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Neurosurgery Awareness Month: So How Do You Become A Neurosurgeon?
Neurosurgeons perform intricate surgeries on the brain, spine, and the different peripheral nerves as they course throughout the body. They meticulously open a patient's skull to stop bleeding vessels, remove tumors with precision measured in millimeters and strategically reshape the spine to correct conditions like scoliosis, restoring alignment and enhancing the patient's quality of life.
In essence, neurosurgeons transform lives through their expertise. But how do they achieve such mastery? How are neurosurgeons made?
Step 1: Get Into Medical School
Each medical school has variations in its prerequisites, but all require a strong foundation in the sciences. This includes courses such as the notoriously recondite organic chemistry as well as biology, general chemistry, and physics. These courses must not only be completed but mastered, as applicants need to distinguish themselves among peers pursuing the same rigorous curriculum, all with the same goal.
Competition for medical school acceptance can be stiff. My alma mater, Georgetown University School of Medicine, for example had 14,480 applicants in 2024 for a class of around 200, with an acceptance rate of 2.89%. The average GPA was 3.76, achieved while tackling the most demanding courses.
Grades serve as only the baseline hurdle. In addition to academic excellence, applicants must distinguish themselves outside the classroom through leadership, extracurricular activities, and meaningful exposure to clinical medicine. These accomplishments are essential for standing out in the highly competitive medical school admissions process.
Step 2: Do Well In Medical School And Match In A Neurosurgery Residency
Medical school spans four years, with the first two years focused primarily on classroom-based learning and the latter two emphasizing clinical, patient-centered training. Upon graduation, students earn the title of medical doctor but lack any specialization. Each student's unique interests and strengths guide their choice of specialty, with subsequent training varying significantly. Residency provides the specialized training in a chosen field of medicine. Residencies range from three years for some specialties to five years for others, with neurosurgery requiring the longest commitment—a grueling seven-year program known for its intensity.
Aspiring neurosurgeons must excel in their preclinical years, perform exceptionally during clinical rotations, and achieve high scores on national exams. Research is also critical, as is participation in audition rotations—commonly called "away rotations"—at other university hospitals. To secure a neurosurgery residency, students need compelling letters of recommendation from neurosurgeons at their home institution and from others across the country.
Ultimately, neurosurgery faculty evaluate candidates by asking critical questions: Is this individual someone we want to train as a neurosurgeon? Can they handle the demands? Most importantly, can we trust them to care for a vulnerable patient population?
As a nod to a familiar saying, the person who graduates last in their medical school class may be called "doctor," but they are highly unlikely to be called anyone's neurosurgeon.
Step 3: Survive And Thrive In Neurosurgery Residency
Neurosurgery residency is a remarkable yet formidable endeavor. The cases are often lengthier than those in other specialties, with exceptionally high stakes. This makes the hours long. Residents learn to care for critically ill patients, a process that demands intensive hours, extensive study outside of work to prepare for cases, and the emotional resilience to confront life-and-death situations daily. Neurosurgery offers the extraordinary power to save and transform lives, but it carries the sobering reality of the potential to cause harm. It's also very busy; it is not uncommon for a junior resident to oversee the care of 40 to 70 patients during a single night shift, underscoring the intense and demanding nature of neurosurgery training. Attrition rates reflect this intensity, varying from 2.6% in recent years to 10.98% between 2005 and 2010.
The first year, known as the internship, serves as an introductory training period, historically focused on responsibilities outside the operating room. As training progresses, residents undertake junior and then senior rotations as well as dedicated research periods. The culminating year, called chief residency, is when neurosurgery trainees tackle the more complex cases and assume significant leadership roles in managing the neurosurgery service, ensuring they develop into safe, competent surgeons. All neurosurgeons receive comprehensive training in the large variety of neurosurgery including pediatric neurosurgery, tumors, spine, stroke and vascular neurosurgery, equipping them to handle the field's diverse challenges.
