How hard is it really to land a surgical residency

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Neurospy

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I am not a medical student yet, although for most of my life I have thought I would like to go into neurosurgery or neurology. The brain and it's internal workings have always been of interest to me and due to this I want to go to medical school and train.
Reality recently struck and I thought to myself "if I don't get into a neurosurgery residency, is their anything else in medicine I actually have any desire to do." well I can't be positive but I really feel as though neurosurgery is where I want to be.

Ultimately I am asking how hard it is to get a neurosurgery residency as this is probably the reason I will be going to medical school.

Thanks for advice guys.
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That's what I heard from like 20% of the students in the beginning "neurosurgery or nothing", but students changes their mind. You will likely become a better candidate for neurosurgery if you keep an open mind.

Regarding your chances, look into the NS forum, there is a good "ask a NS"-thread there: http://forums.studentdoctor.net/showthread.php?t=919891
 
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Neurospy said:
I am not a medical student yet, although for most of my life I have thought I would like to go into neurosurgery or neurology. The brain and it's internal workings have always been of interest to me and due to this I want to go to medical school and train.
Reality recently struck and I thought to myself "if I don't get into a neurosurgery residency, is their anything else in medicine I actually have any desire to do." well I can't be positive but I really feel as though neurosurgery is where I want to be.

Ultimately I am asking how hard it is to get a neurosurgery residency as this is probably the reason I will be going to medical school.

Thanks for advice guys.
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From what I've seen on these forums, uncleharvey.com, and at my school, nsurg isn't too difficult to get into as a specialty (last year it's competitiveness was considered "intermediate"), but matching where you want can be very challenging. It's a small field and residency programs are tiny (1-3 residents per yr), so applicants often match further down on their rank lists.
 
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Is it bad to go into medical school with a desired speciality?
 
Neurospy said:
Is it bad to go into medical school with a desired speciality?
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It's fine to have strong interests, but most consider it a bad idea to be locked in to particular specialties this early. And people will absolutely give you sh:t if you tell them that your heart is set on neurosurgery as an M1, mostly because it just makes you look very naiive.

All that being said, there's a large portion of students who have a very good idea of what they want to do from the start and end up in the specialty that initially interested them. Just tell people you like the surgical specialties, and sometime in your M1 year start to get acquainted with the neurosurgery department.
 
I know it sounds naive as "every man and his dog (usually not trained in medicine)" wants to do neurosurgery. I'm not saying it whimsically and have some sound reasoning behind my interest although I understand what you are saying.
 
Neurospy said:
I know it sounds naive as "every man and his dog (usually not trained in medicine)" wants to do neurosurgery. I'm not saying it whimsically and have some sound reasoning behind my interest although I understand what you are saying.
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Many of those "neurosurgery or nothing" tells they have a very good reasoning behind. There is a lot more than just neurosurgery, would you like to have good family life? are you comfortable working your ass off for a long time? It is hard to answer these questions early.

However, it is good to have a interest in a field, but I doubt even the NS guys are impressed to hear MS1 tell that the reason they went to med school is because of neurosurgery. They have probably heard that a thousand times with fancy motivations. I do not see any weird to try build up a good relation with NS department though.

Good luck!
 
While neurosurg may have "dropped" to an intermediate level of difficulty in matching, what other users failed to mention is that those applying to neurosurgery are a self-selected group. Having low board scores or low grades means you are unlikely to match, and those interested in neurosurg may be encouraged or told to apply to something else. This leaves those who are most likely to match within the applicant pool for this field.

Neurosurg lifestyle is what it is....the OP will have to make a decision when the time comes.

To have a realistic shot at neurosurg, you have to 1. get into med school, 2. do well in med school and be near the top of your class, 3. do very well on step I, 4. Impress on your rotations, especially surgical rotations, 5. get good LORs from neurosurgeons/do away rotations to impress and 6. impress during your interviews.
 
As previously stated, as opposed to other fields where many borderline applicants dual apply (e.g. plastics + general surgery, ortho + general surgery/PMR) the neurosurgery applicant pool weans itself prior to actually applying and tends to apply only to neurosurgery. Thus, the ratio of matched individuals to applicants is higher than other similarly competitive surgical fields. Likewise, neurosurgery emphasizes research experience as well as encourages MD/PhDs. Further, it is generally a requirement to rotate at multiple external sites during the 4th year of medical school and most neurosurgeons have no qualms with identifying students who show interest but not aptitude (after sufficient redirection) and guide them to more appropriate fields. Objectively, it may have moved to "intermediate difficulty," however the bigger picture indicates otherwise.
 
