Questions & Answers for Neurosurgery Residents

The following questions were submitted by residents and answered by volunteer Mentors of the AANS Resident Mentoring Program.

1. What should I do to be a good resident?

Russell Amundson, MD: "I was advised that laziness was less acceptable than ignorance. Remember that the patient comes first. You are there to service the patient and their family. Care always, Comfort often, Cure occasionally. Be familiar with the patient’s problems – clinical presentation the anatomic and physiologic implications of the presumed diagnosis the differential diagnosis all labs, studies and interpretations treatment options risks, relative merits and costs of treatments Present succinctly and clearly. Make your attending's job easier by pointing in the right direction, not whatever way the wind ( work up ) is going. Be cheerful and attentive. If you are not happy working really hard, find a new career."

Nicholas Barbaro, MD: "The definition of a "good resident" changes throughout the training process. Initially, good residents are not expected to have a full knowledge base, but should communicate clinical issues frequently (i.e. ask for help). As time goes on, they should assume more responsibility and take "ownership" of patients. This includes outside and in the operating room. By the end of training, they should be assuming near-total care of patients and using faculty more as advisors. Each resident moves through this process at their own rate and should receive feedback from faculty that they are progressing appropriately (if this is not given, ask for it)."

David Baskin, MD: "Take every second of your time in the hospital seriously and realize that you have a unique and wonderful opportunity to learn. Be humble and respectful of your patients and the opportunity you have to learn about neurosurgery as you help them with their disease."

Catherine Mazzola, MD: Good residents are reliable, eager to learn, learn quickly, and become "problem solvers". As a Chief Resident, I appreciated the residents who were team players. As a junior resident, work hard to get the "scut work" done, delegate out what you can and use your free time to study. As a senior resident, protect the junior residents, teach them well, and have the patience to let them try. As you become more senior, if you have been a good teacher, your juniors will always remember that and be thankful for your efforts.

Michael McDermott, MD: "Be honest, work hard and enjoy other activities outside of work."

Praveen V. Mummaneni, MD:

• "A. Take good care of patients. Pay attention to detail. Work efficiently and work hard. The faculty can easily spot the "solid" resident.
• B. Be honest. Never lie to your faculty, even if things go wrong. The faculty will respect and trust you if you are honest.
• C. Read. With the 80 hour work week there should be more time to learn. Your faculty will be impressed if you know the basics about major neurosurgical diseases. Read your Greenberg daily and study for your written board exam."

Craig Rabb, MD: "Be humble. There is no room for arrogant attitudes. You are just beginning your training, and don't know as much as you might think you do."

Clarence Watridge, MD:

• "Be available, reliable and HONEST.
  
• Accept responsibility for your actions; if you made a mistake learn from it and don't look for something or somebody to blame besides yourself.
  
• Work well with colleagues - go above and beyond the call of duty to lessen the load for a co-resident; avoid the urge to compete.
  
• Take constructive criticism to heart and learn from it."

Jeffrey Weinberg, MD: "Be organized, learn how to prioritize. Give clear, succinct, reports. Understand that being a good neurosurgeon is more than being able to operate"

2. What books should I read?

Russell Amundson, MD: "Standard texts, current literature. Read everything you can get your hands on. I used Youmann's as a text, I enjoyed Kempe's operative Neurosurgery. These are probably ancient references by now."

Nicholas Barbaro, MD: "Read whenever you can and try to read about techniques in advance of doing them and clinical problems after seeing a patient. The exact book is not important as long as it is current. Trying to study for boards (written or oral) just prior to the tests is much more difficult than if you develop a habit of reading throughout training;"

Subrata Ghosh, MD: "I have compiled a rather comprehensive list that I have found useful in my career. This list is certainly not complete and does not indicate that there are no other better books out there. I believe in building a basic foundation through textbook reading first and then strengthen your knowledge with the latest articles in journals. One good practice would be to read everything about every operative case in detail prior to surgery."

    NEUROANATOMY:

• Core Text of Neuroanatomy by Carpenter. This is the most commonly used book and is comprehensive enough for our review of neuroanatomy.
• Carpenters Human Neuroanatomy. This book comes in a hardcover version and is apparently out of print, but can be found on the web. This book is much more detailed and initially can be intimidating to handle. However, this was the best text that I found on neuroanatomy.

