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Neurosurgery Rotation and Application Changes Due to COVID-19: A Medical Student Perspective (Part II)

By COVID-19, GMENo Comments

The COVID-19 public health crisis upended many norms in medical education. Most of medical school is built around significant in-person contact. During COVID-19, educators and students have had to adapt to the changing times to protect public health. Perhaps the most strongly affected individuals are those who applied for the 2021 match. Students and program directors alike were in an unprecedented time — trying to find the right resident “fit” without away rotations and in-person interviews. As an applicant to neurosurgery, I was looking forward to learning how different programs operate compared to my home institution while also furthering my education in my field of interest. While COVID-19 significantly affected this plan, the pandemic also allowed for changes and innovations to the neurosurgery match — some of which may persist beyond the 2021 match cycle.

Home neurosurgery rotations were extended to eight weeks due to the limitations of away rotations. I was fortunate enough to rotate at a high-volume academic program, and I felt that I had excellent exposure to the field. I also became more familiar with the residents, faculty and program at my institution. To accommodate canceled away rotations, I attended virtual sub-internships and Zoom happy hours for programs that I had previously applied to for away rotations. Additionally, I scheduled phone calls with individual residents at these programs, which proved incredibly helpful and insightful. Finally, I built a Twitter profile, which was a great avenue to virtually connect with other applicants and faculty.

The most significant impacts of this cycle may be felt by those in states with few neurosurgery programs in their area. Obtaining letters of recommendation — considered “make or break” during the match — is undoubtedly a challenge for applicants without home programs. Standing out as an applicant — even with a home program and stellar letters — was also a challenge during this cycle. There is certainly a unique pressure to beef up “on-paper” qualifications such as the United States Medical Licensing Examination and publications. For applicants — particularly those without home programs — focusing on getting to know your programs of interest virtually was helpful. The residents I interacted with were more than willing to share their stories and highlight as much of their program as they could over a phone call. It was also helpful to hear more about their surrounding area. These conversations were a great way to get to know new people in an era of limited in-person contact.

The COVID-19 era has ushered in a disruption of the neurosurgical match. Finding meaningful connections during this time was a logistical hurdle for every applicant — particularly those without home programs. I focused on building as many connections virtually as possible — and fortunately, there were plenty of opportunities. I think that some of these resources, such as the virtual sub-internship or neurosurgical education webinars, are great resources that should continue in post-COVID-19 match cycles. While we live in a unique time, I find that the sense that “we’re all in this together” has persisted through my virtual and in-person interactions with others in the field. We are, after all, made to be resilient to the many trials of medicine — both the expected and unexpected ones.

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

Somnath Das
Medical Student
Sidney Kimmel Medical College at Thomas Jefferson University
Philadelphia, Pa.

Neurosurgery Rotation and Application Changes Due to COVID-19: A Medical Student Perspective (Part I)

By COVID-19, GME, MedEdNo Comments

The COVID-19 pandemic has resulted in many changes in the neurosurgery residency application process. Early decisions by the Society of Neurological Surgeons led to the canceling of away rotations, installation of virtual interviews, and a required eight-week home rotation in lieu of visiting rotations. Despite being disappointed that I would be unable to visit programs physically, the neurosurgical response to the challenges as a result of COVID-19 was very proactive, and it was a relief to have a definitive idea of the process early on.

Standing out during the home rotation became essential. Letters of recommendation could only come from home programs, so I used the eight weeks to form stronger relationships with key faculty members. During my rotation, I went to clinic with two of my anticipated letter writers, which proved to be an excellent opportunity to prepare and showcase history-taking, physical exam and imaging interpretation skills. Standing out in the operating room did not change much, but the added time of the rotation allowed me to see a wider variety of cases than I would have on a four-week rotation. I have become more familiar with the inner workings of my home health system. As the eight weeks progressed, I was able to take on more and more tasks associated with running the clinical service. The wider breadth of these experiences helped me learn much more about how to function as a neurosurgical resident than I would on a shorter, four-week rotation.

Many neurosurgical programs have started webinars or meet-and-greet sessions, where applicants can learn about the program directly from faculty and residents. Some programs — my home institution included — have organized lecture series, where faculty and residents give didactic sessions about various neurosurgical topics. These are great opportunities for students to get to know both the logistical aspects of the program, such as rotation schedules, research emphases and to get a feel for the all-important “fit.”As the time to submit applications approached, I reached out to friends who applied last year, current residents and faculty members to better understand the programs and compile my list. While the process has certainly been different from years past, some positive things have come from these changes, including the longer home rotation, webinars and lecture series. To say that the virtual interview dramatically affected the ability of programs and applicants to gauge “fit” may be an overstatement, and the real drawback is likely from loss of longitudinal exposure during in-person rotations. Nevertheless, this year has been exciting for both programs and applicants, and I enjoyed seeing how programs showcased themselves through virtual interviews.