KinasePro said:
It's fine to have strong interests, but most consider it a bad idea to be locked in to particular specialties this early. And people will absolutely give you sh:t if you tell them that your heart is set on neurosurgery as an M1, mostly because it just makes you look very naiive.

All that being said, there's a large portion of students who have a very good idea of what they want to do from the start and end up in the specialty that initially interested them. Just tell people you like the surgical specialties, and sometime in your M1 year start to get acquainted with the neurosurgery department.
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I just don't understand how deciding on one specialty early on could make you look any more naive than the fact that you're in medical school. You could just broaden the criteria for "naïveté," e.g., why medicine and not business, etc. Or someone could equally well say it's naive for someone to enter medicine without knowing what specialty they want to do.

Just bringing this up because I hear at least once a week that you can't know what you want to do until you've seen everything, and I disagree with the premise on multiple levels. For one thing we won't be able to see everything. For another you can never truly know what something is like until you have done it, and we won't be able to "do" a specialty until we've already matched into it.
 
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I told them in my medical school interview that I wanted to do EM. It's approx 4 years since that interview and I am now applying to the match for EM.

I kept my mind open in third year and was very surprised by how fun some other specialties are. For example, OB/GYN was amazing. No way on Earth I expected that. I still can't believe I enjoyed it that much and it was the only rotation I didn't honor.

Anyway, get into medical school, do your best with everything, step 1, shelfs, LORs, Research and what not and you will have all doors open to you. Even if it turns out that you want to do something else, you will be competitive for that specialty. People often forget that the best programs for any specialty get the best applicants as well. Many consider peds less competitive but if you want to train at CHOP or Hopkins, you want to be a derm caliber candidate.
 
CaptainSSO said:
I just don't understand how deciding on one specialty early on could make you look any more naive than the fact that you're in medical school. You could just broaden the criteria for "naïveté," e.g., why medicine and not business, etc. Or someone could equally well say it's naive for someone to enter medicine without knowing what specialty they want to do.

Just bringing this up because I hear at least once a week that you can't know what you want to do until you've seen everything, and I disagree with the premise on multiple levels. For one thing we won't be able to see everything. For another you can never truly know what something is like until you have done it, and we won't be able to "do" a specialty until we've already matched into it.
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Because most people who have their hearts set on neurosurgery know absolutely nothing about it. They know it involves surgery. They know it involves the brain. The know it pays well. They don't know anything about the cases, the hours, the lifestyle etc. I understand if people say they want to go into pediatrics or something like that. Someone sticking with that goal is far more plausible than someone wanting to do neurosurgery and sticking with it. Every year tons of people enter medical school wanting to be neurosurgeons (for obvious reasons). The number of people who actually go through with it is very small. You can't know you want to do neurosurgery without trying it. So, yes, first year med students who say they want to do neurosurgeons are almost always called naive. And yes you can "do " a specialty without matching. It's called rotations.
 
I hear that neurosurgery has a high attrition rate though. How do top tier places (Hopkins, mayo etc.) get residents if people are leaving. I know very little about the whole residency things, can you transfer from pgy1 general surgery to neurosurgery? Can you transfer between institutions or hospitals?
 
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xf3rn4nd3sx said:
Because most people who have their hearts set on neurosurgery know absolutely nothing about it. They know it involves surgery. They know it involves the brain. The know it pays well. They don't know anything about the cases, the hours, the lifestyle etc. I understand if people say they want to go into pediatrics or something like that. Someone sticking with that goal is far more plausible than someone wanting to do neurosurgery and sticking with it. Every year tons of people enter medical school wanting to be neurosurgeons (for obvious reasons). The number of people who actually go through with it is very small. You can't know you want to do neurosurgery without trying it. So, yes, first year med students who say they want to do neurosurgeons are almost always called naive. And yes you can "do " a specialty without matching. It's called rotations.
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I wouldn't call watching someone else do neurosurgery "doing" neurosurgery.

Very few basic science students I've talked to want to do neurosurgery. I think it's common knowledge that the hours are long and the lifestyle can be brutal.
 
CaptainSSO said:
Very few basic science students I've talked to want to do neurosurgery. I think it's common knowledge that the hours are long and the lifestyle can be brutal.
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Actually, it's pretty common for medical students who studied neuroscience to think they want to do neurosurgery. Just as xf3rn4nd3sx suggested, they have no clue what neurosurgery actually is aside from their mental image and what they've seen on TV.
 