    NEUROPHYSIOLOGY:

• Principles of Neural Science by Kandel, Schwartz & Jessel. This is an excellent textbook for certain topics and is a very useful reference book.
• Neuroscience by Dale Purves, Augustine, Fitzpatrick, Katz et al. I found this textbook to be much more comprehensive and very easy to read. I would recommend this text in preparation for written board examination.
• Manter & Gatz’s Essential & Clinical Neuroanatomy & Neurophysiology. This is an extremely useful guide to prepare for written board review examination.
• Comprehensive Neurosurgery Board Review by Citow et al. This is a concise and very useful last minute guide for written board preparation.

    NEUROPATHOLOGY:

• Surgical Pathology of the Nervous System & its Coverings by Burger & Scheithauer. AND
• Manual of Basic Neuropathology by Poirier, Gray & Escourolle. Both these books were useful for examination purposes.
• Pathology & Genetics of Tumors of the Nervous System by Kleihues & Cavanee. This book is the most comprehensive, up-to-date, concise yet detailed, that I have found for tumor pathology and it deserves special mention. It is published by IARC of WHO and ISN (International Society of Neuropathology) and is hard to find but one can get lucky in the web. This is a must have for every neurosurgery resident/training program in my opinion.

    NEUROLOGY:

• Merritt’s Textbook of Neurology. An excellent textbook for review.
• Neurology by Greenberg, Aminoff & Simon. An excellent and very popular book for review in preparation for written board examination.
• Dejong’s Neurological Examination. A very detailed reference book for fundamentals of neurological examination. Mastering this book can be difficult but would definitely help you achieve excellence in clinical evaluation of patients so critical and fundamental to our training starting and right through the training.

    NEURORADIOLOGY:

• Diagnostic Neuroradiology by Osborn. A must have with excellent pictures and very detailed discussion with differential diagnoses about various diseases that goes well beyond the domain of radiology.
• Introduction to Cerebral Angiography by Osborn. Another excellent reference text for understanding cerebral vasculature.
• Vasculature of the Brain & Cranial Base by Hopkins. Another excellent reference for understanding variations in vascular anatomy.
• Radiographic Neuroanatomy a working atlas by Fischer & Ketonen. This book compares actual CT and MRI pictures with illustrative anatomical drawings and helps understand very detailed MRI and CT scan anatomy that can be very practical and useful.

    GENERAL NEUROSURGERY:

• Handbook of Neurosurgery by Greenberg. This excellent guide is of course a MUST HAVE for every resident and beyond. This same book is actually recommended even for oral boards. The size of this guide may fool you but the amount of relevant information contained in this book is phenomenal and useful in EVERYDAY practice.
• Neurosurgery vols. I-III by Wilkins & Rengachari. OR
• Yeomans Neurological Surgery vols I-IV . Both these textbooks are excellent reference texts and there is very little to choose from. You need to have either one of these depending upon the availability and most recent date of publication. One of these textbooks should be the foundation of your background knowledge and enrich that with recent journal articles. I have always been a firm believer of textbooks because information in textbooks is always comprehensive and the references cited are all generally well established facts. Also, by reading a multi-authored textbook form first to last page, you would actually repeat several topics over and over again as viewpoints from different authors, which solidifies your background knowledge.
• Brain Surgery by Apuzzo vols I & II Complication avoidance and management. This is a must for all neurosurgery residents when it pertains to cranial surgery. This book is presented in a unique format with contributions from experts with tons of experience which would be extremely useful not only during your training but also out in practice.
• Spine Surgery vols I & II by Benzel techniques, complication avoidance and management. This is also a very similar format and has been extremely useful to me over the years.
• Operative Microneurosurgery vols I,II by Tew, & Van Loveren. I have several atlases that I have used over the years and this one is the easiest and most useful in my opinion for cranial surgery. This series also has a third volume edited by Prof. Kline which covers peripheral nerves and is very useful as well.
• Microneurosurgery vols I,II,IIIA,IIIB,IVA & IVB by Prof. Yasargil. This series is a collector’s reference text and does not need introduction. It’s a must have if you are inclined to specialize in cranial microsurgery.