Step 4: Become An Expert, Fellowship Training
Upon completing residency, a surgeon is deemed a board-eligible neurosurgeon, qualified to practice independently and perform surgeries. However, some pursue additional fellowship training, typically lasting one year, or in rare cases, two years, extending their post-medical school training to eight or nine years, respectively. These fellowships allow surgeons to master the most challenging cases or develop advanced research expertise in a specific sub-specialty, such as pediatric neurosurgery, vascular neurosurgery, trauma neurosurgery, functional neurosurgery, complex spine surgery, minimally invasive spine surgery, or tumor and skull base neurosurgery.
Surgeons seeking to advance the field through academic practice frequently pursue specialized fellowship training. For instance, I am fellowship-trained in complex spinal deformity, equipping me to handle difficult, long-duration spine reconstruction surgeries. My partners, who perform most other spine surgeries, refer these complex cases to me. And, my practice is actively engaged in several spine research projects. Similarly, while I manage brain tumor surgeries when on call, my partner, who is fellowship-trained in complex tumor surgery, specializes in meticulous microscopic procedures for challenging tumors in high-risk brain regions. I refer those difficult cases to him. This pattern extends to my colleague in pediatric neurosurgery and so on.
Step 5: Pass The Neurosurgery Boards And Become A Board-Certified Neurosurgeon
The certification process begins during residency, where prospective neurosurgeons must pass a written examination. Then, completing residency renders them board-eligible. After a few years in practice, neurosurgeons sit for the neurosurgery boards, marking the culmination of their training and education—and the definitive affirmation of their expertise as safe neurosurgical practitioners. Upon passing, they become board-certified and diplomats of the American Board of Neurological Surgery (ABNS).
It typically takes three to four years in practice for neurosurgeons to undertake the oral board process. This rigorous evaluation involves masters of the field guiding the candidate through cases step by step, incorporating clinical scenarios, MRIs, X-rays, CT scans, and occasionally anatomical models. In essence, they are assessing: did the surgeon know what to do? Did he or she understand the differential diagnosis? Was he proficient in the anatomy? Did he know when to operate? Could he articulate the surgical procedure? How could he manage a hypothetical complication?
Even more critically, candidates submit their actual performed cases, including clinical notes and pre- and post-operative imaging for over a hundred sequential cases. This serves as a quality and safety audit: are the candidates delivering safe and effective care? The process is fair yet demanding, as it must be to uphold the profession's standards.
Step 6: Develop The Mindset Of Mastery: Continuous Learning in Neurosurgery
Neurosurgery is a field shaped by new research and data-driven techniques. To succeed and be safe, a neurosurgeon must be a dedicated learner, consistently engaging with the latest journals and attending conferences to stay current. Equally vital is the capacity to shed ego and engage in daily, introspective reflection on the successes and shortcomings of their practice. This disciplined self-examination is the foundation for refining skills and advancing toward mastery.
I frequently advise our trainees that the moment they believe they've executed a flawless surgery is when they are on the pathway to becoming dangerous. Progress in this exacting specialty demands humility and an unwavering commitment to self-improvement. The most exceptional neurosurgeons are those who maintain a rigorous, yet constructive, self-critical mindset, perpetually seeking ways to elevate their calling.
The emotional weight of neurosurgery also imposes a formidable challenge. Complications, setbacks, and the daily reality of facing mortality rigorously test any surgeon's resilience. Yet, this resilience enables them to process these profound experiences, draw insights from adversity, and return home to their families with renewed clarity. It is not that uncommon, for example, for a neurosurgeon to inform a patient's spouse at 6:40 p.m. that his or her husband or wife will not survive a traumatic accident, only to embrace one's own spouse hours later. I have been summoned on an idle Sunday from moments of play with my four-year-old to perform urgent surgery on another family's young child. Navigating this emotional intensity alongside personal life requires a steadfast support system and a capacity to find purpose amid hardship.
Step 7: Express Gratitude
Neurosurgery is an extraordinary profession, it requires profound sacrifice, steadfast support, and an unwavering commitment to personal and professional growth. Our patients are truly inspiring. It is, undeniably, a calling. As Arthur Brooks articulates, a happy life hinges on three core elements: enjoyment, satisfaction, and purpose. Neurosurgery offers these in abundance.
