A career in neurosurgeryBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1123 (Published 01 April 2009) Cite this as: BMJ 2009;338:b1123
- Jonathan R Ellenbogen, year 1 specialty trainee in neurosurgery
Jonathan Ellenbogen explains recent changes to the selection process and training in neurosurgery
Neurosurgery is a fascinating specialty that offers the prospect of curing patients with a wide range of benign pathologies as well as improving and prolonging the quality of life for patients with debilitating neurological diseases. Neurosurgery encompasses all aspects of the diagnosis, assessment, and surgical management of brain, central nervous system, and spinal pathologies. There are several subspecialties (box 1).
Box 1: Neurosurgical subspecialties
Functional neurosurgery (surgical management of intractable pain, epilepsy, and movement disorders)
Skull base surgery
Advances in our understanding of neurophysiology and neuroanatomy and improvements in microsurgical techniques, neuroradiology, image guided surgery, and interventional radiology have extended the variety of neurosurgical practice.
Entry to specialty
Entry into the specialty is now through a national selection process. The Neurosurgical National Selection Board leads this process, which is hosted by the Yorkshire and the Humber Deanery. The aim of a national selection process is to enable equity of access and consistency in the application of selection standards, enhancement of open competition, removal of local bias, and improvements in the specialty-specific aspects of selection. The Neurosurgical National Selection Board has representatives from the Specialist Advisory Committee in Neurosurgery, the Society of British Neurological Surgeons, the British Neurosurgical Trainees’ Association, and each of the neurosurgical training programmes in England, Scotland, and Wales.1
The selection process combines up to eight 10-15 minute stations including structured interviews, problem solving, image interpretation, clinical scenario management, communication, and practical skills assessment. Performance at each station is assessed independently by a pair of selectors.
In the national recruitment process for neurosurgery in 2008 there were about five applications for each vacant post. Twenty seven run-through posts are currently available for entry across specialty training years 1-4 (ST1-4) for August 2009.2
The UK neurosurgical specialty training programme consists of eight training years (ST1-8) in three stages. Entry to the programme is usually at ST1 for trainees, who will have completed a UK foundation programme (or equivalent). For 2009, there are still opportunities for entry at ST2-4 for those who meet the specifications for these levels. As specialty training in neurosurgery is a run-through programme there is no additional competitive step once a programme has been entered. Academic neurosurgical training follows as a further competitive step for those with a neurosurgical national training number.
The initial stage of neurosurgical training (ST1-3) incorporates a first year of core knowledge in the clinical neurosciences. This training year comprises a six month attachment in neurosurgery and a six month attachment in an acute neurology specialty, incorporating experience in clinical neurophysiology and neurorehabilitation; or four month attachments in neurosurgery, neurology, and neurointensive care. During ST2 and ST3, trainees undertake one or more placements in complementary surgical disciplines to acquire core surgical skills and knowledge. By the end of ST3 all trainees will have done a minimum of 12 months’ full time training in basic neurosurgery. The intermediate stage (ST4-5) provides two years in full time general neurosurgical training. The final three year stage (ST6-8) encompasses advanced neurosurgical training and incorporates a final year of special interest training in one of the neurosurgical subspecialties.3
Progress through the programme depends on acquisition of the necessary competencies (clinical, operative, and generic) as described in the curriculum, receiving satisfactory workplace based assessments (box 2), and other assessments of competence to satisfy the annual review of competence progression. Passing the examination for membership of the Royal College of Surgeons (MRCS) is obligatory for progression to ST4, and passing the joint intercollegiate exit examination, the FRCS(SN), is required for a certificate of completion of training and entry on to the specialist register. You will also have to show a portfolio of experience that includes activities such as formal teaching, leadership and management, research, and audit.
Box 2: Workplace based assessments
Mini-peer assessment tool
Mini-clinical evaluation exercise
Case based discussion
Direct observation of procedural skills in surgery
Procedure based assessment
Competition for consultant posts is becoming fiercer. Most senior trainees will have published several papers as first name authors or hold a doctorate of philosophy or medicine (PhD or MD) to make themselves more employable in a consultant post. Many senior trainees will also take up fellowship posts in other units in the United Kingdom or abroad to broaden their experience and increase their employability.
Neurosurgical services are usually provided in tertiary regional neuroscience centres serving populations of 1-3.5 million. The UK has 34 neurosurgical units, and most are situated in major cities, so you might be limited in choice if you want to work in a rural environment. Some of these neurosurgical units are part of standalone neuroscience centres, and others are incorporated into larger teaching hospitals. Neuroscience units’ services include neurology, neuropsychology, neuroradiology, neuropathology, and neurorehabilitation.