    SUBSPECIALTY REFERENCES:

    The following list is certainly not all inclusive and contains several texts and references that I would highly recommend and therefore worth adding to your library. Some of these books may unfortunately be out of print but one can almost always find a new or used one in the web.

• Surgery of the Third Ventricle by Apuzzo.
• Neurotrauma by Narayan et al.
• Principles & Practice of Neurosurgery by Albright et al.
• Surgery of the Craniovertebral Junction by Dickman, Sonntag & Spetzler.
• Endoscopic Anatomy for Neurosurgery by Perneczky.
• Intracranial Aneurysm Surgery techniques by Samson & Batjer.
• Surgical Management of Neurovascular Disease by Ojeman, Ogilvy, Crowell & Heros.
• Cranial Base Surgery by Robertson et al.
• Surgical Exposure of the Spine: an extensile approach by Benzel.
• Techniques of Spine Fusion & Stabilization by Hitchon et al.
• The ICU Book by Marino

Catherine Mazzola, MD: "Handbook of Neurosurgery is a MUST for junior residents. As a more senior resident, reading about tomorrow’s or next week’s cases in a more in-depth manner, is beneficial. It also helps to do a quick literature search before the case, just to learn about some of the controversy or current thinking about the case on which you will be assisting. As a Pediatric NS Fellow, I read Albright’s Pediatric Neurosurgery and found his text an easy read. The Operative Guide really complements the text well."

Michael McDermott, MD: "There are several good textbooks. My advice is pick one then start on the first page when you begin residency. Make notes as you go then you can refer to these when you have to study for exams. Select a separate book for neuropath and do the same. Find a good book on CT, MR and angiography of the nervous system. Before cases try to find Rhotons articles on the specific part of the nervous system you will be operating on and read that the night before."

Clarence Watridge, MD:

• "Standard textbooks of Neurosurgery such as Wilkins/Rengachary "Neurosurgery" and Youmans "Textbook of Neurosurgery" are excellent references for review and basic neurosurgery. Reading them cover to cover may be unproductive.
• Read textbooks on Neuro-Imaging such as Osborn's "Handbook of Neuro-Radiology" and Rubenstein's "Textbook of Basic Neuropathology"
• Read something that gives you leisure and balance in life.
• How to balance clinical responsibilities/academic research
• Everything we do in neurosurgery has to do with providing patient care of the highest regard
• A conflict between research/clinical duties will generally favor clinical duties first
• Co-residents who work with researchers will find conflict if the researcher doesn't get his/her work done and others have to do it."

Jeffrey Weinberg, MD: "Neurosurgical Intensive Care; Carpenter's Neuroanatomy; Pediatric Neurosurgery; Have subspecialty specific books available for reference (e.g. a vascular, tumor, etc); Youmans; Surgical text book such as Schmidek and Sweet for reference before each case you do."

3. How to balance academic research with clinical care responsibilities?

Russell Amundson, MD: "See above, Q. #1 response. Patients first. This will be dictated by your assigned responsibilities. Clinical concerns tend to ebb and flow. Academic issues can be put on a shelf, a sick patient cannot."

Nicholas Barbaro, MD: "Developing a balance between clinical care, academics and (see later) family is the biggest challenge of your career. Delegating clinical work to others without losing overall control of care is one technique. Budgeting time for academics works best if you actually put time onto the schedule. Most junior people (during and immediately after training) don’t understand how much control they actually have over their own schedules."

Catherine Mazzola, MD: "Your first two or three years out in practice, you will be collecting patient data for your oral boards. Clinical data should be carefully maintained in an easy to use, electronic medical record (EMR) format. You will need to access that data for your boards. Clinical outcome data can be used for "research" publications at a later date. In an academic setting, there will always be residents and medical students who will be interested in working with you, if you teach them well. Mentorship has its’ rewards, because your mentees will reflect your dedication to neurosurgery."

Michael McDermott, MD: "Most programs separate these 2 during training and so you will have no clinical responsibilities during your research time. If you want to continue a project part time then learn how to organize your time."

