2007 Young Neurosurgeons Committee Silent Auction
Matthew J. McGirt, MD

Reflections on the past, present and future of neurosurgery: An interview with Edward R. Laws Jr., MD
Jay Jagannathan, MD

San Diego: Nightlife
Henry Aryan, MD and Ben Newman, MD

Top Gun Continues to Fly High in 2007
J. Bradley Bellotte, MD

Why I chose Vascular and Endovascular Neurosurgery Fellowships
Shervin R. Dashti, MD, PhD

Twenty Million to One: life of a neurosurgeon in Ethiopia
Sarah Woodrow, MD, MSc, Med

We Want the Best: Promoting Medical Students in Neurosurgery
Eve Tsai, MD, PhD

Medical Student Summer Research Fellowship Program
Career Fairs
Resources for medical students
Medical Student Courses

The American Society for Stereotactic and Functional Neurosurgery (ASSFN)
(Also known as the AANS/CNS Section for Stereotactic and Functional Neurosurgery)
Invitation to the Fellowship Recruiting and Career Advice Reception

Chairman's Message
Brian R. Subach, MD, FACS

I would like to welcome you to this edition of the Young Neurosurgeons Committee (YNC) newsletter. I am writing to you from a unique vantage point of a decade of observation. I first became involved in the YNC as a volunteer nearly 10 years ago and have watched the group grow in both numbers and responsibilities. Initially, the committee was developed as a means to involve residents and neurosurgeons newly entering practice in the AANS. You may realize that our organizations (AANS, CNS, as well as the Sections) are relatively small but extremely complicated in administration. Perhaps the greatest barrier to getting new blood into these organizations was the absence of a group solely dedicated to the concerns of the most energetic part of neurosurgery: its youth. Now one of the greatest hurdles we face is finding enough chairs for committee meetings or enough sandwiches for the Young Neurosurgeons Luncheon. All kidding aside, the AANS Board of Directors had given us tasks and charges to which we have responded with entirely new ideas, thoughts and plans. The YNC membership is an exceptional, brilliant and motivated collection of surgeons, elected initially as individuals, now functioning as a team.

Did you know that the Marshals at the national meetings are organized by our group? Who do you think does all the calling to find donors for the NREF Silent Auction and occasionally drives objects across a national border in a questionably legal maneuver?

The Top Gun program was not an idea bought on eBay. It came from one young neurosurgeon with a dream. Did you realize that we publish a semi-annual newsletter, conduct Real World courses at the national meetings and educate medical students about our lives and our profession? These tasks are accomplished by the hardest working group of people that I know and furthermore the tasks are accomplished in their spare time. "Why?," you ask; because it matters to the future of our specialty. It matters to our survival. Quite simply, it matters. If we, as the youth of neurosurgery, do not care to dedicate ourselves to worthwhile pursuits and causes, who will?

I am fortunate to be surrounded by outstanding people. I would ask that you strongly consider joining this group. Whether as an elected member or volunteer, get involved. As our achievements continue, our tasks and responsibilities continue to grow nearly exponentially. Whatever your talents or interests, I guarantee there is something rewarding available to you. Consider this question: What have you done with your past decade that mattered to the future of neurosurgery? Or, perhaps more importantly, what can you accomplish within your next?

2007 Young Neurosurgeons Committee Silent Auction
Matthew J. McGirt, MD

The 2007 YNC Silent Auction to benefit the NREF, under the leadership of Alfredo Quinones-Hinojosa, MD, raised a record profit at the AANS meeting in Washington D.C. The auction sold 135 auction items totaling $38,776. Not only was this the single largest revenue to date, it was also the greatest one-year revenue increase in the auction’s history. The use of an online bidding site was implemented for the first time this year. While the online purchased items did not necessarily directly lead to an increased auction total, it did increase access by the meeting attendees to auction items. It effectively extended the booth hours by allowing interested parties to check out the auction items using Internet access at the AANS Annual Meeting, and it allowed them to check out the auction items from anywhere that had Internet access. This resulted in additional bidding after hours when the exhibit hall was physically closed.

The 2008 YNC/NREF Silent Auction will hopefully continue the upward trajectory of the last three auctions. We will sorely miss Terri Bruce, who has worked tirelessly for the YNC and the Silent Auction; she is moving on from the AANS, but will always keep a warm spot in our hearts and we wish her much success. I will be Silent Auction Chair this year, and will be continuing the relationship with the online bidding site, as well as building synergy between the Silent Auction and Top Gun (the battle of wits and dexterity) launched and sponsored the last two years by the YNC at the AANS Annual Meeting. Ultimately, however, the success of the Silent Auction depends on the donors who graciously provide items or cash donations every year. If you, or someone you know, might be interested in donating or helping the YNC solicit donations, please contact myself or Michele Gregory at msg@aans.org.

