Questions
Tell me about yourself. (Make this a succinct summary of how you got to where you are)
How did you decide on neurosurgery?
Where do you see yourself in 10 years?
If you were asked to write an NIH R01 application what three aims might you propose.
Tell me about your most memorable neurosurgical patient.
Tell me about a time you made a mistake in the hospital.
Remember that your peers are a great resource for questions that they have encountered.
Though it is usually an informal conversation, don’t forget to do your reading on both the academic and clinical sides of the program beforehand. If your PhD is in a topic that might be lacking at that institution, be prepared to answer what you plan on doing there.
Unfortunately, the PhD might pigeonhole you-if they are heavy clinically without any R01 funded neurosurgeons they might even ask why you are bothering to interview there! If you plan on doing only clinical research from now on that is completely fine; just be prepared to explain how and why you plan to use your extra training. If not, be prepared to be pushed and pushed hard on how you’re going to balance clinical duties with research duties, no matter where you interview.
The last part of the interview is your chance to ask questions. Always have a question, even if generic, because it shows them that you are engaged and you care. But don’t squander this opportunity. Especially if you want to have an academic career, don't be embarrassed to ask hard questions:
How truly protected research time is?
How many residents have grants?
How they balance their time?
Don’t be afraid to ask to visit labs or talk to more faculty. If the attending works in your field, talk to them about their work, especially if you are considering working with them. These questions will not only show that you are truly interested and have a plan, but it will help you make decisions. Remember, not only are they interviewing you, you are interviewing them.
Good generic questions to ask include:
If you were limited to a single feature that is working very well for your program right now then what might that be
What characteristics would you absolutely want to see in your ideal incoming intern
If today was a typical day on your service and I were one of your junior residents then what would I likely be tasked with from the time I arrive until leaving the hospital again (what does a typical day look like).
There are different schools of thought on post interview communications, and don’t be surprised if the programs don’t follow the NRMP rules. A thoughtful (brief!) thank you email when you return home is never wasted, but don’t worry that you need to contact all your interviewers.
Making the Rank List
This is definitely the hardest part of the entire process. The average marriage in the US is 8 years, presumably these occur after dating. You’re committing for 7 years sometimes with only one date, which is insane. The only way around that is to get collateral information. You need to talk to as many people as possible, from all perspectives. Talk to residents, family members, mentors, PDs. Everyone will have their own viewpoint and their own biases, so try to separate information from opinions. You can definitely contact program administrators to ask to speak with specific faculty that may not have been at the interview day or even just to follow up.
Remember, the program with the best clinical training or most NIH funding is not by definition the best residency for you. Balance personal choices with clinical aspects and academics. You know what it’s like to commit to a place for a long time, make sure you want to be in the areas that you are ranking.
Don’t forget the lessons you learned from your PhD about the importance of mentors-see if you can find residents or attendings that are willing to engage and teach. Of course, it should be noted that you are already functional adults. You have almost a decade of graduate training under your belt and have formed personal and professional identities. Look for programs with residents and attendings who have the life that you want, but don’t be afraid to make your own path. Every program will teach you how to be a neurosurgeon, it is up to you to make the most of the available resources.
Do not be afraid to leave programs off your rank list either. The question is always “would I rather not match this year than attend that program”. You can always apply again, or you may learn that neurosurgery is not the path for you. That is okay. Matching at a program that is not the right fit is far worse than not matching. If you do not match, the general pathway is to enter SOAP for a surgery prelim year and apply again. While a post-doc is possible, it is unlikely that a lack of research is the reason you didn’t match so it is rare that this will be the correct option. Make sure to reach out to people who went through the process for both advice and encouragement.
Your rank list should be solidified at least a week before the deadline, to avoid last minute changes. Don’t forget to review it with the appropriate mentors and contact your top program. Don’t expect a reply, match rules forbid any guarantees by programs, but that doesn’t mean that your email wasn’t noted. If possible, you may want to enlist your chair and PD to contact them for a push as well. After that, relax! Make the most out of your remaining months and get ready for the next stage of your life.
And of course, good luck!!!!
Jason Chung, MD, PhD
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