OP, surgical residencies include gen surg, urology, ortho, ENT, plastics, neurosurg, ophtho etc. I think when you interview it is fine to say you feel you would be interested in a surgical field and with your background in neuroscience perfectly OK to say you would like to explore neurosurgery more. However do not say you will not do any medical field and would not enjoy it. A great majority of medical school is learning adult medicine and not surgery at all. So you have to at least be able to tolerate it. So I suggest expressing interest in surgery but say you still have an open mind and look forward to seeing what else is out there.

I went to med school thinking surgery. Then did surgery and decided I hated it. Now doing internal medicine and find it awesome for me. Lots of people change their mind. Going in with a strong attitude and saying you would never want to do anything else is totally naive.

However... it is no lie neurosurgery is a tough field to match. You'll need good grades and board scores as others have pointed out. But even more importantly you'll need connections and research, lots of research. So getting involved early is pretty critical. I think once you get in to med school finding some sort of neurosurgery adviser early is key and getting started working on research projects is important. You'll have to do this on top of studying. Try also and shadow this guy you find to get further exposed to the field. Likely you'll find the diseases pretty interesting. But if you can't see yourself super enjoying the surgeries or lifestyle then pick something else.

And to be more global regarding surgical fields... they are all hard to match. Every surgical field (not including OBGYN) is significantly harder to match than most every other field save a few; derm, rad onc,. So if you want to do surgery of any kind you gotta do pretty well in med school.
 
I just have to ask, can a colorblind person even become a surgeon?
 
CaptainSSO said:
I wouldn't call watching someone else do neurosurgery "doing" neurosurgery.

Very few basic science students I've talked to want to do neurosurgery. I think it's common knowledge that the hours are long and the lifestyle can be brutal.
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neusu said:
Actually, it's pretty common for medical students who studied neuroscience to think they want to do neurosurgery. Just as xf3rn4nd3sx suggested, they have no clue what neurosurgery actually is aside from their mental image and what they've seen on TV.
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+1. I'd estimate that ~30 students from my class during M1 were interested in neurosurg, and the interest group has historically been very popular at our school. Not surprisingly, no more than 4 ever end up actually pursuing the field in the match. A lot of people want to be neuro, ortho, or CT surgeons when they start medical school because they're inherently bad ass specialties. But its hard to appreciate the demands of each field until you actually spend time on the wards.
 
duckie99 said:
OP, surgical residencies include gen surg, urology, ortho, ENT, plastics, neurosurg, ophtho etc. I think when you interview it is fine to say you feel you would be interested in a surgical field and with your background in neuroscience perfectly OK to say you would like to explore neurosurgery more. However do not say you will not do any medical field and would not enjoy it. A great majority of medical school is learning adult medicine and not surgery at all. So you have to at least be able to tolerate it. So I suggest expressing interest in surgery but say you still have an open mind and look forward to seeing what else is out there.

I went to med school thinking surgery. Then did surgery and decided I hated it. Now doing internal medicine and find it awesome for me. Lots of people change their mind. Going in with a strong attitude and saying you would never want to do anything else is totally naive.

However... it is no lie neurosurgery is a tough field to match. You'll need good grades and board scores as others have pointed out. But even more importantly you'll need connections and research, lots of research. So getting involved early is pretty critical. I think once you get in to med school finding some sort of neurosurgery adviser early is key and getting started working on research projects is important. You'll have to do this on top of studying. Try also and shadow this guy you find to get further exposed to the field. Likely you'll find the diseases pretty interesting. But if you can't see yourself super enjoying the surgeries or lifestyle then pick something else.

And to be more global regarding surgical fields... they are all hard to match. Every surgical field (not including OBGYN) is significantly harder to match than most every other field save a few; derm, rad onc,. So if you want to do surgery of any kind you gotta do pretty well in med school.
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I disagree - I don't think gen surg is typically any tougher to match than medicine. However there is a pretty big difference between a good gen surg program that will make you competitive for fellowships and a bad program which might be malignant and drive you into the ground.

Also the overall interest in just doing gen surg isn't quite as big as it was b/c the pay difference between that and int. med isn't that big; Just as with int med people tend to go into it to do fellowships.
 
KinasePro said:
+1. I'd estimate that ~30 students from my class during M1 were interested in neurosurg, and the interest group has historically been very popular at our school. Not surprisingly, no more than 4 ever end up actually pursuing the field in the match. A lot of people want to be neuro, ortho, or CT surgeons when they start medical school because they're inherently bad ass specialties. But its hard to appreciate the demands of each field until you actually spend time on the wards.
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Demands, yes. Also interest. Most don't know what they're interested in, especially if you have a TV show opinion of the specialties.