Jeffrey Weinberg, MD: "Clinical care during your rotations is your primary responsibility and educational objective; research (clinical projects) early if you have time and are well-organized; begin to address basic science research projects 6 months before you enter your year of research (if you have one)."

4. How to balance family / work?

Nicholas Barbaro, MD: "Putting your family onto your work calendar is not only acceptable, it is critical. Try to learn to put family events, including simple things like attending Little League baseball games or dinner at home directly onto your work calendar and sticking to them just as you would your other “duties”. Strange as it may seem, office and other staff will greatly respect these times, as they should."

Catherine Mazzola, MD: "As a female neurosurgeon, I try to use my time at home well. I have a very supportive husband. It’s important to find a spouse who completely understands your commitment and dedication. It should come as NO surprise, that you will be gone for many hours, sometimes all night long, and then be totally exhausted the next day. It helps to have extended family around, who can support your spouse and children, when you are not around. I chose to work and live close to my parents because they were able to provide that kind of help to my husband and children. I can also rely on my extended family (brothers and sister in law) to pick up my kids from school if they get sick. Additionally, it is always beneficial to join a group or department where the other attendings have families, and understand the demands and responsibilities involved. I would shy away from departments where all the attendings have been or are divorced; this is my own opinion, but I would be afraid that their relationships had all suffered due to their career commitments. It is possible to have a family and be a successful neurosurgeon. I have had the fortune to work with several senior attendings who maintained great family lives. I have tremendous respect for them and their dedication to neurosurgery and their families."

Michael McDermott, MD: "Hardest question. At the end of the day you go home to your family not the chairman/woman or your patients. You will spend more time at work than with anyone else you know so pick one day of the week when you enter practice and make that day your get home early day. Tell your secretaries, colleagues, boss and family that on that day you will sit down for dinner at home."

Clarence Watridge, MD:

• "An issue not unique to neurosurgical residency.
• Time requirements at work increase once out of residency instead of decrease as does the stress load.
• One has to produce good time management skills and grasp the times that otherwise might be wasted to let family know that they are first and above work even though time requirements may look otherwise
• Where do graduates go after residency

Jeffrey Weinberg, MD: "Very difficult. Have a very understanding spouse. Understand your spouse's perspective; make time when you get home early and on weekends."

5. Where have the graduates of each respective program gone?

Nicholas Barbaro, MD: "The majority of our graduates enter academic departments and we have trained faculty at many programs (UVA, Harvard/Brigham, Johns Hopkins, Tulane, UC Irvine among many others). We also have graduates who have entered private practice"

Catherine Mazzola, MD: "Each program will share information about where their residents have ended up. Some programs will provide the information on their website. If you call the residency program director, they will usually be willing to give you these answers. Even the best academic centers graduate some residents who end up going into private practice. There are some residents who start their training with the intention of going into academic medicine, but then change their career track, depending on family situations, financial responsibilities, or the socioeconomic climate of neurosurgery in the area in which they want to practice."

Michael McDermott, MD: "Many from UCSF go on to academic programs but not all. One of an academic center’s greatest contributions in my mind is to also train outstanding clinical neurosurgeons to work in the community. Operate on your patients not the films!"

Clarence Watridge, MD:

• "Often times residents practice near their training program due to relationships developed during training.
• UT/SMC residents have gone all over the country - Tennessee, Idaho, Wisconsin, Alabama, Missouri, Georgia, South Carolina, etc. Most have settled in the Southeast due to family and climate preferences."

6. What is the variety of cases being performed in each program? What are the extra requirements of each resident? Any plans of expansion in the program?

Nicholas Barbaro, MD: "UCSF has a wide range of cases in virtually all aspects of neurosurgery. Our Moffitt clinical service is divided into three categories: tumor, spine and vascular. Within "tumor" are functional, epilepsy, peripheral nerve and pain practices."

Catherine Mazzola, MD: "Each program has a variety of cases and the RRC regularly audits the programs to make sure that they are doing enough cases in each area of neurosurgery. If you have specific questions about a program, call the program and ask to speak to one of the current residents. Even if you get their email, the senior residents will usually be willing to share their experiences with you."

