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The year 2020 required constant adaptation to a rapidly changing environment in many facets of life. Few would have guessed that national travel would be severely restricted or that surgeons would be wearing face masks to the supermarket. As impactful as the COVID-19 pandemic has been on life in general, the effect on the neurosurgical practice has been similarly profound —  from shifting outpatient care towards a more remote, telehealth presence to restricting non-urgent surgical case volume. Perhaps the most significant, potentially long-lasting effect of the pandemic on the neurosurgical profession has been with the transition from medical student to resident physician.

Matching into a neurosurgical residency position in the United States has traditionally been an extensive process spanning months and . Traditionally, students drawn to the field would rotate at a neurosurgical department associated with their medical school before embarking on sub-internship rotations in other neurosurgical departments across the country. This typically benefits the applicant by allowing him or her to observe the diverse practice of neurosurgery across different institutions. Furthermore, it allows the applicant to demonstrate his or her commitment and passion to the field to residents and faculty at these institutions. Moreover, this process is integral to generating letters of recommendation from respected members of the neurosurgical community. While applying for visiting sub-internship positions occurs in the fall to winter of the prior year, these rotations typically happen in the summer to fall of the application year. Once the Electronic Residency Application Service (ERAS) opens, usually in September, residency candidates submit applications to neurosurgery programs nationwide. Based on various selection criteria, applicants are subsequently invited for in-person interviews.

When the COVID-19 pandemic hit the U.S. in March 2020, health care providers nationwide, including neurosurgeons, began focusing all efforts and resources on treating critical patients affected by the SARS-CoV-2 virus. Furthermore, health policies were enacted in various hotspots to limit viral transmission, including stay-at-home quarantine orders, travel restrictions, and strict limitations on hospital visitors. Taken together, these had a noticeable impact on the ability of medical students to participate in visiting sub-internships.

Recognizing that these away rotations are a critical portion of a student’s application for neurosurgery residency, in late April 2020, the (SNS) released its official during the COVID-19 pandemic. The SNS recommended deferring all visiting medical student rotations for the 2020 application cycle.  Instead, the SNS recommended that students rotate internally with their home institution for eight weeks. For students enrolled in medical schools without a neurosurgery program, the SNS recommended rotating at the nearest Accreditation Council for Graduate Medical Education-accredited program. Regarding students’ letters of recommendation, the SNS recommended obtaining two letters from neurosurgery faculty and one additional letter from a general surgeon faculty member. Lastly, to further discourage traveling rotations, the SNS recommended against letters from faculty at external neurosurgery programs. Overall, these recommendations served to level the playing field for applicants in regions harder hit by the pandemic (e.g., those with more significant travel restrictions) and students without a home neurosurgery residency program.

In early May 2020, a coalition comprised of the American Association of Medical Colleges, Accreditation Council for Graduate Medical Education (ACGME), American Medical Association and others released a for external rotations and in-person interviews during the COVID-19 pandemic. First, the group discouraged away rotations among all specialties, except for medical students without an ACGME-accredited program at their home institution. Regarding interviews, the coalition recommended that programs commit to virtual interviews and site visits for all applicants, including local students. Lastly, the standard timeline for the ERAS was delayed to account for students’ missing or delaying rotations.

Given that much of the neurosurgery residency match has traditionally depended heavily on interpersonal interaction, letters of recommendation and in-person interviews, these changes to the application process were quite unique. Anyone familiar with the neurosurgery Twitter-sphere can attest to the growing interest in virtual sub-internships and residency program information sessions. As a community, we continue to adapt to the challenges posed by the COVID-19 pandemic. In many cases, we are finding more efficient ways to educate students and promote residency programs, which may be a transition point away from the traditional — and expensive — model of rotating, applying and interviewing for residency. In this series of blog posts, we highlight the challenges in the application process experienced by neurosurgical programs, medical students and others in organized neurosurgery and showcase their innovative responses during this critical time.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following @Neurosurgery and using the hashtags #Match2021 and #NeurosurgeryMatch.

Krystal L. Tomei, MD, MPH, FAANS, FACS, FAAP

Cleveland, Ohio




Kurt A. Yaeger, MD

New York, N.Y.

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