ArcGurren said:
I disagree - I don't think gen surg is typically any tougher to match than medicine. However there is a pretty big difference between a good gen surg program that will make you competitive for fellowships and a bad program which might be malignant and drive you into the ground.

Also the overall interest in just doing gen surg isn't quite as big as it was b/c the pay difference between that and int. med isn't that big; Just as with int med people tend to go into it to do fellowships.
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Regardless of who is correct, what does it matter. My specialty is more competitive than your specialty. No. Mine is more competitive. No. Mine. No.
 
The past few graduating classes at my school had a good amount people applying for some of the more competitive subspecialties like plastics and in addition apply to several neuro surg programs. Between the two we've averaged about a 60% match rate in plastics with about 2/3 of the remainder matching neuro. The others were pretty much split between gs and a surg prelim year --> reapply.

Neuro surg is still pretty prestigious even though I think many of the top applicants these days are going more for the life style fields.
 
I'm going to go ahead and move this to pre-allo.

As others have said, it is hard, and you will have to put in an extraordinary amount of work to attain it, but it is certainly a reachable goal. If you decide to go to med school and you really are "neurosurgery or bust," then knocking step 1 out of the park is really your first and most important goal in the first two years.
 
Hey what about Ortho? Naive pre-med here looking into that field.
 
ShenanigansMD said:
Hey what about Ortho? Naive pre-med here looking into that field.
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Ortho is a pretty cool guy. Eh fixes fractures and doesn't afraid of anything.

Any specific questions? It's a competitive field, for sure, and definitely attracts a certain breed.
 
VisionaryTics said:
Ortho is a pretty cool guy. Eh fixes fractures and doesn't afraid of anything.

Any specific questions? It's a competitive field, for sure, and definitely attracts a certain breed.
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I've done some engineering work with orthopaedics, and that's what has me interested, and I know a lot of ortho involves the typical joint replacements, arthroscopies, and spinal work.

But I was talking to some residents during shadowing, and he said there are some "sub-ortho-specialties" he would stay away from (hands and spine), because I guess he's afraid of law-suits.

Does the field typically work in in a "sub-specializing" sort of way, or do ortho-surgeons generally do everything?

Edit: At the moment, I'm not "afraid" or working on hands/spine.
 
CaptainSSO said:
I wouldn't call watching someone else do neurosurgery "doing" neurosurgery.

Very few basic science students I've talked to want to do neurosurgery. I think it's common knowledge that the hours are long and the lifestyle can be brutal.
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Yeah, 4 years of med school doesn't come close to doing any specialty, but gives a tiny taste of it.
 
eugggh, most of the neurosurge residents I know are absolutely insufferable.
 
Thanks for the assistance guys.
What kind of stuff besides stellar academic records would render a superior residency application?
Would medical journal publication or CNS or PNS research be significantly advantageous?
 
ShenanigansMD said:
I've done some engineering work with orthopaedics, and that's what has me interested, and I know a lot of ortho involves the typical joint replacements, arthroscopies, and spinal work.

But I was talking to some residents during shadowing, and he said there are some "sub-ortho-specialties" he would stay away from (hands and spine), because I guess he's afraid of law-suits.

Does the field typically work in in a "sub-specializing" sort of way, or do ortho-surgeons generally do everything?

Edit: At the moment, I'm not "afraid" or working on hands/spine.
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Yes orthopods subspecialize. You will generally see groups where one guy is the knee guy and one guy spends two days a week doing nothing but hips and one guy is a foot and ankle specialist and one guy is the spine guy. Hands are almost always a subspecialty you don't dabble in as a generalist. Spine is an area of turf war between ortho and neurosurgery, lots of competition and lots of liability risk. So yeah, you will sub specialize unless you move to an underserved rural area. Don't expect to work on the whole body.
 
xf3rn4nd3sx said:
Because most people who have their hearts set on medicine know absolutely nothing about it. They know it pays well. The number of people who actually go through with it is very small.
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Fixed that for you.

Now, having done cranial surgery on animals, I must say I really loved the experience. Was it actually neurosurgery? Nope. I bet it's the same that could be done for any type of bone. We all have inklings of wanting to become neurosurgeons. I outgrew mine rapidly.
 
VisionaryTics said:
Ortho is a pretty cool guy. Eh fixes fractures and doesn't afraid of anything.