Hope to see you at the next Silent Auction in Chicago!

Reflections on the past, present and future of neurosurgery:
An interview with Edward R. Laws Jr., MD
Jay Jagannathan, MD

[Ed.] A native of New York City, Dr. Laws completed his medical education and residency training at the Johns Hopkins University School of Medicine. During his illustrious career, he has served on the faculty at Johns Hopkins, the Mayo Clinic, the University of Virginia, and most recently as professor and vice-chair of Neurosurgery at Stanford. Dr. Laws has exemplified commitment to neurosurgical training and education, having served as editor of the journal, Neurosurgery, (1987-1992) and as a member of the editorial boards of the Journal of the American College of Surgeons, Journal of Neurosurgery, Cancer, and the Journal of Clinical Endocrinology and Metabolism. Among his many publications include seminal work on the biology of gliomas, pituitary adenomas and epilepsy. He also has trained numerous neurosurgery residents and fellows, many of whom hold prominent positions within neurosurgery in the United States and internationally. Dr. Laws has held many leadership positions within organized surgery, including president of the Congress of Neurological Surgeons (1983-1984), president of the American Association of Neurological Surgeons (1997-1998), and most recently president of the World Federation of Neurosurgical Societies (WFNS) and the American College of Surgeons (ACS) (2004-2005), only the fifth neurosurgeon to hold the latter honor. Recently, Dr. Laws shared some of his valuable time with Young Neurosurgeons’ News, reflecting on his experiences.

JJ: Who would you say were your most influential mentors in neurosurgery?

ERL: I was incredibly fortunate in acquiring a galaxy of important mentors in a variety of areas. I knew I wanted to do neurosurgery as soon as I started working in the neurosurgical laboratories the summer after my first year of medical school at Johns Hopkins. As students we had a wonderful grounding in neuroanatomy (David Bodian, MD, PhD), neurophysiology (Philip Bard, PhD, Vernon Mountcastle, MD, and Gian Poggio, MD), and biochemistry (Al Lehninger, MD). We had surgery in the dog lab that Harvey Cushing, MD, started, staffed by Vivien Thomas. That first year of research, Thomas Langfitt, MD, was chief resident and I wanted to be just like him! George Udvarhelyi, MD, and a neurologist, John O'Connor, MD, were my mentors in the lab. We actually built an ultramicrogasometer Cartesian diver apparatus to measure the metabolism of single neurons – I worked in the lab every summer and throughout my residency.

The neurosurgical faculty all became mentors over the nine years I spent with them. A. Earl Walker, MD, stimulated my interest in epilepsy. Dr. Udvarhelyi got me involved with pituitary surgery and pediatric neurosurgery, and taught me the scholarly way of dealing with neurosurgical problems that he learned from working with Wilhelm Tonnis, Norman Dott, MD, and Dr. Walker, and that fired my own interest in neurosurgical history. Dr. Udvarhelvi also taught me the importance of the cultural aspects of our life and work.

Patient care and technical neurosurgery were taught by two trainees working with Walter Dandy, MD – Frank Otenasek, MD, and John Chambers, MD, who were in private practice at Hopkins. John had also worked with James Poppen, MD, and they both carried on the Dandy spirit of bold and incisive, inspired neurosurgery. Neal Aronson, MD, was also on the faculty – he was the youngest neurosurgeon to have passed the board at that time and brought the best of the traditions of the New York Neurological Institute, and was my first teacher of stereotactic neurosurgery. Ted Hodges taught me neuroradiology at a time when the neurosurgical residents were doing all the angiograms and myelograms. I learned EEG from a real master, Ernst Niedermeyer, MD, and psychiatry from Dietrich Blumer, MD, both during my residency years. Frank Walsh, MD, taught us neuro-ophthalmology in a marvelous session every Saturday, with Frank Ford, MD, ("the judge") of neurology often in attendance.

Monday nights we had neuropathology and brain cutting at the city morgue taught by Richard Lindenberg, MD. Spine surgery was flourishing and I was privileged to work with Robert Robinson, MD (of the Smith-Robinson ACDF). "Robbie" actually scrubbed in to help me as chief resident with an anterior approach to a T-12 burst fracture. His protégées Lee Riley III, MD, and Jack Ivins, MD, at Mayo were important mentors in spinal surgery as well.

In 1968, at the beginning of the microsurgical era, Dr. Walker allowed me to go to New York for the first microsurgery courses taught by Gazi Yasargil, MD, Leonard Malis, MD, and Albert Rhoton Jr., MD. Those individuals set the stage for a new chapter in the history of neurosurgery.

At Mayo, even though I was on the faculty, I had important mentors, including Collin MacCarty, MD, who knew everything about meningioma surgery, Ross Miller, MD, who was cool and calm and versatile, and Thoralf Sundt, MD, who showed me all I did not know about vascular disease. At Mayo my career in pituitary surgery took off under the mentorship of two superb endocrinologists, Ray Randall, MD, and Charles Abboud, MD, who had confidence in me and were fine colleagues.

