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Accreditation Council for Graduate Medical Education Archives - Neurosurgery Blog

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.

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.