Any specific questions? It's a competitive field, for sure, and definitely attracts a certain breed.
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I'm a naive pre-med as well, and I've always assumed that ortho attracts the construction/handyman/DIY type. Is that right, or just an oversimplification?
 
neusu said:
Actually, it's pretty common for medical students who studied neuroscience to think they want to do neurosurgery. Just as xf3rn4nd3sx suggested, they have no clue what neurosurgery actually is aside from their mental image and what they've seen on TV.
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heres a good youtube video of an awaken brain surgery, the part @ 11minutes is so awesome. He has the patient count as he applies an electrical current to determine the speech center
http://www.youtube.com/watch?v=FD8ckoy9NVU
 
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Geebeejay said:
eugggh, most of the neurosurge residents I know are absolutely insufferable.
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That may because you are pre-med and some residents strive to shoo pre-meds away from them, but it may also be due to the small population of them you have encountered at a specific hospital.
 
mmmcdowe said:
That may because you are pre-med and some residents strive to shoo pre-meds away from them, but it may also be due to the small population of them you have encountered at a specific hospital.
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nah, they have no way of knowing I'm a premed.

One of them came down the other day right after we intubated, and finally successfully sedated a young, athletic Pedestrian Struck with a SAH. He wanted to wake him up to perform a neuro exam even though the ED staff had just intubated him because of declining LOC and GCS. The ED resident described our own neuro exam an hour prior upon the patient's arrival, told him he had a low GCS, was combatitive, had purposeful movement and was moving all extremeties. He woke the kid up anyway. The kid pulled out his IVs, almost extubated himself, and required 5 male staff members to hold him down onto the stretcher, probably exacerbating his head bleed and causing more trauma to the patient, let alone another half hour of work for the ED staff to tinker with the sedation again. The neurosurge resident (who didn't help at all to restrain the bucking patient) suddenly leaves before his neuro exam is complete because of some "emergency" in the OR.

As he left, one of the nurses yelled "I guess you can put down "didn't give thumbs up" in your chart now."

Later in the OR with the same patient, the primary nurse says "Hey, and thanks for your help earlier". The resident smiled, said you're welcome. Clueless.
 
ArcGurren said:
I disagree - I don't think gen surg is typically any tougher to match than medicine. However there is a pretty big difference between a good gen surg program that will make you competitive for fellowships and a bad program which might be malignant and drive you into the ground.
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Not true. It has one of the lowest primary match rates out there, just above a few of the extremely competitive specialties. In contrast, there's an extremely high match rate for internal medicine for US allo grads. Granted, the average Step scores for medicine aren't too far off that of surgery, but there's more to it than just Step scores. The people in my class who failed to match their desired specialties were going for ortho, general surgery, and EM.
 
Geebeejay said:
nah, they have no way of knowing I'm a premed.

One of them came down the other day right after we intubated, and finally successfully sedated a young, athletic Pedestrian Struck with a SAH. He wanted to wake him up to perform a neuro exam even though the ED staff had just intubated him because of declining LOC and GCS. The ED resident described our own neuro exam an hour prior upon the patient's arrival, told him he had a low GCS, was combatitive, had purposeful movement and was moving all extremeties. He woke the kid up anyway. The kid pulled out his IVs, almost extubated himself, and required 5 male staff members to hold him down onto the stretcher, probably exacerbating his head bleed and causing more trauma to the patient, let alone another half hour of work for the ED staff to tinker with the sedation again. The neurosurge resident (who didn't help at all to restrain the bucking patient) suddenly leaves before his neuro exam is complete because of some "emergency" in the OR.

As he left, one of the nurses yelled "I guess you can put down "didn't give thumbs up" in your chart now."

Later in the OR with the same patient, the primary nurse says "Hey, and thanks for your help earlier". The resident smiled, said you're welcome. Clueless.
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There are a lot of on edge and frankly abrasive surgery residents out there. However...

You don't trust other people's exams. Cardinal rule of being a resident (or physician really). Do you know if the ED resident's exam is worth anything? Do you know how many times you will be told about an exam or history by a resident or even an attending that will simply be wrong? It happens every day. I can think of 3 instances this weekend alone. They can be as simple as claiming RRR and LCTAB or it can be as mind blowing as seeing a retroperitoneal hematoma on a CT in a patient who's Hgb dropped from 9 to 5 (There was no RP hematoma, happened this morning).

This is especially true when it comes to focused physical exams. Yes, I know how to do a complete neuro exam. But I doubt that I can nuance out the details that a NSGY resident can. Just in the same way that I never trust someone's vascular exam and double check behind people all the time. It is at least 30% of vascular exams done in the ED are incorrect in some way. Most of the time it is inconsequential if not identified, but there are always instances where it DOES matter. Never mind that Neuro exams do change...

