How to Match in Neurosurgery

Neurosurgery Made Ridiculously Simple

Congratulations! By poring over this essay, you will, at the very least, learn the single most important mantra in navigating the neurosurgery match—that is, to ask someone else. Seeking advice is the best thing you can do for yourself throughout the sorority rush that is the neurosurgery match process. In general, the field today is filled with bright, friendly, earnest people, and they are your best bet for honest advice. By now, you have, no doubt, at least heard whispers of clandestine goings-on in the world of neurosurgery known only to those privy to the NSMatch.com (now UncleHarvey.com) underworld. Personally, I visited the site for the first time only after the match, and found it, in retrospect, to be largely inapplicable to my experience. Throughout the process, keep your department chair and faculty mentors updated, and meet with them often. In keeping with my own advice above (about speaking with people directly), I will simply try to give a resident’s-eye-view of the application process, and identify some important landmarks along the way.

Days 1 – 1000 of medical school
The “Board score + Publications = 300” rule, while not entirely accurate, does help to frame the steps involved in preparing to apply in this extremely competitive specialty. One would be well-advised to obtain high marks in a top 10 medical school, and an eye-popping board score surely adds pizzazz to a CV which will, inevitably, sit squarely at the center of the bell curve. While there is no universal Step 1 goal, some programs do use cutoffs in offering interviews. These are, to my knowledge, no higher than 240. Step 2 is certainly not necessary to have taken, though a high score will add to your body of work. High marks, first-author publications, basic-science lab research, international volunteerism, and second degrees are certainly valuable in terms of both experience and CV adornment, but are by no means required for success in the match. However, know that taking a year off for research is a very common practice among those aiming for the top programs (ask around—perhaps there is a lab that produces neurosurgery residents regularly).
On the other hand, letters of recommendation detailing your outstanding sub-internship performance AND the close working relationship you developed with the rest of the residents, are absolutely essential. A thoughtful, grammatically-immaculate personal statement, and a list of interesting extracurricular activities rounds out the competitive applicant’s résumé. Beyond earning the numbers to win an interview spot, try to maintain a tight focus on your vision for your future in neurosurgery throughout the process. Neurosurgery, while regulated nationally, is still a crowded field, and programs will be particularly keen to train someone who will contribute to the collective in innovative and exciting ways.

The Programs
The winter before you apply is the time to plan your schedule for the upcoming process. Specifically, it is time to decide where to rotate away from your home institution. There is much to be gained from rotating away—much more than simply showing off your wares at your potential favorites. Experiencing neurosurgery in a foreign hospital system will go a long way towards helping you gain a feel for what aspects of a program are important to you, and how to evaluate them (or, more accurately, that you cannot do so adequately in an interview day). In addition, some programs carry the reputation of requiring a sub-I to be considered for a spot. Ask around! At no institution is this a hard-and-fast rule; however, it behooves the applicant particularly interested in such a program to keep this reputation in mind. Apply for away rotations early, as spots in August and September fill quickly at a few of the popular programs.
Programs are often attributed characteristics, described in vague adjectives such as “gentlemanly” or “malignant”, “academic” or “clinical”, “teaching” or “sink-or-swim”. Seemingly simplistic, these one-liners are often quite useful in helping applicants decipher which programs will fit them best. Be sure to see a large variety of programs. While there exists NO worthwhile ranking of neurosurgery programs, one can think of program quality in terms of tiers—and, along with location considerations, can develop a fairly accurate picture of each program’s desirability. The best way to gain a good feel for today’s pecking order is to ask both faculty and residents at many different institutions, but residents most of all. They will be able to describe the “top” programs, as well as the “hot”, “solid”, “up-and-coming”, and “under-the-radar” programs. Most importantly, they will be able to point out the programs to be wary about—while never entirely accurate, it is best to be warned.
With board scores and the majority of your grades in hand, try to make an accurate assessment (again, with the help of mentors and friends) of your competitiveness, as well as your goals, as an applicant. Start building a list of interesting programs, and see how they match in January. When your applications for away rotations are done and your interest in neurosurgery established with your program director and chair, it is time to start memorizing Greenberg.

Sub-Internship
1. Show everyone what great care you take of your patients.
2. Show everyone that you are a dependable team player and enjoyable to work with.
3. Develop a relationship with residents and faculty.
4. Show everyone how smart and hard-working you are.
5. Show everyone how much you love neurosurgery.
6. Show everyone how skillful you are in the OR.
7. Get a glowing letter of recommendation from the chair of the program.

There are several objectives to performing well on a sub-I, and these are just a few of the most obvious. They are ranked in order of importance. When beginning a sub-I, find out what will be expected of you. Experiences at different institutions are wildly variable, and it is always best to settle into the daily rhythm, and contribute the best you can. When rotating with other sub-I’s, WORK TOGETHER. Do not try to out-do one another, and if he/she is difficult to get along with, avoid him/her altogether. The worst thing you can do as a visiting sub-I is to make an enemy, no matter who that is. On an altogether separate note, make sure to get away from the hospital and take in your surroundings, preferably with the residents. When you finish your rotation, be sure to keep in touch—for advice, and because everyone will be curious to know where you end up.