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

Sean Neifert
Medical Student
Icahn School of Medicine at Mount Sinai Hospital
New York, N.Y.

Connecting with the Neurosurgery Community in the COVID-19 Era: Lessons Learned at the University of Miami

By COVID-19, GME, MedEdNo Comments

The COVID-19 pandemic has challenged the neurosurgery community to utilize new technologies to create and maintain connections. With social distancing guidelines in place, much attention has turned to the virtual space to accomplish this. At the University of Miami, we have trialed several virtual initiatives to connect with the neurosurgery community across the country and the world — from medical students interested in our residency training program to attending neurosurgeons interested in hearing from the world-leading experts in various neurosurgical subspecialties. We report the lessons we have learned during these unprecedented and challenging times.

Virtual Sub-Internship

Typically, sub-internships represent the culmination of medical school studies where interested final year medical students rotate in our department to gauge interest in both neurosurgery and our residency program. However, given concerns for student safety with travel, the various travel restrictions in place, and differing hospital policies on rotating medical students, the Society of Neurosurgical Surgeons opted for a unified policy for programs and students to afford all applicants the same opportunities. In 2020, away sub-internships were eliminated, and the University of Miami created a 1-day virtual sub-internship. In these, attendees were exposed to different subspecialties via attending presentations, resident life via resident presentations and applying to our program via a question and answer session with the program director, Ricardo J. Komotar, MD, FAANS, FACS. The lessons we learned are:

  • We can host more attendees than we would be able to with in-person sub-internships;
  • Compared to before, attendees of the virtual sub-internship are objectively more familiar with the residency program, faculty, residents and daily life within the program; and
  • All prospective attendees agreed that a virtual sub-internship before in-person sub-internship applications would be of great use after the pandemic.

The Resident Hour

A challenge facing medical students learning about our residency program is getting to know the current residents when they cannot rotate in the department. Given how vital inter-resident personality fit is when planning applications, we sought to increase the exposure of our residents by introducing a monthly resident-run virtual initiative called The Resident Hour. In it, we had residents present on various neurosurgery- and residency-related topics, but in a more conversational manner. The lessons we learned here are:

  • There is interest in hearing from neurosurgery residents from both within the U.S. and overseas;
  • Interactive sessions that encourage conversations greatly facilitates getting to know residents; and
  • Residents enjoy the opportunity to share with the neurosurgery community their knowledge and opinions.

Online Symposia

In the current pandemic, multiple neurosurgical conferences have been canceled. Without these, the neurosurgery community has lost exposure to experts in the field and the most up-to-date didactics. In response, our department has been able to organize our lecture series utilizing virtual symposia, nicknamed Zoomposiums. In it, we can bring in world-renowned experts virtually to discuss in real-time many pertinent and contemporary topics — including brain tumors via the Miami Global Brain Tumor Symposium organized by Michael E. Ivan, MD, FAANS, and Cerebrovascular and Skull Base Symposium organized by Jacques J. Morcos, MD, FAANS, FACS. Attendance is free and open to anyone interested, and all of the recordings (including The Resident Hour) are available on YouTube. From these symposia, we learned:

  • Virtual symposia increase the breadth of neurosurgical experts’ ability to present their work, as well as the neurosurgery community able to attend;
  • There is great interest in these symposiums across the world, with attendees from over 50 countries registering for each symposium; and
  • Being able to store these symposia online, at no cost, dramatically increases the longevity and reach of their impact.

The COVID-19 pandemic has challenged the neurosurgery community to innovate new ways to become and stay connected. Here in the Department of Neurological Surgery at the University of Miami, we have embraced virtual technology and created initiatives to increase exposure and maintain a connection to our program, our residents and our expertise. We have learned several lessons with the overarching goal of increased accessibility at the forefront of our experience. We can implement these virtual endeavors within the neurosurgery community to become more connected than ever.

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.

Victor M. Lu, MD, PhD
University of Miami School of Medicine
Miami, Fla.

 

 

Ingrid Menendez
University of Miami School of Medicine
Miami, Fla.

