The Neurosurgery Candidate

Taylor Gist and Jaime Gasco

What is neurosurgery (NSGY)?

NSGY is the surgical subspecialty that concerns itself with the diagnosis and surgical management of pathology of the brain, spinal cord, spinal column, peripheral nervous system, and vasculature of the spine, head and neck.

How do I find out exactly what being a neurosurgeon (NSG) entails?

Apply the ASK/SEE/DO rule:

1. ASK: Talk with neurosurgeons at your school.

2. SEE: Observe attendings’ and residents’ behavior and work ethic

3. DO: Rotate on an NSGY service. Go to the OR and clinic.

What types of people generally go into NSGY?

NSGs come from all walks of life, from “lab rats” to collegiate athletes. The field typically attracts very active individuals who grow through intellectual, emotional, and physical challenges.

How long is the residency?

NSG is one of the most competitive specialties to match into. The only specialties with higher Step 1 scores in 2009* were dermatology, ENT, and plastic surgery. Applicants are generally near the top of their class but exceptions occur yearly.

What type of attitude is most appreciated while rotating on a NSG service?

The can-do attitude of someone who takes the initiative to foresee what needs to be done and simply does it. A likable personality is also important! Remember, the team members are evaluating whether or not they can work side by side with you for the next 7 years.

Collect morning vitals and laboratories, follow up on cultures, make sure imaging studies are ready to be presented at rounds, write daily progress notes, examine patients and report findings to residents, make a TO DO list and be sure everything is checked off before you leave for the day, etc.

How should I present patients on rounds?

Concisely present only the pertinent information in SOAP format, including:

1. Patient name and reason for admission/consultation

2. Postop day (POD#)/postbleed day (PBD#) if applicable

3. Any acute overnight events

4. Vitals and laboratories ONLY if relevant

5. Focused exam tailored to each patient, remembering to ALWAYS check where indicated dressings/wounds/drain sites

6. EVD and drain height and output for the last 24 hours

7. New radiological studies

8. The plan for the day

9. Answer any questions from the resident or attending truthfully. NEVER LIE.

Example presentation:

“Mr. X is a 45-year-old man who p/w subarachnoid hemorrhage, PBD#7, s/p clipping of a ruptured right MCA bifurcation aneurysm, POD#5. On exam he’s A+O×3, following commands ×4 with a stable mild left hemiparesis. EVD is open at 10 cm. Wound is c/d/i. CT head this a.m. showed stable mild hydrocephalus. Transcranial Doppler showed normal velocities. Plan is to continue NICU care and vasospasm prophylaxis.”

What are some practical skills I can learn to help out the team during rounds?

Learn how to …

1. Take out staples and sutures.

2. Draw CSF from an EVD (external ventricular drain; aka ventriculostomy/ventric).

3. Discontinue EVDs and lumbar drains.

4. Perform lumbar punctures.

5. Place arterial lines, central lines, lumbar drains, and EVDs.

1. Be present when patient arrives and stay until patient leaves unless told otherwise.

2. Introduce yourself to the OR staff (circulating nurse, scrub nurse, anesthesiologist, etc.).

3. Have pertinent films up for viewing.

4. Help with patient positioning.

5. Read up on the case and have a basic understanding of the steps involved and the relevant neuroanatomy. Discuss the case beforehand with a resident or attending.

6. Help tie and cut sutures if asked. Practice your one-handed, two-handed, and instrument ties prior to the OR so that you are competent in the OR.

7. Help clean up after the case.

8. Write the op note and orders.

9. Bring in the bed and help transfer patient.

10. Examine the patient upon his or her awakening from anesthesia.

11. Accompany the patient to PACU.

This is by no means an exhaustive list. The gist is to constantly be looking for ways to expedite the operative process.

1. Honesty and integrity in all you say and do

2. Strong work ethic: come early, stay late, be accessible to the residents/attendings, and work hard

3. Punctuality: Always be on time to rounds, the OR, and clinic.

4. Consistency and control of emotions

5. Assertiveness: Be confident and proactive. Volunteer to take call, do procedures, give presentations, etc.

6. Conscientiousness: Know the plan for each patient on the service and follow-up on what needs to be done.

7. Efficiency: Be resourceful and figure out how to accomplish tasks in a timely manner.

8. Demonstrate compassion and empathy toward patients and their family members.

9. Humility: Be modest. No one likes a braggart. Spend time improving your knowledge and skill set instead of stroking your ego.

10. Teachability: Learn from instruction and from constructive criticism. Being defensive will close doors.

11. Good interpersonal skills: They know you have a stellar CV, but can you play nicely with others in the sandbox? This especially includes your communication with nurses and other ancillary staff. Treat everyone respectfully.

What should I AVOID doing while rotating on a neurosurgery service?

1. NEVER LIE. It is always better to admit a mistake than to cover it up and be found out later. Similarly, it is always better to say, “I don’t know, but I’ll find out” than to fabricate an answer to avoid looking unprepared/stupid/etc. The most sure-fire way to ruin your reputation and/or chances of getting into a program is by being dishonest.

2. NEVER be late to rounds/OR/clinic/etc. Your tardiness affects the whole team in a negative way and reflects poorly on you.

3. NEVER whine, complain, or make excuses.

4. NEVER make a patient care decision without approval from a resident or attending.

5. NEVER leave for the day without checking out with a resident/attending.

Though you will be working long hours and taking call while on service, it is important to look professional at all times. Here’s a list of ways to look your best on service:

1. Change your scrubs daily or more frequently if they become soiled with blood, coffee, food, etc.

2. Keep your hair well groomed and face cleanly shaven.

3. Wear your ID badge at all times.

4. Clean your white coat weekly.

5. Wear minimal or no jewelry.

6. Bathe and brush your teeth daily.

7. Bring a personal hygiene bag with you when taking call to freshen up before rounds the next day.

8. Know when/if you are expected to dress in something other than scrubs (e.g., clinic, grand rounds, lectures, journal club, etc).

What books should I consider buying?

Multiple sources cite annual salaries at around $500,000