To your specific example, the NSGY resident didn't 'wake up' the patient, an ED nurse under directive, likely from the bullied ED resident did. While given the history, the NSGY resident should have had the patient restrained, the ED personnel could have easily restrained the patient prior to lightening his sedation if they 'knew' what was going to happen.

You can put quotes around OR emergencies all you want. They happen. It may come across as abrupt and without a care for what is going on currently, but it isn't the NSGY resident's job to restrain the patient, even if him wanting to do a neuro exam (his job) caused the combative patient in the first place. That is why there are other staff in the hospital... I have no way of knowing what happened that night. But certainly the way you have presented this is more normal and understandable than an example of "an insufferable NSGY resident". Maybe the nurse was upset that she had to help clean up a mess caused by a resident doing his job, but frankly if residents did that, they would never stop complaining...
 
mimelim said:
There are a lot of on edge and frankly abrasive surgery residents out there. However...

You don't trust other people's exams. Cardinal rule of being a resident (or physician really). Do you know if the ED resident's exam is worth anything? Do you know how many times you will be told about an exam or history by a resident or even an attending that will simply be wrong? It happens every day. I can think of 3 instances this weekend alone. They can be as simple as claiming RRR and LCTAB or it can be as mind blowing as seeing a retroperitoneal hematoma on a CT in a patient who's Hgb dropped from 9 to 5 (There was no RP hematoma, happened this morning).

This is especially true when it comes to focused physical exams. Yes, I know how to do a complete neuro exam. But I doubt that I can nuance out the details that a NSGY resident can. Just in the same way that I never trust someone's vascular exam and double check behind people all the time. It is at least 30% of vascular exams done in the ED are incorrect in some way. Most of the time it is inconsequential if not identified, but there are always instances where it DOES matter. Never mind that Neuro exams do change...

To your specific example, the NSGY resident didn't 'wake up' the patient, an ED nurse under directive, likely from the bullied ED resident did. While given the history, the NSGY resident should have had the patient restrained, the ED personnel could have easily restrained the patient prior to lightening his sedation if they 'knew' what was going to happen.

You can put quotes around OR emergencies all you want. They happen. It may come across as abrupt and without a care for what is going on currently, but it isn't the NSGY resident's job to restrain the patient, even if him wanting to do a neuro exam (his job) caused the combative patient in the first place. That is why there are other staff in the hospital... I have no way of knowing what happened that night. But certainly the way you have presented this is more normal and understandable than an example of "an insufferable NSGY resident". Maybe the nurse was upset that she had to help clean up a mess caused by a resident doing his job, but frankly if residents did that, they would never stop complaining...
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This is the part I sort of understood about why the NSGY(Nice Abbreviation) did. I understand that you can't trust someone else's exam, and I definitely agree that a NSGY resident will do a hell of a lot better and more thorough of a neuro exam. But the ED is an uncontrolled environment, and I still don't understand why this had to be done in the ED at that moment and not in the neuro ICU. What did this exam really accomplish? It didn't change anything, but certainly compromised the patient at the time. We knew he had a SAH, and we knew his disposition to the neuro icu. It wasn't the mess that irked the ED staff (nursing mainly), but that we thought the exam was unnecessary and hazardous. Plenty of NSGY residents in the past take our word for it, and (I would expect) perform their exams when there is simply more staff available to tend to the patient and in a controlled environment.

A few more tid bits about the incident: the nurse took directive directly from the NSGY to turn off the sedation for the exam. And I quoted "OR emergency" only because that's what he said, so I don't know much about why he left. "Not your job" to restrain the patient I don't think is good enough....it's technically not our (ED staff) job either, it's security's, but we were doing it anyway out of safety for the patient.

These questions I have are real, and I want to understand what could have been done and if this Neuro exam was really necessary. I'm not trying to argue or anything, I just want to hear your opinion on the situation, because I can understand the reasoning of the NSGY resident, but am unsure if he did the right thing.
 
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I can think of three reasons why the neuro exam was repeated. One is a good reason, one is a bad reason, but happens a lot and the last is very situational.

1) Neuro exams change management. Exams be them CTs or neuro exams are snapshots of the patient and are only valid at the time they are performed. One can guess as to what is going on by knowing the natural progression of a particular pathology (in this case SAH), but you really don't know. What exactly the neuro exam shows dictates OR vs trauma bay intervention vs NICU. In the end it is a judgement call. I'll be the first to admit that I am not up to date on the most current management of acute SAH. I know enough to get by, but I'm going to defer to NSGY or the stroke team every time. No question, they make mistakes from time to time like the rest of us, but their job is to evaluate neuro function and depriving them of their basic tool (neuro exam) is pretty hard for them to compute. Most doctors, especially surgeons (in my experience) need to see to believe. They NEED to read their own films. They NEED to perform their own exams. The reason I do that is a) to learn but also b) because people make mistakes and on average are not nearly as anal as I am about doing things a particular way.