Michael McDermott, MD: "At UCSF in 2006 we did 4300 cases across 4 hospitals, 3400 at Moffitt hospital where the majority of the faculty work. All areas are covered."

Clarence Watridge, MD:

• "Due to variety of staff sub-specialties most all areas of neurosurgery are present
• Paucity of Movement Disorder procedures.
• Lots of spine; particularly minimally invasive but major spine surgery such as deformity work present
• Cerebrovascular and endovascular cases are well represented although the number of craniotomies for aneurysm clipping has decreased as endovascular therapies have and do evolve."

7. I'll like the web to answer some questions on the challenges faced by a Neurosurgical resident.

Nicholas Barbaro, MD: "The CNS Young Neurosurgeons Committee is the best place to look for ideas about networking. Attending meetings as a resident is another."

Catherine Mazzola, MD: "If you need a senior neurosurgical resident, or attending to talk to, try the mentorship program supported by the AANS. Additionally, the Council of State Neurosurgical Society provides opportunities to interact regularly with senior neurosurgeons. Find out when and where your state neurosurgical society meetings are and attend. Introduce yourself, collect phone numbers and emails. Most neurosurgeons will always be willing to talk to residents or medical students."

Michael McDermott, MD: "Speak to the Young Neurosurgeons group and suggest they start their own members blog or list serve for residents."

8. How do I decide on a subspecialty?

Nicholas Barbaro, MD: Subspecialty decisions usually begin developing after residents spend significant amounts of time taking care of patients. Even residents who arrive in programs with stated subspecialty interests frequently change as they actually see what various clinical problems require with respect to neurosurgical care. Research interests also play a large role in this decision as most academic faculty have a direct connection between research and clinical work. My main suggestion is to choose a disease or area that is of interest, rather than a specific type of procedure. Clinical neurosurgery is changing very rapidly and few people will be doing the same procedures they learned in training in 20 years. Having a disease to treat with whatever new technology comes along will result in a more productive career.

Catherine Mazzola, MD: "The decision to sub-specialize usually develops in the second or third year of residency. You may find yourself more interested in spine cases, or pediatric neurosurgery. You may become fascinated with endovascular neurosurgery. There are now opportunities to do fellowships embedded within the residency years. ONLY pediatric neurosurgery has separate boards and specific requirements about the fellowship year. You should talk to people in your area who are already practicing in your field of interest."

Michael McDermott, MD: "Make a 2 column list: 1. what do I like 2. what will make me marketable for the type of job I want where I want to live. Look across both and weigh pros and cons. The worst mistake is to do something you don't like."

Clarence Watridge, MD:

• "Become a proficient general neurosurgeon first and explore most all the field has to offer.
• It isn't necessary to have a subspecialty to be a good and successful neurosurgeon.
• Many residents who do a subspecialty fellowship actually end up doing general neurosurgery.
• Only choose a subspecialty because you have a keen interest in it and are drawn to it. Never choose it for financial reasons."

Jeffrey Weinberg, MD: "First - you don't need to. Second - if you would like to, then determine what you like based on the whole picture of that subspecialty; e.g. for vascular understand that the surgery is complex but so too is the peri-operative care which can be long and drawn out with the surgery being only a small proportion of the amount of time spent caring for the patient; e.g. tumor: understand that patients with malignant gliomas frequently have complex medical issues, family issues, neurocognitive issues and have a high rate of mortality; some people may not be able to tolerate this."

9. What should I look for in a practice?

Russell Amundson, MD: "My experience is that there are zones of practice. Tertiary (or higher ) medical centers where practice is sub specialized. Practices close to these centers where you are "in the shadows" of the experts and your case mix is so influenced. The next zone may allow a complex case mix with relative proximity to the "center" for very complex cases. The "frontier" were you are it.

The other breakdown in a practice is whether there are several individuals practicing in a common space or really a partnership, sharing patient care beyond just "coverage". My experience is that most neurosurgeons "fly solo" although a relationship with alternation of pilot and co-pilot can be less stressful, can be economically beneficial and doubles your "brain power" on troublesome cases.

