Hot on the Trail: A Field Guide to the Neurosurgery Residency Match

Christopher S. Graffeo, MD | Neurosurgery Resident | Mayo Clinic

Pursuing a residency position in neurosurgery is an intimidating prospect for many medical students, due in large part to the competitiveness of the field, which is dramatically worsened by the lack of clear, concise information regarding the application process, expectations and best strategies for preparedness. With this in mind, launched as a joint effort by the AANS, SNS, WINS and YNC to provide a centralized resource for students to help demystify the experience and encourage a broader interest in neurosurgery among top students. As an adjunct to that formal overview, the following is a first-hand account of some key lessons that will equip you for a successful neurosurgery match.

You Must be this Tall to Ride As with any competitive specialty, objective criteria will get you in the door and your application read more critically. Honors or high pass in key clerkships, such as medicine, surgery and, of course, any neurosurgery rotations is critical. Step 1 is an important benchmark. Although people do match with scores in the 220s and 230s, many top programs see 240s and 250s as requisite, absent an exceptional application in other respects. Scientific publications are similarly essential, but keep in mind that, although first-author manuscripts on neurosurgical topics is optimal, many applicants (myself included) did research in other fields or worked with more senior residents and staff as a second author on their manuscripts that they were subsequently able to present as posters or talks at meetings.

Away Rotations Selecting institutions for sub-internships (sub-Is) can involve a complex calculus, as each rotation needs to serve several goals. The away programs will be your best chances at matching, and so rotating at institutions you know you would not want to rank highly for geographic or personal reasons is wasteful. Similarly, if you are a borderline applicant, consider rotating at one less-competitive program, where you and your interest in their program will make a significant impression. Geographically, it may be helpful to select rotations in different parts of the country to signal that you are not limited to your home region. And, to better inform your own experience, consider selecting two programs that are fairly absolute in terms of their tone and personality, particularly as predominantly “academic” or “clinical” institutions – this will provide a useful spectrum of program features and characteristics to compare others against on the interview trail.

You may hear talk from your medical school classmates about avoiding a rotation at your top choice, so that you do not “ruin your chances” by making a poor impression. This is bad advice. Yes, the experience of being constantly under the microscope for a month is intimidating, but the world of neurosurgery is defined by performance in the face of high stakes. If you are uncomfortable with a benign risk such as an away rotation or worried that you will not be able to perform consistently for a month, a reevaluation of your priorities and career choices is in order.

Ideal sub-I performance is nuanced and demands substantial insight into your own personality and behavioral patterns as well as the expectations of the environment. At all times, be interested, helpful, respectful, professional and present – without being obstructive. Even the best students slow down a resident team; show sensitivity to this, and you will stand out by default. Be early and prepared; know your patients, their imaging, their numbers and their plans inside out and ask if there is any pre-rounding you can assist the residents with in the morning. Scrub as many cases as possible, stay late and offer to take on low-impact scut work where appropriate (dressing changes, bed checks, etc.). However, if you are told there is nothing to do or explicitly encouraged to leave the hospital, always do as instructed – few things annoy residents more than a student who does not listen! If possible, make a point to meet and scrub frequently with the chairman, the program director and the senior faculty – while showing sensitivity to the fact that any other rotators will share these same goals, and you need to always be collegial and considerate. Residents will see how you treat co-rotator for evidence of how you’ll get along as a colleague, if matched. Spend time with the chiefs and the juniors to get a real sense for the life of the program and its busy service. Also, get to know the PGY-5 residents, as they are most likely to be your chiefs during your PGY-2 – a crucial relationship.

Almost every rotation will expect you to give a student talk: have a 10-20 minute slide show at the ready. If this is not brought up directly, inquire among the junior residents whether it is standard practice at their program. Ideally, your talk should focus on your research, even if it was not in neurosurgery; however, if you truly have no research to discuss, consider selecting an interesting case from your home institution, and present it alongside a brief review of the topic. You will need at least one recommendation letter from each away rotation. Before the mid-point of the month, reach out to the coordinator to schedule your exit interviews with appropriate faculty; neurosurgery staff are busy and may have travel planned, so you need to plan ahead and avoid missing the opportunity to make a personal impression and request letters face-to-face.