2) They will get yelled at by their attending for not doing their own exam. You can't tell a NSGY attending, "Well the ED resident says the neuro exam was XYZ." Even if you replace ED resident with ED attending, most people will simply not trust them based on their position. This is entirely institution and community dependent, but most residents (again, especially surgery residents) learn very quickly to check and recheck things for fear of being asked something by your attending.

3) Neuro exams evolve. Continuation of #1. If that exam was performed 30 minutes or an hour ago, with the patient intubated/sedated, you really don't have a good gauge for what is going on. If he JUST got the sedation as the NSGY resident walked in, it is silly to do the exam for sure. But again, not knowing the details of management, I don't know if q15min or q30min vs q1h neuro checks are important.

We would have to ask a NSGY resident/attending to justify repeating the exam when they did. I can't really comment on that specifically, which is unfortunate because that is the root of your question :p.
 
mimelim said:
I can think of three reasons why the neuro exam was repeated. One is a good reason, one is a bad reason, but happens a lot and the last is very situational.

1) Neuro exams change management. Exams be them CTs or neuro exams are snapshots of the patient and are only valid at the time they are performed. One can guess as to what is going on by knowing the natural progression of a particular pathology (in this case SAH), but you really don't know. What exactly the neuro exam shows dictates OR vs trauma bay intervention vs NICU. In the end it is a judgement call. I'll be the first to admit that I am not up to date on the most current management of acute SAH. I know enough to get by, but I'm going to defer to NSGY or the stroke team every time. No question, they make mistakes from time to time like the rest of us, but their job is to evaluate neuro function and depriving them of their basic tool (neuro exam) is pretty hard for them to compute. Most doctors, especially surgeons (in my experience) need to see to believe. They NEED to read their own films. They NEED to perform their own exams. The reason I do that is a) to learn but also b) because people make mistakes and on average are not nearly as anal as I am about doing things a particular way.

2) They will get yelled at by their attending for not doing their own exam. You can't tell a NSGY attending, "Well the ED resident says the neuro exam was XYZ." Even if you replace ED resident with ED attending, most people will simply not trust them based on their position. This is entirely institution and community dependent, but most residents (again, especially surgery residents) learn very quickly to check and recheck things for fear of being asked something by your attending.

3) Neuro exams evolve. Continuation of #1. If that exam was performed 30 minutes or an hour ago, with the patient intubated/sedated, you really don't have a good gauge for what is going on. If he JUST got the sedation as the NSGY resident walked in, it is silly to do the exam for sure. But again, not knowing the details of management, I don't know if q15min or q30min vs q1h neuro checks are important.

We would have to ask a NSGY resident/attending to justify repeating the exam when they did. I can't really comment on that specifically, which is unfortunate because that is the root of your question :p.
Click to expand...

Yeah, #2 is sort of what I thought might be going on. The patient literally just received sedation, and it took a lot of tinkering (something we are sort of good at, but we are not anesthesiology or an ICU) to make him comfortable and stabilize his vitals. I understand #1, and hell, that's why we have consults in the ED is because we don't know best either. I can tell you for sure though that we don't do anything less than q1hr neuro checks in the ED....simply not enough time or resources to do these on all our altered, stroke or head trauma patients.

Thanks for your responses though, nice to have some light shed.
 
mimelim said:
1) Neuro exams change management.

3) Neuro exams evolve. Continuation of #1.
Click to expand...
Both of these are right on the mark. Just because you think the patient will be able to go to the neuro ICU regardless doesn't mean that the neurosurgeon feels the same way. This might need to go to the OR emergently.

Other times, it looks stable, but then something dramatic happens. We've had patients herniate right as the ambulance is pulling into the garage and the story goes from "He's awake and talking" to "He's completely unresponsive and his pupil is blown."
 
IMO, once you consult another service, or in this case, transfer a patient into their care because a problem is in their specific area of expertise, then you need to deal with the consequences. If you don't like that, then manage the problem yourself. (obviously within reason, neurosurg should clearly be managing traumatic brain injury/SAH). Doing his own neuro exam is the nsg resident's job, IMO trusting an hours old neuro exam by a ED resident is ridiculous. At my institution, the nsg resident would have been at the L1 trauma as it came in, but I realize institutions are different.
 