A common mind set on lifestyle results in less internal stress in a practice. Productivity formulas can balance discrepancies in work load but can also be manipulated and lead to disastrous results.

Your practice should be in a place where your spouse wants to live. You will spend most of your time in a windowless room, which for all intents and purposes could be anywhere. Your spouse and family will be awaiting your arrival home and they really should enjoy the wait.

The more you work the more money you can earn. The cost of living in your practice location will influence how much lifestyle ( ie size of home, amenities) your salary will purchase.

Do not live somewhere because it is close to an airport that takes you where you really want to be."

Nicholas Barbaro, MD: "Academic practices include support for clinical and research advancement. The balance between the two is critical if you wish to remain in academics. Many programs talk about “protected time” but do not really provide it. If the only time available for research and writing is nights and weekends, then you will have no time for your family (see balance questions above). The main issues that face young practitioners are eagerness to become busy clinically (much easier than you think) and financial incentives/disincentives for balancing clinical work with research. No research project will provide as much financial support as you can earn using the same amount of time in the operating room. Individuals who do not achieve this balance are happier in private practice. Private practice choices are more related to geography than academic practice choices. Ability to work with partners is critical along with an environment that is open to new treatment options."

Catherine Mazzola, MD: "When you are looking for a practice, pick a location where you would like to live and talk to the neurosurgeons already in the area. It is almost impossible to start a solo practice in neurosurgery for financial and medicolegal reasons. It is also beneficial to have the support and experience of senior neurosurgeons to guide you, especially in your early years in practice. Unfortunately, there is a lot of politics involved in both private practice and academic neurosurgery. It is in your best interest to find out the "climate" of neurosurgery where you want to practice. Is there a hostile malpractice climate in that state? How has the hospital's administration treated neurosurgeons in the past? Has the hospital been involved in any disputes with physicians? Departments? Why? What happened to the last spine surgeon at that hospital? Did they leave on good or bad terms? Talk to the group once you find a practice you are interested in. Well organized private practice groups should be able to give you answers quickly. You should not have to ask twice for a written contract. Negotiations should be respectful, concise and reflect the best interests of you and the group. No one is 100% happy at the end of negotiations, but that’s the point. it is a good compromise for each party."

Michael McDermott, MD: "Defer to private clinicians."

Clarence Watridge, MD:

• Stability
• History of good neurosurgical reputation
• Physicians with similar goals in life
• Good age distribution
• Academic relationship - doesn't have to be a university program but a practice involved with teaching is a good thing
• Economically favorable community
• Location you and family want to live

10. What are the economics of a neurosurgery practice?

Russell Amundson, MD: "Your billable charges, based on RVU's, are reimbursed at a discounted rate. ~ 40% for Medicare and perhaps as high as ~ 80% for private insurance.
Your overhead is around 40 – 50 %.
You then pay taxes at ~ 50%.
You consequently receive about 11 cents for every dollar of "billed" work.

You strive to improve your payer mix to higher rates, lower your overhead and maximize your volume on activities that reimburse well.
Many neurosurgical procedures lose money per unit time and therefore become expensive hobbies.
(Amortize pre-operative evaluation, surgical time, counseling of family, post operative care, add in pro-rated cost of insurance and overhead to determine)"

Nicholas Barbaro, MD: "Academic neurosurgeons are less aware of economic issues than those in private practice, but this should not be the case. Everyone has to bill and collect to pay their way. An understanding of billing and coding is important for everyone. Typically, academic departments have people who are happy to explain these things and, in private practice, senior partners will provide some of this support. Universities have their own guidelines for which patients they are willing to accept. Similarly, private practice groups make joint decisions on participation in various health plans. Payer mix is critical, but not always changeable."

Catherine Mazzola, MD: "The economics of each practice are different depending on the payer mix and the sub-specialties of the partners within the practice. There are also many different models of incorporation. Be sure that you have a lawyer who you like, and who works well with the groups' lawyer. It also helps early on to find a group that works with an EMR/ billing software/ program that provides accurate and understandable data early on. The initial starting salaries for neurosurgeons vary greatly depending on the type of practice, private versus academic, and subspecialization. Bonuses are usually given on a regular basis, based on either relative value unit (RVU) billing or on collections. Practices today are struggling to determine the optimal compensation models for their corporation. Some groups also hire employee physicians (MDs who work for salary or salary plus bonus) who are NOT on partnership track."