The Application
Applying to neurosurgery programs through SFMatch (CAS is to SFMatch as ERAS is to NRMP) is a very simple process, so long as you are not pressed for time. Keep extra copies of everything, and call with questions—the staff are very friendly, and usually helpful. Copy the list of programs offered on the SFMatch website, which contains essential information for every program in the country. Contact programs with questions regarding application deadlines, requirements, or interview dates. In particular, a few programs do not lock you into an internship, and so those will require that you apply separately through ERAS for the internship of your choice. Also, many programs settle on interview dates early, while others wait until later in the process. A few will reserve an extra day to interview those unable to attend, should the need arise.
Register for the NRMP whenever (you must rank your neurosurgery internship in the NRMP come February, in order to match into it). But be sure to register for the SFMatch in June when it opens, and aim for mid-August to submit your application. The CAS target date for application submission is typically at the end of August. Some programs set (very loose) application deadlines for themselves, which are typically later than this, but turnover can take up to 2 weeks’ time. The application itself consists of a fill-in-the-blank form for résumé-type information, a personal statement, official copies of your Board scores, and 3-4 letters of recommendation. Obviously, a detailed, personal letter is more valuable than a 2-line generic letter; however, a letter from your chair should be considered mandatory. Any additional letters (letters from the chair at each of your away rotations) must be sent individually by you, or by your school—be sure to send them as soon as you get a chance. Finally, your Dean’s letter will be released by your school in November, and will complete your application. Some programs wait for this letter before extending interview invitations, but most do not.
Most applicants remain unsure of the appropriate number of applications to submit, and the fact that most eventually realize that they submitted too many demonstrates that they have shown the appropriate prudence. Again, determining this number for yourself depends on your own self-assessment, as well as the tier of programs in which you have taken interest. Apply appropriately. Many top applicants send approximately 20 applications, while others may send as many as 50. In the end, you will be hard-pressed to interview at more than 15 programs, so cast a wide net if need be, but if all the top programs are offering you interviews early, it is unlikely that you will fall to your 30th choice. Having typed that, there are always applicants who interview at all of the top programs, but wind up falling through altogether. A deciding factor in how you whittle your list will be your level of interest (and vice-versa) in your home institution. Geographic preference will likely be the other.

The Interview
Waiting for interview offers is probably the most nerve-wracking segment of the entire process. Discovering that programs deem you worthy to meet is a huge relief, and once you start scheduling dates, the interview trail should be quite an enjoyable place to be. Programs typically reserve interview spots for anyone having performed a sub-I; beyond this, there are no guarantees as to interview distribution. Again, while some programs may employ a Step 1 cutoff score, most do not, and a phone call from an influential mentor can go a long way in getting you the interview of your choice. It never hurts to call or write once to the programs that you are most curious about, but there really is not, to my knowledge, much that you can do to help your cause. Making the grade entails exactly that—if you look good enough to interview on paper, then you should arrive at your interview confident in that regard, and look to demonstrate your personality there.
Interview offers are made as early as September, but sometimes are withheld even until December. Interviewing typically begins in October, and ends in December, though a few programs will interview in September or January. When you receive an offer, respond immediately—programs are very good about accommodating schedule changes you may need to make later, but some interview spots do fill up. It goes without saying, but if you must cancel, do so as early as possible—nobody likes a no-show. Show up in the nondescript suit that your mother picked out for you, portfolio tucked under your arm, with a short list of questions that will help you gain a better feel for the program.
Some interview days will be quite short; others will last for two days, and involve as many as 20 interviews. Some programs will close down their OR’s so that everyone can come and meet you, while others will incorporate you into their daily routine however they can. Some residents will be eager to spend time with you, and others will seem to ignore you entirely. Obviously, this is just the normal ebb-and-flow of interviewing, but through it all, programs are looking for a good fit—and so should you be.
Most interview days will begin early and end mid-afternoon, and will usually include a dinner the night before the interview. I found that having dinner or going out with the residents gave me a very good picture of the general environment in which I would be living for 6-8 years. Do everything you can to make it to these events, and be yourself. A decade is a long time to fake a Westminster accent. Show up early for your interview day, and enjoy the time you have to spend with other applicants—they will be your colleagues and contemporaries, and will make national meetings much more bearable. Bring high-resolution, glossy photos with which to augment your well-rehearsed research talk. Neurosurgeons are like everyone else—they like shiny things and bouncy things. Mail thank-you cards when you have finished, and if someone offers you his/her contact information, do keep him/her updated, and ask questions.
Interviews run the gamut in terms of topic and direction. Few are novel or unexpected, and even fewer are pressured or antagonistic. Most interviewers, it seems, are interested to hear the eloquence with which you describe your interest in neurosurgery, your family background, your research experience and interests, and your extracurricular activities. If there is a glaring fault on your application, it is unlikely that you will be asked about it. A few interviewers will present you with impossible questions, tests of skill or knowledge, ethical scenarios, or games, but these generally hold more entertainment value than anything else. By now, it is both cliché and redundant, but it is worth repeating—have fun and be yourself. Neurosurgery is not your 8th grade kickball team, and shyness or an interest in horticulture will not disqualify you from it.