Neurosurgery is both a consultant led and consultant provided service, with fewer than 5% of trained neurosurgeons working in the staff and associate specialist (now specialty doctor) grades. Most consultant neurosurgeons spend four to five programmed activities (PAs) operating each week, with one or two outpatient clinic sessions a week. The remainder of their time is spent on preoperative and postoperative ward care, teaching, and other management and leadership duties.
Emergency work (unscheduled care) referred from hospitals within the regional catchment area accounts for more than 50% of the neurosurgical caseload. Out of hours activity is common and mainly consultant delivered. Neurosurgical consultants must be able to manage a diverse range of adult emergency conditions and provide basic emergency paediatric care (box 3).
Box 3: List of neurosurgical conditions which all neurosurgical consultants are competent managing3
Spontaneous intracranial haemorrhage
Central nervous system infections
Benign intradural tumours
Malignant spinal cord compression
Degenerative spinal disorders
Emergency paediatric care
Subspecialty elective care, referred from other hospital specialties or general practice, is provided by neurosurgeons with special interest training, working within multidisciplinary teams with colleagues in the clinical neurosciences, neuro-oncology, endocrinology, and otolaryngology, as well as maxillofacial, plastic, and orthopaedic surgery.3 Spinal surgery is the largest subspecialty, contributing 50% of the operative workload of some departments. Paediatric neurosurgery accounts for 10-15% of all neurosurgical acitivity.4
Day to day life of a trainee
There is no standard day for an initial stage neurosurgical trainee. In my unit the day starts around 7 45 am gathering patient lists and outstanding results in preparation for the ward round. If the team has been on call the hand over occurs around 8 am, and all patients referred in the preceding 24 hours are discussed and the results of imaging reviewed. This is a good opportunity to learn how to interpret computed tomography and magnetic resonance imaging scans, and to understand patient management. A neurosurgical ward round usually takes only a short time, and there may be ward rounds throughout the day if you look after a number of different consultants’ patients. After the ward round tasks are collated and the day is spent writing in patients’ notes, organising outstanding investigations and results, and managing emergency and elective patient admissions. There may be a teaching session in the middle of the day for an hour.
Patients are generally medically unwell, either with medical comorbidities or with sequelae of their neurological pathology, and require a lot of medical care; your days are invariably busy. If you are organised, efficient, and work as a team with your junior colleagues it is possible to gain theatre and clinic experience. The experience can be rewarding, but as with any job you get out only as much as you put in.
Qualities of a neurosurgeon5
Good at time management and organisation
Comfortable managing acutely unwell patients
Highly self motivated, willing to learn and keep abreast of new developments
Good at analytical thinking and problem solving, with ability to make decisions
Able to handle stress and perform under pressure
Excellent communication skills
Good manual dexterity
Able to deal with emotional stress constructively
Neurosurgery is an increasingly popular career choice as it is constantly evolving. Although neurosurgery has been a male dominated specialty, more women are choosing neurosurgery as a career, and in the United States consultation is under way to encourage women into the specialty.6 The work is diverse, with daily diagnostic challenges and management plans that bring together many different treatment modalities within a multidisciplinary setting. It provides numerous opportunities to do research and academic work and to be at the forefront of our understanding of how our brain works and the surgical correction of its pathological processes.
Full compliance with the European Working Time Directive will have a considerable effect on training in neurosurgery, limiting time available for trainees to gain experience. Only recently have we started to understand fully how this will affect training over the course of an eight year programme. Watch this space.
Advantages and disadvantages of a career in neurosurgery
Forefront of medical and surgical advances, especially high end technologies
Opportunity to improve a patient’s quality of life
Varied and interesting patients and disease processes
Onerous on-call duties with resident on-calls for ST4-8
Units can be far apart—therefore a need to travel for rotational posts and to move for consultant posts
Units in large cities, so not particularly suitable if you like country life
Constant patient load and pressure on beds means there is never a let-up in work
Yorkshire and the Humber Deanery: www.yorksandhumberdeanery.nhs.uk
Intercollegiate Surgical Curriculum Programme: www.iscp.co.uk
Society of British Neurological Surgeons: www.sbns.org.uk
Royal College of Surgeons of England: www.rcseng.ac.uk
My thanks to Gillian Needham, neurosurgery lead postgraduate dean, and Richard Nelson, secretary to the Neurosurgical National Selection Board, for reviewing this article and their comments and suggestions.
Competing interests: None declared.