Michael McDermott, MD: "ibid"

Clarence Watridge, MD:

• "Revenues - Overhead = profit; there is no free lunch and there is not pot of gold at the end of training..
• Medical practice survivability is no different than the viability of any business; if the production does not exceed costs it will not survive.
• Trends are downward for medical care services.
• Relationships with hospitals for call and/or other services can be of great benefit.
• "If it is too good to be true, it probably is".
• Avoid being owned by someone or a corporation; what happens when you are no longer a benefit but a liability for a business?"

Nicholas Barbaro, MD: "UCSF provides full support for a protected year in the laboratory. Other programs usually provide similar support, albeit with various amounts of clinical responsibility. Few programs allow residents to spend extended times away from the parent institution as cross-coverage and other factors must be considered. Individuals determined to do significant research during their residency should take a careful look at how resident research is supported."

Catherine Mazzola, MD: "It is important to choose a residency program that meets your specific expectations. However, if for some reason, you have an interest to work outside your own residency program, realize that this MAY create problems for your residency director. On-call coverage and call schedules may be affected. Especially with current 80 hour work week restrictions, it is tough for a program to “loan out” residents to do research or outside rotations. If you want to do this, speak to your program director as early as possible to let him/ her know about your interests. Ask what you can do to make this happen; be ready to hear the concerns of your fellow residents and attendings."

Michael McDermott, MD: "Look at the literature and find the expert where you could live for a year or two. Ask your program director if research outside the university is allowed. If yes then approach the expert at least 18 months ahead of the start of research to talk about funding issues."

Clarence Watridge, MD:

• "While a common answer to this is NIH those funds are becoming harder to obtain
• NREF (Neurosurgical Research and Education Fund) - look on AANS website for information.
• ACS (American College of Surgeons) educational grants and scholarships.
• Most cities have Foundations that have money earmarked for research applications that are qualified - hospital, Assissi, Plough, etc.
• Hospital foundations"

Jeffrey Weinberg, MD: "You need permission from you chairman to explore other opportunities during your research year; you may not be able to leave your program due to call responsibilities, etc. But if you are knowledgeable about where to find your research interest and your program will support your travel/leave, then there is no reason not to pursue it."

12. What is the general feeling on infolded fellowships? Are they equivalent?

Nicholas Barbaro, MD: "Infolded fellowships are not the same, but are not all bad. As the neurosurgical knowledge base expands, it is becoming more difficult to train all residents in all things. In addition, few people in practice perform all of the procedures they were trained to do. A certain degree of sub-specialization exists even in private practice. With the exceptions of pediatric neurosurgery and endo-vascular surgery, specific fellowships are only needed if the individual has not been exposed to enough clinical material during residency. One way to do this is with "infolded fellowships"

Catherine Mazzola, MD: "With 80 hour work week restrictions, more residency programs are struggling to find ways to cover call schedules. Losing residents to outside rotations makes it nearly impossible to cover without hurting the remaining residents. After 6 or 7 years of residency, most senior residents would prefer NOT to spend an additional year or two in fellowship. Yet in these years, a lot of specialized training and learning occurs. These fellowship years are not really equivalent to infolded "mini-fellowships" because as a resident, you don't have the same responsibilities and opportunities that you have as a fellow. Fellows don’t have the same onerous schedules, and even though they may be on call all the time, or every other, the call is more inline with attending level call. You also have the opportunity to act and operate as an attending. You have time to read textbooks that you had no time to read, cover to cover, in residency."

Michael McDermott, MD: "No"

Praveen V. Mummaneni, MD: "No, they are not equivalent. Fellows are given much more responsibility after completing their chief resident year. This is because the chief resident year teaches responsibility and autonomy, and there is no substitute for t. At UCSF, I have stopped accepting "infolded" spine fellows for this reason. Furthermore, potential fellows should be aware that the Senior Society/CAST is now accrediting many subspecialty fellowships (tumor, spine, vascular, etc). The criteria for accreditation is "12 months of post-residency fellowship in an approved institution." Therefore, if you want the full fellowship stamp, you should consider doing a 12 month post-residency fellowship."