Christmas Break
Follow-up each interview with a thank-you card, and be sure to keep in touch with the people you spent significant time with at your interviews. Ask questions, especially the ones which, if answered undesirably, would change the way you rank a program. The quintessential one is probably, “Are you happy here?” While the answer is usually inconsequential, you will often find that, in asking it, you will gain some insight as to whether you yourself would be happy there. If you receive phone calls from programs, consider it a compliment and a sign of at least top 10, if not higher, interest. If you receive letters in the mail, consider it similarly. Emails, unless personally addressed, are typically sent to all interviewees. Receiving such interest is flattering and reassuring, but when you rank your list, they should play absolutely no part in determining the order.
As was previously stated, an interview day is insufficient for learning about a program. Some programs are very good at putting their best foot forward, while others are not. If there is a program you are considering ranking in your top 5 and you did not rotate there, GO FOR A SECOND LOOK. Just contact the program coordinator to set this up. Do not go to look at real estate—instead, go to evaluate the program. Spend time in the OR, in clinic with a faculty member, and round with the team. See how confident the chief residents are as surgeons, as physicians, and as teachers. Observing the inner workings of a program for a day or two, in addition to being around the residents in their work environment, is always revealing, sometimes surprisingly so.
There is no list of characteristics that programs look for in their applicants. A good fit, while measured totally by Gestalt, is often the most important feature of all that an applicant has to offer. Of course, CV, your essay, and your interview will contribute to your rank order. Some programs pool the opinions of interviewing faculty by utilizing an aggregate rating system. Others sit down after each interview date and compare the applicants in a board meeting. There are those programs at which the chair makes the final decision, irregardless of input. Residents rarely play an important role in determining rank order, but they certainly can disqualify an applicant with little resistance. If you were good enough on paper to interview, then you are good enough to match. Where you sit on a program’s rank list is determined largely by your performance at your interview, along with your desirability as compared with the other applicants in your class. Finally, the interest that you show in a program will play a minor role in determining your final rank as well.
Away rotations, second looks, and correspondence are obviously the means by which you can express your interest. However, it is customary in neurosurgery to advise one program (JUST ONE PROGRAM) of your intention to rank them #1. Otherwise, you can contact the programs on your list however you choose. Start organizing your thoughts over Christmas, and be ready to submit your rank list at least one week before the deadline in mid-January. The factors which you consider in making your decision are your own; however, if you find that, in the end, you have made a decision based entirely on gut and hearsay, do not be discouraged. Reputations do not come from nowhere, and the collective opinions and experiences of the hundreds of applicants who came before you are worth considering. Case volume and research funding numbers can be deceiving, so if those weigh heavily in your decision, be sure to examine them closely for the portion and proportion that you will have access to. In the end, neurosurgery training is tightly regulated on a national level, and your training will be excellent wherever you match. As much as programs are looking for the right fit, so too are you looking for a program that will fit you well. You will likely find that the match process does quite well at putting the correct applicants in the appropriate spots.

The Couple’s Match
Occasionally, neurosurgery applicants are lucky enough to find a future physician who will support them through the next decade or so. Unfortunately, the Couple’s Match that exists in the NRMP cannot be replicated in the SFMatch, even for subspecialties within the SFMatch. As the one likely to be matching first, you have the responsibility of determining both of your matches, and so must take into account your matching partner’s preferences and chances in determining your list. The best way for you to help make this match work for the both of you is to let everyone know of your situation. Talk about it in your interviews, write letters to remind program chairs, and, in the end, rank your list according to both of your best interests. But fear not, programs often welcome the addition of two new residents to the institution, and chairs will often call other departments for you. In any event, maintain an open dialogue with your programs of interest about your Couple’s Match, and especially after you match, your new chair will usually go to great lengths to help your match succeed.

The Match
After submitting your letter of intent, your rank list to SFMatch, and your NRMP registration, it is time to relax and enjoy the remainder of medical school. You will be notified of your match either when you receive a call from your new program director, or when you contact your medical school administrative office to ask. The euphoria is sure to be short-lived, as you will soon realize that everyone around you is mired in the process of ordering their rank lists. Be sure to rank your internship in February with the NRMP, and take Step 2 if you haven’t already done so. February is a great time to take an away rotation abroad, or go house hunting. But whatever you do, party hard, you of the privileged SFMatch, because after March, your classmates will look at you with great round eyes full of well-practiced empathy when they ask you how long your program will take.