This fabric of wonderful teachers, colleagues and friends has sustained me over the years, with new inspiration and new challenges constantly appearing.

JJ: Many young neurosurgeons are looking for ways to get involved with organized neurosurgical groups (AANS and CNS), but have difficulty getting their 'foot in the door.' What are the best ways to get involved?

ERL: Good ways of getting involved include presenting posters and papers at major meetings, joining the Sections where often there are many opportunities for young surgeons to get involved, and actively volunteering for committee work. Networking is the key and the YNC can help. The ACS has a young surgeons group and the American Medical Association has a residents’ group – these are other avenues that can be explored.

JJ: You have always managed to balance an extremely busy clinical practice and prolific academic career. New faculty members often feel intense pressure to operate, compromising their research time. Any advice on how to balance the two?

ERL: It is never an easy task. Clinical neurosurgery has such an allure and technical excellence demands experience, so there are competing priorities. Always try to take a scholarly approach to the clinical work – as Miller Fisher, MD, said, "They are all interesting patients."

Good neuroscience is so much of a collaborative effort these days: a good strategy is to seek out the right scientists as collaborators, provide them with challenges and insights, and with research material, and utilize their areas of expertise as windows to solve problems.

JJ: The new Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions have changed neurosurgical residency education. There is a fear that surgical training may suffer in years to come because of limited operative time. Do you think this is true? Have you found any specific model of the 80-hour week to be particularly effective?

ERL: We will never be able to change the current limitation on duty hours, and our response in maintaining the integrity of the educational enterprise has been suboptimal. Perhaps we need to rethink the goals of neurosurgical education and provide more versatile pathways to ultimate career choices. I do not know of a model that does this at present. My experience with the "night-float" solution is not encouraging for it creates a servant mentality that is inimical to the educational process.

JJ: What areas of evolving technology do you find particularly exciting?

ERL: Endoscopic neurosurgery is more than a gimmick and is leading to new and better concepts and outcomes. Radiosurgery has acquired a definite role in many areas of neurosurgery. Deep Brain Stimulation (DBS) involves a set of methodologies and concepts that may have very wide applications in the future. Neuro-imaging, image guidance and endovascular neurosurgery continue to evolve.

JJ: As one of the few neurosurgeons who has been president of the ACS, what are your thoughts about the idea of an 'acute care surgeon', as proposed by some in the ACS? Do you see this happening in the future?

ERL: The trauma care system drives manpower in this country in a significant fashion, and most hospitals desperately want recognition as trauma centers. This requires neurosurgeons and we are suffering a neurosurgical manpower crisis that needs to be solved. Regional systems have been proven to work, but this concept threatens the status of individual hospitals. The acute care surgeon will not be capable of dealing with head and spine trauma in an effective fashion, and it is appropriate for us to resist this idea while we educate the public regarding effective systematic solutions.

JJ: What are the most important things to look for when deciding on a first job? What would you consider to be 'red flags'?

ERL: Offer to fill any perceived subspecialty area, but try to maintain the prerogative to do a full spectrum of clinical neurosurgery, at least for a while. Evaluate the collaborative opportunities clinically and scientifically. It is important to feel comfortable working with the residents and fellows. The overall ambience is key. Make sure you have the opportunity to attend the important national meetings. The biggest red flag is discord among members of the faculty and among the residents.

JJ: As president of the WFNS, you had a unique perspective of seeing neurosurgery around the globe. How do you find neurosurgical training outside the United States?

ERL: There was a time that everyone who ended up being a neurosurgical chair abroad had spent at least some time in the United States. That is no longer the case, for a variety of reasons, and this has limited the opportunities for international exchange and dialogue. Neurosurgical education continues to develop all over the world, but is still not close to our model, which remains the envy of many.

JJ: Anyone who has worked with you knows how important your family is to you. Any advice on balancing family life and a successful career (particularly when starting in the field)?

ERL: It is not a good idea to neglect the family for work, even if they appear to be (and are) understanding. No matter how busy I was, I always tried to spend some time with my wife and children each day. You have to take the time to help around the house as a partner, to help the kids with their homework, to get to some of their sports events and school activities. It goes by so quickly, and you will not usually have the chance to catch up later.

JJ: Recently the Internet and online 'chat rooms' have become a forum for residency applicants interested in neurosurgery. There has been concern about the validity of information that is distributed through this media. Do you think that organized neurosurgery should moderate these types of discussion areas?

ERL: This activity will have some good aspects and some that are not so good. There is no way that organized neurosurgery could or should control this. Hopefully the same principles that drive evidenced-based medicine will ultimately prevail in this arena – practically speaking, however, that is unlikely.