Interview Insights Most of the keys to a successful interview experience are self-evident; nevertheless, every year a surprising number of students do not heed basic common damage their prospects. Keep in mind that every moment of every interaction is part of your interview – rudeness or inconsideration with a coordinator or resident, even via email, will quickly ruin your application. If you do not get the date you are most interested in, politely ask to be placed on a waiting list; do not complain or express any negativity about the process.

On the interview day, show up early, be well dressed and show deference to the conservative decorum of our specialty – flashy dress may be remembered, but not favorably. Socialize with the other applicants, residents, coordinators and staff and be amicable, flexible and positive at all times – there is no room for negative commentary of any kind, and a student who criticizes a colleague or institution will be identified as foolish at best and untrustworthy at worst. Show grace in the face of the unexpected: flight delays, hotel cancellations and other logistical road bumps are common and yours will be met with kindness and understanding by the program, so long as you keep your cool and remain professional at all times. By contrast, cancelling an interview at the last minute (absent a cancelled flight) will incite resentment against you that may spread beyond that institution, as you have denied a colleague and the institution the opportunity to fill that interview slot.

During the formal interviews, be prepared to speak about every item on your resume in thorough detail. A forgotten abstract in an unrelated field on which you were a minor author may seem safe to ignore, yet it could pique a particular attending’s interest unexpectedly – do not be caught off guard. Similarly, if there are obvious deficiencies in your board scores or grades, if you’ve never done any research or if there are other significant black marks on your record, assume you will be asked about them, and take ownership for the shortcomings in a way that shows maturity, insight and growth. Consider rehearsing these answers beforehand with a faculty or resident mentor at your home institution and, above all, never ever lie.

At the dinner, be friendly, sociable, engaging and participatory, but do not make a fool of yourself. Dominating the discussion is inconsiderate, and you will be identified as a poor candidate for seven years in the trenches together. Over-indulging, particularly where alcohol is concerned, is an easy way to ruin an otherwise successful interview and potentially earn a negative reputation elsewhere, if your misbehavior is spectacular enough to earn you a spot in the pantheon of trail lore.

Following up, Following the Rules and Following your Instincts Sending thank you notes is appropriate after any interview and especially recommended if you intend to rank a program very highly. Brief and personalized letters to the chairman and PD are typical and potentially supplemented by notes to other staff or residents who you had an especially memorable interaction with. Email is acceptable, and may be more likely to garner a response. Be attentive during the interview, as a program may specify that they either do not want follow-up or will accept follow-up but are not permitted to respond.

When rank time comes, you are permitted to inform institutions of your plans, but are not required to do so – a program that asks about your decisions is in violation of NRMP policy. Still, you may encounter indiscretions, and how you respond is a judgment call: in most circumstances, an abstract answer delivered with finesse allows you to maintain privacy without offending an interested program. My recommendation is that you inform your top rank of their status. Although institutional rank lists are largely independent of this information, it may subtly elevate your position and is effectively risk-free. Beyond that, notifying programs that they are “very high on your list” will be remembered but also clearly signals that they are not your first choice, which may have unintended, Ultimately, solicit advice broadly, but settle on a rank list that is highly personal. Avoid allowing the choices of your colleagues, biases of your mentors, preferences of your family members or pre-conceptions of the neurosurgery community to excessively shape your decisions: you are the one signing up for seven years of service and picking a place to lay the foundation of your career. Consider all the variables – case volume and complexity, access to mentorship in your areas of interest, research resources, geography and culture and so on – but at the end of the day, go with your gut. For a motivated resident, almost every institution can provide outstanding training and tremendous opportunity. By contrast, the ineffable “fit” between yourself and your program can make residency feel effortless or unendurable. Assess every community honestly, and consider yourself as a resident with as much introspective insight as you can muster: there is no substitute for synergy, and there is no amount of prestige that will make up for a poor fit. Finally, take a deep breath. In many ways, the process is out of your hands, and accepting that will make your application year much less psychologically burdensome. You have worked hard and come far; trust your instincts, trust the Match and good luck!