After fast-paced, rewarding, but often exhausting years of completing highly technical neurosurgical training as a resident, the decision to pursue an additional one to two years of fellowship training is ultimately highly personal. As a mid-level resident, I weighed the pros and cons of this path after graduating in the context of my professional and personal goals.
Among the pros:
- Greater job opportunities for those who have completed advanced subspecialty fellowship training;
- Marketing opportunities in areas with significant market competition;
- Exposure to and education on new procedures;
- Refining surgical technique and learning variation in management;
- Opportunities to educate residents; and
- Expanding your professional network of mentors and advocates.
Among the cons:
- The opportunity cost of delaying attending level salary;
- Delaying building of your neurosurgical practice; and
- Potential for another relocation following fellowship.
As a spine-focused neurosurgeon, I decided to pursue fellowship training at the Society of Neurological Surgeons Committee on Advanced Subspecialty Training-approved Stanford University School of Medicine program. I felt very fortunate to have worked with excellent spine faculty during my residency at the University of Michigan. I viewed the fellowship as adding to that foundation, particularly regarding the evaluation and decision-making for outpatients. As a resident, we would typically enter the elective spine care timeline near the end, with a pre-op patient ready to undergo a defined surgical procedure. The resident focused on the procedure’s safe and effective performance and high-quality immediate post-operative care. Time spent in the clinic can be variable and limited, particularly with a high-volume inpatient service. Yet, most spine operations are performed on patients who were referred to and evaluated in the clinic, and the vast majority of referred patients do not ultimately have surgery. It is paramount for the spine surgeon to identify who needs surgery to help them accomplish their goals, which operation is best suited to that objective, and how to maximize benefit while mitigating risk.
My fellowship, with equal time under the mentorship of Jon Park, MD, FAANS, FACS, and John K. Ratliff, MD, FAANS, FACS, was well-structured to address these topics and more. Following an attending meant following an attending’s schedule, providing a window into how independent practice feels over the course of a week, and an education on how to run a successful practice. We would typically spend two days per week in the clinic and two days in the operating room, with the fifth day available for add-on cases or academic work. Each of my mentors worked with talented advanced practice providers, so I gained insight into how this physician-led team-based approach made patient care more efficient. An efficient clinic means improved patient wait times and access. I saw how to communicate with referring physicians to coordinate care and develop professional relationships.
Perhaps most importantly, I learned a great deal about how to methodically evaluate the patients in the clinic to determine if they would benefit more from surgical or non-surgical care. It is helpful to remember that you can always bring patients back to the clinic to evaluate the results of additional testing or treatments. It is also useful to remember that there is almost always more than one reasonable surgical strategy if surgery is best suited to treating the situation. I developed new scripts to facilitate informed, shared decision-making regarding treatment options, elicit patient perspectives and address concerns. That has proven immensely valuable in independent practice.
The operative experience was valuable in learning new ways to accomplish operations I had seen or done before. For components of procedures that were already very familiar, fellowship affords more autonomy and a preview of what being an independent surgeon is. That made scrubbing into my first genuinely independent cases less stark of a difference. I had opportunities to “moonlight” on call, which also provided glimpses of independent practice. I also enjoyed operating with residents and learning how to teach in the operating room, which requires its own skillset. In weighing the pros and cons of fellowship, I can confidently state that the pros were undoubtedly more numerous. I will continue to benefit from a rewarding experience over the rest of my neurosurgical career.
Editor’s Note: We hope you will share what you learn from our posts in the Making and Maintaining a Neurosurgeon series. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtag #Neurosurgery.
Jay K. Nathan, MD
Trinity Health IHA Medical Group
Livonia, Mich.