San Diego: Nightlife
Henry Aryan, MD and Ben Newman, MD

Click to enlarge map (PDF 2.53 MB)

San Diego sizzles after dark with dance clubs and nightspots, cultural happenings, casino action, and bars galore – from beach bars to piano bars, sports bars, dive bars, and just plain neighborhood bars. Weekends are especially hot. Most cultural happenings – symphony, theater, and opera – unfold downtown. Coffeehouse culture, with music at night, is also big. At the nearby Gaslamp Quarter, martini bars and upscale dance clubs abound, including the three-story Stingaree restaurant and nightclub with waterfalls and translucent floating staircases leading to a rooftop bar. Dance clubs and bars of Pacific Beach and Mission Beach attract a more casual, typically younger crowd. Bikers hang out at Ocean Beach to soak up reggae and Grateful Dead-style jam bands. San Diego's music scene rocks, dominated by hard rock, alternative rock, and indie rock. Alcoholic beverages are not sold after 2 am.

Here are our top picks.

Deco’s
Deco-dent: '30s sleek, Miami and Havana mix and the 20-somethings mingle. If you're looking for an L.A.-style nightclub and do not mind queues, covers or crowds, hit up Deco's in the Gaslamp. With two dance floors featuring hip-hop and the best of the 80s and 90s, you are sure to find a beat that will get you groovin' at this hotspot owned by local nightlife impresario, Mike Viscuso (On Broadway).

731 5th Avenue
San Diego , CA 92101
619/696-3326
Cuisine: American, Steakhouse
Neighborhood: Downtown-Gaslamp

Altitude Sky Bar
Head for great heights at Altitude, the Gaslamp Marriott's rooftop bar. Gazing down from the 22nd floor, you can take in the sights of the harbor and downtown skyline. The best view of all is of neighboring Petco – you can see right in the ballpark. Because this is an open-air bar, it may be closed during inclement weather.

660 K Street
San Diego , CA 92101
619/446-6088
Neighborhood: Downtown-Gaslamp

The Grape
San Diego 's first wine bar has the feel of a small European bistro, where you would love to wile-away time by the glass. A blink-and-you'll-miss-it spot on Fifth Avenue, it pays homage both in name and ambience to the humble fruit that makes life worth living for oenophiles the world over.

823 Fifth Avenue
San Diego , CA 92101
(619) 238-8010
Neighborhood: Downtown-Gaslamp

W San Diego Hotel
With San Diego experiencing a nightlife boom, a W Hotel was sure to follow. Their ground-floor bar known as the Living Room is a glamorous, carpeted space serving fantastic cocktails to the lucky well-groomed and glossed, black-clad, trendy-yuppie crowd, who have managed to gain access. Martinis and Cosmopolitans are the name of the drinks game but arrive early and dress the part to get in – the weekend queues stretch to the California highway. Beach Bar is the rooftop spot upstairs, where the floor is covered in heated sand – yes, heated. It has beach chairs, cabanas for rent and a heated fire-pit to keep patrons warm at night.

555 West B Street
San Diego , CA 92101
619/231-8220
Neighborhood: Downtown-Gaslamp

Onyx
This underground speakeasy emanates class. Walking down the stairs into Onyx, you don't know if you're in for a seedy, underground bar or a swanky, posh venue for those in the know. Lucky for you, it's the latter. Dimly lit fixtures accent the low ceilings, casting a warm glow on the small (but comfortable) red chairs that hug the numerous tables about the room. Dozens of multicolored bottles line the shelves behind the bar, buttressed by a beautifully luminescent counter.

852 5th Avenue
San Diego , CA 92101
619/235-6699
Neighborhood: Downtown-Gaslamp

Side Bar
Side Bar has fabulous NYC-style right in San Diego. Side Bar is a space-age, bachelor-pad fantasy straight out of Wallpaper magazine. The swank urban lounge is housed in a historical building with brick walls and archways and a lofted ceiling. Though the decor is mid-century, Side Bar's high-definition plasma TVs and sleek sound system are decidedly modern.

536 Market Street
San Diego , CA 92101
619/696-0946
Cuisine: American, Californian, Desserts/Ice Cream, Seafood
Neighborhood: Downtown-Gaslamp

Thin
Onyx owner, Greg Strangman, wanted a stylish place to kick back and socialize with his friends. Rather than seek it out elsewhere, he opened Thin, a street-level lounge above Onyx on Fifth Avenue. The detail-oriented Mr. Strangman spared no expense outfitting his newest nightclub – “stylish” barely does it justice.