 

 

Ricardo J. Komotar, MD, FAANS, FACS
University of Miami School of Medicine
Miami, Fla.

Virtual Sub-internships and Remote Interviews: A Sudden Paradigm Shift in the Neurosurgical Residency Application Process Due to COVID-19

By COVID-19, GME, MedEdNo Comments

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 costing applicants upwards of $10,000. 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 Society of Neurological Surgeons (SNS) released its official guidance on external medical student rotations 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 set of recommendations 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
Rainbow Babies and Children’s Hospital
Cleveland, Ohio

 

 

 

Kurt A. Yaeger, MD
Mount Sinai Medical Center
New York, N.Y.

AANS Neurosurgeon Spotlight: The State of Neurosurgical Education

By AANS Spotlight, Burnout, COVID-19, GMENo Comments

Recent global circumstances have had considerable effects on neurosurgery. In the latest articles from AANS Neurosurgeon, the official socioeconomic publication of the American Association of Neurological Surgeons (AANS), authors discuss the state of neurosurgical education. Practices have taken steps to not only adapt to a multitude of changes due to the COVID-19 pandemic, but to thrive among them, while helping their patients do the same. Browse the Education issue for a scientific, artistic and realistic view from those tasked with providing and navigating valuable educational experiences during a time when there is no such thing as “normal.”

Article Spotlight

This Crisis is an Opportunity
Lola B. Chambless, MD, FAANS

Dr. Chambless explains how the pandemic has provided an unprecedented opportunity to study, learn and reform.

A Combined Spine Surgery Fellowship
Jason Savage, MD ꟾ Michael P. Steinmetz, MD, FAANS

Discover the makings of a successful spine fellowship – strong leadership, constant re-evaluation and a collaborative surgeon group.

Pen versus Penfield: A Proposed New Training Modality for Neurosurgery Residents
Erin N. D’Agostino, MD

Dr. D’Agostino describes how art “can serve a role in surgical skill building, learning and teaching of anatomy, patient education and combating burnout.”

Read More

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COVID-19 and Neurosurgical Training: Impact on the Next Generation of Neurosurgeons (Part II)

By COVID-19, Faces of Neurosurgery, GME, Guest PostNo Comments

What started as a brief segment on the evening news has consumed our daily lives as COVID-19 spreads across the globe. As health care facilities became inundated with critically ill patients, the nation’s intensivists, internists, emergency medicine physicians, nurses and respiratory therapists took to the front lines to fight this invisible enemy. With years of education behind us and at the cusp of the most significant health crisis in recent history, many residents are apprehensive of the future. What would be our role? Would we have adequate personal protective equipment (PPE) and critical care supplies to care for the sick? How can we keep ourselves and families safe?

Life in neurosurgery changed in step with the sweeping changes across the medical community, necessitated by potential supply shortages and increased patient volume. As social distancing took effect, the coveted morning sign-out — the bedrock of day-to-day functioning of a busy neurosurgery service — was transitioned to video conferencing. Next was the cancellation of all elective cases, then semi-urgent cases, and eventually, in some hospitals, emergency cases could only be performed after chair/faculty committee approval. Clinic visits were canceled if deemed non-urgent or conducted as telemedicine visits to provide care while limiting disease spread. To protect residents from unnecessary exposure and maintain a reserve, call schedules were changed to limit the number of residents seeing consults at one time or available for cases. As these changes were implemented, unprecedented collaboration, flexibility and ingenuity was prevalent as everyone did their part to ensure care remained as safe and effective as possible.

All neurosurgery residents have been affected. The junior residents, who spend the majority of their time seeing consults in high exposure environments such as the emergency department, saw a significant decrease in volume. Many patients with non-life-threatening concerns were now staying home or triaged appropriately to outpatient follow up. When patients did require evaluation, proper PPE was a necessity, and focused examinations were performed with as minimal patient contact as possible to ascertain the most clinically actionable portions of the exam. The workup of neurosurgical patients was done with an extreme focus on critical data and imaging, necessitating a thoughtful and evolving approach in a resource-constrained environment. For off-call, junior residents, residency experience changed even more dramatically, with potential operating room time virtually eliminated in most programs and off service rotations as neuropathology or neuroradiology postponed. Junior residents turned towards productivity in different areas, such as pursuing research opportunities and reviewing neurosurgical literature. For many residents affected by the cancellation of the written portion of the American Board of Neurological Surgery board exam, the additional study time was a welcome opportunity for further preparation.