Geebeejay said:
Yeah, #2 is sort of what I thought might be going on. The patient literally just received sedation, and it took a lot of tinkering (something we are sort of good at, but we are not anesthesiology or an ICU) to make him comfortable and stabilize his vitals. I understand #1, and hell, that's why we have consults in the ED is because we don't know best either. I can tell you for sure though that we don't do anything less than q1hr neuro checks in the ED....simply not enough time or resources to do these on all our altered, stroke or head trauma patients.
Click to expand...
Geebeejay said:
Thanks for your responses though, nice to have some light shed.
Click to expand...



As I often played the culprit in the above situation I can try to enlighten you on our thought process.
  1. The patient had an exam, albeit declining, and presumably a head CT sometime prior to being intubated.
  2. The ED resident conveyed pieces of a GCS "purposeful" (i.e. localizing) but I'll speculate misrepresented the true GCS or indication for intubation. Intubation for airway protection due to a declining GCS, totally indicated. Intubation for agitation, not indicated
  3. The ED resident assessment was an hour ago. The patient is now intubated and, at best, is an 11T. A GCS of 8 or less is an indication for an intracranial pressure monitor. This is placed at the bedside, in the ED. Being comfortably sedated with stable vital signs generally equates to a GCS of 3. The patient's real GCS is necessary to determine the immediate course. In all likelihood, the patient was not urgently OR bound based on the initial head CT and a follow-up CT, or ICP monitoring and serial neuro examination, is necessary to track the trajectory of the patients course
  4. Having a baseline examination to which further examinations can compared is necessary. This is not only true for new patients in the ED but also for a neurosurgery resident coming on shift to see patients already admitted who are fluctuating.
While I agree, some of my colleagues are insufferable, it seems your prejudice arises more from a misunderstanding of the severity of the situation and need for a thorough examination and less from some jack wagon neurosurgery resident out there.
 
neusu said:




As I often played the culprit in the above situation I can try to enlighten you on our thought process.
  1. The patient had an exam, albeit declining, and presumably a head CT sometime prior to being intubated.
  2. The ED resident conveyed pieces of a GCS "purposeful" (i.e. localizing) but I'll speculate misrepresented the true GCS or indication for intubation. Intubation for airway protection due to a declining GCS, totally indicated. Intubation for agitation, not indicated
  3. The ED resident assessment was an hour ago. The patient is now intubated and, at best, is an 11T. A GCS of 8 or less is an indication for an intracranial pressure monitor. This is placed at the bedside, in the ED. Being comfortably sedated with stable vital signs generally equates to a GCS of 3. The patient's real GCS is necessary to determine the immediate course. In all likelihood, the patient was not urgently OR bound based on the initial head CT and a follow-up CT, or ICP monitoring and serial neuro examination, is necessary to track the trajectory of the patients course
  4. Having a baseline examination to which further examinations can compared is necessary. This is not only true for new patients in the ED but also for a neurosurgery resident coming on shift to see patients already admitted who are fluctuating.
While I agree, some of my colleagues are insufferable, it seems your prejudice arises more from a misunderstanding of the severity of the situation and need for a thorough examination and less from some jack wagon neurosurgery resident out there.
Click to expand...

Eh, my prejudice comes from a lot of examples, not just this one.....this was only the most recent. I've seen NSGY residents take patients from rooms unmonitored without telling staff, I've seen them bust into rooms demanding CT scan results only minutes after the patient arrived, while completely freaking out the patient/family. I get it, stroke is a time-sensitive matter, but we can't administer contrast without good access in a compatible IV site, and we aren't going to the scanner until the multi-system trauma is off the table.

I think a lot of it comes from the stress and workload, but eh who knows. I surely can't know for sure until I do neuro rotations myself.
 
What would someone do if they were to now get into their desired residency but were adamant they would do it?
Do universities or clinics look at just the medical school you studied at or your results?
 
What is the policy on accepting international applicants to the neurosurgery residency.
For example is an MBBS from England or Australia acceptable?
Does the qualification have to be MD from a north american university?
thanks
 
Neurospy said:
What is the policy on accepting international applicants to the neurosurgery residency.
For example is an MBBS from England or Australia acceptable?
Does the qualification have to be MD from a north american university?
thanks
Click to expand...

If you want to practice in the US, do everything you can to train in the US. Matching as an IMG is a long shot for the surgical specialties.
 
Let's say you do all your training and residency in the UK. Can you then get a fellowship and pass the exams in the US and practice in the US?
 
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