852 5th Avenue
San Diego, CA 92101
619/231-7529
Neighborhood: Downtown-Gaslamp

On Broadway Event Center
Finally, San Diego has attained upscale nightlife status. We may have tasted it at the Bitter End or E Street Alley, but both pale next to this night-and-day event facility, located on the Gaslamp Quarter's north border. Thousands of square feet of Italian marble floor glitter under state-of-the-art lighting and a 30-foot-high gold ceiling. Two 72-inch monitors and a stratosphere of lights coat the dancefloor and walls with flashing color. Within this cavernous space is a 35-foot-long ruby-red bar, a VIP lounge and a sushi bar – and this is just the first floor.

615 Broadway
San Diego, CA 92101
619/231-0011
Neighborhood: Downtown-Gaslamp

House of Blues
House of Blues has finally opened in San Diego, and it was well worth the wait.

1055 Fifth Avenue
San Diego, CA 92101
619/299-BLUE
Neighborhood: Downtown-Gaslamp

Jbar
San Diego 's newest boutique hotel offering, East Village's Solamar, dazzles the senses. From the Hemingway-esque lobby Living Room to the enticing menu at restaurant JSix, it's all about luxury and distinction. But you needn't be a visitor in San Diego to appreciate such upscale glamour. Take a mini-vacation at Jbar, the hotel's fourth-floor rooftop deck, which features a pool and ample room for lounging and socializing.

616 J Street
San Diego, CA 92101
619/531-8744
Neighborhood: Downtown-Gaslamp

57 Degrees
This hip wine bar is on the outskirts but worth the trip. The place's raison d'être, though, is wine storage; 57 Degrees refers to the ideal temperature for storing red wine. The guys behind the bar are proud to show off their 110,000-bottle cellar, where individuals can rent space to store their fine wines. And when "tenants" come in to enjoy some of their swag, there's no corkage fee.

1330 G Street
San Diego, CA 92101
619/234-5757
Neighborhood: Downtown-Gaslamp, East Village

The Waterfront Bar & Grill
With the city's oldest liquor license, The Waterfront Bar and Grill epitomizes all the best San Diego has to offer.

2044 Kettner Blvd.
San Diego, CA 92101
619/232-9656
Neighborhood: Downtown-Gaslamp

Honey Bee Hive
This subterranean East Village dive is a sweet place to hang, but tends to summon bad insect-related puns.

1409 C Street
San Diego, CA 92101
619/702-6010
Neighborhood: Downtown-Gaslamp

Dobson's Bar & Restaurant
An "in" place for all sorts of power-elite types, Dobson's downtown location also attracts a dedicated pre-theater crowd.

956 Broadway Circle
San Diego, CA 92101
(619) 231-6771
Cuisine: American, French, Seafood
Neighborhood: Downtown-Gaslamp

Westgate Hotel
The opulent, indulgent feel of a European castle.

1055 Second Avenue
San Diego, CA 92101
619/238-1818
Neighborhood: Downtown-Gaslamp

Casbah
This is where cutting-edge locals go to see the bands everyone else will be talking about tomorrow.

2501 Kettner Blvd.
San Diego, CA 92101
619/232-4355
Neighborhood: Downtown-Gaslamp

Bondi
These guys are bringing Australia (physically and otherwise) to the Gaslamp area to create an authentic Aussie experience.

33 Fifth Avenue
San Diego, CA 92101
619/342-0212
Neighborhood: Downtown-Gaslamp

Top Gun Continues to Fly High in 2007
J. Bradley Bellotte, MD

The Second Annual Neurosurgical Top Gun competition was held in conjunction with the 2007 AANS Annual Meeting in Washington, D.C. this past April. The competition allows residents to try their hands at three different skill stations. The resident with the highest score earns the honors of "Neurosurgical Top Gun."

This year's tasks again included a virtual ventriculostomy simulator, but this time with shifted ventricles approached from the left side. As always, it was a favorite of the contestants.

The motion analysis station measured tremor and smoothness of movement to the micron level, and was the source of the greatest anxiety among the three stations.

The spine station this year was a percutaneous pedicle screw simulation. Using a specially modified OEC 9800 C-Arm with built in spinal navigation technology; a simulated fluoroscopy environment was created. Players were asked to place two simulated pedicle screws percuntaneously in a flesh simulator box that contained a registered lumbar Sawbone. Scores were calculated based on the screw entry point, trajectory, and number of "fluoro" shots used to place the screws.

Carla Sofia Reizinho, MD, a resident from Lisbon, took top honors at this year's competition.

Congratulations to all the residents and fellows that participated for making this event a success. As in the past, the turnout was great and the competition was fierce. More than just fun competition, Top Gun is also an introduction to computer-assisted neurosurgery and surgical simulators, which are gaining increasing interest as a tool for future resident training and assessment.

Planning for Top Gun 2008 is underway for the AANS 2008 Annual Meeting in Chicago. Next year’s event will have even more challenging stations to test your surgical skills. Open to all residents and fellows, this competition will offer the top performers prizes, fame, and glory. Anyone interested in assisting or sponsoring can contact Sean Armin, MD, the chair of Top Gun, at sarmin@llu.edu, or me at bradbellotte@gmail.com.