Senior residents, who traditionally spend the majority of their time operating or developing the next steps of their career, saw their world go on pause. Interviews for fellowships and jobs were delayed or canceled altogether. Apprehension about how these changes will affect the significant drop in case volumes has compounded their future. At our institution, there was a 95-100% reduction in weekly cases as compared to January of 2020. As a department, we implemented a weekly review of cases that were considered urgent, to identify the few that should be done. Difficult discussions involved patients without emergent indications for surgical intervention — including those with myelopathy, radiculopathy or brain tumors. Alternative treatments and management considerations were instituted as temporizing measures while maintaining close communication with these patients. This case review considered not only the patient’s course without surgery, but also the likelihood of the patient utilizing an ICU bed post-operatively, or the risk to their health if they were to contract COVID-19 during hospitalization.

Operative times increased as the operative team was required to vacate the operating room for a designated period during intubation and extubation to lower transmission risk. Universal testing protocols have been implemented to save valuable PPE and time. Room cleaning and turn-over times also increased. Operating room availability diminished in some institutions as anesthesia machines were utilized as ventilators, and the rooms turned into makeshift ICUs to cope with the surge of patients. The Accreditation Council for Graduate Medical Education began accepting COVID-19 patient management as approved cases to accommodate the drop in operative cases nationwide.

While not always called to the front lines, neurosurgical residents across the country sought ways to utilize their unique skillsets to help their colleagues and patients during this crisis. Using the spirit of innovation and ingenuity, some developed projects to 3D print ventilator parts, testing swabs or respirators. Others devised ways to manufacture face shields and other protective devices. The surgical suturing skillset took a twist as neurosurgical services turned to produce homemade masks from cloth and HEPA air filters. Others used COVID-19 webinars to increase their critical care skillset in preparation for possible time on the frontlines.

Neurosurgical education has also been altered. Traditional teaching methods have been abandoned for digitization. Much like the broader educational system, neurosurgery responded with unification over video platforms. Journal clubs offer opportunities to share screens and materials. Morbidity and mortality conferences continued via a secure connection. National organizations such as the Congress of Neurological Surgeons expanded their education platform to include virtual visiting professors and webinars. Information sharing through social media platforms have triggered unprecedented opportunities to communicate and learn with both the national and global neurosurgery community.

The future remains uncertain for now. While there is talk of restrictions being eased in some parts of the globe, the U.S. still has difficult days ahead. We are grateful to the intensivists, internists, emergency medicine physicians, nurses and respiratory therapists who are bearing the brunt of this war. They are the true heroes. The silver lining of this experience is what we have learned about ourselves and what we have achieved with our ingenuity.

As will be the case in other specialties, telemedicine has shown its utility in neurosurgery and is here to stay. Although lacking the personal connection many of us hold sacred, telemedicine has proved to be a suitable alternative for patients in rural settings with long travel distances or those with debilitating conditions that make travel a stressful experience. This creates new opportunities to provide highly specialized neurosurgical care from a central location with patient experience and convenience at the forefront. Virtual video meetings have changed how we share information, collaborate on research and learn. The ability to 3D print ventilator parts and PPE has shown us the promise of technology. With time, the focus will shift away from the needs of the pandemic and to newfound innovations with relevance to neurosurgery. As a profession will come out from this with a renewed focus on the improvement of patient care.

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 and using the hashtag #COVID19.

Redi Rahmani, MD
PGY-4 Neurosurgery Resident
University of Rochester Medical Center
Rochester, N.Y.

 

 

Nathaniel R. Ellens, MD
PGY-2 Neurosurgery Resident
University of Rochester Medical Center
Rochester, N.Y.

 

 

Tyler M. Schmidt, DO
PGY-7 Neurosurgery Resident
University of Rochester Medical Center
Rochester, N.Y.

AANS Neurosurgeon Spotlight: Winter 2020 – The Mind of a Neurosurgeon

By AANS Spotlight, GME, Loss of Life, MedEd, Voices of Neurosurgery DepartmentsNo Comments

In The Mind of a Neurosurgeon, join authors as they discuss navigating life as a neurosurgeon. From work-life balance to processing loss, pursuing creative outlets to the responsibility of training the next generation, neurosurgeons have a unique calling that leads to a special life serving others. Browse the articles and step into the mind of a neurosurgeon for stimulating conversations about the alternate mind, retirement, mindfulness, the outsider’s perspective, music and much more.

Check back later in January and February for more on The Mind of a Neurosurgeon. Here are just a few articles out now:

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