Craig Rabb, MD: "It is my opinion that they are not totally equivalent, as the fellow would not have had the same level of experience as a graduating chief resident prior to starting the fellowship. In addition, I think that, if the fellowship is in lieu of an additional research year, it has more credibility than if it is just one year of the training."

Clarence Watridge, MD:

• Infolded fellowships are valued.
• Depends on the fellow, the location and the particular fellowship desired.
• With a focused time in a particular subspecialty a bright and capable neurosurgeon will develop into an appropriately talented neurosurgeon in the subspecialty of his/her choice.

Jeffrey Weinberg, MD: "I don't think they are equivalent, but they are not bad either. The main difference is the amount of experience (surgical) that you have before beginning a post-graduate fellowship is much more and you are likely to "do more" (i.e. have more autonomy) in the operating room than during an infolded fellowship. You are more likely to know how to do the routine procedures and will need further training in the more complex procedures."

13. The most important information is related to job analysis to find a right fit. Should one use a recruiter?, etc.

Nicholas Barbaro, MD: "I would advise against using a recruiter except in very specific situations. They are generally working for institutions rather than for you."

Catherine Mazzola, MD: "I have no experience with recruiters. Usually, if you know other neurosurgeons in your field of interest, they can point you out in certain directions. It helps to know someone who can pick-up the phone, make a phone call and get you an interview where you want to work. I think that if you are relocating across the country, and don't really know anyone in the area, then a recruiter may be helpful."

Michael McDermott, MD: "Recruiters are very good about advising you about the business/legal aspects of a private job. Not needed for academic position."

Craig Rabb, MD: "You should not hesitate to use a recruiter if you are going into private practice. This service should cost you nothing. The practice or hospital usually pays the recruiter if they deliver a neurosurgeon. They may be able to provide insight into various practices' history, as well. Use someone who specializes in neurosurgery, if at all possible."

Clarence Watridge, MD:

• "Recruiters in general are bad.
• Recruiters are financially driven to put an applicant in place.
• Many positions are best filled by recommendation of a mentor in the program. Discussions with your chairman or other faculty members will prove more beneficial than talking to a recruiter who doesn't know you or your family situation."
• The CNS has a placement service for those looking for a job.
• The AANS has an online Career Center.

14. How to assess a possible physician-firm for employment opportunities?

Russell Amundson, MD: "See above regarding practice."

Catherine Mazzola, MD: "Again, talk to other neurosurgeons who have worked with the group you are looking at. Most neurosurgeons will give you an honest answer about their experience within the group. You can ask questions about "range of income within the group". Ask if anyone has left the group or firm. Talk to the hospital administrators in the area. How is that group doing? Are they the only group in town? Be careful about being the second person joining a previously "solo practice". Make sure that there is a plan if the other neurosurgeons becomes sick or disabled. You don't want to be responsible for all the call, and an equal split of group net income, at that point. If joining a large group, this is not an issue. Find out how call is split and if there are nurse practitioners or physician assistants who help with call. Who gets the PA's on call….just the senior partners?? What if you are spine trained, and joining a generalist practice? Are you going to be called in every night to see spine cases? In pediatrics, if you are the only peds person in the group, how do you get "free time"? These are all important questions that you need to ask before joining a group or department."

Clarence Watridge, MD:

• "Transparency - if there is a lot you don't know or do not have access to, be careful.
• Look at recent employment track record - has there been a lot of short term physician tenure, if so - bad sign.
• Stability and legacy - physician groups that have been in place for a long time, have good community reputation, and have been economically viable have found ways to work together and be successful.
• Understand that everything doesn't come easily. Time and experience in practice have value. Those having gone before that have established an opportunity a new physician deserve something for that.
• Be leery of no-compete clauses."
• Be leery of large buy-in's to partnership.
• Look for a group that gives one a significant bargaining position when dealing with outside influences; the enemy is not your colleagues or necessarily your neurosurgical competition!