Why I chose Vascular and Endovascular Neurosurgery Fellowships
Shervin R. Dashti, MD, PhD

Sometime during the fourth year of my residency, I realized that I was interested in vascular neurosurgery. I am not sure if this was really an informed decision, because I had virtually no experience as a first assistant on a vascular neurosurgery case; in my program, as is the case in most other training programs, the chief resident usually does all the vascular cases. I met with the the chairman of my department and a nationally recognized leader in vascular neurosurgery, Warren Selman, MD. I told him that I wanted to apply for vascular fellowships, and he was very supportive. However, he advised that I consider endovascular neurosurgery fellowships. He felt that by the time I finished residency, I would feel very comfortable performing open vascular and skull base procedures, and that an additional year of training would not be necessary. As I mentioned before, at that time I did not have much experience as a first assistant in vascular cases and I did not really share Dr. Selman’s conviction that I would be ready by the end of residency, so I applied for vascular/skull base fellowships anyway. There are a number of good fellowships around the country, and ultimately I ended up choosing the vascular/skull base fellowship at Barrow Neurological Institute under the direction of Robert Spetzler, MD.

In retrospect, Dr. Selman was largely right. In the last six months of my residency, I operated on 27 aneurysms, three cavernous angiomas, one AVM, four carotid endarterectomies, 11 acoustic neuromas, and 24 skull base tumors (meningiomas, epidermoids, etc.), giving me a broad exposure to skull base and open microvascular surgical techniques. Although I had an amazing teacher in Dr. Selman, who is a master surgeon, I am still looking forward to the vascular fellowship. I think of it as an opportunity to refine my techniques, as well as be involved in cases that I did not have much experience with, such as AVM’s and vascular bypass. Furthermore, since I did my MD, PhD, and residency training all at Case Western Reserve University, I think it will be very helpful to see how things are done at a different leading institution in the hands of another master surgeon who may have a very different perspective on cerebrovascular and skull base surgery.

As I already mentioned, at our initial meeting, Dr. Selman strongly advised me to do an endovascular neurosurgery fellowship. Endovascular neurosurgery has quickly become an important force in the treatment of cerebrovascular disease. Dr. Selman felt that future vascular neurosurgeons would ideally be able to offer both endovascular and surgical options to the patient. I took his advice and arranged an infolded diagnostic endovascular fellowship at our neuroradiology department during the fifth year of my residency. I will be completing my endovascular training by doing an additional year at the Barrow Neurological Institute under the direction of Cameron McDougall, MD, and Felipe Albuquerque, MD, after the completion of my cerebrovascular/skull base fellowship. More programs with strong traditions in cerebrovascular and skull base surgery are developing opportunities to train in both, either as part of an infolded fellowship during residency or as part of an accelerated training program. Most of the “living giants” in cerebrovascular and skull base surgery are now telling their trainees to consider combined training, and more and more surgeons are pursuing and completing combined training, in part because surgeons with both skill sets are more marketable both at academic and community practice settings.

Twenty Million to One: life of a neurosurgeon in Ethiopia
Sarah Woodrow, MD, MSc, Med

Tukuls

We all enter medicine to make a difference, to help people when they cannot help themselves. It is easy during medical training to lose sight of this. It is not surprising, really. It is not that you stop wanting to help people or do the right thing, it is just that during residency you spend whatever spare energy and time you have focusing on yourself. Between the sleepless nights and countless pages, there often is little time for anything else. You forget the big picture. And then one day, something happens to change your perspective, to make you take a step back and realize what is really important to you. For me, that moment came in the fall of 2006 when I had the privilege of working as a Foundation for International Education in Neurological Surgery (FIENS) volunteer in Addis Ababa, Ethiopia. This is my story.

Blue Nile Falls

Ethiopia is a landlocked country located in the northeast corner of Africa with a population of over 75 million people. Addis Ababa is the country’s capital and its largest city – with over two million inhabitants. Geographically, Ethiopia is an amazingly diverse country with large mountain ranges separated by the semi-dry plateaus of the rift valley and a tropical forest in the east. Its people are just as amazing and equally as diverse with over 80 distinct cultural groups, each with its own associated language. Despite this cultural wealth, Ethiopia remains economically one of the poorest countries in the world with most of the population surviving on subsistence farming and more than 50 percent living below the poverty line.

Family care

Healthcare in Ethiopia is largely privatized. There are a few government-funded hospitals, mostly located in larger cities. The Black Lion Hospital, where I worked, is one of them. It is one of the two public hospitals in the country (both in Addis) that offer neurosurgical services. For the majority of the population, their poverty level means they cannot access adequate healthcare – let alone afford the often two or three day journey into a larger city for care. Most, I expect, did not make it that far.

Highlands

Twenty million to one. That, roughly, is the neurosurgeon to patient population currently in Ethiopia with only four neurosurgeons (three local and one Norwegian) currently in practice, all in Addis Ababa. Twenty million to one. Although some might argue that the current North American benchmarks may be exceedingly generous, there can be no doubt this ratio is exceedingly low.

Me operating

There is hope in Ethiopia, however. And, at present, that hope comes in the form of two young doctors – Gebru Mersha, MD, and Fikre Abat, MD – taking a path that hopefully many will follow. They are both fully trained general surgeons who are currently re-training in Addis to become neurosurgeons. Experience from other fields in medicine has repeatedly demonstrated that the key to effectively training and retaining healthcare workers in developing world countries is to train them in their own environments. Foreign-based training simply results in too high a "brain drain." Such experience has led the Department of Surgery at the Addis Ababa University to initiate a four-year neurosurgical subspecialty training program. Developed in association with FIENS, the curriculum is approved and monitored by the College of Surgeons of East, Central, and Southern Africa (COSECSA). Knowing this, my travel to Ethiopia was planned less to provide a set of hands for the operating room and more to help develop the knowledge and skills of the new recruits.

Observing crowd

I still remember my first day vividly, as if it were yesterday, and how quickly I was exposed to the full breadth of challenges facing both the practice and the training of neurosurgery in a developing country. I accompanied one of the staff surgeons on morning rounds along with the residents. We had a lot of time for rounds that day because the autoclave had broken down. It would take two days to repair. All elective operations were cancelled. Even emergent operations were tenuous as instrument trays had to be shipped to a neighboring hospital for sterilization. This was to happen two more times during my tenure in Addis.

Operating room

The first patient we saw was a young man who had been struck by a car with a severe head injury. He was GCS 4, by my estimation, extending bilaterally but doing little else. A large canister of oxygen sat on one side of his bed, the kind that reminded me of the ones used to fill helium balloons at parties. Along with the nasal prongs he had in place, it was the only attempt anyone had made to address the As and Bs of resuscitation when he was admitted the week before. His mother sat on his other side. She, like all the other family members of patients in this 14-bed general ward room, had been taught how to administer NG feeds and change IV bags to help augment the overtaxed nursing care.

Surgery

Next we moved onto a post-op patient – a 76-year-old man who had undergone a two-level ACDF for cervical myelopathy. One of the surgeons had ingeniously used a radial bone plate as a makeshift cervical plate on the occasion. The pride of the moment, however, quickly dissipated as the fresh post-op films were displayed. It turns out that in the absence of intra-operative imaging capabilities the risk of wrong-level surgery is a very real one.

Road to market

In the next bed lay a new admission – an alert but very confused, 51-year-old farmer. Although English is the most common foreign language taught in schools, many Ethiopians from smaller, more isolated communities do not attend school. And with so many cultures in Ethiopia, each with its own languages, many did not speak Amharic, the predominant language in Addis. Trying to elicit a history was like watching the Ethiopian version of broken telephone. I often wondered how accurate our history taking could have been as we recruited at least three or four different individuals, often family members of neighboring patients, to participate in the lengthy process. As it turns out, this farmer had been going "crazy" according to family members – seeing things that were not there. Somehow they had pooled their resources and managed to buy him a CT scan which revealed the largest olfactory groove meningioma I have ever seen. It was not unlike many of the cases I would see and, for which I coined the term, extreme pathology. With personal resources as scarce as they were and with the burden of both travel and healthcare, most families never sought out medical advice until diseases were often far more advanced than anything that would be seen in the United States.

Working on the farm

What struck me that first week was how different our two worlds were. Having grown up in neurosurgery in the computer-based image-guided era, I felt initially crippled in my new environment where CT scans and power tools were considered luxury items. I wondered how I could effectively teach them anything. My concerns for my own abilities were quickly overshadowed by the overwhelming educational needs of the residents. With both neurosurgeons at the Black Lion also running busy private practices, resident teaching was frequently overlooked. I quickly learned not to waste any teaching opportunity. I was on call 24/7. I agreed to operate at any time and often we did. Every case appeared to spawn a spontaneous teaching session to general surgeons, anesthetists and neurosurgeons alike. When operations were unexpectedly cancelled we spent hours on the wards reviewing physical exam skills and dissecting any imaging study we could find. This was the case in clinics too as most were walking textbooks of neurosurgery.

I wrestled with many of my own demons during my stay in Addis, both personal and professional. As overcome as I was at times by the poverty and disposition of its people, I was amazed by their warmth and encouraged by their persistence. This is especially true of Drs. Mersha and Abat. Twenty million to one. They have their work cut out for them. They are struggling to learn so that they can make a difference to the people of their country. I can only hope that in helping to train these young surgeons, I too have made a difference.

There is no shortage of Dr. Mershas and Dr. Abats in the world. FIENS is currently operating in 19 developing countries worldwide. Their focus is on providing neurosurgeon volunteers to help augment the education of practicing and training neurosurgeons in these countries. One dozen neurosurgeons willing to volunteer one month of their time would be all that is required to staff the Addis Ababa site and help train the residents for an entire year. If you are up for the challenge, visit www.fiens.org for more details.

We Want the Best: Promoting Medical Students in Neurosurgery
Eve Tsai, MD, PhD

The YNC was recently charged by the AANS Board of Directors with promoting medical student interest in neurosurgery. While the number of medical students applying for neurosurgical residencies has remained stable, the demand for neurosurgeons and the number of training positions has increased in part due to the resident duty hour restrictions. As a consequence, organized neurosurgery must increase potential applicant interest in the field of neurosurgery to enable the continued delivery of optimal neurosurgical care. Women medical students require encouragement. As the number of women in each graduating medical school class increases, we must make an extra effort to show women that neurosurgery is a viable and invigorating career for women as well as men. Misconceptions about whether one can be a woman and a neurosurgeon should be corrected.

Because not so long ago most members of the YNC were medical students, we are uniquely qualified to address the concerns of medical students considering a career in neurosurgery. The committee as a whole responded with great enthusiasm as we canvassed our members and volunteer medical students on ways to promote the best medical students into what we know is the best specialty – neurosurgery. While many of our ideas have already been adopted, what follows below is a list of resources available to medical students who are considering a career in neurosurgery, and also some of the efforts our committee has pursued to improve the support of medical students interested in neurosurgery.

Medical Student Summer Research Fellowship Program
The summers during medical school are a good time for medical students to do research and explore specialties. We all know that the body is not a democracy: the brain reigns supreme, and there is no more interesting a field of research as neuroscience research. In addition, much of the best research in neuroscience originates from neurosurgical diseases (brain tumor and stem cell research, encoding of neural circuitry for control of movement, brain and spinal cord injury and repair, and stroke) For that reason, the AANS is sponsoring fellowships for medical students who want to do neuroscience research. In 2007, the Medical Student Summer Research Fellowship began and 10 fellowships were awarded. These fellowships provide a stipend to cover a two-three month period of research in a lab over the summer, and in 2008 the funding has been increased to provide 15 fellowships. The applications are straightforward and are available on the AANS Web site at http://www.aans.org/medical_students/summer_research_opps.asp. The deadline for 2008 applications is February 1, 2008.

Career Fairs
Most medical schools give students an early exposure to different medical and surgical specialties through career fairs, typically a meet-and-greet opportunity where medical students can hear a presentation about the appeal of a particular specialty and have a chance to ask questions about what it is like to be a practitioner in that field. This is an excellent opportunity for neurosurgeons to encourage and inform medical students about neurosurgery, and its importance is hard to overestimate. As a rule, neurosurgeons are confident, smart, engaging and the ONLY people that get to do what we do. As a consequence, these career fairs are a unique venue through which one person can generate broad interest with minimal investment of time. The YNC has put together a package for neurosurgeons to assist them when they speak to undergraduates. This package includes a PowerPoint presentation describing neurosurgery and ideas for formal and informal career counseling presentations. We are also working to make the package applicable internationally, and are currently working on packages tailored for the specifics of training in Canada and Mexico.

Resources for medical students
The YNC has compiled a list of Internet Web sites that provide information for medical students about research and career opportunities in neurosurgery. The information provided includes lists of the neurosurgical residency programs, a glossary of neurosurgical terms and career counseling sites that describe neurosurgery as a career. It also includes bulletin boards for medical students where they may ask questions. It is important to note that some of these bulletin boards are unmonitored and may provide misinformation. Various neurosurgical organizations including Women in Neurological Surgery (WINS) are now working to provide a bulletin board to provide those interested in a career in neurosurgery with a safe environment to ask questions and be assured of valid information. The Web site for this list of resources is: http://www.aans.org/medical_students/resources.asp.

Medical Student Courses
At the AANS Annual Meeting, there is a practical course for medical students and junior residents on becoming a neurosurgeon. This course is complimentary for medical students and provides information on the process for applying and getting into a residency. The course also gives tips on dealing with the challenges of residency and how to prepare for a career when finished with residency. The above is only a small list of the support available to encourage medical students and the YNC is continuously working to develop more ideas. If anyone has any further ideas or suggestions to help promote medical students, please contact Chris Philips, Director, AANS Membership Services, at: cap@aans.org.

Our taskforce is always open to ideas and would welcome any feedback that will improve our support of medical students.

I would like acknowledge all the contributions made by the current members of the task force for promoting medical students in neurosurgery: Jay Jagannathan, MD, Jeffrey Jacob, MD, Edward Smith, MD, and G. Edward Vates, MD, PhD.